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 Percentage attributed to falls by older women

Wrist Proximal humerus Hip Ankle Pelvis Face Tibia/fibula Face Vertebral

96 95 92 88 80 77 65 59 <25

a.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 Normal bone Osteoporotic bone .000 osteoporotic fractures p.7 billion/year • 47. • Estimated costs = £1.a. – 90% occur in people aged over 50 – 40% die within the next year – Estimated cost of treatment and care: £7.Osteoporosis • >300. 471 hip fractures p.

Why are old people so prone to falls? .

Balance and Ageing: reaction times .

D.327:712-717 Copyright ©2003 BMJ Publishing Group Ltd. BMJ 2003. BMI.Annual prevalence of falls in older women and number of simultaneous chronic diseases Chronic diseases included e. . circulatory disease. A et al.g. depression. alcohol consumption. Hb concentration and social class Lawlor. and arthritis Crude data adjusted for age. each drug taken.

Who is at risk of falling? .

8 1.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 4.0 2.5 2.7 AGS et al.9 2.4 2.3 2.2 1. J Amer Geriatr Soc 2001 .4 3.9 2.6 2.7 1.

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. inappropriate footwear and walking aids • Falls cannot be predicted from the number of hazards present • Trips often occur on objects not assessed as hazardous .g.

1996 .Falls risk factors increase the risk of fracture Independent risk factors for # in those over 75 years: ↓muscle strength visual impairment ↑postural sway neuromuscular impairments Nguyen et al. BMJ 1993 EPIDOS study. Lancet.

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 .

0002) Outcome Reduction in any fall Reduction in recurrent falls Reduction in hospital admission Odds ratio (95% C.39 (0.05) Close.16-0.353:93 .61 (0.PROFET: results • 12 months later: – 183 falls in intervention group – 510 falls in controls (p=0. Lancet 1999.35-1.I. J et al.66) 0.23-0.68) 0.33 (0.) 0.

Effective interventions for falls prevention Cochrane Review Update 2004 1.85 0. 2004.73 Gillespie LD et al.co.I. Issue 3.cochrane.uk) . Oxford Update Software.Multidisciplinary. (www.86 0.73 0.98 0.50-0. The Cochrane Library. 0.60 95% C. multifactorial risk factor screening and intervention Population Unselected History of falls or risk factors In Residential care RR 0.76-0.63-0.

80 (95% C.98) 3.81) . Home hazard assessment and modification – Professionally prescribed – In those who have fallen (only) RR 0.54-0.66 (95% C. 0.I.I. 0. Muscle strengthening and balance retraining – Individually prescribed – Delivered in patient’s home by a health professional RR 0.Effective interventions 2.66-0.

20 (95% CI -9.36-0.34 (95% CI 0.51 (95% CI 0.16-0.4.-1.74) 5. Cardiac pacing for fallers with Carotid Sinus Syndrome WMD -5.0) 6.73) . Withdrawl of psychotropic medication RR 0.Effective interventions 4. Tai Chi group exercise intervention RR 0.

Br J Ophthalmol 2005 .04) Harwood et al.03) • Fractures: reduced from 8% in controls to 3% in the early surgery group (p<0.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.

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.uk .gov.

context and characteristics of the fall(s) • Those who have fallen or who are considered at risk. – Get up and go test NICE guideline 21 .Case / Risk identification • Older people should be asked routinely if they have fallen in the past year. should be observed for balance and gait deficits. – + frequency.

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balance and mobility Visual impairment Multifactorial assessment Neurological examination Medication review Functional ability/ fear of falling Cognitive impairment Cardiovascular examination Osteoporosis risk Urinary continence NICE guideline 21 .Falls history Gait.

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 .Multifactorial intervention • Individualised to patient according to diagnosis.

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.Applying the guidelines to the individual • Treat any acute illness that precipitated the fall • Treat specific conditions affecting balance e. safety awareness Commence osteoporosis treatment where indicated .g Parkinson’s disease.

nice.org. www.ac.uk SIGN guideline 71. www.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.uk .sign.

Uncertainties .

0.98) but… Hospitals: Multifaceted interventions reduced falls rate (0. 334:82) Care homes: Hip protectors reduced hip fractures by 0.I.67 (CI 0.68-0.46-0.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 2007.82 (C.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 .

Parker et al. 0.62-0.I.97) (but weak cluster randomisation methodology in 7 trials) • Meta-analysis of 3 individually randomised trials in community settings: No reduction (RR 1. BMJ 2006 .16 (95% C.77 (95% C.I.85-1. 0.Hip protectors Cochrane review 2006 • Meta-analysis of 11 trials in care home settings: Reduction in incidence of hip fracture (RR 0.59) • 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.

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 .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.

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 .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.

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? .

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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 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 • Housebound • ≧ 2 falls in the past month • Injury sustained due to fall 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 .

ac.uk .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.

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. Lancet 2005 . BMJ 2005 Grant AM et al. N Engl J Med1992 Porthouse J et al.

97) • Meta-analysis of 3 individually randomised trials in community settings: No reduction in hip fracture (RR 1.I.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.Hip protectors Cochrane review 2006 • Meta-analysis of 11 trials in care home settings: Reduction in incidence of hip fracture (RR 0. 0. 0.16 (95% C. Parker et al.77 (95% C. BMJ 2006 .85-1.62-0.I.

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Falls and fracture prevention • • • • • • • Balance and ageing Risk factors for falls Falls prevention: Evidence Falls prevention: Guidelines Applying the guidelines National developments Local services .

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