Joints

Background:

- Falls and associated injuries are a significant area of concern for older adults. Approximately 30% of those aged over 65 and 50% of those aged over 80 experience at least one fall each year.

- NICE guidelines state, “Older people who present for medical attention because of a fall, should be offered a multifactorial falls risk assessment”, which includes review of visual impairment.

Aims:

- To identify if visual impairment was documented on the orthopaedic clerking document for patients admitted following fall.

- To raise awareness of visual impairment as being a significant risk factor for falls in the elderly population.

Methods:

- Data collection was carried out retrospectively for patients presenting following a fall at Tunbridge Wells Hospital, via the orthopaedic admission list.

- Initially, data was collected from April to May 2024 and then from July to August 2024 following the first teaching intervention.

Results:

- 6% of patients (n = 50) admitted following a fall had visual status documented in the orthopaedic clerking document.

- Following the first intervention, 20% of documentation noted visual impairment.

Conclusion:

- Visual impairment was not routinely documented on orthopaedic clerking.

- The first intervention involved delivering a teaching session to the orthopaedic department, highlighting the significance of visual impairment contributing to falls.

- Data collection from July to August 2024 has shown an improvement in documentation, whereby 20% of documentation noted visual impairment.

- The second intervention will involve including these findings in the departmental induction and designing a poster to raise awareness.

Introduction:

Parkinson's disease (PD) is associated with an increased risk of osteoporosis and fractures to factors like falls resulting from postural instability, polypharmacy, and muscle weakness. Reduced bone mineral density (BMD), often caused by vitamin D deficiency, disease severity, and low BMI, further elevates fracture risk in PD patients. This project aims to improve awareness and bone health testing in PD patients by focusing on vitamin D, bone profile assessments, DEXA scans, and FRAX scores for fracture risk evaluation and management.

Methodology:

This QIP involved two cycles focused on managing Parkinson’s disease (PD) patients. The first cycle interventions focused on educating doctors through sessions and a poster, while the second cycle introduced personalized treatment plans for PD patients, recorded in their clinical notes. A comparative analysis of post-intervention data was conducted to evaluate the effectiveness of both interventions.

Results:

Bone profile testing was successfully completed in 100% of patients after both interventions. In cycle 1, 63.3% of patients required vitamin D testing, compared to 25% in cycle 2. Of these, 14.3% received testing after the first intervention, and 100% after the second. However, none of the patients had their FRAX scores calculated or DEXA scans scheduled. The teaching session increased overall confidance amongst junior doctors in diagnosing osteoporosis from 60% to 70%, and managing osteoporosis from 10% to 80%. It also improved the overall awareness on how to use the FRAX tool from around 50% to 90%. 

Conclusion:

Personalized treatment plans and targeted interventions led to significant improvements in vitamin D testing. However, notable gaps remain in adherence to FRAX calculation and organizing DEXA scans. Future efforts should focus on these limitations and ensuring complete bone health assessments for PD patients. The teaching sessions proved to be highly effective, significantly enhancing participants' understanding of bone health issues in Parkinson's disease.

The National Institute for Health and Care Excellence (NICE) guidelines for management of head injuries on anticoagulation were updated in 2023, to maximise detection of clinically important falls whilst minimising unnecessary scans. They recommend computed tomography (CT) imaging to be considered within 8 hours if clinically appropriate [NG232].[1] The Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) current local inpatient falls protocol recommends that all patients who have fallen with suspected head injury, on anticoagulation but in the absence of neurological changes or other underlying risk factors, should undergo CT imaging. This quality improvement project reviewed outcomes in this patient subset, retrospectively analysing patient data during a four-month period.

Between April to August 2024, 550 inpatient adult non-contrast CT head scans were performed at the Freeman Hospital (NUTH). 172 (31.2%, median age 77) of these scans were performed following an inpatient fall. 73 (42.4%) of these scans were performed with active anticoagulation as the solitary indication; in these patients, none (0%) had haemorrhagic pathology and therefore no neurosurgical intervention was required. This data strongly supports a review to rationalise our inpatient fall guidelines to align with the updated NICE recommendations which emphasise clinical judgement and shared decision making. This change should result in a meaningful reduction in valuable CT scanning and reporting time, associated costs and radiation exposure, without compromising patient care and outcomes.

Introduction

Hip fracture is the most common fracture in adults over 60 years, affecting approximately 70,000 people in the UK in 2019. Mortality after hip fracture continues to be high and the cost of hip fracture is estimated at £1.1 billion per year for the NHS. It has been shown that there are key clinical indicators which can improve patient outcomes. These are monitored annually in the UK by the national hip fracture database (NHFD).

Methods

Our aim was to look at the demographics and clinical codes for patients admitted with hip fracture, codes when they are readmitted and cause of death. Information analysts at both hospitals provided authors with these data from hip fracture admissions in 2020. Inclusion criteria reflected the inclusion criteria for the NHFD. Cause of death was identified from records in the medical examiner's offices for inpatient deaths. Data were viewed and analysed in Microsoft Excel.

Results

In total, there were 878 admissions for hip fracture in 2020, 312 at Barnsley Hospital (BH) and 566 Sheffield Teaching Hospitals (STH). Average age was 80.9 at BH and 82.6 at STH. The most frequent codes on admission were 'fall' and the most common complication was pneumonia, coded in 23% of patients. 174 (56%) individuals at BH had at least one readmission in the first year and 318 (57%) at STH. The codes for readmission were varied, most commonly for musculoskeletal or orthopaedic conditions, including fracture. 85 died within one year (27.2%) and 26 died within 30 days (8.3%) at BH. 186 died within one year (32.7%) and 69 within 30 days (12.1%) at STH. The commonest cause of death was pneumonia, in 26 of 66 inpatient deaths.

Conclusions

This analysis of coding data confirms known complications following hip fracture. Morbidity and mortality following hip fracture remains extremely high.

Hip fractures tend to affect older, frailer people and are associated with high morbidity and mortality. The Best Practice Tariff (B PT) was introduced to recognise gold standard care. Features of the BPT include prompt surgical and orthogeriatric input, with multidisciplinary working throughout. Subsequent service changes have led to the creation of specialist hip fracture wards. However, it is not always possible to admit patients with a fractured neck of femur to a specialist hip fracture ward.

We reviewed data for 691 patients admitted with a primary neck of femur fracture to a district general hospital in Sussex between 01/02/2023 and 29/02/2024. We compared the demographics and outcomes of patients admitted to a specialist hip fracture ward (SHFW) and a general surgical ward (GSW) using data available from the National Hip Fracture Database. 570 patients were admitted to the SHFW, 121 to the GSW.

BPT achievement was significantly higher on the SHFW (74% SHFW, 53% GSW, p<0.00001). 30-day mortality was lower on the SHFW, although this was not statistically significant (2.98% SHFW, 5.79% GSW, p=0.126). We found no significant difference in patient age, time to surgery, time to orthogeriatrician review, or length of stay.

This analysis highlights the importance of a specialist multidisciplinary team approach in the management of patients presenting with fractured neck of femur. While not a perfect metric, non-achievement of the BPT is likely to result in worse patient care, with higher mortality and poorer longer term functional outcomes. BPT non-achievement is also associated with significant loss of income to NHS trusts. We suggest that, wherever possible, beds on specialist hip fracture wards should be ring fenced for patients with primary neck of femur fracture.

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Vitamin D deficiency has become commonplace, especially in older people. Given the role it plays in bone health and falls prevention, as well as the growing evidence of its extra-skeletal actions, it is important to treat vitamin D deficiency adequately. Our practice has been 2 to 3 weeks of daily treatment with 50,000IU ergocalciferol as a loading dose. However, recent guidelines recommend half this total cumulative dose given over a period of 6 to 8 weeks. Rather than promptly following the guidelines and changing our practice, we opted to conduct a quality improvement project (QIP) looking at the effectiveness of our protocol for treating Vitamin D deficiency in older patients. In the initial project patients admitted to an acute geriatric ward and found to have vitamin D deficiency were prescribed a 2 weeks course of daily ergocalciferol. In the second project, patients with severe deficiency (<20 IU/ml) received 3 weeks of treatment. In all patients pre- and post-treatment vitamin D levels were done. In total 76 patients were included. Results: all patients demonstrated significant improvement. Post-treatment serum vitamin D levels returned to normal in 66%. The median change in vitamin D level was 265%. Importantly no side effects were noted and no patient reached toxic serum vitamin D levels. Conclusion: Our results show that doses higher than the current recommendations for treating vitamin D deficiency are needed to replenish depleted vitamin D stores in older people. Compared to recommended strategies which generally span over 6 to 8 weeks, our daily protocol provides rapid replacement over 2 to 3 weeks. It is effective and safe with no side-effects. The short course of daily treatment should also increase patient compliance

Introduction.

In older adults, dizziness is often experienced as a vague feeling of subjective unsteadiness, where people perceive themselves to be swaying more than they actually are. One factor that potentially drives such distorted perceptions of instability is (hyper)vigilance towards balance. This study aimed to investigate if older adults who report higher levels of trait balance vigilance (i) are more likely to report sensations of general unsteadiness when their balance is acutely threatened, and (ii) if this is accompanied by maladaptive changes in postural control.

Methods.

Forty-eight healthy older adults without vestibular diagnosis (Mean age = 71.0, range = 60–83) completed the recently validated Balance-Vigilance Questionnaire to quantify trait balance vigilance. Participants were fitted a VR headset and completed 60-second, narrow-stance balance trials on a force platform, under conditions designed to create a threatening (standing at a 20-meter virtual height) or non-threatening (virtual ground level) environment. For each condition, we assessed self-reported stability (0-100%) and fear of falling (0-100%), postural control (sway amplitude and frequency), muscular control (tibialis anterior activity), and prefrontal and somatosensory cortical activity using fNIRS.

Results.

Preliminary results are reported. When presented with a postural threat, high-vigilant older adults (Balance Vigilance Score≥18; N=13) reported significantly greater fear of falling (+25%; p=.027) and more reduced perceived stability (-25%; p=.006) compared to low-vigilant older adults – despite there being no differences in actual sway amplitude (p=.157). Only the low-vigilant group showed evidence of an adaptive ‘stiffening’ strategy in response to threat: i.e. increased sway frequency (p=.028) and tibialis anterior activity (p=.027). fNIRS analysis is ongoing.

Conclusions.

These preliminary findings suggest that, in response to a postural threat, older adults with high balance-vigilance are more likely to experience excessive fear of falling and perceptions of instability, and may fail to make adaptive changes to their postural control. Screening for excessive balance vigilance may therefore be recommended.

Abstract Content - Introduction. When required to multitask while walking, older adults (OA) will walk slower and use maladaptive stepping strategies such as cross-steps that may increase the risk of falling. However, most studies to date have been limited to steady-state straight-line walking, which requires limited to no visual planning, which is unrepresentative of common outdoor environments. Therefore, this study aimed to (i) investigate the impact of dual-tasking during walking of complex routes, and (ii) assess if such impact can be reduced when older adults deliberately preview their route to improve planning. Methods. We aim to recruit 45 community-dwelling OA. Preliminary results are reported for 19 (13F & 6M) community-dwelling OA without neurological or musculoskeletal diagnosis (Mean age = 75.7, range = 64–84). Participants walked along different winding paths on an 8-meter-long walkway under three conditions for 6 trials per condition: Single-task (ST), Dual-task (counting backwards) without previewing their route (DT) and Dual-task with deliberate previewing of the walking route (DTP). For each condition, we recorded walking speed, stepping errors (deviations from the pathway), and cross-steps. Results. Participants walked significantly slower during the DT condition (M=58.3 cm/s, SD=15.4) vs. ST condition (M=82.6 cm/s, SD=12.6; p<.001). during the dt condition participants also made more errors (m="1.3/trial," sd="1.4;" p=".029)" and frequent cross-steps compared to ST (no noted; m="0.4" />trial, SD=0.4). However, when allowed to preview their route prior to dual-tasking (DTP condition), participants walked faster (M=69.9 cm/s, SD=18.7; p=.002) and with fewer errors (M=0.1/trial, SD=0.1; p=.006). Conclusions. The imposition of an attentional load during adaptive walking reduces speed and increases the likelihood of potentially risky stepping strategies. Taking the time to deliberately preview the walking route seems to reverse some of these negative changes, and particularly to allow older adults to walk faster with fewer stepping errors.

Introduction

The Action Falls programme has demonstrated effectiveness in reducing falls amongst care home residents in a trial but has not been implemented widely (Logan et al, BMJ, 2021, 375, e066991). Co-production of implementation has been identified as a mechanism for achieving buy-in. This study aimed to co-produce an implementation model.

Methods

Systemic action research with an appreciative approach framed co-production workshops in three stakeholder groups: residents and relatives, care home staff and representatives from health and social care organisations. Topics explored were stakeholder priorities, design of the implementation model and evaluation outcomes. Data collection and analysis occurred concurrently to identify key themes. Participating stakeholders were invited to a celebration event to discuss key themes, share ideas and finalise the model.

Results

One action research cycle was completed. Eighteen workshops were undertaken with 16 stakeholders (7 care staff, 7 health and social care representatives, 1 resident and 1 relative). Falls training was reported as an area requiring improvement. The main priority identified was the need for a shared approach to learning about falls. Other themes were: tailoring training to individual and care home learning needs, involving key people in falls learning, safe spaces to share experiences and build relationships, providing regular learning opportunities, confidence in falls management as an appropriate measure of implementation success, and the need for a mixed methods approach to evaluate the model. A shared learning model was developed at the celebration event. The model included three components: accessible information for residents and relatives, bespoke training for each care home, and provision of ongoing support.

Conclusions

A shared learning model was co-produced as part of the Action Falls implementation strategy. This now needs evaluation.