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Press Release: New physio guidelines for the elderly at risk of falls
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Taking a fall in older life can not only result in injury, but also a potentially debilitating loss of confidence. But new guidelines for physiotherapists, co-compiled by a leading academic in the field from the Peninsula College of Medicine and Dentistry (PCMD), University of Exeter, aim to refresh out-dated guidelines and introduce better direction for physiotherapists who work with elderly people at risk of falling.
As we get older our risk of falling increases, regardless of environment and social background – King Juan Carlos of Spain is a high profile example. As well as the physical and psychological impact of falls on the individual, they also have impact on a pressed NHS – according to Age UK some 3.5m people aged 65 and over take a fall each year, at an estimated cost to the NHS of £4.6m a day.
The new guidelines have been developed with the help of academics by Agile, the Chartered Society of Physiotherapy's professional network for those working with older people. Physiotherapists play a key role in the care of older people at risk of or who have had a fall, both in hospitals and in primary care and community health environments.
The last guidelines were published in 1998 and since then there have been significant advances in policy, practice and technology.
The new guidelines have been compiled following a review of research around falls in the elderly, looking at issues including management, assessment, prevention and the role of exercise.
It focuses on four main components: preventing falls; improving the ability of older people to withstand threats to their balance; preventing the consequences of older people being unable to get up from a fall, the so-called 'long lie'; and optimising confidence and reducing the fear of falling.
Each component includes clear guidance on assessment and management for physiotherapists with key messages to help enforce the guidance.
Among the major changes is an increased emphasis on the steps that physiotherapists can take to help prevent falls, including specific recommendations on exercise programmes. These have a high balance challenge component, delivered at 'high dose'.
Janet Thomas, chair of Agile, said: "The previous guideline was really very old, and a lot of new evidence and guidelines have been published since then. We're saying that it really needs to be 50 hours – roughly twice a week for six months. I hope that physios will use this guidance to show commissioners that this is a really important issue."
Dr. Victoria Goodwin, from PCMD, University of Exeter, co-wrote the guidelines. She said: "We hope that clinicians will find it user friendly. It's very short but it contains the information that physiotherapists need. Other guidelines can be quite general and end up just sitting on the shelf. We really hope these will be used."
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The guidelines are available from the Chartered Society of Physiotherapy website, www.agile.csp.org.uk.
Interventions for preventing falls in older people living in the community.
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Cochrane Database Syst Rev. 2012 Sep 12;9:CD007146. t
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BACKGROUND:
Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009.
OBJECTIVES:
To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community.
SEARCH METHODS:
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers.
SELECTION CRITERIA:
Randomised trials of interventions to reduce falls in community-dwelling older people.
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate.
MAIN RESULTS:
We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors.
AUTHORS' CONCLUSIONS:
Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.
New falls guidelines
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