Falls Prevention for SPRs Feb 07

7/28/2019 Falls Prevention for SPRs Feb 07

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Falls and fracture prevention

Dr Nicki Colledge

Liberton Hospital and

Royal Infirmary, Edinburgh


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Why are falls important?


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High incidence:

30% of those over 65 report a fall each year Rises to 60% of those in care homes

Sometimes fatal: 85% of deaths due to accidents at home are caused by

falls in those over 65 Injuries are frequent:

Falls cause 1 million non-fatal injuries per year

Psychological impact:

Fear of falling is the most frequent reason given for amove to a care home

Expensive: 909 million p.a. to the NHS


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Falls and fractures

Type of fracture Percentage attributed to

falls by older women

Wrist

Proximal humerusHip

Ankle

Pelvis

Face

Tibia/fibula

Face

Vertebral

96

9592

88

80

77

65

59


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Osteoporosis

>300,000 osteoporotic fracturesp.a.

Estimated costs = 1.7 billion/year

47, 471 hip fractures p.a. 90% occur in people aged over 50

40% die within the next year

Estimated cost of treatment and care:7.26million/year

Cost to the individual: 80% of womenaged over 75 would rather die than havea hip fracture that led to admission to anursing home

Normal bone

Osteoporotic bone


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Why are old people so prone to falls?


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Balance and Ageing: reaction times


8/46Copyright 2003 BMJ Publishing Group Ltd.

Lawlor, D. A et al. BMJ 2003;327:712-717

Annual prevalence of falls in older women andnumber of simultaneous chronic diseases

Chronic diseases included

e.g. circulatory disease,

depression, and arthritis

Crude data adjusted for age,

each drug taken, BMI, alcohol

consumption, Hb concentration

and social class


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Who is at risk of falling?


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Risk factors for falls

Risk factor Relative risk ratio/Oddsratio

Muscle weakness

History of falls

Gait deficit

Balance deficitWalking aid use

Visual deficit

Arthritis

Impaired ADL

DepressionCognitive impairment

Psychoactive drugs

Age >80

4.4

3.0

2.9

2.92.6

2.5

2.4

2.3

2.21.8

1.7

1.7

AGS et al. J Amer Geriatr Soc 2001


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Cardiovascular disease and falls

Increased prevalence of falls in those with: Intermittent claudication

Post-prandial hypotension

Lower standing systolic blood pressure

Overlap between symptoms of falls and syncope

Causal association identified with

Postural hypotension Carotid sinus syndrome

Vasovagal syndrome


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Environmental hazards

A third to a half of falls are due to environmental factorse.g. inappropriate footwear and walking aids

Falls cannot be predicted from the number of hazardspresent

Trips often occur on objects not assessed as hazardous


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Falls risk factors increase the risk of fracture

Independent risk factors for # in those over 75 years:

Nguyen et al. BMJ 1993

EPIDOS study. Lancet,1996

muscle strength

postural sway

visual impairment

neuromuscular impairments


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Can falls (and fractures) be prevented?


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PROFET :Preventing falls in patients presenting to A&E

Patients aged > 65 attending A & E with a fall

184 randomised to medical and Occupational Therapy assessment

213 controls

Medical assessment and treatment of cause of fall

72% balance impairment

59% visual impairment

34% cognitive impairment

28% reduced muscle power

20% peripheral neuropathy

17% cardiovascular disorders

OT home visit: safety education and environmental adaptations

Close et al, Lancet 1999


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PROFET: results

12 months later:

183 falls in intervention group

510 falls in controls (p=0.0002)

Outcome Odds ratio (95% C.I.)

Reduction in any fall 0.39 (0.23-0.66)

Reduction in recurrent falls 0.33 (0.16-0.68)

Reduction in hospital admission 0.61 (0.35-1.05)

Close, J et al. Lancet 1999;353:93


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Effective interventions for falls prevention

Cochrane Review Update 2004

1.Multidisciplinary, multifactorial risk factor screening and

interventionPopulation RR 95% C.I.

Unselected 0.73 0.63-0.85

History of falls or risk factors 0.86 0.76-0.98

In Residential care 0.60 0.50-0.73

Gillespie LD et al, The Cochrane Library, Issue 3, 2004.

Oxford Update Software. (www.cochrane.co.uk)


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Effective interventions

2. Muscle strengthening and balance retraining

Individually prescribed

Delivered in patients home by a health professional

RR 0.80 (95% C.I. 0.66-0.98)

3.Home hazard assessment and modification Professionally prescribed

In those who have fallen (only)RR 0.66 (95% C.I. 0.54-0.81)


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Effective interventions

4. Withdrawl of psychotropic medication

RR 0.34 (95% CI 0.16-0.74)

5. Cardiac pacing for fallers with Carotid Sinus SyndromeWMD -5.20 (95% CI -9.4- -1.0)

6. Tai Chi group exercise intervention

RR 0.51 (95% CI 0.36-0.73)


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Cataract surgery and falls

RCT of expedited cataract surgery (approx 4 weeks) vsroutine wait (12 months)

306 women aged >70 randomised

Rate of falling: reduced by 34% in the early surgerygroup after 12 months (p


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NICE guideline 21 : Assessment and

prevention of falls in older people

Key priorities

Case/risk identification

Multifactorial Falls risk assessment Multifactorial interventions

Encouraging older people to participate in these

Professional education

National Institute for Clinical Excellence

NICE.gov.uk


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Gait, balance

and mobility

Visual

impairment

Cognitive

impairment

Cardiovascularexamination

Osteoporosis risk

Urinary

continence

Neurological

examination

Functional ability/

fear of falling

Medication

review

Falls history

Multifactorial

assessment

NICE guideline21


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Multifactorial intervention

Individualised to patient according to diagnosis,causes and risk factors

Most successful programmes include:

Strength and balance training

Home hazard assessment and intervention

Vision assessment and referral

Medication review and modification

NICE guideline 21


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Applying the guidelines to the individual

Treat any acute illness that precipitated the fall

Treat specific conditions affecting balance

e.g Parkinsons disease, osteoarthrosis, stroke

Correct postural hypotension or arrhythmia

Rationalise medication especially psychotropic agents

Correct visual impairment where possible

Physiotherapy: balance and strength training

OT: environmental hazard check, safety awareness

Commence osteoporosis treatment where indicated


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Treatment of osteoporosis in older women

In those with 1 fragility fracture and/or +ve DEXA

Bisphosphonate: Alendronate or Risedronate

+ Vitamin D and Calcium

Not tolerated or contra-indicated

Raloxifene (or Strontium ranelate)

Further fractures or very severe osteoporosis

Teriparatide

NICE Technological Appraisal 87,

www.nice.org.ukSIGN guideline 71, www.sign.ac.uk


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Uncertainties


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Falls prevention in hospitals and care homes

Meta-analysis of the evidence for strategies to prevent falls or fractures in

care home residents or hospital in-patients (Oliver et al BMJ 2007; 334:82)

Care homes:

Hip protectors reduced hip

fractures by 0.67 (CI 0.46-0.98)but

Hospitals:

Multifaceted interventions reduced

falls rate (0.82 (C.I. 0.68-0.997)


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Other interventions investigated:

Multifaceted interventions in care homes

Single interventions:

Physical restraint removal

Fall alarm devices

Exercise in care homes

Calcium and vitamin D in care homes

Changes in physical environment

Medication review in hospitals


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Hip protectors

Cochrane review 2006

Meta-analysis of 11 trials in care home settings:

Reduction in incidence of hip fracture (RR 0.77 (95% C.I. 0.62-0.97)(but weak cluster randomisation methodology in 7 trials)

Meta-analysis of 3 individually randomised trials in communitysettings: No reduction (RR 1.16 (95% C.I. 0.85-1.59)

Poor acceptance (median 68%) and compliance rates (median 56%)

Conclusion: hip protectors are ineffective for those living at home andtheir effectiveness in an institutional setting is uncertain.

Parker et al. BMJ 2006


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Falls prevention in dementia:

Multifactorial intervention in patients with cognitiveimpairment

RCT of those with MMSE of


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From guidelines to service delivery

England and Wales:Older Peoples NSF Standard on Falls 2001:

NHS (with local councils) should take action to reduce falls andresultant injuries in their older populations

All who have fallen should receive effective treatment andrehabilitation, and advice through a specialised falls service

Response

Falls registers for those at risk

Falls specialist nurses

Falls service coordinators Integrated Care Pathways

Consultant-led falls clinics

Exercise classes and safety advice


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Scotland???

Falls have not been a National Executive orhealth board priority

Key challenges Scale of problem: at least 15% of those over 65 years? Delivery of annual check for falls

Follow up of A&E attenders with falls

Follow up of those helped up at home by emergencyservices

Bolting on osteoporosis management

Acceptability of programmes to older people

Cost effectiveness?


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Cit f Edi b h F ll d F t


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City of Edinburgh Falls and Fracture

Prevention Pathway

WHO SHOULD BE REFERRED?

All those with more than one fall in the past year

All those who have presented to the medical serviceswith a fall

All those who have had one fall in the past year and are

unsteady on a Get up and Go test

Those whose falls are possible blackouts


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Prevention Pathway

RAPID RESPONSE TEAMS

Housebound

2 falls in the past month

Injury sustained due to fall

DAY HOSPITAL

(Liberton or Royal Victoria or Leith)

Blackouts

Unsteady with no obvious cause

Postural hypotension that is difficult

to control Patients who dont fulfill RRT criteria

WHERE SHOULD THEY BE REFERRED?

OPTHALMOLOGY: Cataracts


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Prevention Pathway

WHAT INTERVENTIONS TAKE PLACE?

Full MDT assessment + Physio: strength and balance training

OT: home hazard assessment and safety advice Integrated Care pharmacist team: medication review

Osteoporosis risk assessment and referral for DEXA if needed

Postural blood pressure check

Referral back to GP where medication or blood pressureproblems are identified or ?reason for poor balance.


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Fracture prevention =

Falls prevention

+

Osteoporosis treatment

Next challenge: a comprehensive integrated service for all

with falls and fractures


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Downloaded from: StudentConsult (on 10 September 2006 03:19 PM)

2005 Elsevier

Measurement of Bone Mineral Density:

Dual energy X ray absorptiometry (DEXA)

T score = no of SD by which patient differs from mean peak BMD for young normal subjects

Z score = no of SD by which patient differs from BMD in subjects of the same age

OSTEOPENIA: T-score -1 to -2.5

OSTEOPOROSIS: T-score < -2.5


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Non-pharmacological interventions

High intensity strength training

Low impact weight bearing exercise

Dietary intake of calcium = 1000mg/day+ stop smoking

moderate alcohol intake

Scottish Intercollegiate Guidelines Network

SIGN 71: Management of Osteoporosis

www.sign.ac.uk


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Vitamin D and Calcium

Residents of care homes or specialist housing for theelderly

Non-vertebral fracture reduced by 32%

Hip fracture reduced by 43%

Those with previous fragility fractures living in thecommunity

No reduction in fractures

?beneficial effects on neuromuscular function associatedwith falls

Chapuy MC et al. N Engl J Med1992

Porthouse J et al. BMJ 2005

Grant AM et al. Lancet 2005


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Hip protectors

Cochrane review 2006

Meta-analysis of 11 trials in care home settings:

Reduction in incidence of hip fracture (RR 0.77 (95% C.I. 0.62-0.97)

Meta-analysis of 3 individually randomised trials in communitysettings: No reduction in hip fracture (RR 1.16 (95% C.I. 0.85-1.59)

Poor acceptance (median 68%) and compliance rates (median 56%)

Conclusion: hip protectors are ineffective for those living at home andtheir effectiveness in an institutional setting is uncertain.

Parker et al. BMJ 2006


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Falls and fracture prevention

Balance and ageing

Risk factors for falls

Falls prevention: Evidence Falls prevention: Guidelines

Applying the guidelines

National developments

Local services

Falls Prevention for SPRs Feb 07

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