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.

1. 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

2. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Falls are energy management
problems

3. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
...which become more challenging
to solve with age

4. 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

5. 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

6. 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

7. 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

8. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Energy
(Joules)
old
femur
young
femur
300
Energy to Failure
Energy Available
in a Fall from Standing
0
10
20
30
290
Any fall from standing has the
potential to cause hip fracture

9. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Energy
absorption
mechanisms!
during falls

10. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
injury
risk
frequency
of falls
severity of falls
(energy absoprtion/
protective responses)
tissue strength
(resistance to trauma)
tissue
loading

11. 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

12. 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

13. 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:

14. 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

15. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Technology for Injury Prevention
in Seniors (www.sfu.ca/TIPS)

16. 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

17. 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)

18. 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)

19. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
52% of fallers captured have 2 or
more falls per yearNumberoffalls/year
0
5
10
15
20
25
30
35
40
0 20 40 60 80 100
Faller ID
n = 108 fallers,
322 falls
(MDS database)

20. 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 ± 1.5
ADL 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 ± 1.5
ADL 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%)

21. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Location
Dining
room
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

22. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
BR
DRL DRL
BR
Mapping location of falls in frequent
fallers

23. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Activityattimeoffalling
Transferring
Seated
Walking
Standing
Incorrect
transfer
Lossof
support
Hit/
bump
Collapse
Slip
Trip
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

24. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Activityattimeoffalling
Transferring
Seated
Walking
Standing
Incorrect
transfer
(44%)
Lossof
support
(23%)
Hit/bump
(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

25. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
LandingConfiguration
0.00
0.25
0.50
0.75
1.00
Forward
(17%)
Backward
(39%)
Sideways
(28%)
Straightdown
(16%)
Initial Fall Direction
Forward
(11%)
Backward
(57%)
Sideways
(32%)
Direction of falls
n = 351 falls, 148 fallers

26. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
0
10
20
30
40
50
60
70
80
Hand/
Forearm
Knee Hip Head
frequencyofcontact
site
69%
33%
43%
30%
Impact sites
n = 351 falls, !
148 fallers

27. 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
Frequencyofhipimpact
0.00
0.25
0.50
0.75
1.00
Forward
Backward
Sideways
Straight
down
Initial fall direction
Yes
(43%)
No
(57%)
351
N
3
DF
31.412114
-LogLike
0.1311
RSquare (U)
Likelihood Ratio
Pearson
Test
62.824
61.247
ChiSquare
<.0001*
<.0001*
Prob>ChiSq

28. 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

29. 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
Frequencyofhipimpact
0.00
0.25
0.50
0.75
1.00
Yes
(69%)
No
Hand impact
Yes
(43%)
No
351
N
1
DF
12.026515
-LogLike
0.0502
RSquare (U)
Likelihood Ratio
Pearson
Test
24.053
23.032
ChiSquare
<.0001*
<.0001*
Prob>ChiSq

30. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Hip fracture case study

31. 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

32. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
0
10
20
30
40
50
60
70
80
Hand/
Forearm
Knee Hip Head
frequencyofcontact
site
69%
33%
43%
30%
Head impact occurs in 30% of
falls
Reference: Schonnop et al.,
CMAJ, 2013

33. 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

34. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014

35. 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)

36. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Predictor Variable Head ImpactHead ImpactPredictor Variable
Crude Odds Ratio 95% CI
Age
Highest vs. Lowest quartile 1.0 0.4 - 2.6
Gender
Female vs. Male 2.4* 1.3 - 2.6
ADL performance
Dependent vs. Independent 0.7 0.3 - 1.5
Standing balance
Unsteady vs. steady 1.2 0.5 - 2.7
Cognitive performance 0.4 0.2 - 1.2
Moderate to severe impairment vs. intact
Vision
Moderately impaired vs. Adequate 2.7* 1.0 - 7.7
Hypertension
Yes vs. No 2.4* 1.2 - 4.8
Stroke
Yes vs. No 1.9 0.8 - 4.8
Dementia
Yes vs. No 0.6 0.3 - 1.4
Antipsychotic
Yes vs. No 0.6 0.3 - 1.0
Antidepressant
Yes vs. No 0.4* 0.2 - 0.8
Risk for head impact associated with
gender, vision, and hypertension
n = 322 falls, !
108 fallers

37. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Multivariate model of probability for
head impact
n = 322 falls, !
108 fallers

38. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Avoiding head impact
during falls
AN INSTRUCTIONAL
EXERCISE-BASED COURSE
tips
technology
for injury
prevention
in seniors
www.sfu.ca/tips

39. 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

40. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
SmartCells provides more force
attenuation than most hip protectors
SmartCell
Laing et al., Accident Analysis & Prevention, 2009
34%

41. 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
PeakForce(N)
SmartCell, 50 durometer,
covered by
Source: Dr. Andrew Laing

42. 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

43. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
FLIP Trial Design
New 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

44. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Frequencyofheadimpact
0.00
0.25
0.50
0.75
1.00
Low
Med
(23%)
High
(68%)
Fall frequency category
Yes
(30%)
No
351
N
2
DF
3.7921337
-LogLike
0.0177
RSquare (U)
Likelihood Ratio
Pearson
Test
7.584
7.821
ChiSquare
0.0225*
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

45. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
What caused this fall?

46. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
What caused this fall?

47. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
How could this fall be prevented?

48. Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014
Acknowledgements
Collaborators:
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