Falls, fracture Falls, fracture prevention and prevention and

bone healthbone healthJane Reddaway

(Falls prevention lead TCT)

Osteoporosis

Falls

To achieve

Fracture

Reduction

Fracture PreventionFracture Prevention

Force

What is a fall?What is a fall?‘Unexpected event in which the participant comes to rest on the ground, floor or other lower level

than intended’(Lamb et al 2005)

• Includes falling out of bed or a chair, slipping in the bath.

• Excludes tripping and correcting self, banging into a wall, being pushed or knocked over, lying on floor intentionally.

Falls GuidanceFalls Guidance• National Service Framework for Older People (2001)

• AGS/BGS Guidelines (2010)

• NICE Guidance: Falls (2004)

• NICE Guidance: Osteoporosis (2004)

• RCP National Audit for falls and bone health 2006

• NPSA slips trips and falls in hospital 2007

• WHO global report on falls prevention 2007

• SW Strategic Health Authority ambitions 2009

Categories of FallsCategories of Falls• Explained fall:

a simple slip or trip

• Explained loss of consciousness (LOC):

When the diagnosis of LOC is made at the time of the fall or within 7 days. ie MI, CVE.

• Unexplained LOC: No cause found even after routine assessment and investigations

Unexplained fall / Recurrent falls:no apparent cause or explanation for the fall

Identify risk factors: Personal and/or Environmental

Can be summarised as:

D.A.M.EDRUGS

AGEING

MEDICAL CONDITIONS

ENVIRONMENTAL

Drugs:Drugs:• Side effects/out of date drugs

• Poly-pharmacy (more than 4 medications)

• Culprit groups: sedatives, diuretics, anti-hypertensives, hypnotics, antidepressants, and benzodiazepines

• Alcohol/recreational drugs

• Compliance/over dosing

• Alternative therapies

Ageing:Ageing:• Impaired vision

• Hearing/vestibular problems

• Reduced strength, balance, gait, bone density

• Cognitive impairment, dependence

• Housing type, living alone, bereavement

• Fear of falling/reduced confidence

Medical Conditions:Medical Conditions: • CVE/TIA (stroke), Parkinson’s disease, epilepsy, dementia

• Cardiac arrythmias, myocardial infarction (heart attack), chronic heart failure, postural hypotension

• Arthritis, osteoporosis

• Incontinence, alcoholism

• Infection (chest/UTI etc)

• Diabetes, hypothyroid

• Dehydration

Environmental Hazards:Environmental Hazards:

• Lighting full spectrum light bulbs

• Stairs • Loose carpets, rugs,

slippery floors • Ill-fitting footwear • Lack of safety

equipment or adaptations in the home.

• Inaccessible lights, windows, sockets

• Pets, clutter• Weather• Unfamiliar

environment• Other people• Uneven surfaces

InstantInstantAgeingAgeing

Interventions that Interventions that demonstrate good evidencedemonstrate good evidence

• Exercise programme - Balance, gait and lower limb strength training-either 1:1 or group(A)

• Minimise use of Psychoactive medication(B)• Reduce total no. of meds(B)• Expedite cataract surgery (B)• Vit D supplements<800IU/day for proven Vit

D deficiency (A)• Home environment interventions (A)

AGS/BGS 2010

OsteoporosisOsteoporosisNormal bone Osteoporotic bone

Osteoporosis literally means

“porous bones”

What are the risk factors for What are the risk factors for osteoporosis?osteoporosis?

• Low trauma fracture.• Oral steroid exposure

(any dose for > 3/12).• Hysterectomy or

premature menopause < 45 years of age.

• Amenorrhoea > 1 year• Family history of hip

fracture.• Anti-convulsants

• Some medical conditions eg. malabsorption of calcium, hypogonadism.

• Low BMI <19kg/m2

• Kyphosis• X ray evidence of

vertebral deformity or osteopenia

Calcium & Vitamin D Calcium & Vitamin D SupplementationSupplementation

• 37% of older people in institutional care are vitamin D deficient

• High dose calcium and vitamin D prevents hip fracture in institutionalised elderly people by up to 43%

• Reduces body sway and improves balance • Available as a sachet dissolved in water

Calcichew D3, Caplet; Calfovit, drink once daily, Cacit D3 2 x daily drink or a chewable tablet, Adcal D3 1 tablet twice daily (Ask GP for alternative if non-compliant)

• Few side effects – mainly gastrointestinal.

Fracture PreventionFracture Prevention•Diet

•5 a day fruit and veg

•1200 mg calcium

•800iu Vitamin D

•Avoid fizzy drinks, caffeine and excess alcohol

•Exercise

•Bone loading

•Strength training

•Site specific (hip/wrist/spine)

•Avoid smoking

•Plus falls prevention strategies

This tortoise was raised on a high protein, calcium

deficient diet. This is a terrible example of poor diet resulting in extreme deformity.

This healthy tortoise had a well balanced, calcium rich

diet

Fragility fracture through the life span1

Osteoporosis + falls = fragility fractures

1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell

2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ

“Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk”2

Morbidity from other causes

Additional morbidity from fragility fractures

The Falls registerThe Falls register

• Identifies those at risk (3/3+)• Informs the GP surgery their patient has had a fall.• Should lead to further assessment if at

risk

BenefitsBenefits

The GP practice should ‘Read Code’ the

fall: 16D

PARIS (IT system for Torbay Care Trust) holds the falls register and will send the details to the GP

practice (proforma emails Hdrive/useful resources/forms_templates/falls)

Falls PathwayFalls PathwayComplete the Falls register

01803 219700Including falls risk assessment (FRAT) tool

Falls Risk Assessment Tool (FRAT) YES NO

1*Ask the person is there a history of any fall in the previous year (include this fall)? Number of falls in previous 12 months =

2Is the patient/client on four or more medications per day?Identify number of prescribed medications.

3 Does the patient/client have a diagnosis of stroke or Parkinson’s Disease?

4 Does the patient/client report any problems with their balance?

5Is the patient/client unable to rise from a chair of knee height?Ask the person to stand up from the chair of knee height without using their arms/ask person to describe how they rise from the chair

*If the answer is YES to question 1 complete falls register3 or more positive (YES) responses = at risk of fallsIf scores >3: complete falls register if not already done and carry out a personal and environmental (multifactorial) risk assessment If scores <3 suggest: giving patient information on falls preventionTelephone the falls register to report each fall: 01803 219700

Multifactorial falls assessment

If low risk: scores <3 on FRAT : send ‘Staying Steady’ falls prevention leaflet

If at risk: scores >3 on FRAT: Should lead to further assessment:

What should happen next?What should happen next?

Falls In Hospital

NSPA 2007 identified the following risks as most significant in hospital:

• Walking unsteadily

• Being confused

• Being incontinent/needing the toilet frequently

• Previous falls

• Taking sedatives

Falls the FutureFalls the Future

Falls, fracture prevention and bone health clinical commissioning

group

If you would like to join the falls special interest group that meets quarterly email your details to jane.reddaway@nhs.net

Useful ContactsUseful Contacts• Chris Dixon, Lead Nurse, Osteoporosis.

Tel: 01803 655603 chris.dixon2@nhs.net

• Jane Reddaway, Lead OT, Osteoporosis/Falls. Tel: 07776 207358

Jane.reddaway@nhs.net

Map Of Medicine

• The national falls care pathway is available to you on the internet

http://www.mapofmedicine.com

This outlines the evidence behind falls interventions and what effective interventions can be employed to modify falls risks

ResourcesResources• NSF for Older People, Standard Six Falls

(www.doh.gov.uk)• National Osteoporosis Society

(www.nos.org.uk)• Age UK (previously Help the Aged and Age Concern)

(www.ageuk.org.uk)• Nice guidelines for Falls

(www.nice.org.uk)• Hip protectors:

– Promedics 01254 619000– BSN medical 01482 670100

email: orders.uk@bsnmedical.com – Win Health 01835 864866

Measuring Postural Drop

• Lie patient flat for 5 minutes (in silence) then take blood pressure (BP)

• Stand patient and repeating BP• Repeat at 3 minutes

Orthostatic hypotension- systolic fall more that 20mmHg, diastolic more than 10mmHg

Resources

• National Patient Safety Agency www.npsa.nhs.uk

• Royal College of Physicians National Audit for falls and bone health 2006www.rcplondon.ac.uk.

Leaflets for service users• Torbay Active Ageing leaflet 01803 208840

• What is Postural Hypotension? 01803 219745

• Having Falls? 01803 219745

Exercise ResourcesExercise Resources

Age UK DVDs –’Be Strong, Be Steady’

‘Step to the Future’ £12 each + p&p

www.ageuk.org.uk

Thank you Thank you

Any questions?Any questions?