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
function, reaction time!• cognitive impairment!• medications (hypnotics, antipsychotics)!• neurological disease (e.g., stroke, Parkinson’s)!• cardiovascular disease!• fear-of-falling!• activity level
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%)
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 ± 1.5ADL 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%)
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%)
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Loca
tion
Diningroom
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
BR
DRL DRL
BR
Mapping location of falls in frequent fallers
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Activity a
t tim
e o
f fa
llin
g
Transferring
Seated
Walking
Standing
Inco
rre
ct
tra
nsfe
r
Lo
ss o
f
su
pp
or t
Hit/
bum
p
Collapse
Slip
Tri
p
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Activity a
t tim
e o
f fa
llin
g
Transferring
Seated
Walking
Standing
Inco
rre
ct
tra
nsfe
r
(44%
)
Lo
ss o
f
su
pp
ort
(23%
)
Hit/b
um
p
(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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Land
ing
Con
figur
atio
n
0.00
0.25
0.50
0.75
1.00
Forw
ard
(17%
)
Back
war
d(3
9%)
Side
way
s(2
8%)
Stra
ight
dow
n(1
6%)
Initial Fall Direction
Forward(11%)
Backward(57%)
Sideways(32%)
Direction of fallsn = 351 falls, 148 fallers
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
0
10
20
30
40
50
60
70
80
Hand/
Forearm
Knee Hip Head
frequency o
f conta
ct
site
69%
33%
43%
30%
Impact sitesn = 351 falls, !
148 fallers
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
Freq
uenc
y of
hip
impa
ct
0.00
0.25
0.50
0.75
1.00
Forw
ard
Back
war
d
Side
wa y
s
Stra
ight
do
wn
Initial fall direction
Yes(43%)
No(57%)
351N
3DF
31.412114-LogLike
0.1311RSquare (U)
Likelihood RatioPearson
Test62.82461.247
ChiSquare<.0001*<.0001*
Prob>ChiSq
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
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
Fre
quency o
f hip
im
pa
ct
0.00
0.25
0.50
0.75
1.00
Yes
(69%)
No
Hand impact
Yes
(43%)
No
351
N1
DF12.026515
-LogLike0.0502
RSquare (U)
Likelihood Ratio
Pearson
Test24.053
23.032
ChiSquare<.0001*
<.0001*
Prob>ChiSq
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Hip fracture case study
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
0
10
20
30
40
50
60
70
80
Hand/
Forearm
Knee Hip Head
fre
qu
en
cy o
f co
nta
ct
site
69%
33%
43%
30%
Head impact occurs in 30% of falls
Reference: Schonnop et al., CMAJ, 2013
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
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)
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Predictor Variable Head Impact Head ImpactPredictor Variable
Crude Odds Ratio 95% CI
Age
Highest vs. Lowest quartile 1.0 0.4 - 2.6Gender
Female vs. Male 2.4* 1.3 - 2.6ADL performance
Dependent vs. Independent 0.7 0.3 - 1.5Standing balance
Unsteady vs. steady 1.2 0.5 - 2.7Cognitive performance 0.4 0.2 - 1.2Moderate to severe impairment vs. intactVision
Moderately impaired vs. Adequate 2.7* 1.0 - 7.7Hypertension
Yes vs. No 2.4* 1.2 - 4.8Stroke
Yes vs. No 1.9 0.8 - 4.8Dementia
Yes vs. No 0.6 0.3 - 1.4Antipsychotic
Yes vs. No 0.6 0.3 - 1.0Antidepressant
Yes vs. No 0.4* 0.2 - 0.8
Risk for head impact associated with gender, vision, and hypertension
n = 322 falls, !108 fallers
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Multivariate model of probability for head impact
n = 322 falls, !108 fallers
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Avoiding head impact
during falls
AN INSTRUCTIONAL
EXERCISE-BASED COURSE
� �8SSH U � O LPE � I D O O � D U U H V W �� � V W U D W HJ L H V
� �7U XQN � � QHFN � FRQ W U R O
� �5R W D W L Q J �GX U L Q J� � GHVFHQ W
tipstechnologyfor injurypreventionin seniors
www.sfu.ca/tips
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
SmartCells provides more force attenuation than most hip protectors
SmartCellLaing et al., Accident Analysis & Prevention, 2009
34%
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
Pea
k Fo
rce
(N)
SmartCell, 50 durometer, covered by
Source: Dr. Andrew Laing
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
Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
FLIP Trial DesignNew 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
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