Transcript Falls and fracture prevention

Falls and fracture prevention
Dr Nicki Colledge
Liberton Hospital and
Royal Infirmary, Edinburgh
Why are falls important?
• 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 a
move to a care home
• Expensive:
– £909 million p.a. to the NHS
Falls and fractures
Type of fracture
Wrist
Proximal humerus
Hip
Ankle
Pelvis
Face
Tibia/fibula
Face
Vertebral
Percentage attributed to
falls by older women
96
95
92
88
80
77
65
59
<25
Osteoporosis
• >300,000 osteoporotic fractures
p.a.
• Estimated costs = £1.7 billion/year
• 47, 471 hip fractures p.a.
Normal bone
– 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 women
aged over 75 would rather die than have
a hip fracture that led to admission to a
nursing home
Osteoporotic bone
Why are old people so prone to falls?
Balance and Ageing: reaction times
Annual prevalence of falls in older women and
number 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
Lawlor, D. A et al. BMJ 2003;327:712-717
Copyright ©2003 BMJ Publishing Group Ltd.
Who is at risk of falling?
Risk factors for falls
Risk factor
Muscle weakness
History of falls
Gait deficit
Balance deficit
Walking aid use
Visual deficit
Arthritis
Impaired ADL
Depression
Cognitive impairment
Psychoactive drugs
Age >80
Relative risk ratio/Odds
ratio
4.4
3.0
2.9
2.9
2.6
2.5
2.4
2.3
2.2
1.8
1.7
1.7
AGS et al. J Amer Geriatr Soc 2001
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
Environmental hazards
• A third to a half of falls are due to environmental factors
e.g. inappropriate footwear and walking aids
• Falls cannot be predicted from the number of hazards
present
• Trips often occur on objects not assessed as hazardous
Falls risk factors increase the risk of fracture
Independent risk factors for # in those over 75 years:
↓muscle strength
↑postural sway
visual impairment
neuromuscular impairments
Nguyen et al. BMJ 1993
EPIDOS study. Lancet,1996
Can falls (and fractures) be prevented?
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
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
Effective interventions for falls prevention
Cochrane Review Update 2004
1.Multidisciplinary, multifactorial risk factor screening and
intervention
Population
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)
Effective interventions
2. Muscle strengthening and balance retraining
– Individually prescribed
– Delivered in patient’s 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)
Effective interventions
4. Withdrawl of psychotropic medication
RR 0.34 (95% CI 0.16-0.74)
5. Cardiac pacing for fallers with Carotid Sinus Syndrome
WMD -5.20 (95% CI -9.4- -1.0)
6. Tai Chi group exercise intervention
RR 0.51 (95% CI 0.36-0.73)
Cataract surgery and falls
• RCT of expedited cataract surgery (approx 4 weeks) vs
routine wait (12 months)
– 306 women aged >70 randomised
• Rate of falling: reduced by 34% in the early surgery
group after 12 months (p<0.03)
• Fractures: reduced from 8% in controls to 3% in the
early surgery group (p<0.04)
Harwood et al, Br J Ophthalmol 2005
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
Case / Risk identification
• Older people should be asked routinely if they
have fallen in the past year.
– + frequency, context and characteristics of the
fall(s)
• Those who have fallen or who are considered at
risk, should be observed for balance and gait
deficits.
– Get up and go test
NICE guideline 21
Falls history
Medication
review
Gait, balance
and mobility
Visual
impairment
Cognitive
impairment
Functional ability/
fear of falling
Multifactorial
assessment
Neurological
examination
Cardiovascular
examination
Urinary
continence
Osteoporosis risk
NICE guideline 21
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
Applying the guidelines to the individual
• Treat any acute illness that precipitated the fall
• Treat specific conditions affecting balance
e.g Parkinson’s 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
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.uk
SIGN guideline 71, www.sign.ac.uk
Uncertainties
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)
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
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 community
settings: 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 and
their effectiveness in an institutional setting is uncertain.
Parker et al. BMJ 2006
Falls prevention in dementia:
• Multifactorial intervention in patients with cognitive
impairment
– RCT of those with MMSE of <24 found no benefit
from multifactorial assessment and intervention after
a fall which led to presentation to A&E
(Shaw et al, BMJ 2003:326:73)
• Hospital and Care homes meta-analysis:
– Meta-regression showed no significant association
between effect size and prevalence of dementia or
cognitive impairment
From guidelines to service delivery
England and Wales: Older People’s NSF Standard on Falls 2001:
• NHS (with local councils) should take action to reduce falls and
resultant injuries in their older populations
– All who have fallen should receive effective treatment and
rehabilitation, 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
Scotland???
• Falls have not been a National Executive or
health 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 emergency
services
– Bolting on osteoporosis management
– Acceptability of programmes to older people
– Cost effectiveness?
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 services
with 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
City of Edinburgh Falls and Fracture
Prevention Pathway
WHERE SHOULD THEY BE REFERRED?
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 don’t fulfill RRT criteria
OPTHALMOLOGY: Cataracts
City of Edinburgh Falls and Fracture
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 pressure
problems are identified or ?reason for poor balance.
Fracture prevention =
Falls prevention
+
Osteoporosis treatment
Next challenge: a comprehensive integrated service for all
with falls and fractures
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
Downloaded from: StudentConsult (on 10 September 2006 03:19 PM)
© 2005 Elsevier
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
Vitamin D and Calcium
• Residents of care homes or specialist housing for the
elderly
– Non-vertebral fracture reduced by 32%
– Hip fracture reduced by 43%
• Those with previous fragility fractures living in the
community
– No reduction in fractures
• ?beneficial effects on neuromuscular function associated
with falls
Chapuy MC et al. N Engl J Med1992
Porthouse J et al. BMJ 2005
Grant AM et al. Lancet 2005
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 community
settings: 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 and
their effectiveness in an institutional setting is uncertain.
Parker et al. BMJ 2006
Falls and fracture prevention
•
•
•
•
•
•
•
Balance and ageing
Risk factors for falls
Falls prevention: Evidence
Falls prevention: Guidelines
Applying the guidelines
National developments
Local services