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
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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Transcript
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
tipstechnologyfor injurypreventionin seniors
www.sfu.ca/tips
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Falls are energy management problems
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
...which become more challenging to solve with age
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
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
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
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Energy(Joules)
oldfemur
youngfemur
300
Energy to Failure
Energy Availablein a Fall from Standing
0
10
20
30
290
Any fall from standing has the potential to cause hip fracture
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Energy absorption mechanisms!during falls
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
injuryrisk
frequency of falls
severity of falls (energy absoprtion/ protective responses)
tissue strength(resistance to trauma)
tissueloading
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
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
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:
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Technology for Injury Prevention in Seniors (www.sfu.ca/TIPS)
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
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)
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)
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
52% of fallers captured have 2 or more falls per year
Num
ber o
f fal
ls/ y
ear
0
5
10
15
20
25
30
35
40
0 20 40 60 80 100
Faller ID
n = 108 fallers,322 falls(MDS database)
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 ± 1.5ADL 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%)
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 ± 1.5ADL 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%)
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Fre
quency o
f head im
pact
0.00
0.25
0.50
0.75
1.00
Low
Med
(23
%)
Hig
h
(68
%)
Fall frequency category
Yes
(30%)
No
351
N2
DF3.7921337
-LogLike0.0177
RSquare (U)
Likelihood Ratio
Pearson
Test7.584
7.821
ChiSquare0.0225*
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
What caused this fall?
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
What caused this fall?
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
How could this fall be prevented?
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
AcknowledgementsCollaborators: 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