falls fractures and frailty
TRANSCRIPT
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Falls Fractures and Frailty
Dr Damian Gormley
Consultant Geriatrician Southern Trust
5th October 2017
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Summary
• Epidemiology of falls
• Guidelines/Evidence
– Frailty
– Risk factors
– Interventions
• Falls, Fracture and Frailty Southern Trust
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Epidemiology
• 28-35% of >65 fall each year1
• 50% of >80 fall per year
• 5% falls result in fracture and hospitalisation
• Distress, pain, injury, loss of confidence, immobility, mortality
• Effect on carers 60% fear further fall2
• £4.4 billion per year
1WHO 2007 2Liddle et al 1995
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Craigavon and Banbridge
Craigavon Area Hospital
Emergency Department
Trauma and orthopaedic
inpatients
Fracture clinics
Lurgan Hospital
Falls clinic
Strength & Balance
classes (3)
Armagh and Dungannon
South Tyrone Hospital
Minor injuries Unit
DXA scanner
Falls Clinic
Mullinure Hospital
Falls clinic
Strength & Balance classes (4)
Newry and Mourne
Daisyhill Hospital
Emergency Department
Fracture clinics
Falls Clinic
Strength & Balance
classes (2 )
NISRA MYE 2014
SHSCT Population =
370000
Over 65 population =
52,556
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Southern Trust NI
• Number of fallers/year=17,518
• 350 People attend ED/month
• Number of consultant falls clinics per
yr=126
• Number of new patients per year = 630
• Able to see 3.6% of fallers
• Oops!
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Who should I see?
• Patients at risk of further falls
• Patients at risk of harm from falls
• Patients in whom I can alter their risk
• Patients who need a consultant to alter
their risk
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NICE Guidelines CG 161 (2013)
• Ask older people have they fallen (1 yr)
– Perform gait and balance assessment
• Multifactorial risk assessment Multifactorial interventions
1. Gait/balance problem
2. Report for medical attention
3. Recurrent falls “This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service”
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Gait and Balance Screen
1. Timed up and Go test
2. Turn 180º
3. Performance-oriented assessment of
mobility problems (Tinetti scale)
4. Functional reach
5. Dynamic gait index
6. Berg balance scale
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Frailty
• Related to the ageing process
• Multiple body systems gradually lose their
in-built reserves
• Adverse outcomes
• Dramatic changes in wellbeing after an
apparently minor event
BGS Fit for frailty June 2014
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eFI Frailty Categories
• Fit (eFIscore 0 -0.12): People who have no or few long-term conditions that are usually well controlled. This group would mainly be independent in day to day living activities.
• Mild frailty (eFIscore 0.13 –0.24): People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation.
• Moderate Frailty (eFIscore 0.25 –0.36): People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing.
• Severe Frailty (eFIscore > 0.36): People who are often dependent for personal cares and have a range of long-term conditions/multi-morbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6 -12 months
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5. FOR THOSE WITH SEVERE
FRAILTY Undertake falls
assessment and medications review
• Annual review of medications.
• Annual direct review to establish if patient
has fallen in last year.
– No fall in last 12 months - No further action
– One or more falls in past 12 months - See
guidance and best practice
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Risk factorsPrevious falls Relative Risk
Muscle weakness* 4.4
History of Fall 3.0
Gait deficit* 2.9
Fear of falling* 2.8
Balance problems* 2.8
Use of assist device 2.6
Visual deficit* 2.5
Arthritis 2.4
Depression* 2.2
Cognitive impairment 1.8
Psychotropic Medications* 1.7
Age >80 1.7
Perell et al 2001
NICE 2013
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Intervention Evidence
• Inconsistant
• Poorly designed trials
– Not blinded
– Multiple outcomes
– Heterogeneous populations
– Variable outcomes• Risk of falling
• Time to first fall
• Rate of falling
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Cochrane Review 2012Interventions for preventing falls in
older people living in the community
• 159 Trials
• 79 193 participants
• Exercise only 59 trials
• Multifactorial 40 trials
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ResultsRate of falling Risk of falling
Multicomponent group Exercise 0.71* (0.63-0.82) 0.85* (0.76-0.96)
Multicomponent Home exercise 0.68 *(0.58-0.80) 0.78* (0.64-0.96)
Tai Chi 0.72 (0.52-1.00) 0.71* (0.57-0.87)
Multifactorial 0.76 *(0.67-0.86) 0.93 (0.86-1.02)
Vitamin D 1.00 (0.90-1.11) 0.96 ( 0.89-1.03)
Home Safety 0.81* (0.68-0.97) 0.88* (0.80-0.96)
Visual intervention 1.57 *(1.19-2.06) 1.54* (1.24-1.91)
Prescribing intervention 0.61* (0.41-0.91)
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Interventions for preventing falls in older
people in care facilities and hospitals 2012
• 43 trials
• 30 373 participants
Rate of falling Risk of falling
Exercise 1.03 (0.81-1.31) 1.07 (0.94-1.24)
Vitamin D 0.63* (0.46-0.86) 0.99 (0.90-1.08)
Multifactorial 0.78 (0.59-1.04) 0.89 (0.77-1.02)
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Secondary falls prevention
exerciseOtago Home Exercise Programme (OEP)
• – 1 yr; 3 x p/w; 6 home visits and telephone support
• – 6 mths; 3 x p/w (1 p/w group, 2 p/w home)exercise instructor
• – Effects on strength and balance in a group
Falls Management Exercise Programme (FaME/PSI)
• – 9 mths; 3 x p/w (one group, two home); includes floorwork;
• – Increases habitual physical activity as well
(Campbell 1997; Robertson 2001; Campbell 2005;
Liu_Ambrose 2008;
Kyrdalen 2014; Skelton 2005, 2008)
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What works
• Greatest effects of exercise on fall rates (38% reduction) from interventionsincluding:
– Highly challenging balance training
– 3 Times a week
– High dose (50+ hours)
– Progressive strength training
– Avoid brisk walking
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NICE what not to do
1. Brisk walking
2. Low intensity exercise
3. Untargeted group exercise
4. Visual intervention as single
5. Vitamin D
6. Hip protectors
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Post Hospital Home Exercise
Program
• 340 older people
• 81.2 yrs. 70% fallen in past year
• 15-20 mins exercise /week (S+B-WEBB)
• 12 months
• 10 physio visits
• Falls 177 v 123 IR 1.43 (1.07-1.93)
• Fallers 98 v 70 RR 1.38 (1.11-1.73)
Sherrington et al 2014
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Multifactorial intervention after a fall in older
people with cognitive impairment
• 274 patients with dementia
• >65 presented to ED after fall
• Fallers 74% v 80% RR0.92 (0.81-1.05)
• No difference
– Number of falls
– Time to first fall
– ED attendances or admissions
– Injuries
– Mortality
Shaw et al 2003 BMJ
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Exercise for falls prevention in Parkinson
disease: a randomized controlled trial
• 231 PD patients
• Exercise 40-60mins x3 weekly 6 months
• Falls rate RR 0.73 (0.45-1.17)
Canning et al 2015 Neurology
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Falls Fracture Frailty Pathway
Southern Trust
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Fracture Liaison Service
DXA Scan
Fracture risk
assessment and falls
screen
Falls screening
no further action
required
DXA not appropriate
or feasible
Falls Service
Community based
Strength & balance
Classes
Level 2
AHP Assessment
S&B classes
Level 3
Medical
AssessmentFrail Elderly
Falls & Fracture Pathway >65
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Summary
• Falls are common with potentially serious
consequences
• Not all fallers need seen
• Not all fallers need to see a doctor
• High intensity S+B exercise key in
community dwellers
• Frail patients need CGA