Falls

Dr. Fiona ShawConsultant Geriatrician

Rehabilitation and Intermediate Care Services

Overview Background Evidence Risk factors and causes of falls GP interventions Orthostatic hypotension Case Services - current Proposed service improvements New guidelines etc. Websites

Background Less than 1 in 50 older people recorded as

having a high risk of falling has a recorded referral to a falls service or exercise programme

….in part due to not entering data…. ….workload of falls services would increase

substantially……

QRESEARCHEvaluation of standards of care for osteoporosis and falls in primary care, 2007

Local background

35 – 65 % fall pa

5% fracture

Fractures in A&E:

Fallers seen by services:

14, 525 – 24,900

726 – 1245

1710 (age > 50)

1500

Newcastle population age > 65 = 41,500

Actual figures 2007

Reactions?

a Oh gosh! I must refer more patients to falls clinics

b The falls services couldn’t possibly cope with those numbers – don’t be silly!

c I would refer more patients with falls if there were more appropriate services

d There’s no evidence for falls clinics so why would I waste money sending more patients there?

Falls clinics – negative press ‘The evidence indicates falls clinics have negligible

clinical effect’ Scoping exercise on fallers clinics SDO 2008 Actually didn’t have data to comment

BMJ article ‘Multifactorial falls assessment and intervention’ Lamb et al 2008 Only 6 of 19 trials were of multifactorial assessment and

intervention ‘High intensity interventions’ successful Contrast Campbell and Robertson 2007 and Chang

et al 2004 and NICE 2004

What is the evidence? Good evidence:

Multi-factorial assessment and intervention provided by MDT

Targeted strength and balance exercise (community populations)

Some evidence Home hazard assessment alone Medication review alone Correction of visual impairment alone

Multifactorial assessment and intervention Assessments and interventions delivered by MDT:

Campbell 2007: 6 RCTs: RR 0.78 (0.68 – 0.89) Chang 2004: 8 RCTs: RR 0.82 (0.72 – 0.94) Gates 2008: higher intensity int: RR 0.84 (0.74 – 0.96) Chang 2004: falls / month: 0.63 (0.49 – 0.83) Chang 2004: NNT to prevent 1 person falling/year = 11

There is lots of evidence to support multifactorial assessment and intervention delivered by a multidisciplinary team

What should be included?

Medication review Orthostatic blood pressure Gait, balance, strength Environmental hazards Vision Cardiovascular Education

Research base:

Agrees with NICE – added a few more

Targeted balance and strength exercises Meta-analyses:

Chang 2004: 13 RCTs: RR 0.86 (0.75 – 0.99) Gillespie 2003: RR 0.80 (0.66 – 0.98)

Individual result (FaME, Skelton 2005): 30% reduction in falls over 18 months 32% reduction in death or move to institutional care

at 3 years

Again good evidence to support targeted balance and strength exercises as per NICE

So in summary….

multifactorial assessment and intervention delivered by MDT

and

targeted strength and balance exercises in community populations as a single intervention

Robust evidence to support:

Risk factors & causes of falls

How many can you name in 2 minutes?

Risk factors & causes of falls General medical problems

e.g. UTI, anaemia Visual impairment Medication Depression Specific diagnoses e.g.

Parkinson’s Stroke Cognitive impairment /

dementia Gait and balance

impairments Muscle weakness Inappropriate footwear Inappropriate aids Feet Environment

Low blood pressure Orthostatic hypotension Vasovagal syncope CSH Cardiac arrhythmia Drop attacks BPPV Acute vestibular problems Cerebrovascular disease Epilepsy Narcolepsy Vertebrobasilar insufficiency Psychogenic etc…..

What should the GP be doing?

Your views?

What do I think the GP should be doing? Looking for underlying general medical

problems – UTI, chest infection, anaemia, malignancy, etc

Checking for injuries Reviewing medication – esp recent changes Checking pulse, BP, orthostatic hypotension Assessing (briefly) mobility, gait and balance Thinking about osteoporosis Looking at others issues e.g. safety at home Referring to falls services

Measuring orthostatic blood pressure

What’s the physiology?How do you do it?

Orthostatic hypotension Mechanism – venous pooling on standing Contributing mechanisms – impaired heart rate

response, volume depletion, impaired cerebral circulation and autoregulation, medication, other diseases

Result: Falls or Syncope

Measurement GP: LYING (10 mins!?) and standing at / within 2 minutes, should be in the morning

Measurement Falls Clinic: 10 minutessupine rest, beat to beat blood pressurereading recording at 30 secs, 1 min, 90 secs, 2 mins, in the morning

Falls case

Female – 88 years old – independent 2 falls – tripped on paving stones Lightheaded but Bp 160/70, no postural drop PMH – MI 1998

Medications: Atenolol 50mg od, Aspirin 75mg od, Lisinopril 10 mg od, Zopiclone 7.5 mg nocte

What did we do for our initial assessment? What did we find?

Falls case History – lightheaded esp mornings, standing

quickly, up from bending Exam – unsteady initial standing, blind L eye

Bloods – normal 12 lead ECG – SR 62 / min (rate 48 / min 2007) Active stand – No OH DXA – osteoporosis – treatment commenced Physio

Do we need to do anything else?

Falls case 24 hour ECG SR 51 - 82

24 hour Bp

Lisinopril stopped (kept Atenolol – not too bradycardic, previous MI, good history OH)

If the history is good,think of OH and low BPin spite of surgery readings

Beware white coat hypertension

Current falls services

Falls and Syncope Service, RVI Belsay and Melville Day Hospitals, NGH & FRH Community Resources Teams (North, East, West) Osteoporosis Service, FRH

Who do we want to see?

3 or more falls in past year 1 or 2 falls and unsteady walking Unsteady walking and other risk factor – inc 4

or more medications Fall presenting to medical attention

What can you expect?

Multifactorial falls assessment and interventionHx, Ex, ECG, AS, OPx, PT

FASSProlonged cardiac & Bp monitoring

CSM, HUTSpecialist vestibular

OTDay Hospital / CRT

for MDT

Day HospitalsProlonged cardiac& Bp monitoringBasic vestibularVestibular rehab

Full MDTFalls Groups

FASS for CSM / HUT

CRTMDT at home

Day Hospital for other

Interventions provided Medication changes Physio gait, balance and strength exercises Treatment for OH General medical Podiatry OT Treatment for VVS Vestibular rehabilitation Driving advice SW PPM (via cardiology) – CSH, bradyarrhythmia Psychiatry (psychology) referral Referral to: ENT, neurology, specialist bone, ophthalmology

Proposed service improvements

Expand referral criteria – any fall (or blackout) Simplify referral mechanism – FAB hotline Fill some gaps - Staying Steady exercise groups

CommFASS Joint standards of working across all services and

more explicit joint working Expansion and better profile for existing services DXA scanning West of City (Belsay) Improved links with others – orthopaedics, ENT,

A&E

New guidelines etc.

A new ambition for old age (2006)

To extend initiatives to improve exercise, balance, medicines management & footwear

To improve emergency response To have a falls assessment service for people

with recurrent falls To increase capacity in osteoporosis To improve rehabilitation services for people

who have lost functional ability or confidence after a fall

RCP Falls & Bone Health (2007)

Most patients returning from A&E after a low impact fracture were not offered multidisciplinary falls risk assessment

Only 22% were referred for exercise training After 3 months only 20% on appropriate treatment for

osteoporosis

For the minority of patients who attended a falls clinic, falls and fracture risk assessments and treatments were better

www.rcplondon.ac.uk

Useful web links www.shef.ac.uk/FRAX www.helptheaged.org.uk

www.rcplondon.ac.uk www.ic.nhs.uk

www.profane.eu.org