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  • There are an estimated 4 to 6 million postmenopausal women with low bone mass or osteoporosis in the US female population. Based on NHANES III, 54% of the women 50 to 64 years of age are estimated to have low bone mass or osteoporosis (T score –1.0 standard deviations or lower). These statistics increase as women age. Up to 86% of women 65 years of age and older have low bone mass or osteoporosis.
  • Why are falls important? Introductory slide
  • Hip fractures are generally disastrous for the patient.
  • Costs to the health services (Dolan and Torgerson, 2000) Currently there are just over 60,000 hip fractures in England and Wales each year, occupying 25% of all orthopaedic beds. These figures form the basis of Department of Health’s calculations for the costs of hip fractures. Based on these figures the annual costs of treatment of fractures among women is now estimated to be in excess of £1.8 billion pounds per year (Dolan and Torgerson, 2000).
  • Intrinsic vs extrinsic risk factors Everyone is a potential ‘tripper’ in that we stumble over objects and extrinsic risk factors such as unsafe or poorly lit stairs, slippery floors or carpets. Over half of all falls in the home are caused by such environmental hazards. Normally, we are able to adjust and correct the tripping movement by quickly grabbing a supporting object (a chair or rail) or making an adjustment to our balance or foot position. With declining functional capacity, e.g. muscle power and balance, we are less able to make these corrections, with the consequence that what might have been a slip or trip becomes an injurious fall.
  • Targeting the modifiable risk factors for falling While it is acknowledged that some risk factors for falls and fractures are not modifiable, others  – such as physical activity, environment and the effects of medication – can be positively influenced through appropriate education and intervention (Tinetti et al, 1995). Modifiable risk factors include low strength and power, poor balance/gait, fear of falling, functional capacity, depression, urinary urgency and incontinence, postural hypotension, and multiple medications (Skelton and Dinan, 1999). Those risk factors highlighted in the slide in bold are suitable for modification through physical activity programmes through specific targeting.
  • Improving risk factors – duration vs outcome There is substantial evidence to show that some of the risk factors for falls can be improved within a relatively short space of time (Skelton and McLaughlin, 1996). The immediacy of these improvements will greatly enhance the confidence of participants themselves as they will be able to experience at first hand significant improvements. This will also help in motivating older people to continue to participate. However, sustained participation is critical to ongoing and continued improvement. Such gains will soon be lost if participation is halted.
  • During the past decade, these therapeutic agents have a place in the osteoporosis treatment protocol. Efficacy data about increasing BMD, controlling bone turnover, and reducing fracture risk is included in this slide presentation. Interpreting the data through an analytical approach is important. Anabolic therapy for osteoporosis is also under investigation. Parathyroid hormone (PTH) stimulates bone formation and resorption, and its use in women and men with osteoporosis has been studied. 1,2 More research needs to be done on this possible therapeutic choice, however. 1 Neer et al. N Engl J Med . 2001;344:1434-1441. 2 Kurland E et al. J Clin Endocrinol Metab . 2000;85:3069-3076.
  • How active are older people? This section looks at some of the evidence relating to current levels of physical activity among older people. It contains some of the slides from the similar section in the Making the case for physical activity and older people presentation. Additional slides from that resource could be used to supplement this section.
  • Levels of sedentary behaviour, WOMEN aged 50+, England This chart indicates the proportion of women aged 50 and over whose behaviour is described as sedentary (Skelton, Young et al, 1999). ‘ Sedentary’ here means participating in physical activity less than once a week at an intensity defined as sufficient, at their age, to be likely to produce a health benefit. These figures are age-adjusted.
  • Putting it into practice – Recommendations and guidelines This section summarises current recommendations and guidelines for the role of exercise in the prevention of falls in older people.
  • Effective interventions The studies listed in this slide provide evidence of the effectiveness of exercise components both within a multi-factorial intervention and as a stand-alone intervention .
  • This suggests that among community-dwelling older people with a history of falls, exercise-alone interventions were significantly more effective in reducing recurrent falls compared to multifactorial interventions. More specifically, exercise-alone interventions were approximately 5 times more effective in reducing the incidence of falls compared to the multifactorial interventions.
  • Chair-based exercise – effective at targeting risk factors Chair-based exercise programmes have been shown to have a beneficial effect on maintaining or promoting independence and mobility in older people. The range of improvements demonstrated in research trials lasting 8 weeks or longer, considering chair-based seated and chair-assisted standing exercises, include: • strength • power • flexibility • functional ability • static balance • rehabilitation following a hip fracture, and • the performance of everyday tasks e.g. rising from a chair or using stairs. Compliance with chair-based programmes is generally better than compliance with standing or dynamic exercise, especially among the oldest old and among those with low baseline levels of fitness and function.
  • Chair-based exercise – effective at targeting risk factors (continued) Chair-based exercise programmes have been shown to have a beneficial effect in reducing: • depression • arthritic pain • postural hypotension • body fat and • the risk of future falls. Chair-based exercise has specific benefits as a training method. It stabilises the lower spine by providing a fixed base (particularly important in those with kyphosis or lordosis of the spine); it facilitates a greater range of movement by providing points of leverage and support; it minimises load-bearing and reduces balance problems in those with particularly poor mobility and arthritic pain; and it increases confidence in those unable to perform free-standing exercise.
  • Dionyssiotis

    1. 1. Shifting the focus from osteoporosis to falls ( prevention) in the elderly Yannis Dionyssiotis, MD, PhD, FEBPRM Director of Physical and Social Rehabilitation Center Amyntæo Florina, Greece
    2. 2. Prevalence of Osteoporosis <ul><li>Based on NHANES III, 54% of the women 50 to 64 years of age are estimated to have low bone mass or osteoporosis (T score –1.0 standard deviations or lower). </li></ul><ul><li>These statistics increase as women age. </li></ul><ul><li>Up to 86% of women 65 years of age and older have low bone mass or osteoporosis. </li></ul>Looker AC et al. J Bone Miner Res. 1997;12:1761-1768.
    3. 3. Epidemiology of falls and fractures <ul><li>Approximately 30 % of people over 65 years of age and living in the community fall each year; the number is higher in institutions. </li></ul><ul><li>Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention . </li></ul>Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4):CD000340
    4. 4. <ul><li>A key concern is not simply the high incidence of falls in older persons (young children and athletes have an even higher incidence of falls) but rather the combination of high incidence and a high susceptibility to injury. </li></ul><ul><li>This propensity for fall-related injury in elderly persons stems from a high prevalence of comorbid diseases (e.g., osteoporosis) and age-related physiological decline (e.g., slower reflexes) that make even a relatively mild fall potentially dangerous . </li></ul>
    5. 5. Why are falls important?
    6. 6. Viscous Cycle <ul><li>Fall </li></ul><ul><li>Fear </li></ul><ul><li>Immobility </li></ul><ul><li>Deconditioning </li></ul><ul><li>Higher Risk for Falls </li></ul>
    7. 7. Hip Fracture Outcomes <ul><li>24% mortality rate within first year * </li></ul><ul><li>50% of patients are unable to walk without assistance † </li></ul><ul><li>~ 33% are totally dependent ‡ </li></ul>*Ray NF et al. J Bone Miner Res . 1997;12:24-1235. † Riggs BL, Melton LJ III. Bone. 1995;17(5 suppl):505S-511S. ‡ Kannus P et al. Bone. 1996;18(1 suppl):57S-63S.
    8. 8. Costs to the health services The financial costs of hip fractures <ul><li>Estimated acute hospital costs for fractured neck of femur </li></ul><ul><li>Long stay/social cost </li></ul><ul><li>Primary care costs </li></ul><ul><li>Total cost </li></ul>£4,808 £7,125 £164 £12,097 The annual cost of treatment of fractures among women is now in excess of £1.8 billion. (Dolan and Torgerson, 2000) England & Wales
    9. 9. RISK FACTORS FOR FALLING can be classified as either : <ul><li>Intrinsic </li></ul><ul><li>E xtrinsic </li></ul><ul><li>Exposure </li></ul><ul><li>to risk </li></ul>Todd C, Skelton D (2004). What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe (Health Evidence Network Report ; http://www.euro.who.int/document/E82552.pdf , Guideline for the Prevention of Falls in Older Persons American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Preventionhttp://www.americangeriatrics.org
    10. 10. The relationship of intrinsic and extrinsic risk factors to falls and fracture Carter ND, Kannus P, and Khan KM. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and evidence. Sports Med. 2001;31:427-438.
    11. 11. Intrinsic vs. extrinsic risk factors “We are all trippers.” <ul><li>Over half of falls experienced in the home are due to environmental hazards – e.g. trips, slips, unsafe or unlit stairs. </li></ul><ul><li>A decline in a person’s intrinsic risk factors (declining function and balance) means that the extrinsic risk factors (loose mat, slippery floor) no longer cause a correctable trip; they cause an injurious fall. </li></ul>
    12. 12. <ul><li>Exposure to risk </li></ul><ul><li>Some studies suggest a U-shaped association, that is, the most inactive and the most active people are at the highest risk of falls 24-28 . </li></ul>24. Graafmans WC, Ooms ME, Hofstee HM, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol. 1996;143:1129–1136. 25.Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701–1707. 26. Sorock GS, Labiner DM. Peripheral neuromuscular dysfunction and falls in an elderly cohort. Am J Epidemiol. 1992;136:584–591. 27. O’Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137:342–354. 28. Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc. 1995;43:1214–1221 .
    13. 13. Targeting the modifiable risk factors for falling <ul><li>Low strength and power </li></ul><ul><li>Medical condition </li></ul><ul><li>Medications </li></ul><ul><li>Incontinence </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Balance/gait </li></ul><ul><li>Postural hypotension </li></ul><ul><li>Vision/hearing </li></ul><ul><li>Foot care </li></ul><ul><li>Poor housing </li></ul><ul><li>Depression </li></ul><ul><li>Previous falls </li></ul><ul><li>Fear of falling </li></ul><ul><li>Functional capacity </li></ul><ul><li>Poor heating </li></ul><ul><li>Poor diet </li></ul>
    14. 14. Improving risk factors – duration vs. outcome <ul><li>Gait (8 weeks) </li></ul><ul><li>Balance (Static 8 weeks + Dynamic 8 weeks) </li></ul><ul><li>Muscle strength (8-12 weeks) </li></ul><ul><li>Muscle power (12 weeks) </li></ul><ul><li>Endurance (26 weeks) </li></ul><ul><li>Transfer (6 months) </li></ul><ul><li>Postural hypotension (24 weeks) </li></ul><ul><li>Bone strength (1 year for femur and lumbar spine) </li></ul><ul><li>(Skelton and McLaughlin, 1996) </li></ul>
    15. 15. Therapeutic Options <ul><li>Antiresorptive Therapy </li></ul><ul><ul><li>Calcitonin </li></ul></ul><ul><ul><li>Raloxifene </li></ul></ul><ul><ul><li>Bisphosphonates </li></ul></ul><ul><ul><ul><li>Alendronate </li></ul></ul></ul><ul><ul><ul><li>Risedronate </li></ul></ul></ul><ul><ul><ul><li>Ibandronate </li></ul></ul></ul><ul><ul><ul><li>Zolendronic Acid </li></ul></ul></ul><ul><ul><li>Denosumab </li></ul></ul><ul><li>Anabolic Therapy </li></ul><ul><ul><li>Parathyroid hormone (1,84 PTH) </li></ul></ul><ul><ul><li>Teriparatide (1,34 PTH) </li></ul></ul>Strontium ranelate
    16. 16. Drugs BMD and vertebral fracture risk
    17. 17. Drugs and non-vertebral fracture risk
    18. 18. Bisphosphonates: Benefits and Risks <ul><li>Benefits </li></ul><ul><li>Fracture reduction </li></ul><ul><li>BMD increase </li></ul><ul><li>Non-hormonal </li></ul><ul><li>Risks </li></ul><ul><li>Nausea </li></ul><ul><li>Upper gastrointestinal irritation </li></ul><ul><li>Myalgias and arthralgias </li></ul><ul><li>Atrial fibrillation </li></ul>
    19. 19. Cramer JA, Gold DT, Silverman SL, Lewiecki EM. A systematic review of persistence and compliance with bisphosphonates for osteoporosis. Osteoporos Int. 2007 Aug;18(8):1023-31.
    20. 20. Vitamin D – Falls prevention Meta-analysis
    21. 21. Predictive value of bone density measurements <ul><li>The planar scanning principle of dual energy x ray absorptiometry (DXA), and assumptions in processing the scan data, can underestimate or overestimate bone mineral density by 20-50%. 8 </li></ul><ul><li>Over 80% of low trauma fractures occur in people who do not have osteoporosis (defined as T score ≤−2.5). 11 </li></ul><ul><li>Even if a T score of −1.5 is used to define osteoporosis, 75% of fractures would still occur in people without osteoporosis </li></ul>8 Bolotin HH, Sievanen H. Inaccuracies inherent in dual-energy x-ray absorptiometry in vivo bone mineral density can seriously mislead diagnostic/prognostic interpretations of patient-specific bone fragility. J Bone Miner Res2001;16:799-805. 11 Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, et al. BMD at multiple sites and risk of fracture of multiple types: long-term results from the study of osteoporotic fractures. J Bone Miner Res2003;18:1947-54.
    22. 22. NORA: Fracture Rates, Population T-Score Distribution, and Number of Fractures 0 10 20 30 40 50 60 > 1.0 1.0 to 0.5 0.5 to 0.0 0.0 to -0.5 -0.5 to -1.0 -1.0 to -1.5 -1.5 to -2.0 -2.0 to -2.5 -2.5 to -3.0 -3.0 to -3.5 < -3.5 BMD T Scores 0 50 100 150 200 250 300 350 400 450 BMD distribution Fracture rate # Fractures ≤ – 2.5 – 1.0 to – 2.5 > – 1.0 Siris ES, et al JAMA . 2001;286:2815-2828. Number of Fractures Fracture Rate per 1000 Person-Years
    23. 23. <ul><li>A 1 SD reduction in bone mineral density increases the fracture risk 2-2.5 times. </li></ul><ul><li>By contrast, a sideways fall increases the risk of hip fracture three to five times, and when such a fall causes an impact to the greater trochanter of the proximal femur, hip fracture risk is raised about 30 times. </li></ul>Robinovitch SN, Inkster L, Maurer J, Warnick B. Strategies for avoiding hip impact during sideways falls. J Bone Miner Res2003;18:1267-73.
    24. 24. <ul><li>the strongest single risk factor for fracture is falling and not osteoporosis </li></ul>Kannus P, Niemi S, Parkkari J, Palvanen M, Heinonen A, Sievanen H, et al. Why is the age-standardized incidence of low-trauma fractures rising in many elderly populations? J Bone Miner Res2002;17:1363-7. Kannus P, Sievanen H, Palvanen M, Jarvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet2005;366:1885-93. Järvinen TL, Sievänen H, Khan KM, Heinonen A, Kannus P. BMJ. 2008 Jan 19;336(7636):124-6.
    25. 25. www.shef.ac.uk/FRAX
    26. 29. <ul><li>How active are older people? </li></ul>
    27. 30. Levels of sedentary behaviour among WOMEN aged 50+, England <ul><li>% participating less than once a week </li></ul>(Skelton, Young et al, 1999) Age 0% 20% 40% 60% 80% 50-54 55-59 60-64 65-69 70-74 75-79 80+  5 kcal/min including brisk/fast walks  2 miles  4 kcal/min including all walks  2 miles  4 kcal/min plus all walks  1 mile
    28. 32. Putting it into practice Recommendations and guidelines
    29. 33. Effective interventions <ul><li>Tinetti et al, 1994 </li></ul><ul><li>FICSIT Trials: Province et al, 1995 </li></ul><ul><li>Wolf et al, 1996 </li></ul><ul><li>Campbell et al, 1997 </li></ul><ul><li>PROFET: Close et al, 1999 </li></ul><ul><li>FaME Project: Skelton, 2001 </li></ul><ul><li>Day et al, 2002 </li></ul>
    30. 36. <ul><li>The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program.[A] </li></ul><ul><li>Exercise, particularly balance, strength, and gait training [A] </li></ul>
    31. 37. <ul><li>Included 111 studies (55.303 participants ). </li></ul><ul><li>Multiple-component group exercise reduces rate of falls and risk of falling. ( RR 0.83, 95% CI 0.72-0.97) </li></ul><ul><li>Tai Chi as a group exercise reduces rate of falls and risk of falling ( RR 0.65, 95% CI 0.51-0.82) . </li></ul><ul><li>Individually prescribed exercise carried out at home reduces rate of falls and risk of falling ( RR 0.77, 95% CI 0.61-0.97), but there is no evidence to support this intervention in people with severe visual impairment or mobility problems after a stroke, Parkinson’s disease, or after a hip fracture. (A) </li></ul>Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007146.
    32. 38. <ul><li>the findings from the meta-analysis more likely reflect problems inherent to meta-analyses themselves, rather than problems in the rationale or effectiveness of the multifactorial intervention programs </li></ul><ul><li>these multifactorial falls prevention studies have had many between-studies differences and limitations to be fairly and reasonably included in one meta-analysis (Kannus P, email interview with BoneKEy) </li></ul>
    33. 41. <ul><li>Low intensity balance exercises ( tandem walking and standing on one’s foot) combined with coordination exercises . </li></ul><ul><li>Advise to perform strengthening in the quadriceps, hip extensors, abductors & back and arms’ muscles. </li></ul><ul><li>Older people who have had recurrent falls should be offered long-term exercise and balance training (B). </li></ul>Dionyssiotis Y, Dontas I, Economopoulos D and Lyritis GP. Rehabilitation after falls and fractures. Journal Musculoskel Neur Interact 2008 Jul-Sep;8(3): 244-50. Recommendations for Greek people
    34. 42. CLINICAL EVALUATION <ul><li>asked routinely about falls in the past year and about their frequency, characteristics, and context. </li></ul><ul><li>observed for deficits in gait and balance and considered for suitability to benefit from interventions to improve strength and balance. </li></ul>
    35. 43. Recommended Components of Clinical Assessment and Management for Older Persons Living in the Community Who Are at Risk for Falling . Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003 Jan 2;348(1):42-9.
    36. 44. The dual role of Rehabilitation picture modified with permission from: Dionyssiotis Y, Dontas IA, Economopoulos D, Lyritis GP. Rehabilitation after falls and fractures. J Musculoskelet Neuronal Interact. 2008 Jul-Sep; 8(3):244-50.
    37. 45. Research in Greece HELIOS Fitness Index Dionyssiotis Y, Galanos A, Michas G, Trovas G, Lyritis GP. Assessment of musculoskeletal system in women with jumping mechanography . International Journal of Women’s Health 2009; 1:113–118. PR evention O f FA lls N etwork E urope (PROFANE) Jumping Mechanography
    38. 46. <ul><ul><li>Numerous studies show that among older people falling, not osteoporosis, is the strongest risk factor for fracture. </li></ul></ul><ul><ul><li>strength and balance training, followed by </li></ul></ul><ul><ul><li>reduction in the number and doses of psychotropic drugs, </li></ul></ul><ul><ul><li>dietary supplementation with vitamin D and </li></ul></ul><ul><ul><li>in high risk populations, assessment and home hazards’ modification </li></ul></ul><ul><ul><li>is needed to prevent falls. </li></ul></ul>Conclusions
    39. 47. www.kafkaamyntaiou.gr www.medreha.com THANK YOU FOR YOUR ATTENTION
    40. 48. Chair-based exercise – effective at targeting risk factors <ul><li>Improvements in: </li></ul><ul><li>strength (Fiatarone et al 1990; McMurdo et al 1993; Skelton et al 1995, 1996) </li></ul><ul><li>power (Skelton et al, 1995) </li></ul><ul><li>flexibility (McMurdo et al, 1993; Mills, 1994; Skelton et al, 1996) </li></ul><ul><li>functional ability (McMurdo et al, 1993, 1994; Skelton et al, 1995, 1996) </li></ul><ul><li>static balance (Skelton et al, 1996) </li></ul><ul><li>rehabilitation following hip fracture (Nicholson et al, 1997) </li></ul><ul><li>the performance of everyday tasks </li></ul><ul><li>(McMurdo et al, 1994; Skelton et al, 1995, 1996) </li></ul>
    41. 49. Chair-based exercise – effective at targeting risk factors <ul><li>Also reductions in: </li></ul><ul><li>depression (McMurdo et al, 1993) </li></ul><ul><li>arthritic pain (Hochberg et al, 1995) </li></ul><ul><li>postural hypotension (Millar et al, 1999) </li></ul><ul><li>body fat (Nicholson et al, 1997) </li></ul><ul><li>risk of future falls (Allen et al, 1999) </li></ul><ul><li>Particularly valuable for frailer older people </li></ul><ul><li>Stabilises lower spine. </li></ul><ul><li>Greater range of movement. </li></ul><ul><li>Minimises load-bearing. </li></ul><ul><li>Reduces balance problems. </li></ul><ul><li>Increases confidence. </li></ul>
    42. 50. Physical Examination <ul><li>Blood Pressure(orthostatic) </li></ul><ul><li>Visual Acuity </li></ul><ul><li>Cervical ROM </li></ul><ul><li>Cognition </li></ul><ul><li>Cerebellar/peripheral/proprioception </li></ul><ul><li>Muscle strength and tone </li></ul><ul><li>Joint ROM </li></ul><ul><li>Feet and Footware </li></ul>
    43. 51. Gait and Balance Assessment <ul><li>Get up and Go </li></ul><ul><li>One-leg balance </li></ul><ul><li>Tinetti </li></ul><ul><li>Functional Reach </li></ul>