SP - Falls

Introduction

Falls in older people are common and can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken by organisations to prevent deaths, but dissemination of the findings from these Prevent Future Deaths (PFD) reports remains poor, limiting their possibility to effect change. We set out to identify preventable fall-related deaths, classify coroners’ concerns, and explore organisational responses to these deaths.

Methods

A protocol for a retrospective case series of fall-related PFDs was pre-registered. A novel, openly available, computer code was created to download and read PFDs from the Courts and Tribunals Judiciary website from July 2013 to November 2022. Demographic information, coroners’ concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data.

Results

527 PFD cases (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (71%). A high proportion of cases experienced fractures, major bleeding, or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations most commonly produced new protocols, improved training, and commenced audits in response to PFDs.

Conclusion(s)

One in eight preventable deaths reported in England and Wales involved a fall. Adequately addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken at the local level. Wider dissemination and learning from PFD findings may help reduce preventable fall-related deaths nationally.

Introduction
Older people are the fastest growing group of hospitalised trauma patients, most commonly due to falls from standing height. The Scottish Trauma Audit Group (STAG) collect extensive national data, but this does not currently include frailty and longer-term dependency.

Method
We retrospectively reviewed consecutive cases in the STAG database for the Royal Infirmary of Edinburgh between September 2018 and February 2019. Casenote review was used to calculate baseline Charleston Comorbidity Index (CCI) and frailty status using the Clinical Frailty Scale (CFS). Outcomes of residence and mortality were collected to 1 year.

Results
We included 442 patients (mean age 62±20 years old, 43% female), of whom 218 (49%) were ≥65 years old (mean 78±8 years, 57% female). CFS could be ascertained in 209 (96%) patients ≥65 years, of whom 73 (35%) were frail (CFS ≥5). Frail patients were older (82±8 years vs. 77±8 years,
p<0.001) and had more comorbidities (mean CCI 5.4±1.8 vs. 4.4±1.8, p<0.001) prior to trauma compared to non-frail patients >65 years old. Median Injury Severity Scores (ISS) did not vary by age (9 [5-12] ≥65 years vs. 9 [8-16] <65 years, p=0.07) or frailty status (9 [9-10] frail vs 9 [4-14] non-frail, p=0.59). Frail older patients were twice as likely to die within one year of trauma (32% vs 14%
in non-frail, p<0.001), and this was independent of age (adjusted odds ratio 2.4, 95% confidence intervals 1.2–4.9, p=0.02). In survivors to 1 year, 16% of frail older patients required increased care at home (vs. 8% of non-frail older patients, p<0.001) and 14% were newly admitted to a care home
(vs. 4% of non-frail, p<0.001).

Conclusion
A third of older patients with trauma are frail and this is an important predictor of patient outcomes beyond death. Frailty provides more prognostic information than age in this setting.

Background: Foot pain in older adults may reduce physical activity, resulting in impaired mobility and an increased risk of falls. Orthotics, both with and without a metatarsal pad, may provide foot pain relief and improved stability. Objective: Compare the use of Aetrex orthotics with and without a metatarsal pad in decreasing pain and fear of falling in older adults. Methods: 206 participants over 60 years old were randomised into the intervention group, who received Aetrex L2305 Orthotics with a metatarsal pad, or the control group, who received Aetrex L2300 Orthotics with no metatarsal pad. At baseline and 6-week follow-up, musculoskeletal pain was reported via Numerical Rating Scales (NRS), foot pain and functionality via the Foot Health Status Questionnaire (FHSQ), and fear of falling via the Short Falls Efficacy Scale International. Results: Both groups reported significant improvements in pain in the back, hips, knees, ankles, and feet using the NRS (P < 0.001). Using the FHSQ, foot pain significantly improved in both the intervention (x̄= 18.47 ±20.58, P < 0.001) and control group (x̄= 17.21 ±18.74, P < 0.001). Function also improved significantly in both groups (x̄= 18.35 ±20.67, P < 0.001 and x̄ = 15.07 ±20.15, P < 0.001, respectively), as did fear of falling (x̄= 1.55 ±3.79, P < 0.001 and x̄= 1.23 ±3.53, P < 0.001, respectively). No statistically significant difference was observed between groups for any outcome (P > 0.05). Conclusion: Aetrex orthotics, with and without metatarsal pads, decrease pain and fear of falling in older adults.

Introduction: Oral nutritional supplement (ONS) prescription is commonly recommend for malnourished patients in hospital. However, compliance to ONS is often low. Ice cream may be a promising nutritional intervention. We undertook a study designed to compare the acceptability of high protein, fortified, ice cream called Nottingham-Ice Cream (N-ICE CREAM) with routinely prescribed milkshake ONS.

Methods: Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited from Queens Medical Centre, Nottingham. Patients were randomised into two groups, receiving two days of N-ICE CREAM and milkshake ONS. Group A received N-ICE CREAM first and Group B, milkshake ONS first. We measured compliance, acceptability (hedonic characteristics; rating 0 dislike a lot to 7 like a lot), attitudes towards length of prescription (rating 0 very unconfident to 4 very confident) and preference.

Results: Mean (standard deviation, SD) age of patients was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both Groups (Group A (n = 22) 69.9 (30.0) % and Group B (n = 26) 56.3 (39.3)%) compared to the milkshake ONS (Group A (n = 22) 43.4 (4.7) % and Group B (n = 26) 53.6 ± (40.2) %). This was statistically significant in Group A (p < 0.05). Mean hedonic ratings were higher for N-ICE CREAM with an overall impression score of 5.8 compared with 4.6 for milkshake ONS. Confidence score for both products decreased with increasing time length. Both had an overall confidence score of 2.9.

Conclusions: High protein N-ICE CREAM is more accepted and preferred by older patients with a hip or spine fracture compared to standard milkshake ONS. Further research should explore optimal timing for N-ICE CREAM administration and long-term compliance, as well as clinical outcomes.

Introduction: Malnutrition is a debilitating condition in hospitalised older people. There has been limited studies exploring dietary intake and oral nutritional supplement (ONS) compliance in these people. The purpose of this service evaluation was to observe daily energy and protein intake, plate waste and ONS compliance and to report food waste at ward level.

Methods: Three-day dietary (food-only) intake and plate waste of 19 older (≥ 65 years) people on a hospital trauma and orthopaedic (T&O) ward were assessed. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetics Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a Dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for five days. Thirty-three ONS from 11 patients were collected before disposal and weighed.

Results: Mean age of the patients were 84 ± 9 years (9 female, and 10 male) with the most common injury hip fracture (68.4%). Mean (standard deviation, SD) intake for ‘nutritionally well’ was 1592 (257) kcal/day and 65.7(8.5) g/day protein and ‘nutritionally vulnerable’ (n= 15) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Plate waste for ‘nutritionally well’ was 4.1 (5.8)% at main meals and 1.7 (3.4)% at pudding and for ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. This equates to approximately 4526kg/year (4.5T).

Conclusions: Energy and protein intake and compliance to ONS in older T&O patients is sub-optimal. Food waste is high and urgently needs addressing. Further, interventions are warranted to improve dietary intake in hospital and to explore the acceptability of alternative ONS food/drink styles.