Falls Fractures and Frailty

Dr Damian Gormley

Consultant Geriatrician Southern Trust

5th October 2017

Summary

• Epidemiology of falls

• Guidelines/Evidence

– Frailty

– Risk factors

– Interventions

• Falls, Fracture and Frailty Southern Trust

Epidemiology

• 28-35% of >65 fall each year1

• 50% of >80 fall per year

• 5% falls result in fracture and hospitalisation

• Distress, pain, injury, loss of confidence, immobility, mortality

• Effect on carers 60% fear further fall2

• £4.4 billion per year

1WHO 2007 2Liddle et al 1995

Craigavon and Banbridge

Craigavon Area Hospital

Emergency Department

Trauma and orthopaedic

inpatients

Fracture clinics

Lurgan Hospital

Falls clinic

Strength & Balance

classes (3)

Armagh and Dungannon

South Tyrone Hospital

Minor injuries Unit

DXA scanner

Falls Clinic

Mullinure Hospital

Falls clinic

Strength & Balance classes (4)

Newry and Mourne

Daisyhill Hospital

Emergency Department

Fracture clinics

Falls Clinic

Strength & Balance

classes (2 )

NISRA MYE 2014

SHSCT Population =

370000

Over 65 population =

52,556

Southern Trust NI

• Number of fallers/year=17,518

• 350 People attend ED/month

• Number of consultant falls clinics per

yr=126

• Number of new patients per year = 630

• Able to see 3.6% of fallers

• Oops!

Who should I see?

• Patients at risk of further falls

• Patients at risk of harm from falls

• Patients in whom I can alter their risk

• Patients who need a consultant to alter

their risk

NICE Guidelines CG 161 (2013)

• Ask older people have they fallen (1 yr)

– Perform gait and balance assessment

• Multifactorial risk assessment Multifactorial interventions

1. Gait/balance problem

2. Report for medical attention

3. Recurrent falls “This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service”

Gait and Balance Screen

1. Timed up and Go test

2. Turn 180º

3. Performance-oriented assessment of

mobility problems (Tinetti scale)

4. Functional reach

5. Dynamic gait index

6. Berg balance scale

Frailty

• Related to the ageing process

• Multiple body systems gradually lose their

in-built reserves

• Adverse outcomes

• Dramatic changes in wellbeing after an

apparently minor event

BGS Fit for frailty June 2014

eFI Frailty Categories

• Fit (eFIscore 0 -0.12): People who have no or few long-term conditions that are usually well controlled. This group would mainly be independent in day to day living activities.

• Mild frailty (eFIscore 0.13 –0.24): People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation.

• Moderate Frailty (eFIscore 0.25 –0.36): People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing.

• Severe Frailty (eFIscore > 0.36): People who are often dependent for personal cares and have a range of long-term conditions/multi-morbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6 -12 months

5. FOR THOSE WITH SEVERE

FRAILTY Undertake falls

assessment and medications review

• Annual review of medications.

• Annual direct review to establish if patient

has fallen in last year.

– No fall in last 12 months - No further action

– One or more falls in past 12 months - See

guidance and best practice

Risk factorsPrevious falls Relative Risk

Muscle weakness* 4.4

History of Fall 3.0

Gait deficit* 2.9

Fear of falling* 2.8

Balance problems* 2.8

Use of assist device 2.6

Visual deficit* 2.5

Arthritis 2.4

Depression* 2.2

Cognitive impairment 1.8

Psychotropic Medications* 1.7

Age >80 1.7

Perell et al 2001

NICE 2013

Intervention Evidence

• Inconsistant

• Poorly designed trials

– Not blinded

– Multiple outcomes

– Heterogeneous populations

– Variable outcomes• Risk of falling

• Time to first fall

• Rate of falling

Cochrane Review 2012Interventions for preventing falls in

older people living in the community

• 159 Trials

• 79 193 participants

• Exercise only 59 trials

• Multifactorial 40 trials

ResultsRate of falling Risk of falling

Multicomponent group Exercise 0.71* (0.63-0.82) 0.85* (0.76-0.96)

Multicomponent Home exercise 0.68 *(0.58-0.80) 0.78* (0.64-0.96)

Tai Chi 0.72 (0.52-1.00) 0.71* (0.57-0.87)

Multifactorial 0.76 *(0.67-0.86) 0.93 (0.86-1.02)

Vitamin D 1.00 (0.90-1.11) 0.96 ( 0.89-1.03)

Home Safety 0.81* (0.68-0.97) 0.88* (0.80-0.96)

Visual intervention 1.57 *(1.19-2.06) 1.54* (1.24-1.91)

Prescribing intervention 0.61* (0.41-0.91)

Interventions for preventing falls in older

people in care facilities and hospitals 2012

• 43 trials

• 30 373 participants

Rate of falling Risk of falling

Exercise 1.03 (0.81-1.31) 1.07 (0.94-1.24)

Vitamin D 0.63* (0.46-0.86) 0.99 (0.90-1.08)

Multifactorial 0.78 (0.59-1.04) 0.89 (0.77-1.02)

Secondary falls prevention

exerciseOtago Home Exercise Programme (OEP)

• – 1 yr; 3 x p/w; 6 home visits and telephone support

• – 6 mths; 3 x p/w (1 p/w group, 2 p/w home)exercise instructor

• – Effects on strength and balance in a group

Falls Management Exercise Programme (FaME/PSI)

• – 9 mths; 3 x p/w (one group, two home); includes floorwork;

• – Increases habitual physical activity as well

(Campbell 1997; Robertson 2001; Campbell 2005;

Liu_Ambrose 2008;

Kyrdalen 2014; Skelton 2005, 2008)

What works

• Greatest effects of exercise on fall rates (38% reduction) from interventionsincluding:

– Highly challenging balance training

– 3 Times a week

– High dose (50+ hours)

– Progressive strength training

– Avoid brisk walking

NICE what not to do

1. Brisk walking

2. Low intensity exercise

3. Untargeted group exercise

4. Visual intervention as single

5. Vitamin D

6. Hip protectors

Post Hospital Home Exercise

Program

• 340 older people

• 81.2 yrs. 70% fallen in past year

• 15-20 mins exercise /week (S+B-WEBB)

• 12 months

• 10 physio visits

• Falls 177 v 123 IR 1.43 (1.07-1.93)

• Fallers 98 v 70 RR 1.38 (1.11-1.73)

Sherrington et al 2014

Multifactorial intervention after a fall in older

people with cognitive impairment

• 274 patients with dementia

• >65 presented to ED after fall

• Fallers 74% v 80% RR0.92 (0.81-1.05)

• No difference

– Number of falls

– Time to first fall

– ED attendances or admissions

– Injuries

– Mortality

Shaw et al 2003 BMJ

Exercise for falls prevention in Parkinson

disease: a randomized controlled trial

• 231 PD patients

• Exercise 40-60mins x3 weekly 6 months

• Falls rate RR 0.73 (0.45-1.17)

Canning et al 2015 Neurology

Falls Fracture Frailty Pathway

Southern Trust

Fracture Liaison Service

DXA Scan

Fracture risk

assessment and falls

screen

Falls screening

no further action

required

DXA not appropriate

or feasible

Falls Service

Community based

Strength & balance

Classes

Level 2

AHP Assessment

S&B classes

Level 3

Medical

AssessmentFrail Elderly

Falls & Fracture Pathway >65

Summary

• Falls are common with potentially serious

consequences

• Not all fallers need seen

• Not all fallers need to see a doctor

• High intensity S+B exercise key in

community dwellers

• Frail patients need CGA