Transcript Slide 1

Falls
Dr. Fiona Shaw
Consultant 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……
QRESEARCH
Evaluation of standards of care for osteoporosis and falls in primary care, 2007
Local background
Newcastle population age > 65 = 41,500
 35 – 65 % fall pa
 14, 525 – 24,900
 5% fracture
 726 – 1245
Actual figures 2007
Fractures in A&E:  1710 (age > 50)
Fallers seen by services:  1500
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?
Research base:
 Medication review
 Orthostatic blood pressure
 Gait, balance, strength
 Environmental hazards
 Vision
 Cardiovascular
 Education
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….
Robust evidence to support:
 multifactorial assessment
and intervention delivered
by MDT
and
 targeted strength and
balance exercises in
community populations as a
single intervention
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 minutes
supine rest, beat to beat blood pressure
reading 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 BP
in 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 intervention
Hx, Ex, ECG, AS, OPx, PT
FASS
Prolonged cardiac
& Bp monitoring
CSM, HUT
Specialist vestibular
OT
Day Hospital / CRT
for MDT
Day Hospitals
Prolonged cardiac
& Bp monitoring
Basic vestibular
Vestibular rehab
Full MDT
Falls Groups
FASS for CSM / HUT
CRT
MDT 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