How is my resident falling?

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Objectives:
This presentation will review and discuss the new knowledge generated from the collection and analysis of “real-life” falls (over 1000 falls in 350 individuals, captured on video in long-term care), on the cause and prevention of falls and fall-related injuries in older adults. Specific objectives include:

1.To gain an improved understanding of the circumstances of falls in older adults. Topics include: causes of imbalance and activities associated with falls; balance recovery and safe landing strategies; role of mobility aids in falls; interactions between intrinsic, situational and environmental factors; and accuracy of fall incident reports.
2.To understand the factors that separate injurious and non—injurious falls, with specific focus on head impact, and hip fracture.
3.To identify new methods for preventing falls and fall-related injuries. Strategies to be discussed include: the role of upper limb strengthening in exercise programs; hip protectors and compliant flooring; fall risk assessment; and opportunities for data sharing.

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How is my resident falling?

  1. 1. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 How is my resident falling? Lessons from videos capture on the cause and prevention of falls and fall- related injuries in older adults in! long-term care. Stephen N. Robinovitch, Ph.D.! Canada Research Chair! Dept of Biomedical Physiology and Kinesiology &! School of Engineering Science! Simon Fraser University tips technology for injury prevention in seniors www.sfu.ca/tips
  2. 2. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Falls are energy management problems
  3. 3. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 ...which become more challenging to solve with age
  4. 4. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Incidence of fall-related injuries in older adults wrist fractures:! • similar in frequency to hip fractures! • >90% caused by falls hip fractures:! • ~23,000/yr in Canada, $1 billion in treatment costs! • 25% die within one year! • 50% lose independence! • >90% caused by falls head injuries:! • ~20,000/yr in Canada! • 60% caused by falls! • 3-fold increase in past 10 years
  5. 5. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Falls are common in older adults, but most do not cause serious injury • 30% of older adults living in the community fall at least once per year! • 50% of older adults in residential care fall at least once every year! • 15% of falls cause serious injury! • 1-2% cause hip fracture
  6. 6. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Due to three factors:! 1. declines in bone strength! 2. increase in falls! 3. changes in mechanics of falls Hip fracture incidence increases exponentially with age Source: Singer et al.,1998
  7. 7. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 3-fold increases in rates of fall- related head injuries in seniors Source: Kornhonen et al., 2013
  8. 8. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Energy (Joules) old femur young femur 300 Energy to Failure Energy Available in a Fall from Standing 0 10 20 30 290 Any fall from standing has the potential to cause hip fracture
  9. 9. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Energy absorption mechanisms! during falls
  10. 10. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 injury risk frequency of falls severity of falls (energy absoprtion/ protective responses) tissue strength (resistance to trauma) tissue loading
  11. 11. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Falls are associated with multiple risk factors, thereby difficult to prevent •impaired muscle strength, flexibility! •impaired vision, proprioception, vestibular function, reaction time! •cognitive impairment! •medications (hypnotics, antipsychotics)! •neurological disease (e.g., stroke, Parkinson’s)! •cardiovascular disease! •fear-of-falling! •activity level
  12. 12. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Bisphosphonates n = 6,007! Source: McLung, 2000 Percent of fractures (non- vertebral) 70 60 50 40 30 20 10 0 Women Above -1 (Normal) -1 to -2.5 (Osteopenia) -2.5 or below (Osteoporosis) Bone density based on T-score: 70 60 50 40 30 20 10 0 Men Percent of fractures (non- vertebral) Source: Marshall, 1996
  13. 13. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 1 SD decrease in BMD*: ! 2-3x increase! falling sideways: ! ! ! 6x increase! impact to hip: ! ! ! ! 30x increase! lower limb weakness: ! ! 5x increase! impact to hand or knee: ! ! 3x decrease! upper limb weakness: !! 2x increase! ! Sources: Greenspan et al., 1994; Schwartz et al., 1998; Nevitt and Cummings, 1993 Risk factors for hip fracture during a fall:
  14. 14. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 • few studies have directly recorded body movements during falls! • lab studies are challenging, and may lack external validity! • recall of fall mechanisms may be inaccurate; most falls are unwitnessed! • we require better understanding of how and why falls and fall injuries occur; role of intrinsic, situational, and environmental factors The missing evidence base in falls research
  15. 15. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Technology for Injury Prevention in Seniors (www.sfu.ca/TIPS)
  16. 16. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Video capture of real-life falls in LTC •270 digital video cameras in common areas of 2 LTC facilities! •fall incidence report triggers video collection! •between 2007-2013, collected and analyzed 1074 falls in 358 residents! •3-member team used validated questionnaire to probe characteristics of fall, situational and environmental aspects
  17. 17. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Conceptual basis for Fall Video Analysis Questionnaire Reference: Yang, Y., et al., BMC Geriatrics, 2013 (internal validation and ! downloadable questionnaire)
  18. 18. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Consent process • protocol approved by offices of research ethics at SFU and FHA ! • each resident or proxy provides written consent for video capture in common areas of LTC! • video footage is shared as secondary data! • additional consent from residents captured falling for:! − access to medical records (n=108 fallers, 322 falls)! − physical/ cognitive testing (n=69 fallers, 223 falls)! − sharing of images for educational purposes (n=51 fallers, 267 falls)
  19. 19. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 52% of fallers captured have 2 or more falls per yearNumberoffalls/year 0 5 10 15 20 25 30 35 40 0 20 40 60 80 100 Faller ID n = 108 fallers, 322 falls (MDS database)
  20. 20. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Number (percent) or mean ± SD Number (percent) Gender Male 43 (40%) Female 65 (60%) Age (yrs) 81 ± 9 Number of falls per participant: 2 falls 56 (52%) 1 fall 52 (48%) Cognitive (CPS) scale (0-6) 4.0 ± 1.5 ADL performance (0-6) 3.4 ± 1.6 Balance assessment Unsteady or need support 43 (40%) Unable to attempt test 27 (25%) Vision Mild impairment 22 (20%) Moderate to severe impairment 16 (15%) Chronic disease: Diabetes 24 (22%) Hypertension 46 (43%) Parkinson’s disease 3 (3%) Stroke 16 (15%) Alzheimer’s disease (AD) 32 (30%) Dementia other than AD 66 (61%) Medications Antipsychotic 43 (51%) Antianxiety 16 (19%) Antidepressant 44 (52%) Hypnotic 11 (13%) Diuretic 21 (25%) Analgesics 48 (57%) Number (percent) or mean ± SD Number (percent) Gender Male 43 (40%) Female 65 (60%) Age (yrs) 81 ± 9 Number of falls per participant: 2 falls 56 (52%) 1 fall 52 (48%) Cognitive (CPS) scale (0-6) 4.0 ± 1.5 ADL performance (0-6) 3.4 ± 1.6 Balance assessment Unsteady or need support 43 (40%) Unable to attempt test 27 (25%) Vision Mild impairment 22 (20%) Moderate to severe impairment 16 (15%) Chronic disease: Diabetes 24 (22%) Hypertension 46 (43%) Parkinson’s disease 3 (3%) Stroke 16 (15%) Alzheimer’s disease (AD) 32 (30%) Dementia other than AD 66 (61%) Medications Antipsychotic 43 (51%) Antianxiety 16 (19%) Antidepressant 44 (52%) Hypnotic 11 (13%) Diuretic 21 (25%) Analgesics 48 (57%)
  21. 21. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Location Dining room Hallways Lounge Other 1 am - 10 am 10 am -1 pm 1 pm - 7 pm 7 pm - 1 am Time Location and time of falls n = 351 falls, 148 fallers
  22. 22. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 BR DRL DRL BR Mapping location of falls in frequent fallers
  23. 23. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Activityattimeoffalling Transferring Seated Walking Standing Incorrect transfer Lossof support Hit/ bump Collapse Slip Trip Cause of imbalance (32) (10 ) (16) (14) (3) (1) (53) (2) (0) (5) (2) (45) (5) (31) (3) (4) (0) (2) (67) (39) (0) (2) (1) (1) Combinations of cause of imbalance and activity when falling n = 351 falls, 148 fallers Reference: Robinovitch et al., Lancet, 2013
  24. 24. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Activityattimeoffalling Transferring Seated Walking Standing Incorrect transfer (44%) Lossof support (23%) Hit/bump (9%) Collapse Slip Trip (14%) Cause of imbalance Activity Transferring (31%) Seated (13%) Walking (34%) Standing (22%) Combinations of cause of imbalance and activity when falling n = 351 falls, 148 fallers
  25. 25. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 LandingConfiguration 0.00 0.25 0.50 0.75 1.00 Forward (17%) Backward (39%) Sideways (28%) Straightdown (16%) Initial Fall Direction Forward (11%) Backward (57%) Sideways (32%) Direction of falls n = 351 falls, 148 fallers
  26. 26. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 0 10 20 30 40 50 60 70 80 Hand/ Forearm Knee Hip Head frequencyofcontact site 69% 33% 43% 30% Impact sites n = 351 falls, ! 148 fallers
  27. 27. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Hip impact was just as likely during forward as sideways falls n = 351 falls, ! 148 fallers Frequencyofhipimpact 0.00 0.25 0.50 0.75 1.00 Forward Backward Sideways Straight down Initial fall direction Yes (43%) No (57%) 351 N 3 DF 31.412114 -LogLike 0.1311 RSquare (U) Likelihood Ratio Pearson Test 62.824 61.247 ChiSquare <.0001* <.0001* Prob>ChiSq
  28. 28. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Variable Odds Ratio (95% CI) Initial Fall direction Sideways vs. Forward 1.7 (0.8 – 3.6) Backward 5.3 (2.6 – 10.8) Straight down 5.0 (1.8 – 13.3) Forward vs. Backward 3.2 (1.6 – 6.1) Straight down 2.9 (1.1 – 8.7) Landing configuration Sideways vs. Forward 12.7 (3.4 – 47.5) Backward 38.6 (13 – 114.3) Hip impact was just as likely during forward as sideways falls
  29. 29. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Probability of hip impact was not reduced by hand impact n = 351 falls, ! 148 fallers Frequencyofhipimpact 0.00 0.25 0.50 0.75 1.00 Yes (69%) No Hand impact Yes (43%) No 351 N 1 DF 12.026515 -LogLike 0.0502 RSquare (U) Likelihood Ratio Pearson Test 24.053 23.032 ChiSquare <.0001* <.0001* Prob>ChiSq
  30. 30. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Hip fracture case study
  31. 31. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Hip fracture case study Cause of imbalance Activity Initial fall direction Landing configuration Greatest energy absorption Other impacts Trip/ stumble Walking Forward Sideways Right hip/ buttock R/L hands, right knee, head Co-morbidities Functional status Medications Behaviour • CHF • HTN • Alzheimer's Di • Stroke, TIA hx • Renal failure • Poor vision • No mobility aid • Unable to rise from chair without using arms • Mild dementia • Needs supervision in dressing and hygiene • Number of meds: 8 • Antipsychotics • Antianxieties Moderate fear of falling
  32. 32. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 0 10 20 30 40 50 60 70 80 Hand/ Forearm Knee Hip Head frequencyofcontact site 69% 33% 43% 30% Head impact occurs in 30% of falls Reference: Schonnop et al., CMAJ, 2013
  33. 33. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 • Head struck the floor in 63% of cases, wall in 13% and furniture in 17%! • 87% of floor impacts were onto vinyl or linoleum (13% carpet)! • Head injury was documented in 34% of cases (45% lacerations or abrasions, 30% hematoma)! • 20% of cases resulted in hospital visits! • No concussions were noted
  34. 34. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
  35. 35. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Variable Odds Ratio (95% CI) Initial fall direction Forward vs. Backward 2.7 (1.3 – 5.9) Sideways 2.8 (1.2 – 6.3) Straight down 7.2 (1.8 – 29) Landing configuration Forward vs. Backward 2.7 (1.2 – 6.4) Sideways 1.2 (0.5 – 2.9) Hand impact Yes vs. No 1.2 (0.6 – 2.4)
  36. 36. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Predictor Variable Head ImpactHead ImpactPredictor Variable Crude Odds Ratio 95% CI Age Highest vs. Lowest quartile 1.0 0.4 - 2.6 Gender Female vs. Male 2.4* 1.3 - 2.6 ADL performance Dependent vs. Independent 0.7 0.3 - 1.5 Standing balance Unsteady vs. steady 1.2 0.5 - 2.7 Cognitive performance 0.4 0.2 - 1.2 Moderate to severe impairment vs. intact Vision Moderately impaired vs. Adequate 2.7* 1.0 - 7.7 Hypertension Yes vs. No 2.4* 1.2 - 4.8 Stroke Yes vs. No 1.9 0.8 - 4.8 Dementia Yes vs. No 0.6 0.3 - 1.4 Antipsychotic Yes vs. No 0.6 0.3 - 1.0 Antidepressant Yes vs. No 0.4* 0.2 - 0.8 Risk for head impact associated with gender, vision, and hypertension n = 322 falls, ! 108 fallers
  37. 37. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Multivariate model of probability for head impact n = 322 falls, ! 108 fallers
  38. 38. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Avoiding head impact during falls AN INSTRUCTIONAL EXERCISE-BASED COURSE tips technology for injury prevention in seniors www.sfu.ca/tips
  39. 39. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 SmartCells: commercially available compliant floor for fall injury prevention Installation of compliant flooring (SmartCells) in a demonstration bedroom of 
 Delta View Rehabilitation Centre in Delta, BC SmartCells
  40. 40. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 SmartCells provides more force attenuation than most hip protectors SmartCell Laing et al., Accident Analysis & Prevention, 2009 34%
  41. 41. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 SmartCells reduces force to the head by 70% during simulated falls headform Head impact simulator floor mounted on load cell 9543 2541 2374 2523 0 2000 4000 6000 8000 10000 Rigid Carpet Regular Vinyl PeakForce(N) SmartCell, 50 durometer, covered by Source: Dr. Andrew Laing
  42. 42. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 SmartCells has little effect on mobility and balance of older women Laing et al., Accident Analysis & Prevention, 2009
  43. 43. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 FLIP Trial Design New Vista = 236 rooms Exclude 86 rooms
 - 49 Willow Grove (non-ambulatory) - 37 floor cannot be raised 1” 150 single-occupancy rooms across 4 villages will be randomized within villages Intervention (INT) flooring 1” SmartCells w/ vinyl cover Control (CON) flooring 1” plywood w/ vinyl cover Track outcomes for 4 years Notification & Installation 16 rooms/wk for ~10 wks CON will also be installed in adjacent hallways Primary outcome • moderate/severe fall-related injuries Secondary outcomes • all fall-related injuries • falls Assess baseline characteristics ClinicalTrials.gov Identifier: NCT01618786
  44. 44. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Frequencyofheadimpact 0.00 0.25 0.50 0.75 1.00 Low Med (23%) High (68%) Fall frequency category Yes (30%) No 351 N 2 DF 3.7921337 -LogLike 0.0177 RSquare (U) Likelihood Ratio Pearson Test 7.584 7.821 ChiSquare 0.0225* 0.0200* Prob>ChiSq 1-2 falls/yr 8+ falls/yr 3-7 falls/yr Highest frequency fallers were least likely to experience head impact
  45. 45. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 What caused this fall?
  46. 46. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 What caused this fall?
  47. 47. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 How could this fall be prevented?
  48. 48. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014 Acknowledgements Collaborators:   Fabio Feldman, PhD (Fraser Health Authority) Ming Leung, PT, MSc (Fraser Health Authority)   Joanie Sims-Gould, PhD (VCHRI/CHHM) Ed Park, PhD (SFU Mechatronics) Greg Mori, PhD (SFU Computing Science)   Teresa Lui-Ambrose, PT, PhD (UBC, Physical Therapy)   Andrew Sixsmith, PhD (SFU Gerontology)   Cathy Arnold, PT, PhD (U. Saskatchewan, Physical Therapy) Aleks Zecevic, PhD (Western U, Kinesiology) ! Parters:   Fraser Health Authority Deltaview Life Enrichment Centre   New Vista Society Long Term Care Centre for Hip Health and Mobility IPML Staff/ Trainees:   Yijian Yang, MD   Omar Aziz, MAppSc   Joseph Choi, PT, MSc   Alex Korall, MSc Chantelle Lachance, MSc Emily O’Hearn, BSc Shane Virani, BSc Ryan Woolrych, PhD   Bobbi Symes, MA   Colin Russell, MASc   Rebecca Shonnop, BSc   Kayla McGowan Kimberley Chong Alan Tang

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