Preventing further falls for

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Preventing further falls for older people
presenting to an Emergency Department after a
fall Developed by National Ageing Research
Institute For further information, contact
Pauline Galvin info_at_nari.unimelb.edu.au Funded
by the Australian Government Department of Health
and Ageing
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Frequency of falls in older people (Australia)

• Approximately 30 of community dwelling people
  aged 65 experience one or more falls in a 12
  month period
• 2/3 of fallers presenting to an ED have fallen in
  the preceding 12 months
• Falls risk and injury risk increases with age
• 9 times risk of hospitalisation for 85 compared
  to 56-69 years
• 40 times risk of death from accidental fall for
  85 compared to 56-69 years
• With our ageing population health costs are
  expected to triple by 2050 if current rates
  remain unchanged
• Requiring 2500 additional hospital beds and 3320
  more nursing home places

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Definition of a fall

• Need for a standard definition
• A fall is an event which results in a person
  coming to rest inadvertently on the ground or
  floor or other lower level
• (World Health Organisation)

Includes all slips, trips, faints, not
concentrating accidents that fit in the
definition.
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Major causes of injury related ED presentations
in Victoria 2001 among persons aged 65
Falls
Source VEMD and VISAR, Autumn 2003
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Why target falls prevention in the ED? (1)

• 14 to 26 of all presentations to hospital EDs
  are people aged over 65 years
• At one large Melbourne Hospital in 2000
• 11,500 aged 60 presented
• 900 had a fall recorded as the primary diagnosis
• 57 were sent directly home (516 people)
• In Victoria in 2006
• 19,933 aged 65 presented with an injury due to a
  fall
• 50 were discharged home plus 21 discharged back
  to their residential care facility

Source VEMD data for 2006
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Falls Risk Factors

• Usually a combination of factors
• Intrinsic health problems affecting balance
  performance (includes medications)
• Balance problems
• Chronic health problems (stroke, PD)
• Cognitive impairment
• Vision impairment, etc
• Continence
• Extrinsic environmental hazards, and activities
  associated with high falls risk
• Poor lighting
• Uneven or slippery surfaces
• Obstacles on floor

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Why target falls prevention in the ED? (2)

• Older people presenting to an ED following a fall
  usually exhibit multiple risk factors
• These people are at high risk of subsequent falls
  
• Some evidence that ED management for older people
  presenting with a fall focuses on management of
  injuries, but not on identifying and managing
  causes of the falls presentation

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Research evidence effective approaches to
preventing falls (community setting)

• There is good research evidence that a number of
  single interventions can reduce falls
• exercise (home exercise Tai Chi, group exercise)
• cataract extraction
• psychotropic medication withdrawal
• home visits by Occupational Therapists
• vitamin D and calcium supplementation, can also
  reduce falls injuries
• There is good research evidence that multiple
  interventions, including those based on a falls
  risk assessment have also been shown to be
  effective, even in high risk groups such as
  people presenting to an ED after a fall

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Cognitive Impairment

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

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Client Perspectives

• Older people can have ambivalent attitudes to
  falls prevention advice.
• Maintaining independence, rather than falls
  prevention, may be a more acceptable approach to
  older people.

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Best practice falls prevention in the ED

• Clear policy and procedures for screening,
  assessment and referral
• Staff education
• Evidence based falls risk screening procedure
  applied
• If high levels of falls risk identified, actions
  are implemented to support further assessment and
  management (eg referrals)
• Consider osteoporosis screen and Vitamin D
  supplements for people with high falls risk

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Screening of risk is a key component

• Identifies those at greatest risk of further
  falls
• Can be used to determine
• those in need of detailed falls risk assessment
  (either by ED staff member, or referral)
• Presence of some important risk factors, which
  can be used to initiate treatment referrals

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An evidence based falls risk screening tool (1)
1. History of falls (0 3 points)

SCORE Number 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)
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An evidence based falls risk screening tool (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)
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An evidence based falls risk screening tool (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
•  
•  

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Case study low falls risk

• 88 year old man, presents to ED after a fall,
  moderate bruising to face and knees, shaken up
  by fall.
• Reasonably active man, fell while carrying 2 bags
  of shopping home, tripped on uneven footpath.
• Past history of hypertension, type 2 diabetes
  (diet controlled), left total hip replacement
  (good recovery).
• Feels eyesight has deteriorated in past few
  years, hasnt had a review for 5 years.
• No other falls in past 12 months.
• Steady on his feet

Falls risk screen scores History of previous
falls 1 Sensory loss (vision) 1 Balance
0 TOTAL SCORE 2
Recommended actions Vision advise to see an
optometrist for review of vision Overall risk
low (total score 2) no other actions
recommended
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Case study high falls risk

• 83 year old lady, presents to ED after a fall
  causing moderate bruising to left hip. Fall
  occurred on rear steps at home.
• Past history of moderate osteoarthritis in
  knees, cataracts, peripheral neuropathy.
• Has had 2 other falls at home in past 12 months,
  no serious injuries.
• Is a little unsteady when standing from sitting

Falls risk screen scores History of previous
falls 2 Sensory loss (vision)
1 Balance 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.
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Where to refer for further assessment / treatment
(examples)
General Practitioner
HARP program
Community Health Service
Falls Clinic
Community Exercise Group
District Nursing Service
Podiatrist
Emergency Dept
Physiotherapist
Vision Australia
Optometrist / ophthalmologist
Community Rehabilitation
Occupational Therapist
Dietitian
Options will vary depending upon your area
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Summary

• Older people presenting to the ED after a fall
  are at increased risk of further falls
• A screening tool can help identify those at high
  risk of recurrent falls,
• ED can help in risk identification and referral
  for assessment and treatment

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Further Information

• Information on Falls Prevention is available from
• Department of Human Services www.health.vic.gov.au
  /agedcare/maintaining/falls/index.htm
• Australian Commission on Safety and Quality in
  Healthcare www.safetyandquality.org/