I will start emitting everyone. So we've got Basman and then Sanka and then May, is that right? Okay, good afternoon everyone from Thailand and good morning, good evening to everyone who joined us today, our young doctor, family doctor and our friends. It is a great pressure for me to welcome you to the second webinar series of working parties and spatial interest group collaborative webinar series. Thank you to each and every one of you for being here with us today. First, let me introduce myself. My name is Basman. I'm a people and family doctor from Thailand, member of the Raja Kuma movement. On behalf of Wong Kai young doctor movement and the Raja Kuma movement, we are pleased to welcome you for this second webinar series of fall in order person and please welcome our translator Dr. Brando Kancha, share of Mexico young doctor movement, who will translate us in Spanish and Dr. Chloe Shan Hong Kong representative from Raja Kuma movement, who will be translated as in Mandarin. Our participant can click the button below in the global button to do for the language interpretation for Spanish and Mandarin. Now, moving along to our session, let me welcome you, Dr. Shan Gat, Randon Mekumara, Wong Kai young doctor movement representative to give us welcome speech. Thank you very much, friend, the colleagues who have joined the webinar from all over the world. Welcome to the second webinar of the webinar series by the Wong Kai young doctor's movement in collaboration with the Wong Kai working parties and special interest groups. I'm grateful to the Raja Kumar movement, especially to the chair, Ping Fu, my colleague, who was instrumental in organizing this webinar on behalf of the young doctor's movements. So I also would like to thank the Wong Kai SIG special interest group in aging and health for collaborating with us for this important webinar. I think our objective was to discuss topics related to family medicine and which would be interesting to all our trainees and doctors and whoever would like to learn about them. And I think this webinar itself is very important because of few reasons. One is the world population is aging. The second reason is as family doctors, we have to manage a lot of all people. And thirdly, falls in elderly some very, very common and we have to prevent that and we have to also identify the causes for that. So for those three reasons, I think this webinar fall in all people is very, very important. So thank you very much. Again, the Raja Kumar movement for join in hands with all the other young doctor movements around the world to organize this webinar and also the Wong Kai working part, sorry, SIG in aging and health for supporting us. And I welcome you all and I think you would enjoy this webinar. Thank you very much, Ping. Thank you, Basma. Thank you so much, Dr. Changa for your welcome message and remark on following older person. Now I would like you to formally welcome Dr. Professor Dr. Dimiti Ponds to give us introductory speech. Professor Dr. Dimiti Ponds is a professor in general practice School of Medicine and Public Health Faculty of Health University of New England, Australia. Thank you very much, Dr. Basma. And welcome everybody. It's lovely to see so many people attending. And I'd also like to very much thank my colleagues from the special interest group in aging and health. And I'd like to invite any of you who are attending and who are interested in this important area to feel free to join the special interest group. And it is easy to do. You just go into the Wong Kai website, which you're probably familiar with. But you can just search for that on the net. It's globalfamilydoctor.com. And then you look at Wong Kai groups. Right. And you'll find the special interest groups there. And then you just go down to aging and health and click on that. And there's an invitation to join our group. And you click on that and just put some details about yourself. And that will come through to me as the convener of the group. So that's the way to do it. But if you can't remember all that, it's a bit complicated beginning of the session. Just go into the Wong Kai website and it will be easy to work it out. So without any more ado, I'd like to introduce our first speaker. All three speakers are members of our special interest group. And so our first speaker is Professor Suniya Sabswari from the Department of Family Medicine at Aga Khan University in Pakistan. So welcome, Suniya. Oh, I should, excuse me, I should say if you have questions, please feel free to put them in the chat. And each speaker will answer some questions after their presentation. Okay, Suniya, welcome. Thank you so much to me again. And thank you to everyone for joining on a Sunday and taking your time out. And I hope that this webinar is useful for all of you. So I'm thankful if you can move to my objective slide, please. And the next one, thank you. Okay, so by the end of the session, I hope that all participants are able to, number one, identify patients in that require a call assessment. Understand some of the tools we'll be going through in this session and also then know the causes of falls and know how to look at a multifactorial fall assessment. Next slide, please. So just a couple of slides as an introduction to falls. I think all of you who are here probably seen patients who've fallen, falls are on the rise and now they're the second leading cause of unintentional injury and deaths in the world. And if you look at this, about 80% of fall deaths are now in LMICs. And this is a concern for all of us who see patients who are now getting older and older in the older age group. Most falls occur at home and are largely ignored. And we as physicians sometimes are also not good at assessing falls because we deal with the injury that the patient comes in with. But then we send them back home only for them to fall again because the fall itself is not addressed. Next slide, please. So fall is one of the geriatric giants. I'm sure you're all familiar with that. It is multifactorial and it's a combination of aging physiology, pathologies, environment and medications. And those are the things we will cover as we talk about fall assessment. Next slide, please. So the first question is which patients should get a fall assessment? Obviously, we're all limited in our time in our clinics. So we need to be strategic about which patients need to be assessed and not everyone needs an assessment. The AGS and the BGS 2011 fall guideline does recommend a multifactorial assessment for all older adults who've either fallen twice or more in the last year who come to us with an acute fall or who talk about or complain of difficulty in walking and balance. All of these subsets of our older adults require a multifactorial assessment. Next slide, please. So I'm going to start with the case. This is a 74-year-old woman with hypertension diabetes. She attends after falling in the bathroom and this is her second fall in the last eight months. She also reports numbness in her feet, visual loss in one eye and her daughter is concerned about her increasing forgetfulness. She takes multiple medications and will go through medications in a little while. I'm sure a lot of you are familiar with this case. It's a very standard case that we see and I'm sure all of you have encountered such patients. Now, how would you proceed in this situation? And the next few slides will help us with that. Next slide, please. Thank you. So the first thing, in a patient who presents to you with a fall or presents to you after a fall, in addition to our standard, his speed that we take, our focus needs to be on how the patient fell, what were the circumstances around the fall. So what were the preceding circumstances? What was the patient doing before the patient fell? Were they trying to get out of bed, go to the bathroom? Were they just walking? Were they on stairs or navigating steps? Those are important questions to ask. Were there any prodromal symptoms? Did the patient stand up and feel lightheaded, for example? Did they have any dizziness or vertigo or chest pain? So those are important questions to ask. What happened during the fall? Where did you fall? When did you fall? Was it in the middle of the night when you were slightly drowsy and trying to get to the bathroom? Was it in the kitchen, in the bathroom, outside of the home? Those are questions that are important to us so that we can actually guide them for precautions after the fall to hopefully reduce the occurrence of a fall. And what is very important is downtime. So when you fell, so a patient who presents and says, well, I fell in the bathroom, were you able to get up on your own? Or how long was your downtime? Or were you, did you require someone else to come and pick you up or help you up? Those are important questions because they tell us and overall give us an idea about the patient's penalty status, how much muscle weakness the patient has, or whether they are well enough to be able to stand on their own after falling. And obviously, we talk about injuries, whether it's any loss of consciousness, any broken bones or bruises, contusions, etc. Next slide. So when we look at causality of falls, this pie chart tells you a very nice number. It's one-third, all of these account for one-third of falls. So medications, obviously, there's a lot of polypharmacy in this age group because of the patient factors, number of home orbits go up as we age. And the extrinsic factors are the environmental factors and we'll cover each of these one by one. Next slide please. So when we look at intrinsic factors, which are patient factors, some of these are non-modifiable.  What we need to look at is, which of the modifiable ones can we make a change in? Can we do something about the oresostasis? Can we do something about incontinence? Can we do something about their foot problems and maybe alter there, help them with their footwear? Can we advise them to use a cane or a walker? And those are things we need to look at. If you look at this list on the right-hand column, however, what's important to see is that muscle weakness alone increases the risk of fall by 40. And at the gate, an ability increases falls by three times. Dementia, things like dementia increase our fall because our sense of the environmental cues may go down. Another question I'll leave for you to think about is how many of us look at feet in non-diabetic patients? You know, we often don't do a foot examination if the first patient does not have diabetes. So those are questions you need to kind of think of and consider when you're evaluating a patient who's come with a fall. Next slide please. Indoor hazards and outdoor hazards. Of course, steps are a big hazard. It's not necessarily that we can change their living situation, but we can certainly advise them, things like railing and how to hold on and climb up and downstairs to help them mitigate their risk of falling. Uneven pavements, slippery floors, poor lighting, you know, poor lighting and slippery floors can certainly be addressed. Next slide please. Medications. This is a big one and I think of all the three things, the three areas of, you know, the causality bit. I think this is something that's particularly under our control as physicians. And when we look at medications, pretty much all cardiovascular medications, you know, ACE inhibitors, diuretics, medications that reduce heart rate, psychoactive medications, be it antidepressants, benzodiazepines, and even over the counter cough and cold medications sometimes can increase the risk of falls in this age group. And a lot of older patients take medications for pain management and alcohol again is another thing that we sometimes need to take into account in a patient who's falling. Next slide please. So there are certain additional recommendations which cover things like visual acuity, functional assessment, the activities of daily living, how independent the person is, gives us a clue as to how robust they are versus how failed they are, and then use of adaptive equipment, mobility aids becomes an important question to us in these patients. Fear of falling is very important and sometimes patients will just elicit their fear of falling without even having to have fallen before and that should prompt us to consider doing a multifactorial risk assessment in such patients. Next slide please. So when we look at falls, these are the three organ systems that are really, really play a role in a person who's falling. So it's our CNS, CVS, and our musculoskeletal systems that we need to focus on when we're examining such patients. So look for a person who complains of lighter in us on standing. We need to look at also static blood pressures, pulse rate and rhythm, easy enough to do CNS. We need to see if the patient has any acute confusion. Is this patient delirious for any reason? Does the patient have memory issues or dementia? Are there any focal neurologic deficits that led to the patient falling? Is there poor vision? Is there peripheral neuropathy? And then musculoskeletal maybe look at bones, joints, muscle weakness, range of motion, which all play a role in this. So these are targeted exams, but they're really helpful in identifying all the factors that are playing a role in this patient falling. Next slide please. So now we move on to the different tests that are used to assess mobility and balance and date. And the most commonly used and probably the one that you're most familiar with is the get up and go test. We cover that, we go through rhombus, SWPB and the tinnitus. So this is a list of tests that we'll go through in this presentation. Next slide please. So the time get up and go test is the one in which we time how the patient, if you look at the right hand side column, how the patient rises from a chair, how he or she stands momentarily, how the person walks 10 feet, turns around and comes back and sits. What we want to do in this situation is that we really need to be focused on the patient's rise. If the patient is having difficulty rising from a chair, it is likely suggestive of muscle weakness, proximal muscle weakness. And then other illnesses like Parkinson's, in which there is Bredi, Kinesia may also increase their level of difficulty rising. As the patient stands more momentarily, we need to see the patient has any lightheadedness or does he or she sway when they stand? Or do they hold on to something when standing, which would suggest all the stasis. How they're walking, which will help unmask gates like Parkinsonian gate patients who has an intelligent or painful gate, patient who has a wide-based attack gate, all of those gates can be unmasked in this. When the patient turns around, often peripheral neuropathy and cellar issues may play a role in their becoming unsteady and how they come back and sit down. Most individuals can do this in 10 seconds, up to 20 is acceptable. And this is really one of the most dynamic tests to do. It doesn't require equipment. It doesn't require any special training. It can be done easily within an office room as well. The sensitivity of this test is about 70%. It is not very specific, but it's still one of the most recommended tests and suggested in most guidelines. Next slide, please. So, a Rumbert's test. This is a test that looks at stands and balance. And a common mistake that I know my students and sometimes our residents make is that they don't have the patient get their feet together. It's very important to first align the feet together as much as a patient can. And then just look straight ahead. They can extend their arms, which adds to the challenge of the test. Look straight, keep their eyes open initially. See this way with their eyes open.  So, next slide, please. This is a short physical performance battery. As you can see, it's a battery of tests. And it includes balance. It includes gate and then includes a five-chair stand. So, rise and stand, rise and stand. And I want you to focus on the five-chair stand because if you can go to the next slide, I think. The next slide talks about this was a large-scale study done in Boston Longitudinal Study that looked at the rise, and it talked about if the patient took more than 16.7 seconds to do the five-chair stand, that in itself was an independent predictor of falling and injurious falls. So, positive fall history and a slow chair stand, both were associated with almost 50 percent two-year cumulative incidence of falling. And so, this is the study concluded that the chair stand was significant in this case. Can I have the next slide, please? DINET is, again, a slightly longer test. It doesn't require special equipment, but it is a 16-item test that looks at balance and weight. It takes about 10, maybe 15 minutes to complete. And it has a whole score in it and less than 19 predicts a high-risk fall. What's important here to see is that this also has a sensitivity of about 70 percent. Next slide. The Berg test is actually one of those which has the highest specificity we see on the right-hand side. Again, it's a series of activities that the patient is asked to do, you know, stand, balance, transfer, eyes open, closed, and achieving objects, and also turning. So, it makes the patient do all of these things. Again, if the score is less than 40, that requires intervention. Next slide. Thank you. This is a systematic review that was done in JAMA in 2020-21, I think. And it looked at, so it did the grade scoring and it identified why it identified intervention as well. My focus here is on assessment. If you look at this, they talked about looking at the various assessment tools and they said using any one assessment tool is important when they're assessing someone who presents with a fall. They talked about medication review, which was again given a grade 1A, which is the highest grade given, and then they talked about vision as well. So, looking at vision as well in terms of assessing a fall or doing a multifactorial assessment. So, now we go to the next slide, which sort of solves the case for you. So, we see this woman, again, a very commonly occurring, you know, presentation for all of us. That we start off with, you know, after we get her history of the fall and get the details and circumstances of the fall, we look at this history and based on this history, we decide we need to look at her pulse and her blood pressure. Why? Because she is taking a beta blocker. She is taking two other antihypertensive agents, which can cause or increase the risk of horses stratified potential. We must look at her visual equity because she is reporting visual loss in one eye. She does complain of numbness in the feet, so the peripheral neuropathy and foot examination becomes important. We need to assess her functional status. Why? Because there is a history of forgetfulness in this patient as well as for her daughter. And a memory assessment is also warranted in this situation. And then any of the mobility or tests or a balanced test that you choose, you prefer to use, can be done in this patient. That is, again, when you look at literature, there is no preference of one over the other, other than the fact that the AGS-PGS suggests term T because of the ease of use here. Again, if you look at the medications, which, like I said earlier, is really, really very important and the one that we can make a most impact in is when we look at her medications, we need to think of, is the hydrochlorothiazide causing an electrolyte balance, for example, is this patient having hypoallergenia, which could be adding to the weakness and increasing her risk of fall? Is she ready-cardic, which, again, could be one of the reasons for the patients falling? Is she on, she's on glimeparite and that is a long-acting sulcanal urea. Can that cause hypoglycemia in this patient? Wet formin, is that associated with the B12 deficiency causing more therapeutic neuropathy? And of course, the benzodiazepine, again, very, very common list of inappropriate medications, which can cause confusion, it can cause drowsiness, and can definitely lead to a fall. And the atorvastatin, again, is it causing, is the dose high enough to talk about the cause muscle weakness? Here, I didn't deliberately mention the doses because I wanted to have this message as a take-home for all of you. So we need to look at the dosages of all the medications in detail because just listing the medications and not looking at when the patient takes them and what doses makes this an incomplete drug review. So I wanted that message sort of there in the presentation. So if you can move to the next slide, please. So this is, this is just, I want you to think about this. You don't necessarily have to answer me now. So this is a gentleman who's 69, has a history of coronary artery disease, who's had a left-sided CVA and now reports difficulty in walking in balance. He does not report a history of fall. How would you proceed in this case? Would you do everything the same way? Would you do anything differently? That's a take-home message. Well, that's a take-home thing for you. And what I would say here is that because the patient didn't fall, the only thing that you can exclude from this is doing a doing a fall history because there is no fall history. Everything else would be exactly the same as you would because if you remember from the initial slides, AGS, BGS recommend that patients reporting a difficulty in walking also require a complete and comprehensive fall risk assessment. So next slide, which is my last slide. So there is no single tool of balance or gauge that is enough to assess such patients. We must make sure that whatever tool we use, that has to be combined with a relevant and focused history.  And that sort of completes your assessment of a patient who presents to you with a fall. So thank you so much. And I'm going to hand over to Demetina. Thank you very much, Sonia. That was very comprehensive and interesting. And it makes me think that certainly in family practice we could be using some of those tests a bit more. I don't have any questions in the chat. Does anyone want to put their hand up and ask a question? I don't see any hands up. It's always hard to break the ice with the questions. If I've missed someone, please feel free to just unmute and ask something. All right. Well, in that case, we might move on. Oh, we do have. Ah, we have, ah, from, ah, Sanka, we have a comment, Sonia, that the presentation is very clear. And that's why you don't have any questions. So, um, so there we go. So that's good. We may have an opportunity for questions at the end, too, if something occurs to someone. So, ah, and we have a few other congratulations coming through. Thank you very much, Sonia. Thank you. So our next speaker is Dr. Mercy Nefula, who's head of the Directorate of Primary Health Care in Embu County in Kenya. So, Mercy has a lot of details on her CV there, but we discussed that in the interests of time or just, ah, I just include that simple introduction. And Mercy, I think you're going to share screen yourself. So, thanks, Mercy. Oh, yes, that's good. Thank you. Thank you so much, Dimitri, and thank you, Sonia, for that wonderful start to the presentations. I think it gives us a good piece to move on forward to this presentation, um, that will be looking at how we are going to prevent falls in all the adults by using quality improvement and patient safety approaches. So, quality improvement has a very special place in public health and public health performance in that it helps in what we call continuous quality improvement so that we improve the quality of care that we're giving, not only at the community level, but also at the hospital, institutional level as well, because here we are also including care homes. So, it's important to do, always have a QI approach because it helps you to use data for decision making and managing changes and also creating a learning organization as well. So, the model of improvement that I'm going to use in the presentation today is a simple model that is used by the Institute of Healthcare Improvement, where it encourages, first of all, looking at the three tenets of the model, which is what are we trying to accomplish? That is your aim. How will you know that change is an improvement? That is, how will you measure that what you're doing is actually working? And then you come down to what change can be made that will result in an improvement, which comes into your intervention. And then you follow what you call the plan to study up cycle, where you start small as you continue making changes that will that will lead to a better intervention for your patients, a better intervention for your community. And it also encourages the use of different kinds of measures, because most of the time you find that we use what is called either outcome measures and or outputs, rather than looking at the structure that you're using the process and measuring the process. And then also balance measures like equity issues, for instance, if you're looking at maybe a community of older adults, what could be the balance measures there? One could be things like education, things like exposure to technology, things like which side of the community do they live in. So those are some of the balance measures that you can look at as well using the model of improvement. Coming down to our topic today, where it's on falls among older adults or persons, what we're trying to accomplish is to prevent the falls. Because as you can see, this is a huge public health concern and burden as well because you can see one in four adults fall each year under the who are 65 and older. And this is costing, this is US based statistics because in most of the world we don't really have a statistic to show the cost or the burden on the healthcare system. And you can see we lose 50 billion annually in terms of treating falls or treating the repercussions of falls and yet the falls are actually quite preventable. So how will we know that a change is an improvement? So we need to do a baseline assessment and also a risk assessment and stratification to know where we are. Because the problem we have with falls in older adults right now is we do not have the data. Even if you look maybe at your community, where you practice and ask yourself, do I have data on how many older adults fall each year? Do I have data on how many of them are at risk of falling or data on any interventions that have been tried? And you will find that you have none. That's why this approach is very important because apart from improving the quality of care, apart from mitigating risks that will cause all the adults to fall, it will also give you data. And data is very important when it comes to the decision making and interventions. And in terms of measurement and tracking, once you have sat down and maybe you have decided, I want to look at the falls in older adults in my community, then you have to ask yourself, how am I going to measure this? How am I going to do the baseline assessment? And how am I going to do the risk assessment and stratification so that I know where I'm starting from? Then once I've put in place an intervention, what next? So in terms of measurement, some of the things that would be important for you to look at as you're doing the measurement is, for instance, the number of older adults you have in your community. So this refers to either the community that is for the family physicians who practice at the community level, then those at the institutional level as well. And look at their data from a disaggregated by age, by sex, and any other characteristics that you think would be important that will give you a baseline of where you're starting from. Then also the number of adults who have had falls disaggregated by age, by fall type, by injury type, because this will also help you know where will I tailor my interventions. Then from there you can look at the causes of falls in older adults in general, in your community, in your country, in your institution, because that will give you an idea of what has been happening in the past and what is most common. And where, for example, you can apply the 80-20 principle to see if I put an intervention in this one area, maybe decide to put maybe rails along the walls for them to support themselves while you're walking in an institution or an initial of a ramp. So depending on the fall type and the cause, you can actually put one intervention that might actually prevent 80% of the falls as well. That's why it would also be good to look at what has been causing the falls previously. Then when it comes to the number of older adults at risk or falls disaggregated by individual characteristics and risk type, I think this is where some of the tools that Sania has mentioned are very important. And even as you're doing your planning, if you realize, for example, you either don't have a comprehensive tool, this is where you might also decide that you want to come up with a tool that will be able to give you all this information so that you can collect that information as well. Then you might look at the intervention in terms of what interventions are currently in place to prevent falls and what interventions have been tried before. What type of intervention was it? Was it at individual level, for instance? Was it at community level? Was it at institutional level? Was it on the patient side or on the provider side? Because you also have to realize that even measures can also be taken on the provider side to ensure that the older adults do not fall. For instance, if you're living in a care home and you have maybe five or six classes per shift for maybe 30 residents, you might decide maybe to increase the number of nurses so that you can have more vigilance over the older adults, and that is also a preventive measure. So looking at the time, the type, and the location as well, and then from there you have to decide how often will I now, once I've done my planning and then once I go to my doing, how often will I be doing the analysis? After two weeks, after three weeks, after one month, how often will I now be start collecting the data and how will I do the analysis and who will be doing the data collection and also the analysis in terms of the different areas that you want to measure. So Sania had gone through some of this so I'll not go through it, but it's good to always look at risk factors in a more stratified manner, the modifiable, potentially modifiable, non-modifiable then in the modifiable, you have to look at them from a biological point of view, from an environmental point of view, and also look at the different systems, the different body systems and what risk factors they pose to the older persons. Then also it's good to do a good medication analysis for the older adults as well and also have it in your risk certification and assessment because, as Sania mentioned earlier at this, with older adults you have a lot of polypharmacy and that can put an older adult who is otherwise strong and does not have any muscular or any other physical disability, it places them at risk of falls because maybe it causes some kind of somnolence or any other side effects associated with the drugs can cause them to be at risk of falls. So it's also good to include that in your assessment. So this is an example of how we used to do continuous assessment for older adults in Cuba where I did my residency in family medicine. So this is a skill, this is a geriatric scale for functional evaluation and what we used to do is every year we had to do it for every single person over the age of 60 and then from there we classify them according to what we call fragility or fragility. So it depends on the scale of how fragile the older adult is and it is, it depends on the score. It is not only based on one thing, it is based on how they score in terms of continency, mobility, equilibrium, vision, hearing and also the use of medications. For example, any adult who uses more than three medications is classified as at risk and then based on that risk certification throughout the year you have to do a certain number of visits for them including home visits to see what their risk factors are environmentally, to see who they live with. Then the other thing we used to classify them as a risk factor is any person older than 60 years of age with any risk factor in any of these areas and also living by themselves would also be considered an older person at risk. So this is how now we were doing it annually and on a continuous basis so that we make sure we monitor all the older adults in our community throughout. So now coming down to you have done your planning, you are saying you want to prevent the faults in older adults, you have decided what you're going to measure and how you're going to measure it. So now after that you need to go to your doing and your doing is once you have gotten the data that gives you your baseline, your risk certification, you know how many older adults you have, how many of them have you assessed and how many of them would you like to assess. So it is always advisable when you're doing QI projects to start with a small group. So you might decide for example if I'm in the community just give me a minute to play some notes in my environment let me just put on my headset sorry. So once you have looked at your community you might decide for instance let me start with the older adults that live in this home community or live in these addresses and then now you bring them in, you do the risk assessments for all of them after doing the risk assessments based on the risk assessment, certification and the causes that you have found maybe you pick one cause and decide for instance I'm going to deal with faults related to sleeping for example in bathroom and then from there now you decide these are the older adults I'm going to look at and this is what I'm going to measure and then I'm going to measure it maybe over a period of two months or three months and see if the intervention has worked. So now in the intervention stage is where we come to looking at patient safety and system level factors that affect safety. So you see at the core of system level factors we have the patient characteristics which we'll do in the assessment and then we also have the individual provider so that could be you if you're practicing or some of your colleagues and how they take care of older persons so what are some of the interventions that you can make at that level as well then you have to look at team factors especially for primary care practices that have a team-based approach and it is always advisable to do a team-based approach you have a nurse on your team you have a family physician on your team you have a physiotherapist on your team maybe even an occupational therapist on your team as well so that they can look at interventions in a more multidisciplinary multifactorial way then also the work environment if you're working in an institution and then the home environment for the older adults then departmental factors if you're doing a departmental approach maybe from the department of aging or something like that then also look at the hospital and any other institution that you're looking at so these are all the different levels at which you can decide to place your intervention depending on the courses that you have found and looking at patient safety let's remember the biopsychosocial approach to everything so the biopsychosocial approach to your patient and the biopsychosocial approach now bringing in other people the community the environment and everything that can affect your older adults and their health so the most effective strategies are based on hazard identification and effective mitigation strategies because studies have shown that once an older adult has even one fall then that places them at risk of getting subsequent falls so the best place you have to intervene is ensuring that the ones who have never had falls never have falls and the ones who have had even at least one fall never have a second one because the more they fall the more you increase their risk and the more falls they're likely to have then it is good to take also use of a change management model for behavioral modification because as you look at some of the interventions a lot of them are actually behavioral so how do you walk through this with the older adults and ensure that they pick up your recommendations and modify any modifiable individual risk factors that they have so some of the proposed strategies and which I think some Sonia mentioned are based on one exercise particularly balance strength and gait and some of the interventions that have been effective in this is using Tai Chi where in the community where I practiced and I did my residency we had every day we had groups of older adults who would go into the park and also and practice Tai Chi every morning to increase their movements and also strengthen their muscles and also movement and and improve their gait as well and this I realized helped a lot of older adults because many of them in fact you'll find a whole year they have barely had any they've not had any falls we'd have like maybe one or two reports of falls within our community of we had 1500 people with about 600 older adults so vitamin supplementation with or without calcium has also been shown to be very helpful especially for female patients because you saw being female is a risk factor especially with osteoporosis that comes after menopause and so this I have seen it work even in the communities in the community where I did my residency then management of medication we've talked about that especially psychoactive medication which may cause somnilans and other things that put the older adults at risk home environment made modification looking at things like loose carpet slippery floors if for example you have an older adults living at the top floor can they come down and live maybe at the bottom floor is it a possibility so modifying such like things management of posterior hypertension vision problems with problems and footwear especially for posterior hypertension which is common in older adults who take hypertensive medication it's also common just as part of the aging process so having for instance if you're in a care home or in a hospital setting ensuring that maybe each morning or evening they monitor the blood pressure of older adults that can actually help you with checking what time do they get that hypertension on when what time does it begin to happen before an older adult rises from a sitting or lying position and then they get the hypertension and fall down so these interventions have been shown to be very effective at whether it's community hospital based nursing home setting and then another thing that I found very interesting and very important in terms of prevention of fall as an intervention is reimbursing it as part of the Medicare annual wellness visit because what we have especially in countries where people have to pay for care and you have to reimburse either the primary care team or the individual provider for the services they've been given if a wellness check as or a fall prevention check is not reimbursed then it's not going to be done but if it's reimbursed it's a very important move in to ensure that fall prevention and risk assessment is done as part of every older adult wellness visit or as part of their risk assessment so I talked about the use of now the change model change management model for fall prevention and we normally have stages from the pre-contemplation stage to the maintenance stage and the importance of knowing these stages is knowing where your patient is at and where you can intervene so for instance you have done a risk assessment for an older adult then you have found that maybe they have a bit of muscle weakness and maybe they should they need to improve their date and you decide an exercise like Tai Chi is good for you so how do you start so you start by talking to the patient and ascertaining what stage they are at if for example they are still at the pre-contemplation stage that means maybe a bit more education a bit more support needs to be done for you to be able to get these adults to a place where they'll be able to do their exercises so depending on what stage they are you will have to do health education you'll have to do support and support can also mean bringing in the family and other support structures that they have so they can help the older adults make that decision to come to a place where they accept the new behavior which is maybe exercise and then once they start doing the exercise since you're doing measurement then you start measuring from the time they're doing the exercise to maybe three months later or six months later have they had any fault have they had also near misses and then now you would see that this intervention strategy is working at the individual level and we should maintain it or maybe we should improve it then now you start your PDSA cycle again so this is for when you're doing it you're doing the intervention at a at an individual level so this is an example of an assessment by a care home who are doing a false prevention framework using quality improvement that's the PDSA cycle so you can see at their planning stage they plan to meet their client needs in terms of full prevention so they did a false assessment they used a false assessment risk assessment tool they talked to the support staff they came up with false prevention policies and procedures and they came up also with a committee to measure the change or to see at the change then when it came to now how do we do it they use this you can patch the beach model where they use education equipment environment activity these are points where they were intervening clothing and footwear and health management modifications to drive behavior change so this beach model is just a framework that shows you how you can intervene where you where where you can intervene and then different kinds of approaches that you can use then now from there from they're doing now it is time to study so the study part is where now they came to measure what it is that their change has achieved so in terms of measuring they did a false incident report later to see how many have fallen and types of false etc then false indicators they were also measuring that and other types of false reporting so after you have done your intervention you come back to do a review and see how well you have done then now you act so you evaluate the intervention programs continuing self-education and also accreditation in terms of being maybe a false free environment or a care environment or a care home that is that has the necessary things in place to to prevent falls in older adults and this is something very interesting that I found as as I was preparing for today and it said united withstand divided they fall just to remind us that whatever approach we are taking in preventing falls in older adults it has to be multidisciplinary and multifactorial in terms of approach and assessment as well and with that I finish and I think I can take some questions back to you demity you're working through thank you sorry I forgot to um yeah thank you ah dear um you'd think we would have learned by now after three years of pandemic but anyway I'm unmuted now so um there's been quite interesting discussion on this very interesting presentation thanks mercy um there there's a few people who know about their data um uh in Sri Lanka Sankar tells us that a hospital based study reported 24 percent of people over 65 years of age had fallen within a year and Ping Fu tells us that the prevalence in Malaysia is around 14 percent so um it doesn't but I they are the only two that came up in response to a question so I think you're right we often don't know how many people are falling and there are some questions uh one is um a question about physical abuse as a as a as a background cause of falls have you have you got any thoughts about that screening for that how we should suspect it um certainly it's a it's a problem amongst some of my patients so um when I was doing my residency I did my my thesis around care of the older adults in the home setting the community as well and you are looking at it from a bioethic perspective and um some of the questions um you are asking um were indirectly uh related to abuse because there's one um how do you make your decision as an older adults maybe about your medication do you know about your health and health care so it is good to do that assessment but if you do it directly you will never get an answer but some of the indirect pointers that I found is one and all the adults telling you that every decision is made by the caregiver that is one um two we also ask the caregiver's questions around like um for instance if you ask an older adult to do something for example take this medication or do this and they um how do you usually proceed so when you dive deeper you'd actually find that apart from physical abuse there was that um other um how how do I put it almost almost like emotional abuse and it would come out through those questions so I do agree it is good to assess that but the approach it should be not directly just maybe find out um the power dynamics if you look at the power dynamics between a caregiver and an older adult it can point to that then um like I mentioned like the best practice that I found in Cuba was doing that annual assessment for an adult we not only do that evaluation but we also do a physical evaluation and that can also point out to one or two things that is not um that is not right and then the third thing that you can do and which I found best practice there we always had to visit the older adults in their homes so when you visit the home maybe look at where the older adult is sleeping what their bed looks like where they spent most of their time sitting you know how many times they're turned over so those are some of the pointers that you can also look at which are also risks in themselves because someone might not be necessarily hitting them directly but the kind of environment that they've placed them into care for them is placing them at risk so it is not like directly abused like I've hit you physically but now I am doing it through the kind of environment that have placed you in that is placing you at risk as well so those are some of the ways that I found that you can look at it as well thank you that's very thorough response mercy especially our question that you didn't know was coming to you thank you very much and Mel who asked that question wants to thank you very much as well and and thinks that maybe it's under reported and I'll just put in a little plug that the the special interest group in abuse and violence has written to me today asking if we can do a joint webinar on abuse elder abuse so that hopefully will be coming up next year and I think it would be important to do and there there's there were a little bit of a discussion about about the the thought that having the country's primary care benefit package include falls assessment and some some people don't have that some people do in my country it's listed among a long list of things that we should assess in about half an hour every year so it's and it's not well it's not well taken up but I guess it's there at least so there's certainly room for movement on that have you got any comments on that from your perspective if there's any payment or process for making a routine I think one of the things that we are struggling to push in primary care even in my country is how do you how do you reimburse things like home-based visits how do you reimburse things like wellness checks and I think in general not even from the older adults perspective it is something that we need to push for because as we are pushing towards health systems that are primary care based then that means reimbursement has to be primary care based so some of the approaches instead of maybe just saying for falls alone you can decide and say a package should be there for all all the adults to have at least one annual you know one annual check and then when you get that at least put pushed through then you can include things like falls prevention and assessment and any other major things that of importance for you in your country because I found sometimes pushing one thing can be detrimental in that you realize there's another thing that you want to do and now you've pushed for only one thing and now just reimbursing falls prevention only or a wellness check so it's better to push for a package a wellness check package for older adults and then in that include the things that are important for you so interesting that prevention is underfunded when it could be such a powerful lever for reducing costs and improving quality of life isn't it thank you mercy are there any other questions for mercy you might have to yell out at me because I can't see everyone on the screen no well that was very interesting thanks mercy and I like the way it complimented the other presentations by being a systems based approach yeah so very good thank you and I encourage everyone to think about quality improvement approaches okay so our third and final speaker is Professor Nairie Curse who's the Joyce Cook chair in aging well at the University of Auckland in New Zealand and you can see the rest of Nairie's CV up there so Nairie I think Pingu is you've asked Pingu to present you yeah thank you Diary well thank you very much Dimity and I'm coming to you today from Adelaide although I usually live in New Zealand and I also want to thank Dimity for keeping us all involved in the special interest group and also acknowledge Wonka as a very important organiser for all of us so the next slide please I thought I would talk about falls for very frail people and falls in residential care and I just noted a few things here which have already been covered that injury is indeed in the top three causes of injury related death for older people and amongst our broad whole populations are important to think about special groups such as those with Parkinson's disease any kind of dementia but Lewy body dementia in particular and I wanted to mention that injury is probably just the tip of the iceberg in the impact thinking about the impact of falls because of course any fall in an older person can increase their hesitancy to get out and about and they will correspondingly have a reduction in their overall function this slide here just shows that the unintentional injury hospitalisations are much more common in the older age groups looking at a per person risk of ending up in hospitals related to age when you think about 30 people over 65 about 80% of people in aged residential care will fall in any year so the two populations are quite different and when I was starting out in research in New Zealand where everyone was very interested in the community but there was not very much work in aged residential care trying to reduce all so I thought I'd tell you about a trial that I did so the next slide please so we took up so we were looking in residential care and we noticed that there was huge variation in the risk of falling in and the actual occurrence of falls throughout the industry and so we had 45 different units we were doing a study about hip fracture use actually we asked them to report their falls I'm sorry about hip protector use it was and you can see here that the number of mean number of falls per person in these homes really varied by 10 times and this was over the uh uh falls in each specific unit so I was fascinated by that why on earth should that be and I've been trying to unpick that for quite some time so the next slide please so we did a for an intervention it was a very straightforward intervention based on risk assessment so I ran into this wonderful person Meg Butler who's a falls prevention researcher in the lift shortly after I'd come to Auckland and she had been developing a lovely fall risk assessment which involved questions about whether they were on medications they shouldn't be whether they had additional functional limitations whether they were a continent all of the risks were evidence based and the nurse who was to do the risk assessment gave them so many points that if they were at a high risk there were specific strategies that the staff were they were recommended for the staff so that included a high risk logo which was to go on the bed beside on the wall beside the bed we had education for the staff which we went a couple of times to talk about falls prevention the staff strategies also suggested that the GP should review the medications if there were too many medications and that they should get the person going with specific exercise now I want to emphasize that this was a low intensity intervention so you can see there was just a nice folder which included the risk assessment one of the staff at the facility and we undertook doing the assessments on each on each resident and then they would they were to work with the staff to institute the suggestions there was no additional resources and so the if you just click one more time or to show that pink food if you just give one more click some more information will come up on this slide so we increased falls by 34% with this very simple intervention now this is not supposed to happen but if you look at the graph if you've been pondering upon it the blue line is actually the intervention group and the pink line is the control group and you can see that after we started which was in the March April the falls increased in the intervention groups homes compared to the control group homes and it was a cluster randomized trial so we were perplexed by that I was so perplexed that I spent some time on my heart this fellow should actually working as a hospital aid in a volunteer situation like a participant observation and I quickly realized that the staff are very busy and they have a high workload the job is difficult we were asking them to do a whole lot more things without actually giving them any more any more resources no more staff no more no no additional physios or anything like that so this was an unsuccessful trial which taught me a lot about falls prevention and so the next slide please the next slide talks about the Cochrane review so I was involved in this Cochrane review and a Cochrane review is a very very detailed difficult review it searches the all of the literature when this Cochrane review group started they had one Cochrane review for all falls prevention but after quite soon after starting they split this into a review of hospital and residential aged care and community so I'll talk about the hospital and residential aged care review and so there were initially 60 trials and in 2018 we updated it and found an additional 35 trials so 95 trials there's a lot of information 71 of these were in care facilities and the remainder in acute hospitals so let's go to the next slide and you'll see I think it's a something called a forest plot and you can see the line in the middle is the line where it makes no difference and each trial represents one line each so if you look down and give it one more click please ping through you'll see the arrow points to my trial which is on the wrong side of the line so there I was on the wrong side of the line this is not supposed to happen and I was very worried but you can see that there's another trial on the wrong side of the line as well and when I looked at this trial it was 16 facilities and they had done a very similar intervention with a risk assessment alone and then suggestions with individualized strategies but no additional support so these two trials on the wrong side of the line mean that the summary continues to cross the line which means that it's very difficult to identify exactly what strategies are very useful the top first two trials there by Clemens Becker and and a wonderful Dr Dyer from Scandinavia you can say you can see they are clearly on the correct side of the line where they reduced falls or the intervention result favored the intervention facilities and both of those trials had considerable resources which they gave to the facilities they had a whole physiotherapist who joined the staff in the trials they gave them extra nursing time to help with the strategies and they focused on physical exercise of the right kind okay the next trial next slide please so I wanted to talk about two specific and so well I want to talk about two specific uh trials they were both in actually in hospitals the first was a successful trial by Ann Marie Hill and this had looked at um ways to to spend time with patients educating them about the falls of risk and it was done in a rehabilitation unit so in New Zealand and Australia we have sort of low level rehab where older people can go to recover and get specific rehabilitation the length of time in hospital is longer and this trial was successful so each patient got at least 45 minutes over two visits from a nurse they also had some patient alerts uh alerted the patients to the risk of falls and raised their knowledge about falls and they gave them videos to watch about falls prevention and a written workbook where they were to assess their own their own um their own risk of falls the staff were also trained about falls and patient behaviors and the next slide does the results and it was a step wedge design and I talked to Ann Marie Hill if we could have the next slide please yes and just do two more clicks and you'll see some red circles come up and this is where you compare this the in a sequential way how the um how the yes that's the way how the um uh homes that have had the intervention you compare their fall rates with everybody else so that first circle the control group home rate was 13.2 which was a rate per person year and then the intervention had already reduced to to the 8.5 and as you see more homes coming into there you can see that the intervention group rate went down to 7.7 and 5.9 so that was a very successful trial in several and then eight hospital units across Australia and the next slide please is about a trial that was not successful uh there we go 40 reduction in falls but they didn't include as many of those with significant dementia now this is an interesting trial where they had a very very successful pilot study which suggested that the six pack was going to be fantastic and the six pack included the placement of a falls alert signed by the patient's bed additional supervision this was education of the staff and they also gave them extra people to sit by the bed to watch supervision of the patients while in the bathroom they used the low low beds which are beds almost on the floor so that if you fall out you don't hurt yourself and then there were some simple staff strategies like making sure that the patient's walking aid was available and that there was establishment of a toileting routine or a routine so that the many of the falls happening in acute hospitals are around patients trying to go to bed trying to go to the toilet so this was a very large trial around 16 hospital units with 46 000 people the uptake was very good they did lots of observation or observations just make sure that the staff were doing what they would they should do but there was actually no impact on fall injuries so you can see you can spend a lot of time and energy and still not have an impact I think the caution retail both from my trial and from this trial are that you really do need to understand the evidence base that you're working with and try to do things that that can be very effective so the next slide is the summary from the Cochrane review and the things that they found to be very useful in care facilities was vitamin D you understand that most people in care facilities are not outside very often and don't get the sunlight they need to make their own vitamin D so vitamin D should be a mandatory prescription for everyone in age residential care except for those who have hyperparathyroidism I think that's the only exclusion they also noticed that falls risk tools such as the risk assessment used in my trial probably didn't make very much difference in comparison to a nurse's judgment using her sensible clinical judgment so spending a lot of time on risk assessment alone without focusing on actually the things you're going to do to change that risk whether it be providing the exercise that would increase the lower leg strength and balance whether it would be providing an occupational therapist to help with the environment those kind of things were important and in hospitals multifactorial interventions may be useful particularly if they're in the subacute setting which is the rehab hospital and they incorporated tailored patient education so they thought that was important I've got two more trials to tell you about so the next slide please these were both successful and they were at the time after the Cochrane review finished their searching so a wonderful person called Hewitt again in Australia presented this trial which was attended at a specific exercise class and these exercise classes were called the Sunbeam class and they went for one hour twice a week and they did this for I think six months and then after the six months they had a maintenance program where they continued to do some exercise they found that the physical performance increased and falls were reduced almost by 50 by more than 50 percent in the intervention group they also reduced injuries now if we could have the next slide it's it is a little more detail about what this intervention was it used some specific gym type equipment which was designed specifically for older people and so the resistance training that it produced could be increased in very small increments you can imagine older people in the regular gym really struggling with even the three kilogram weights these could go up by a hundred gram increments but there wasn't just that they used the exercise equipment they had a physical therapist who instructed them in its use who designed the the program for them after a functional assessment and then every every week that they were doing their exercises they were taken and and with well they were off the equipment they had specific balance exercises so it was a whole picture and one more click on that slide please Peng Fu you can say they did they did usually were given 10 reps which they had to do three times and they did this for at least twice a week it was physio lead and they had a whole physio one whole physio FTE for every five residents so there was a lot of uh in in in extra resources going into the homes and one more clip one more slide please we've got this next trial which was about nutrition and it was a trial led by nutritionists and they took them a long time to get this trial going but they included 60 facilities with over 7 000 residents and they randomized them to more food or the same food and the more food included dairy serves and protein intake and they had an additional five serves of dairy a day and they measured the amount of protein to make sure that they reached the minimum recommended amount of protein now what this trial did in a very short time within six months they had reduced fractures and over 12 months they reduced fractures by 30 percent and 46 percent reduction in hip fractures interestingly there was a small reduction in falls but it was significant and I wanted to say the food was donated by Fonterra which is a dairy company from New Zealand and so it was important that that food was given to the homes at no charge to themselves or to the residents the graphs that you see there just show the differentiation between the intervention and control group about all fractures and hip fractures and then falls in the lower in the lower left interestingly mortality was not impacted by this trial okay so if we could have the last slide please this second last slide this just is to remind us about the interaction of the many risk factors and so you can see the person and the intrinsic risk factors there in the gray we know quite a lot about that lower leg strength balance problems having arthritis having specific conditions like us having had a stroke that we had a good talk about that and then the place or the environment so you know is there slippery flaws is the person able to function well in their own environment is there enough light but also remember the exposure what exactly was that person doing when they were found to have fallen can we help educate patients can we help educate older people about falls and the risk for falls I think that's quite important and I'll share one funny story with you my father who was in his 80s at this time I went home to visit him and I said dad what have you been up to and he said oh Nairi oh well I've managed to paint the roof and I said dad you're 80 something what are you doing on the roof and he said now Nairi I knew you would be worried so I tied myself to the chimney and so I was immediately imagining him dangling off the edge of the roof on whatever he tied himself to the chimney with but that would be perceived as a risky activity in anybody's books for an over 80 year old man however my father had been a farmer all his life and was used to doing very physically challenging things and so he managed to paint his roof quite well and just the last slide there ping-foo um Justin in summary there's clues the clinicians which have been given a very good overview of already the blood pressure the medications very important the gate assessment thinking about the cognition and the conditions but also remember after the fall you need to give them time to recover and offer them some rehabilitation services such as physiotherapy or simply encouraging them gradually to get back to the usual activities now or if you're the owner or a manager of a hospital or a home please take care of how much food you feed the older people make sure that they're getting an adequate amount of both protein and dairy foods the exercises that people do are very important they must be based on balance and lower leg strengthening Tai Chi is a very good example in New Zealand we have an Otago exercise program which has a lot of sit to stands in it and a lot of simple balance stresses which can be done in their own home remember home safety and then think very hard about the integrated system of your health system and how you can integrate some of these prevention activities into usual care okay so I think that's my last slide just check for me ping-foo yes thank you very much so that's the end of my talk and thank you very much for listening I also just wanted to remind us all that those in the community who live in the community usually are quite a different group than those who are have very a lot of disability in age residential care and so exercises the focus for the people in the community with lower leg strengthening balance retraining and the home assessment to make sure the home is safe and for doctors and nurses and everybody else make sure that the medications get reviewed and changes are made so thank you very much for your time today over to you dimity right no thank you very much there's a question about whether I'm not completely sure I understand Gianna's question but I think he wants to know whether we should focus on people who have fallen already or focus on risk assessment when we're thinking about falls prior to remember I think you're asking about those people who are already in the low rehab units the criteria the low rehab units in some countries are specifically for older people so they're run by geriatricians and there they would do rehab after a stroke or they would do rehab after a period of deconditioning etc and so not all countries have those so the criteria to get in now that you have functional disabilities and that you need to recover so this intervention was done to everybody who was admitted to that low level rehab unit no matter whether they had fallen before or not and those people and so the idea was to prevent them from falling and that's because falls are very common in acute hospitals as well as age residential care and in the community so they were trying to put together strategies that would prevent the fall from happening so that so all of the people who are admitted to the low level rehab unit had that strategy of having some education about falls of watching the videos and trying to themselves understand and prevent the fall and thank you Nairi Mel has asked us about how to advise or encourage older people to do exercise and she did talk about behavioral models as well but have you got any thoughts on that well usually instruction and telling them to exercise alone is not enough of course the simplest thing is to do more walking but actually they need to challenge their balance at the same time as walking and so many countries will have community classes so people who are exercise trainers will say come to my class they will gather together once once a week or twice a week where they will do the falls prevention exercises with an instructor and this is kind of the best way although it is expensive and difficult to organize it's quite possible to train lay people or peers to deliver this kind of exercise and then they can do it with their peers for people who are very disabled it's better to have somebody go to the home to do the exercise with the person and give specific instructions and leave advice leave advice behind so it's not a really easy answer to just go out and exercise it's actually thinking about the exercise you need to do about being lower leg strengthening and balance retraining and that is best done with an expert and then I take the point about the behavioral model concept from discussed before might be helpful and yes I think we can use some of those strategies to help people remember to exercise and then do their exercises and that would be involved with some some feedback to themselves to say hey you're doing a really good job look my if I'm doing my own tests look how many exercises I've done this this week and potentially even some simple balance or or strength stress to show when people are improving no I think it's um I think the exercise classes if you can get people there are wonderful in the community I recently had a lady in her 70s who have been talking to about classes forever and she finally went along and she came in and said to me you know the people are really nice and I'm having a coffee now after the class with several other classes right and she'd lose by herself and this was actual social for her as well it's really good and I think that's a good feedback that's a good feedback message too that actually the classes are social and social activity is really important for older people to get together it gets them out and yes even the cup of coffee could be with lots of milk and a bit of cheese so they get their dairy products and protein and they're not only I was going to ask you because we have people from all over the world and about 60 percent of people from some countries can't digest lactose so what alternatives are you thinking might be useful and then I'll move to Mercy's question well I'm not sure I might I might not be able to answer that but certainly the protein proteins in those countries are easily gotten from other foods but it is a calcium a calcium rich food that you should think about so potentially someone could answer that what sort of calcium or bone health foods are available in countries where people can't digest the lactose thanks nine yeah um mercy you had a question so I might get you to put that question um to Nauri verbally probably easier than me trying to understand it okay I'm really a question um you had put up a question asking um why we think that um when they educated the healthcare providers and didn't give them resources um the fold increased um so it was just my attempt at answering what you had asked yes no I agree with you mercy wrong you've got the wrong intervention right problem wrong intervention you it was a unidimensional approach and I also think that that nurse probably was better off doing what she did before rather than filling in all those forms and being distracted away from the care that she was giving so being very careful that you don't interfere with good practice when you do something as well I think is really important good question though it's interesting about doing a study I was part of a study to reduce pain in older adults in residential care and the intervention group showed increased pain levels just as your intervention group showed increased falls but we decided that's because their pain was being assessed whereas in the control group they weren't being asked about pain and no one was doing a pain scale so it might have been a sign of success if it potentially it's hard to know yes we do have the same problem with falls they don't get reported and sometimes in a trial you prompt the reporting of a lot more falls and it appears that those falls go up so you have to be very careful to give the same kind of encouragement to report your falls to both the control group and the intervention group yeah yeah so I have one more question about balance exercises and also Sinea who comes from a country where probably there is lactose intolerance says green vegetables rice and citrus fruits containing calcium thank you Sinea thank you yay we've got the panel working together well here that's wonderful so balance exercises are there any that you can suggest no yes I can so you must make sure the older person is safe and so generally standing behind a chair or standing near a bench where they can grab quite easily so simply standing with your feet right together with no hands can be quite a balance challenge and then closing your eyes accentuates that balance and then with the eyes open moving the feet so that one foot is slightly in front of the other or all the way in front of the other which would be a tandem gate sort of I don't know how you do it with your hands maybe like that so half way or all the way yes it is a tandem and then you can you can see you're reducing your your base of support and that's a balance challenge in itself and then doing that while with with support by hanging on and then without support and once they can do that they can begin to stand on one leg and so standing on one leg is a very good balance balance exercise the second thing is to challenge your center of gravity and you can see why Tai Chi is quite good for this because you're always leaning over like this or leaning over like this and that why you've got a base of support that's reduced begin a little bit of balance challenge and that is stimulating your balance mechanisms to come to the party and keep you upright another um thank you oh no we've got another comment from mercy about sardines and I think the tiny bones sardines are full of calcium yeah and you call it a mena of mena mercy yes polytomena in a in a local dialect chain Kenya yeah that's lovely and Sonia did you have any other sorry Nari go on I was just going to respond to the question about the balance exercises um so most exercises are recommended to be done twice a week but actually balance exercises can be done every day and they'll work even better they're not strenuous so as often as you can is the answer to that yeah yeah I I just wanted to add uh and uh you know I usually advise patients to try and do them uh barefoot so they're also stimulating their you know the the nerves to their feet as well while they're doing their balance exercises uh so instead of wearing shoes and socks um you know barefoot helps I think as well it's good this this panel is wonderful I think we need to meet again and do do this again sometime thank you very much everyone that was really really good uh ping fu I think I need to hand back to you okay okay thank you um Dr Jimity Dr Sonia Dr Mercy and Dr Nari for sharing your expertise will and valuable advice and now we come to the final part please welcome Dr Wong Ping Fu share of the Raddam movement family medicine specialist head of clinic Suras Baru Health Clinic Ministry of Public Health Malaysia for a closing remark yeah thank you so much Abbas for the time introduction I would like to I would say that it's a very good uh full session that we had here I just want to thank again uh to the commander uh Prof Dimiti and together with the executive of the uh committee in the SIG on aging and health uh Prof Nari Prof Sonia and Dr Mercy and also as well as to my two hour you know uh YDN representative Dr Sankar you know he's a he's our boss you know to the wonka executive role and also I think I would like to thank everyone here especially to my friend uh from other region I can see the lead from the chair from other region Dr China here I think I can and also uh most important to two of uh you know um Dr Brando uh yes YDN chair uh from Mexican and also uh Dr Chloe uh who have been uh helping with me in translating the you know um language for Spanish and also Chinese uh because uh you know we do have a lot of our you know young more young Dr Puma from other region um yeah and also I would like to thank all the seniors and my professors and also um I I have a very good senior like Dr Chen I think I've got a few more professors who have attended this purposely for to support this I think um just to let everyone know that in Malaysia we just concluded our general election yesterday so we have no uh yes um yeah we we just pray and hope for the best for Malaysia and yeah with that I think I would like to end my my closing remarks and just to remind everyone that there will be another YDN the third YDN webinar in collaboration with working party and also the special interest group of Honka uh in January uh which will be hosted by the Arrazi movement okay so basically we have seven we'll say seven regions you know uh movement in seven regions so uh with that I thank everyone again but before we go I think Dr Bas we will have uh a short announcement to make uh I think we will have some photography session yeah yeah okay let's capture our activity today could you please everyone open your camera and give us smiles for the photoshop people could you please capture the photo okay okay please everyone give us a smile thank you so much okay so um I'll give another few seconds for you to uh yes I can see a lot of so many people I think my friends from Indonesia uh Dr I know from Malaysia a lot of friends from Malaysia okay just hang on uh on the count of three uh one two three smile and then I would love you to keep smiling because uh there are three pages here okay okay one two three smile and then my strong man is a uh Dr Mel very strong man of our region okay another one more okay one two three we are a lot we have a lot of GP from Malaysia uh Dr Jayanti Dr Hafizah thank you I think that's all uh we'd like to share a feedback uh link uh no so I think back to you uh Bas you can conclude yeah okay yeah everyone could you please give us your feedback so we can like develop and improve our webinar for the next sessions and I would like to remind you that our webinar has been recorded and you will be able to reopen it later okay and could you please kindly give us feedback here on the link and we hope to see you again on the next session in the January thank you so much have a nice day bye everyone thank you