How can we prevent older Australians from fall-related injuries?

Gretchen Miller: Hello, welcome back to Prevention Works the podcast of The Australian Prevention Partnership Centre. I’m Gretchen Miller, and our topic today is one somewhat overlooked in public health policy and strategy yet it has a profound effect on a large cohort of the population. The issue is falls in the elderly. With us is an Australian researcher ranked third in the world for her work in this area. That’s Professor Cathie Sherrington, Chief Investigator of the Centre of Research Excellence in the Pre-vention of Fall-related Injuries and Professor at the School of Public Health, University of Sydney. Cathie leads the Physical Activity Aging and Disability Research stream within the Institute for Musculoskeletal Health.
Cathie, we’re talking today about the rise in fall-related injuries and what are the various factors involved, and then we will turn to what can be done to bring those figures down. A massive quarter of falls are preventable and here’s something I didn’t know one-third of people aged over 65 and living in the community fall each year. Isn’t that a lot?

Cathie Sherrington: That is a lot. It’s a very common issue. No falls are a spectrum so the fitter people will actually still fall being more active. So people might fall like when they’re out and about or catching a bus or bushwalking, or something like that. But frailer people are more likely to fall doing less demanding activities, such as even walking across the room or something like that but really all falls are a mismatch between our physical function and the demands of the task.

Gretchen: I wonder if you could paint us a picture of the environment in which those figures sit, what is a fall?

Cathie: So we say that the fall is opposite to staying balanced so as we are aware, unfortunately, our physical function starts to deteriorate quite early in life. Even after the age of 30 or 40 we can notice a loss in strength and balance and coordination. And so really it’s being physically active and undertaking the right sort of activities to minimise those losses that are really crucial in preventing falls. If we think about what we need to usually stay upright, we need good vision to see what hazards are coming or if we’re someone with poor vision, then we’ve learnt to use a cane or walking with someone else to help compensate for that.

Usually, if we’re walking along the street and there’s an unevenness of the footpath or something spilt, then we can see that coming if we’ve got a good enough vision. If we actually don’t see it coming and we start to trip or slip, then we need good reaction time to be able to turn our muscles on to be able to stay upright and so a poor reaction time is also a risk. And then if we’ve turned the muscles on then they need to be strong enough to be able to actually hold us upright. In some situations, we might actually take a step to prevent falling and so that’s really balance and the ability to coordinate the muscles within the environment that we’re working in.

Gretchen: What population group are we looking at here? What do we mean when we say older?

Cathie: The risk does actually start to increase in middle age, but it does increase more over the age of 60 or 65 so that’s often what we’re talking about when we talk about older age, but the risk is actually even greater in the, what we call the older, older people so people particularly over 85 or 90.

Gretchen: How many Australians would we find in this cohort of older people?

Cathie: Some millions of Australians so I think already around 15% of our population are in this age group and that’s predicted to rise substantially.

Gretchen: Which part of the cohort we’ve discussed are particularly vulnerable?

Cathie: We know that particular health conditions do increase the risk of falling. We talked before about the importance of vision, the importance of sensation and reaction time and so certain health conditions actually impact on these aspects of physical functioning. For example, diabetes can impact on sensation, having a stroke or Parkinson’s disease or another neurological problem obviously impacts on strength and balance, eye diseases, visual problems, and cataracts limit our vision. All these things definitely increase the risk of falling as well as cognition, our thinking and our insight into our behaviors and risk-taking attitudes.

Gretchen: What about those inappropriate housing, external factors?

Cathie: External factors definitely also play a role in falls. It is really the interaction between the internal and external factors though and the way we think of that is like tripping. For example, if a person with good strength and balance was to trip they actually might be able to save themselves, but with someone who is frail or if they were to trip in the same situation that would result in a fall. So for that reason we do need to be careful with things internally, things like clutter, trip hazards, or for people who are more frail or disabled, being sure that we have things like rails in bathrooms so that people can step safely in and out of a bath or shower.

We also need to look at outdoor safety, such as cracks in the footpath, puddles, all sorts of things. WHO (World Health Organization) talks about age-friendly cities and improving the access for people with movement problems actually improves the access for everybody – also for people using prams or wheelchairs for whatever reason, younger people as well, so we do definitely need to look at access. We also need to consider these factors when we’re designing places for people to be active as well. We need to think about having paths, accessible toilets, parking, or easy public transport – access to places where people can be active in a pleasant environment.

Gretchen: So why are fall-related injuries rising?

Cathie: It’s a very good question that’s not really fully understood. Data from the Australian Institute of Health and Welfare does actually show that the age adjusted rate of fall-related injuries is actually increasing by a couple of percent a year, which is really quite shocking. And so it’s not fully understood why that is. It could be that people are living longer but also perhaps being less active over their lifetimes. And so that the people who are alive at that older age are actually frailer than in previous times.

Gretchen: Is that the case that Australians are getting less fit?

Cathie: Yes, unfortunately, it does seem to be.

Gretchen: I wonder what the flow-on effects of falls in the elderly population are and we could look at it individually and on a population level?

Cathie: Of the one in three people who are falling each year aged over 65, probably around one in 10 have an injury. And even a smaller percent have a severe injury but because of the commonness of the problem that’s still a lot of people being affected. We’ve actually calculated that, over 360 Australians actually end up in hospital from a fall every day and this is older Australians, people aged over 60. So, it really is a large number of people and so an injury, obviously, is one of the consequences, and they can be fractures.

The other serious injuries are actually brain injuries, so people can hit their head when they fall, which can be devastating and it can actually lead to death. If people have managed to avoid injury, sometimes people’s confidence can be shaken after a fall, as you said, it’s very traumatic, it really shocks you. Some people then limit their activities as a result of that.

Sometimes that might be sensible, but it wouldn’t be sensible for you to not do any activity and to stay inside because you’re afraid of falling because then that would actually lead to you being less mobile, less physically able, with the deterioration in strength and balance, which would actually make the risk even greater. And so we talk about that as being a kind of spiral and unfortunately a downward spiral.

Gretchen (9:13): And I was going to say that, of course, it doesn’t just impact on the individual. One of the team at the Prevention Centre, her mother had a fall. She’s in her 70s, but she cares for her elderly mother who’s 94 and as a result of my colleagues’ mothers fall, her grandmother has had to go into nursing care, which we know at the present time isn’t ideal. So there is like this ongoing impact isn’t there?

Cathie: And a lot of stress on the carers and people like your colleague who is then required to step up and she obviously has a job, she may well have her own children and sometimes people in these situations even have their own grandchildren and this burden unfortunately still does tend to fall onto women. There can be a devastating flow-on effects.

Gretchen: When we think about the population level impact, so if we think epidemiologically, what are the impacts for the larger population?

Cathie: So again, the Australian Institute of Health and Welfare have really extracted some detailed data on this. Their latest report tells us that Australia actually spends two and a half billion dollars a year on the consequences of falls for our health system. That’s obviously not considering the sorts of flow-on effects that we were just talking about but that’s purely the hospital treatment. Also, the general practice X-rays and things like that. It is quite an extensive cost to our health system as well as to individuals.

Gretchen: So you’ve done number of reviews and you’ve edited alongside two co-editors a significant book that’s in its third edition, called Falls in Older People, Risk Factors, Strategies for Prevention, and Implications for Practice. Drawing on that fabulous, edited collection, let’s get down into some more detail. You have written alongside co-editors that falls are not random, there are risk factors. Why is it necessary to articulate that?

Cathie: I think the reason that it’s necessary to articulate the fact that falls aren’t random is that sometimes people do just assume that falls are an inevitable part of aging. People being health professionals but also older people themselves. And so, the idea that we can predict falls means that we have factors that we might be able to address in preventing falls.

 Gretchen: So, let’s turn to what to do about this for our aging population. A couple of years ago, you completed the Cochrane Review, and you updated it last year, where you looked at 108 randomized trials and brought together did a meta-analysis of those results. What did it find is the answer to fall-related injuries?

Cathie: It is very clear that exercise programs do prevent falls. This is particularly exercise that challenges our balance focuses on functional activities. So, these are exercise done in standing rather than seated gentle exercise. We found that if you were to follow 1000 people for a year, 850 of those people would actually fall but in the people, who had done exercise, there was 195 fewer falls. So that’s quite a remarkable impact in terms of actually preventing falls.

 Gretchen: So that’s about a quarter, which is quite significant. Can you explain though, if there were 850 falls out of 1000 people that’s a much higher proportion of falls than we talked about at the beginning of the interview. How do those two statistics correlate?

Cathie: Well, that’s actually because some people can have more than one fall. Unfortunately, many people are actually having multiple falls and so that’s where we get the 1000 people having 850 falls. Those figures actually came from the participants in the 108 trials that we looked at.

Gretchen: (13:23) Okay, so how did you model this, maybe you could talk briefly to the Markov model?

Cathie: The Markov model was something that we did where, with the help of a health economist, we looked at the cost effectiveness of implementing fall prevention interventions at a population level. We were looking at the effectiveness of exercise that we’ve talked about, we were looking at the how common falls are that we’ve also talked about, we were looking at the costly consequences of falls, such as being in a hospital treatment, also residential care that we’ve also talked about. Then we were able to, with the help of the health economist, to model what investment in a prevention program would look like, compared to those costs of the falls. That’s where we found that it actually would be cost-effective using the types of criteria that are used in deciding whether to fund drugs.

So, we have a very good system for funding medications and we’re very fortunate that’s based on evidence of their effectiveness and also cost-effectiveness modeling and so that’s basically what we’ve done. And we found that investing in fall prevention programs actually would be cost-effective at a population level, but the problem is that we don’t have a way to fund these type of programs in the same way that we have a system for funding medications.

Gretchen: What are the sort of budget differences between spending the money on funding exercise programs versus just letting things go as they are?

Cathie: Well, the way the modeling works, it’s in kind of cost-effectiveness terminology and so I think it was $28,000 per quality adjusted life year gained at a cut-off of around 40,000 or 50,000 used informally when funding medications.

Gretchen: (15:21) How does exercise help, and I wonder if there were any surprises in the review?

Cathie: We did find that there were certain types of exercise that needed more investigation. For example, dance could be a way of actually improving our balance in a fun way but it had only been tested in one trial and it actually wasn’t effective in that particular trial. We think that it was perhaps because the trial was actually in a residential care setting and the people were perhaps a bit more physically frail and the dance wasn’t modified enough to be able to safely challenge their balance and so that was one thing that really needs more investigation.

Surprisingly, there haven’t been any large-scale trials of yoga for falls prevention. Yoga is an increasingly popular activity and it would make sense that it could prevent falls. Our group is actually currently undertaking a large trial of yoga. My colleague Anne Tiederman is leading that and it’s been very popular, very easy to recruit to and we’ll have the results of that in about another year. So exercise basically helps by improving our physical function and so that’s where exercises that are most relevant to the tasks that we need to undertake. So basically, controlling where our body is in standing and doing different activities is the opposite to falling and so that’s why exercises that actually help us practice doing that are the most beneficial. So, group exercise, movement to music, also Tai Chi, which is also all about controlling where your body is in space, also a home exercise program prescribed by a physiotherapist that targeted that strength imbalance as well.

So, it’s fortunate that there’s a number of different ways to deliver these programs and so that’s where personal choice is important and people can choose really the exercises that they’re most likely to stick to, that they enjoy, or at least dislike less. We also say that the most effective exercise is the one that you’re going to keep doing but we really do need to be looking at exercises that are improving our balance.

Gretchen: And what about walking, as I read it, and I may miss understand this walking is not particularly effective?

Cathie: That’s right and that’s probably because walking is not necessarily actually improving your balance or your strength. It’s perhaps not specifically targeted enough to those actions that you need. There’s also a chance that just telling people to walk will actually increase their exposure to risk of falling. There have been a couple of studies now that have been able to promote walking in a way that hasn’t increased falls, because obviously, there’s a lot of other benefits of walking but if people are at higher risk then we need to give them some additional advice about how to do that safely. And really for falls prevention, we do need to be doing those specific exercises that challenge balance and strength as well as walking.

Gretchen: That’s really interesting because the point I was going to get to later but we might talk about it now is one would assume that walking was going to be of benefit. So how important is it to work with people who have actual skill sets for this particular cohort of elderly Australians? Would you go to your local gym and just pick any old fitness trainer and say help me improve my balance?

Cathie: We need to consider the kind of longer term prevention versus the people who are already at high risk and so a person of any age, but particularly getting into middle age, or that younger older age, then we should definitely be doing exercises that challenge our balance and strength. We should be working out ways that we enjoy doing those and so that could be a sport, it could be playing soccer, or it could be running, could be dancing, those sorts of things.

That’s to do with kind of maximising our physical function and preventing the deterioration in our physical function, which unfortunately does happen with increased age as we’ve discussed, but if people already have some impairment of physical function then they might need to some more specialised input and particularly a lot of older people do actually have various conditions, particularly arthritis or they might have other issues which might mean that they need more of a qualified trainer to give them some some input about how to safely increase their activity. Then we would say that people who are really very frail would really benefit from seeing a physiotherapist and having a program carefully prescribed.

Gretchen: And you talk about multifactorial intervention, what else, other than exercise, can be brought to bear here?

Cathie: There are other risk factors and so we do need other aspects to be maximised as well. But the role of exercise is really so strong that the advice that we give is that someone should start with exercise, but then also have other risk factors addressed. For example, with vision, cataract surgery has actually been shown to prevent fractures. And so if people are developing cataracts, they should definitely talk to their doctor about that. Using psychoactive medication, medications that act on our brain, does actually increase the risk of falling as well. In one study, people who were supported to reduce their medication use, and particularly the sort of sleeping tablet type of things, and so again, that’s something people should speak to their doctor about and get some professional help and explore alternatives.

In people with foot pain, there’s actually evidence that an intervention from a podiatrist can also help prevent falls and that actually involved foot exercises, as well as advice about footwear and also insoles. The overall number of medications can also be an issue with older people particularly developing different health problems and going to different specialists and having new medications added but without anyone reviewing all of those and checking whether they’re interacting with each other and if they are all still necessary. And so a medication review also has some evidence that it can prevent falls.

Gretchen: Okay, that’s super interesting. It is sort of self-evident that exercise would help reduce falls. But as you say, there’s all sorts of details in there that you might not assume. How would you then go about implementing this at a population level? What research strategies are you using to look more closely at that aspect of things?

Cathie: We’ve come to realise that falls, because they affect different people in different ways, and really apply to people across different settings, they probably really need different strategies in different situations. But falls somehow seems to have slipped through the cracks and so we’ve actually done a policy scan recently, and we’re still haven’t quite finalised that but we haven’t found any mention of falls in any of our national health strategies, which we find quite shocking given the extent of the problem. So, we are calling for a more coordinated approach and some type of national strategy to be developed and adequately funded because as we’ve talked about, there’s actually a lot of different solutions that also need to be undertaken in different sectors. In the general population, we need to be giving information about improving balance and strength. Something people have talked about are potentially some exercise voucher type of scheme, similar to what they’ve done in New South Wales for children. Perhaps there could be a role of that at a population level to make exercise easier for people to access. We can also look at health fund rebates more for exercise and some of that is happening.

We can also look at social norms and marketing campaigns to assist in increasing awareness and also with behavior change in terms of exercise but in terms of those other risk factors, as well. We can also look at training of health professionals so that they are more on top of how to address all these different risk factors and put these strategies into place. We need environmental aspects as well, as we’ve discussed and we also need to be aware that people with different levels of functioning are going to need different strategies. So for some people, community exercise will be fine and it’s about that sort of longer term prevention, but for frailer people we need more concentrated and more professional effort, which unfortunately, we’re not particularly good at funding. Within our residential care settings at the moment there’s actually no funding for people to receive exercise or input from physiotherapists or exercise physiologists to improve their physical functioning but that’s obviously crucial for false prevention and also mobility and quality of life. So because there are so many strategies, and so many solutions across different sectors, we are calling for a co-ordinated approach.

Gretchen: It’s a huge wish list, right? How do you go about getting the attention of policymakers to this?

Cathie: That’s where it’s been fabulous to be starting to work with people at the Prevention Centre and to learn from what’s happened in other areas. We’re very pleased with our Centre of Research Excellence that we’re involved with CERI, the organisation that brings together the different centres and calls for greater action on prevention and so we’re excited that falls is now part of that undertaking.

Gretchen: (25:50) Yes, with CERI, the Collaboration for Enhanced Research Impact, brings the Prevention Centre together with 10 NHMRC, Centres of Research Excellence and I wonder how other areas of research might have influenced your own?

Cathie: We have learned from other areas, particularly in terms of systems approaches, and documenting the various influences on things. That initially was done in the obesity area and now in the physical activity area. And again, we’re working with people from the Prevention Centre to apply that approach to falls to help us understand all the different components of the system and then to work out which components could be prioritised for action and to work out which things are going to be easier to change. And which might be some kind of quick win solutions.

Gretchen: The interesting thing there, of course, is the exercise is key to reducing so many other chronic diseases, the risk of which increases with age. So, there is a link there. I think that’s really interesting. Can you talk to how exercise has like this multiplying effect on public health?

Cathie: Yes, it’s really is quite remarkable. I mean, people do talk about it being a magic pill. I mean, the number of body systems that are benefited from physical activity are quite remarkable. And so with falls what is just a little bit different is that we’re sure that we need those exercises that challenge balance and strength, whereas for some other outcomes that might not actually be necessary. The current WHO message is that every move counts and that certainly is the case for cardiovascular disease, diabetes, as I understand it, but for falls prevention it’s actually not enough. So, we do actually need those strength and balance exercises as well.

Gretchen: So, it really does need to be a nuanced understanding of exercise and not just a coverall?

Cathie: That’s right. Although, we are also not wanting to get too caught up in the specifics because there probably is actually some benefit of doing something as opposed to doing nothing. And some work that we’re doing with the Longitudinal Study of Women’s Health looking at women’s physical activity over the life course does actually suggest that. So we are also on board with the Every Move Counts approach and that doing a bit is going to be better than doing nothing.

Gretchen: The Cochrane Review is international right, so I’m wondering how the results apply in different economies to Australia

Cathie: That’s a really important question and I’m actually working with some people on some world falls guidelines and those issues come up a lot. And like a lot of other topic areas, most of the research is undertaken in the more developed countries, but most of the people affected are in low and middle-income countries. We definitely need to know a lot more about how to prevent falls in those economies. We worked with some colleagues in Brazil on a dance program that was incredibly well received and so they brought older people together and they had an interesting culture of the University giving back to the community. This was a program that was run by the University, but open to older people in the population, that maybe we need to be looking at more undertakings like that.

Gretchen: What is next for you and your colleagues? What to do next after this review?

Cathie: Even though I’m a researcher, I don’t think we need any more research. We particularly don’t need more research that controlled sort of experimental environments. I actually went to a conference and people’s idea of research into exercise for older people was to bring people into their laboratory for three times a week to supervise exercise and to take a whole lot of measures on them. I don’t think we actually need any more of that type of research but what we do need is to work out how to actually deliver programs, how to deliver them at scale, how to recruit people, to them, the behavior change piece, the funding piece, and how we can kind of integrate these into our existing services.

That are the sort of budget differences between spending the money on funding exercise programs versus just letting things go as they are? Well, the way the modelling works, it’s in kind of cost-effectiveness terminology and so I think it was $28,000 per quality adjusted life year gained at a cut off of around 40,000 or 50,000 used informally when funding medications.