Preventing further falls for Preventing further falls for older people presenting to an older people presenting to an

Emergency DepartmentEmergency Department after a fallafter a fall

Developed by:National Ageing Research Institute

For further information, contact Pauline Galvin – info@nari.unimelb.edu.au

Funded by the Australian Government Department of Health and Ageing

Preventing further falls for Preventing further falls for older people presenting to an older people presenting to an

Emergency DepartmentEmergency Department after a fallafter a fall

Developed by:National Ageing Research Institute

For further information, contact Pauline Galvin – info@nari.unimelb.edu.au

Funded by the Australian Government Department of Health and Ageing

Frequency of falls in older Frequency of falls in older people (Australia)people (Australia)

Approximately 30% of community dwelling people aged Approximately 30% of community dwelling people aged 65+ experience one or more falls in a 12 month period65+ experience one or more falls in a 12 month period

2/3 of fallers presenting to an ED have fallen in the 2/3 of fallers presenting to an ED have fallen in the preceding 12 monthspreceding 12 months

Falls risk and injury risk increases with age Falls risk and injury risk increases with age – 9 times risk of hospitalisation for 85+ compared to 56-69 years9 times risk of hospitalisation for 85+ compared to 56-69 years– 40 times risk of death from accidental fall for 85+ compared to 56-40 times risk of death from accidental fall for 85+ compared to 56-

69 years69 years With our ageing population With our ageing population health costs are expected to triplehealth costs are expected to triple

by 2050 if current rates remain unchanged by 2050 if current rates remain unchanged – Requiring 2500 additional hospital beds and 3320 more nursing Requiring 2500 additional hospital beds and 3320 more nursing

home placeshome places

Definition of a fallDefinition of a fall

Need for a standard definition:Need for a standard definition:

““A fall is an event which results in a A fall is an event which results in a person coming to rest inadvertently person coming to rest inadvertently on the ground or floor or other lower on the ground or floor or other lower level”level”

(World Health Organisation)(World Health Organisation)

Includes all “slips”, “trips”, “faints”, “not concentrating” & “accidents” that fit

in the definition.

Major causes of injury related ED Major causes of injury related ED presentations in Victoria 2001 among persons presentations in Victoria 2001 among persons

aged 65+aged 65+

Falls Struck/collision Cutting/piercingTransport Natural/environment Burn/scaldPoisoning Assault MachinerySelf harm

Source: VEMD and VISAR, Autumn 2003

Falls

Why target falls prevention in the ED? (1)Why target falls prevention in the ED? (1)

14% to 26% of all presentations to hospital ED’s are 14% to 26% of all presentations to hospital ED’s are people aged over 65 years people aged over 65 years

At one large Melbourne Hospital in 2000:At one large Melbourne Hospital in 2000: 11,500 aged 60+ presented11,500 aged 60+ presented 900 had a fall recorded as the primary diagnosis900 had a fall recorded as the primary diagnosis 57% were sent directly home (516 people)57% were sent directly home (516 people)

In Victoria in 2006:In Victoria in 2006: 19,933 aged 65+ presented with an injury due to a fall19,933 aged 65+ presented with an injury due to a fall 50% were discharged home plus 21% discharged back to 50% were discharged home plus 21% discharged back to

their residential care facilitytheir residential care facilitySource: VEMD data for 2006

Falls Risk FactorsFalls Risk Factors

Usually a Usually a combination of factorscombination of factors– Intrinsic – health problems affecting balance performance Intrinsic – health problems affecting balance performance

(includes medications)(includes medications) Balance problemsBalance problems Chronic health problems (stroke, PD)Chronic health problems (stroke, PD) Cognitive impairmentCognitive impairment Vision impairment, etcVision impairment, etc ContinenceContinence

– Extrinsic – environmental hazards, and activities Extrinsic – environmental hazards, and activities associated with high falls riskassociated with high falls risk

Poor lightingPoor lighting Uneven or slippery surfacesUneven or slippery surfaces Obstacles on floorObstacles on floor

Older people presenting to an ED following Older people presenting to an ED following a fall usually a fall usually exhibit multiple risk factorsexhibit multiple risk factors

These people are at These people are at high risk of subsequent high risk of subsequent falls falls

Some evidence that ED management for Some evidence that ED management for older people presenting with a fall focuses older people presenting with a fall focuses on management of injuries, on management of injuries, but not on but not on identifying and managing causes of the falls identifying and managing causes of the falls presentationpresentation

Why target falls prevention in the ED? (2)Why target falls prevention in the ED? (2)

Research evidence – effective approaches Research evidence – effective approaches

to preventing falls (community setting)to preventing falls (community setting) There is good research evidence that a number of There is good research evidence that a number of singlesingle

interventions can reduce interventions can reduce fallsfalls::» exercise (home exercise; Tai Chi, group exercise)exercise (home exercise; Tai Chi, group exercise)» cataract extractioncataract extraction» psychotropic medication withdrawalpsychotropic medication withdrawal» home visits by Occupational Therapistshome visits by Occupational Therapists» vitamin D and calcium supplementation, vitamin D and calcium supplementation, can also reduce can also reduce falls falls

injuriesinjuries

There is good research evidence that There is good research evidence that multiplemultiple interventions, interventions, including those based on a including those based on a falls risk assessmentfalls risk assessment have also have also been shown to be effective, been shown to be effective, even in high risk groups such even in high risk groups such as people presenting to an ED after a fallas people presenting to an ED after a fall

Cognitive ImpairmentCognitive Impairment

Falls prevention strategies may need to be Falls prevention strategies may need to be different for people with cognitive different for people with cognitive impairment.impairment.

Client PerspectivesClient Perspectives

Older people can have ambivalent attitudes Older people can have ambivalent attitudes to falls prevention advice.to falls prevention advice.

Maintaining independence, rather than “falls Maintaining independence, rather than “falls prevention”, may be a more acceptable prevention”, may be a more acceptable approach to older people.approach to older people.

Best practice falls prevention in the EDBest practice falls prevention in the ED

Clear policy and procedures for screening, Clear policy and procedures for screening, assessment and referralassessment and referral

Staff educationStaff education Evidence based falls risk screening Evidence based falls risk screening

procedure appliedprocedure applied If high levels of falls risk identified, actions If high levels of falls risk identified, actions

are implemented to support further are implemented to support further assessment and management (eg referrals)assessment and management (eg referrals)

Consider osteoporosis screen Consider osteoporosis screen and Vitamin D and Vitamin D supplements supplements for people with high falls riskfor people with high falls risk

Screening of risk is a key componentScreening of risk is a key component

Identifies those at greatest risk of further Identifies those at greatest risk of further fallsfalls

Can be used to determine:Can be used to determine:– those in need of detailed falls risk assessment those in need of detailed falls risk assessment

(either by ED staff member, or referral)(either by ED staff member, or referral)– Presence of some important risk factors, which Presence of some important risk factors, which

can be used to initiate treatment referralscan be used to initiate treatment referrals

An evidence based falls risk screening tool An evidence based falls risk screening tool (1)(1)

1. History of falls (0 – 3 points) SCORENumber of falls in the past 12 months? …….. Nil in 12 months (0) 1 in the last 12 months (1) 2 or more in 12 months (2) 1 or more requiring hospitalisation in the past 12 months (3) [ ] 2. Sensory loss (0 – 1 points)Does the client have an uncorrected vision deficit that limits their functional ability? No (0) Yes (1) [ ] 

Developed from data from a study of 700 older people presenting to Melbourne EDs after a fall (project funded by Department of Veterans’ Affairs / Department of Human Services (Vic)

An evidence based falls risk screening tool An evidence based falls risk screening tool (2)(2)

 

3. Balance (0 - 3 points) SCORE

When walking and turning, does the person appear unsteady or at risk of losing their balance? (NOTE: Rate with usual walking aid. If level fluctuates, tick the most unsteady rating)

No unsteadiness observed (0) Yes, minimally unsteady (1) Yes, moderately unsteady (needs supervision) (2) Yes, consistently and severely unsteady (needs constant hands on assistance) (3) [ ]  Total Risk Score [ ]

Developed from data from a study of 700 older people presenting to Melbourne EDs after a fall (project funded by Department of Veterans’ Affairs / Department of Human Services (Vic)

An evidence based falls risk screening tool An evidence based falls risk screening tool (3)(3)

Grades for Overall Falls Risk   Low falls risk - total score 0 – 2

Recommendations: Implement actions for identified individual risk factors and recommend health promotion behaviour to minimise future ongoing risk (e.g. increased physical activity)   High falls risk - total score 3 – 7

Recommendations: Implement actions for identified individual risk factors and implement additional actions for high falls risk  

Case study – low falls riskCase study – low falls risk 88 year old man, presents to ED after a 88 year old man, presents to ED after a

fall, moderate bruising to face and fall, moderate bruising to face and knees, shaken up by fall. knees, shaken up by fall.

Reasonably active man, fell while Reasonably active man, fell while carrying 2 bags of shopping home, carrying 2 bags of shopping home, tripped on uneven footpath.tripped on uneven footpath.

Past history of hypertension, type 2 Past history of hypertension, type 2 diabetes (diet controlled), left total hip diabetes (diet controlled), left total hip replacement (good recovery).replacement (good recovery).

Feels eyesight has deteriorated in past Feels eyesight has deteriorated in past few years, hasn’t had a review for 5 few years, hasn’t had a review for 5 years.years.

No other falls in past 12 months.No other falls in past 12 months. Steady on his feetSteady on his feet

Falls risk screen scores:History of previous falls 1Sensory loss (vision) 1Balance 0

TOTAL SCORE 2

Recommended actions:Vision – advise to see an optometrist for review of visionOverall risk – low (total score = 2) – no other actions recommended

Case study – high falls riskCase study – high falls risk 83 year old lady, presents to ED 83 year old lady, presents to ED

after a fall causing moderate bruising after a fall causing moderate bruising to left hip. Fall occurred on rear to left hip. Fall occurred on rear steps at home.steps at home.

Past history of moderate Past history of moderate osteoarthritis in knees, cataracts, osteoarthritis in knees, cataracts, peripheral neuropathy.peripheral neuropathy.

Has had 2 other falls at home in past Has had 2 other falls at home in past 12 months, no serious injuries.12 months, no serious injuries.

Is a little unsteady when standing Is a little unsteady when standing from sittingfrom sitting

Falls risk screen scores:History of previous falls 2Sensory loss (vision) 1Balance 1

TOTAL SCORE 4

Recommended actions:Vision – advise to see an optometrist for review of vision.Balance – referral to physio for review and possible balance training.High risk (total score = 4) – letter to GP highlighting high risk identified.

Further assessment including consideration of an OT referral.

Where to refer for further assessment / Where to refer for further assessment / treatment (examples)treatment (examples)

Options will vary depending upon your area

Emergency Dept

General Practitioner

Community Rehabilitation

Physiotherapist

Occupational Therapist

Optometrist / ophthalmologist

Vision Australia

Falls Clinic

HARP program

Community Exercise Group

Dietitian

Podiatrist District Nursing Service

Community Health Service

SummarySummary

Older people presenting to the ED after a fall are Older people presenting to the ED after a fall are at increased risk of further fallsat increased risk of further falls

A screening tool can help identify those at high A screening tool can help identify those at high risk of recurrent falls, risk of recurrent falls,

ED can help in risk identification and referral for ED can help in risk identification and referral for assessment and treatmentassessment and treatment

Further InformationFurther Information

Information on Falls Prevention is available fromInformation on Falls Prevention is available from

Department of Human ServicesDepartment of Human Services www.health.vic.gov.au/agedcare/maintaining/falls/index.htmwww.health.vic.gov.au/agedcare/maintaining/falls/index.htm

Australian Commission on Safety and Quality in Australian Commission on Safety and Quality in HealthcareHealthcare www.www.safetyandqualitysafetyandquality.org/.org/