Falls

1
Falls

• Dr. Fiona Shaw
• Consultant Geriatrician
• Rehabilitation and Intermediate Care Services

2
Overview

• Background
• Evidence
• Risk factors and causes of falls
• GP interventions
• Orthostatic hypotension
• Case
• Services - current
• Proposed service improvements
• New guidelines etc.
• Websites

3
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

4
Local background
Newcastle population age gt 65 41,500

• 35 65 fall pa
• 5 fracture
• Fractures in AE
• Fallers seen by services

• 14, 525 24,900
• 726 1245
• 1710 (age gt 50)
• 1500

Actual figures 2007
5
Reactions?

• Oh gosh! I must refer more patients to falls
  clinics
• The falls services couldnt possibly cope with
  those numbers dont be silly!
• I would refer more patients with falls if there
  were more appropriate services
• Theres no evidence for falls clinics so why
  would I waste money sending more patients there?

6
Falls clinics negative press

• The evidence indicates falls clinics have
  negligible clinical effect Scoping exercise on
  fallers clinics SDO 2008
• Actually didnt 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

7
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

8
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

9
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
10
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

11
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

12
Risk factors causes of falls

• How many can you name in 2 minutes?

13
Risk factors causes of falls

• General medical problems e.g. UTI, anaemia
• Visual impairment
• Medication
• Depression
• Specific diagnoses e.g. Parkinsons 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..

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What should the GP be doing?

• Your views?

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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

16
Measuring orthostatic blood pressure

• Whats the physiology?
• How do you do it?

17
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

18
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?

19
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?

20
Falls case

• 24 hour ECG SR 51 - 82
• 24 hour Bp
• Lisinopril stopped (kept Atenolol not too
  bradycardic, previous MI, good history OH)

21

• If the history is good,
• think of OH and low BP
• in spite of surgery readings
• Beware white coat hypertension

22
Current falls services

• Falls and Syncope Service, RVI
• Belsay and Melville Day Hospitals, NGH FRH
• Community Resources Teams (North, East, West)
• Osteoporosis Service, FRH

23
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

24
What can you expect?
25
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

26
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,
  AE

27
New guidelines etc.
28
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

29
RCP Falls Bone Health (2007)

• Most patients returning from AE 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

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Useful web links

• www.shef.ac.uk/FRAX
• www.helptheaged.org.uk
• www.rcplondon.ac.uk
• www.ic.nhs.uk
• www.profane.eu.org