PROVIDING AN EFFECTIVE FALLS SERVICE

(26/04/16)

Cameron Swift, King’s College School of Medicine, London

KEYS TO AN EFFECTIVE FALLS SERVICE

1.1.1.1. Understanding the phenomenonUnderstanding the phenomenonUnderstanding the phenomenonUnderstanding the phenomenon

2.2.2.2. Adhering to the evidenceAdhering to the evidenceAdhering to the evidenceAdhering to the evidence

3.3.3.3. Coordinating across all boundariesCoordinating across all boundariesCoordinating across all boundariesCoordinating across all boundaries

4.4.4.4. Measuring the outcomeMeasuring the outcomeMeasuring the outcomeMeasuring the outcome

NICE GUIDANCE DEVELOPMENT ON FALLS

FALLS: The Assessment and Prevention of Falls in FALLS: The Assessment and Prevention of Falls in FALLS: The Assessment and Prevention of Falls in FALLS: The Assessment and Prevention of Falls in

Older PeopleOlder PeopleOlder PeopleOlder People

� CG 21 (2004): “Community dwelling” older CG 21 (2004): “Community dwelling” older CG 21 (2004): “Community dwelling” older CG 21 (2004): “Community dwelling” older

people. Insufficient evidence for guidance on people. Insufficient evidence for guidance on people. Insufficient evidence for guidance on people. Insufficient evidence for guidance on

inpatient settingsinpatient settingsinpatient settingsinpatient settings

� CG 161 (2013): CG21 unchanged: CG 161 (2013): CG21 unchanged: CG 161 (2013): CG21 unchanged: CG 161 (2013): CG21 unchanged:

�PLUS new guidance on inpatient settingsPLUS new guidance on inpatient settingsPLUS new guidance on inpatient settingsPLUS new guidance on inpatient settings

� QS 86 (2015): 6 Quality StatementsQS 86 (2015): 6 Quality StatementsQS 86 (2015): 6 Quality StatementsQS 86 (2015): 6 Quality Statements

(1) FALLS IN LATER LIFE – BINOCULAR VISION!

WHAT? WHAT?WHAT? WHAT?WHAT? WHAT?WHAT? WHAT?

A THREAT A SIGNALA THREAT A SIGNALA THREAT A SIGNALA THREAT A SIGNAL

WHY? WHY?WHY? WHY?WHY? WHY?WHY? WHY?

A PREVENTABLE THREAT A PRODUCTIVE SIGNALA PREVENTABLE THREAT A PRODUCTIVE SIGNALA PREVENTABLE THREAT A PRODUCTIVE SIGNALA PREVENTABLE THREAT A PRODUCTIVE SIGNAL

HOW? HOW?HOW? HOW?HOW? HOW?HOW? HOW?

IDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNALIDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNALIDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNALIDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNAL

FALLS IN LATER LIFE – A THREAT

1. 30% >65: 50%>80 fall at least once yearly

2. Injury, disability, dependency, mortality

3. NHS annual cost >£2.3bn

FALLS IN LATER LIFE: A SIGNAL

Commonly detectable:

1. Ageing processes (diminished physiological reserve)

2. Suboptimal physical fitness

3. Stable specific impairment (e.g. sensory, motor,

visual, CNS)

4. Unstable systemic illness (diagnosed or undiagnosed)

NEURAL CONTROL OF BALANCE AND FALLS (HORAK 2005)

EXAMPLES OF ATTRIBUTABLE MEDICAL

PROBLEMS IDENTIFIED - (80% +) (CLOSE ET AL, LANCET 1999)

� Cardiovascular/circulatory – (e.g. postural hyptension , Cardiovascular/circulatory – (e.g. postural hyptension , Cardiovascular/circulatory – (e.g. postural hyptension , Cardiovascular/circulatory – (e.g. postural hyptension ,

arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)

� Visual impairment (59%), poor stereoscopic vision (62%), Visual impairment (59%), poor stereoscopic vision (62%), Visual impairment (59%), poor stereoscopic vision (62%), Visual impairment (59%), poor stereoscopic vision (62%),

cataract (35%)cataract (35%)cataract (35%)cataract (35%)

� Decreased lower limb power (28%)Decreased lower limb power (28%)Decreased lower limb power (28%)Decreased lower limb power (28%)

� Peripheral neuropathy (20%)Peripheral neuropathy (20%)Peripheral neuropathy (20%)Peripheral neuropathy (20%)

� Measured strength/balance impairment (72%)Measured strength/balance impairment (72%)Measured strength/balance impairment (72%)Measured strength/balance impairment (72%)

� Measured cognitive impairment (34%), depression (18%)Measured cognitive impairment (34%), depression (18%)Measured cognitive impairment (34%), depression (18%)Measured cognitive impairment (34%), depression (18%)

� Undiagnosed malignancy (2%)Undiagnosed malignancy (2%)Undiagnosed malignancy (2%)Undiagnosed malignancy (2%)

(2) FALLS IN LATER LIFE – PREVENTABLE (CLOSE ET AL, LANCET 1999)

0

100

200

300

400

500

600

0-4mth 4-8mth 8-12mth Total

203

151 156

510

50 73 60

183

Control

Intervention

FALLS IN LATER LIFE – PREVENTABLE (LOGAN ET AL, BMJ 2010)

(7.68 vs 3.46 control vs intervention)

PREVENTING FALLS IN INPATIENTS

� Highest risk category

� Heterogeneous studies and settings (e.g. acute. non-acute, mixed)

� Inconsistent or negative findings with single factor or non-tailored interventions

� Risk factor prediction tools insufficiently sensitive or specific

� Some moderate evidence for multifactorialassessment and intervention strategies

EFFECT OF TARGETED RISK FACTOR REDUCTION

PROGRAMME ON INPATIENT FALLS (PER THOUSAND

OCCUPIED BED DAYS)(HEALEY ET AL, 2004)

0

5

10

15

20

25

Control Intervention

Pre

Post

CHARACTERISTICS IN COMMON OF UK

INTERVENTIONS WITH POSITIVE FINDINGS

� High risk groups (e.g. A&E attenders, ambulance callers)

� Organised, focused multidisciplinary assessment, diagnosis & intervention

� Strength & balance training, visual assessment, environmental assessment, medication review

� Effective interchange/collaboration: primary care – secondary care (Clinical Gerontology)

QS 86: SOME KEY ELEMENTS OF MULTIFACTORIAL

ASSESSMENT & INTERVENTION

� Falls history

� Gait, balance, mobility, muscle strength

� Functional ability & fear of falling

� Vision

� Cognition, neurology, cardiovascular,

continence, medication review

� Home hazards

“NEGATIVE” OR ATTENUATED INTERVENTION

FINDINGS

� Single interventions – untargeted group

exercise, cognitive/behavioural, vision

correction alone, Vit D (?), hip protectors (?)

� A&E based focus on cognitive impairment (Shaw et

al (2003)

� Unidisciplinary assessment with non-linked

primary care/social services referral (Lightbody et al,

2002; Spice et al 2009)

� Risk factor prediction tools in inpatients

(3) CG 161 GENERIC FALLS ASSESSMENT AND (3) CG 161 GENERIC FALLS ASSESSMENT AND (3) CG 161 GENERIC FALLS ASSESSMENT AND (3) CG 161 GENERIC FALLS ASSESSMENT AND

INTERVENTION ACTIVITY INTERVENTION ACTIVITY INTERVENTION ACTIVITY INTERVENTION ACTIVITY (UK EVIDENCE & FOCUS)(UK EVIDENCE & FOCUS)(UK EVIDENCE & FOCUS)(UK EVIDENCE & FOCUS)

CASE/RISK

IDENTIFICATION

MULTI-

FACTORIAL

ASSESS-

MENT

NETWORKED

FALLS SERVICE

INDIVIDUAL-

ISED SINGLE

OR MULTI-

FACTORIAL

INTERVEN-

TION &

FOLLOW-UP

BONE HEALTH

SERVICE

PRIMARY &

COMMUNITY

CARE

SECONDARY

CARE

Case / risk identified

at health screen

Case / risk identified

at presentation with

fall / other problem

Case / risk identified

at presentation with

fall / other problem

Presentation at A&E

with fall injury/

Inpatient >65 / or

Inpatient >50 with

known clinical risk

GENERIC FALLS SERVICE NETWORK –GENERIC FALLS SERVICE NETWORK –GENERIC FALLS SERVICE NETWORK –GENERIC FALLS SERVICE NETWORK –

AN OPPORTUNITY TO LEADAN OPPORTUNITY TO LEADAN OPPORTUNITY TO LEADAN OPPORTUNITY TO LEAD

PRIMARY & COMMUNITY

CARE

MAINSTREAM SECONDARY

CARE

ACCIDENT &

EMERGENCY

MEDICINE

POPULA

TION-BASED/

OPPORTUN-

ISTIC

SCREENING

HOME-BASED

EXERCISE

PROGRAMMES

DAY HOSPITAL,

OUTPATIENT

CLINICS &

REHABILITATION

NETWORKED

FALLS SERVICE (LINKED TO MEDICAL

GERONTOLOGY)

OTHER

MEDICAL &

SURGICAL

SPECIALITIES

TRAUMA, &

ORTHO-

PAEDICS

BONE

HEALTH

SERVICE

ACUTE

INPATIENT

MEDICAL

GERONTOLOGY

(4) RISK REDUCTION (CONTROL V INTERVENTION) USING

BASELINE ADJUSTED ODDS RATIOS

-0.7

-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

Risk reduction

Falling

Recurrent falling

1+ Hosp admission

FALLS IN LATER LIFE – PREVENTABLE (DAVISON ET AL, 2005)

0

100

200

300

400

500

600

700

Intervention(n=159)

Control (n=154)

Falls*

Fallers (No)

Fallers (%)

Hospital Bed Days

CG 161: COST-EFFECTIVENESS OF INPATIENT

FALLS PREVENTION

EFFECT OF AN A&E-BASED MULTIFACTORIAL INTERVENTION

ON BARTHEL ADL INDEX (FROM DATA OF CLOSE ET AL, 1999)

16

16.5

17

17.5

18

18.5

19

19.5

Baseline 4 mth 8 mth 12 mth

Control

Intervention

CONCLUSIONS – RCP NATIONAL AUDIT 2011

� Unacceptable variation in the quality of falls and

fracture services

� Major gap between what organisations report and

actual services

� Patients with non-hip fragility fractures only 50%

assessment & management v hip # patients

� Important deficiencies remain in the commissioning,

organisation and provision of care

CONCLUSIONS – QS 86 UPTAKE 2013

Royal College of Physicians - Fracture Liaison Service Royal College of Physicians - Fracture Liaison Service Royal College of Physicians - Fracture Liaison Service Royal College of Physicians - Fracture Liaison Service Database (FLS-DB) Feasibility Study Summary ReportDatabase (FLS-DB) Feasibility Study Summary ReportDatabase (FLS-DB) Feasibility Study Summary ReportDatabase (FLS-DB) Feasibility Study Summary Report

� Proportion of index fractures that had evidence in the GP electronic records of a formal falls risk assessment = 3.9%

� Proportion of older people living in the community with a known history of recurrent falls reporting to their GP who are referred for strength and balance training = 0.8%

CONCLUSIONS

� FALLS DIAGNOSIS, MANAGEMENT AND

PREVENTION IS:

� VITAL, EFFECTIVE AND COST-EFFECTIVE

� SPECIALISED – INTEGRAL TO CLINICAL

GERONTOLOGY

� MULTIFACTORIAL AND MULTIDISCIPLINARY

� COORDINATED, FOCUSED & COMMISSIONED

� INSUFFICIENTLY IMPLEMENTED BUT ACHIEVABLE