Joints

Introduction:

This audit was performed by the Northumbria-Healthcare NHS Foundation Trust (NHFCT) Falls and Syncope Service to inform the development of the NHFCT Integrated Falls Strategy (IFS).

Method:

From the opening of the Northumbria Specialist Emergency Care Hospital (NSECH) on 16/06/2015 all ED records were prospectively screened to identify the first 1000 patients aged 65 years and over that had attended with a fall. The 5-year outcome data was obtained from NHFCT electronic records.

Results:

Of the 1000 attends aged 65 years and over with a fall (13.7 attends daily), 55 were patients who reattended having had a further fall. Index characteristics of 945 fallers include: - 64% female, mean age 81.8+/-8.4 years, 79% resided at home, 47% attended with accidental falls, 26% attended with a fracture, 10% with a hip fracture. 5-year outcome data was available for 870 of 945 patients. Of these 870 patients, 28% died within one year and 64% died within 5 years. Men, those who lived in residential or nursing care, those who’s index fall was associated with a hip fracture, those that were admitted to hospital and those who initially presented with unexplained or recurrent falls were more likely to have died at 30 days, one year and 5 years. Of 870 patients, 51% reattended ED with a further fall (mean 2.4 reattends with a fall) and 17% with a subsequent fracture within 5 years. Women, those who lived in sheltered accommodation and those who initially presented with unexplained or recurrent falls were more likely to reattend with a further fall or fracture.

Conclusion:

If the NHFCT IFS aims to reduce further ED attends with a fall and fractures, then this data suggests that the focus should be on those who present with unexplained or recurrent falls and those who live in sheltered accommodation.

Introduction: Orthostatic hypotension is very common and increases with age, affecting about 20% of community-dwelling older adults and it increases up to 50% in long-term care units. Measuring lying and standing blood pressure (LSBP) is an important and simple bedside clinical test needed to diagnose the condition. The regulation of blood pressure depends on the baroreflexes, normal blood volume, and defenses against excessive venous pooling. These mechanisms are altered in older adults that lead to increased incidence of OH. Orthostatic hypotension leads to symptoms of dizziness, syncope, cognitive decline, impaired mobility and falls if it is left untreated.

Objective:

1. The primary aim is to standardize the approach to falls assessment on long term care units amongst all members of the multi-disciplinary team. We plan to address this by focusing on OH.

2. To educate all the multi-disciplinary team and increase knowledge of OH.

3. To improve accuracy in recording and documentation of LSBP to proactively screen patients and plan the clinical management accordingly.

Method: The study adopted an educational approach to orthostatic hypotension assessment in long term care. We did survey questionnaire before and after the study to check the understanding of MDT about the OH. We have undertaken two rounds of data collection with orthostatic hypotension related variables in each cycle. After round one, we did a PDSA that involved small group education sessions by physicians, pharmacists and physiotherapists to raise awareness of orthostatic hypotension.

Results: The study developed a standardized approach to measure LSBP in all long-term care units. It also improved the accuracy in assessment and recording of LSBP and it helped to raise awareness of OH among the MDT in long term care units. The knowledge domain improved to 90% from 10% in MDT. The documentation of LSBP improved to 85% on Long Term Care.

Introduction

Stair falls cause approximately 230,000 injuries and 500 fatalities each year (Roys, 2001). Falls cost the NHS £4.6 million every day (AgeUK, 2010), and approximately £2 billion each year (GOV.UK, 2022), with falls on stairs accounting for the majority of these costs. However, the evidence about how to reduce stair falls is unclear. The aim of this systematic review was to establish which interventions are effective or show greatest potential to improve safety on stairs and reduce falls.

Methods

Five databases were searched: Medline, Scopus, Web of Science, PubMed and CINAHL. Papers were included if they were interventions or provided proof-of-principle to inform an intervention design. Papers were excluded if participants were under the age of 18, or were diagnosed with any clinical condition (disease outside that which we can expect from healthy ageing).

Results

No study reported fall occurrence as an outcome measure. Step-edge highlighters were the only intervention tested in real-world environments, as well as laboratories, and showed good proof of principle, feasibility and acceptability. Five intervention types were found that reduced fall risk in laboratory trials: lighting, horizontal-vertical illusions in ascent, stair dimensions (riser, going and pitch), avoiding multi-tasking and handrail use. These were successful in reducing mechanical demand (reducing or redistributing joint moments) and improving stepping behaviours associated with fall risk (reductions in magnitude and variability of foot clearances and overhang on the step).

Conclusion

This review has established there is no definitive evidence that any intervention reduced fall rates, but that some interventions show good proof-of-principle and feasibility: step-edge highlighters flush to the step edge, increased lighting levels, horizontal-vertical illusions in ascent, use of handrails, avoiding multi-tasking, riser heights 10.2-19cm, going lengths 22.5-32.5cm and reduced pitch angles. Future research must translate these interventions into real world settings and evaluate effectiveness to reduce fall rates.

Introduction

Fragility fractures are associated with significant morbidity and mortality. The National Osteoporosis Guideline Group advise that a FRAX assessment should be completed in all patients with falls. Despite this only 3% of patients admitted to a geriatric ward following a fall had a bone health assessment completed within 72 hours of admission. Our aim is for a bone health assessment to be completed in >90% of these patients.

Method

Our intervention focused on promoting bone health assessment with a ‘FRAX proforma’. This was aimed at junior doctors as the main cohort expected to perform the assessment. The proforma incorporated documentation of the FRAX score including outcome, vitamin D and calcium results, prescribed supplementation and antiresorptives, and a prompt for referral to the fracture liaison service or osteoporosis clinic. The main outcome measure was the percentage of completed bone health assessments using FRAX or Qfracture. Awareness of the proforma was raised through a presentation at a senior health department teaching session and sending an email to all members of the senior health team. Data was collected daily for a week approximately 3 weeks later.

Results

Following our intervention, the percentage of completed bone health assessments increased from 3% to 12%, consistent with a modest improvement. This should translate to a decreased risk of fragility fracture. However, there is ongoing scope to improve. We are planning a further intervention integrating bone health assessment into the ward admission proforma.

Conclusions

Although our intervention has demonstrated a modest improvement, there is scope for further improvement embedding bone health assessment as routine practice for older patients presenting with falls. Future interventions will increase this further by integrating bone health assessment into the existing documentation tools, embedding this as regular practice in the inpatient setting.

Introduction:

Inpatient falls are the most common adverse patient safety incidents in hospitals in the UK. The assessment and management following an inpatient fall is often the responsibility of the most junior doctor on call, particularly out of hours. Frequently, there are key omissions in the assessment of these patients, leading to missed diagnoses, poor management and avoidable patient harm. This study aimed to improve the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls.

Method:

31 patients were identified who had suffered ‘severe harm’ following an inpatient fall and a retrospective review of their notes was performed. A preliminary survey on self-perceived confidence levels on different areas of the assessment and management of inpatient falls was distributed to all foundation doctors at Ipswich Hospital. The key themes of the simulation scenario were subsequently determined by the areas of weakness identified in both the survey and documentation review. A total of 9 foundation doctors at Ipswich Hospital participated in a high-fidelity inpatient fall simulation with a patient actor. Pre- and post-simulation knowledge and confidence surveys consisting of ten multiple choice questions and Likert scales respectively were distributed using QR codes.

Results:

Post-simulation confidence levels improved in all domains measured (p < 0.05) with an overall increase in average confidence levels from 3.3/5.0 to 4.3/5.0 (p=0.007). Average post-simulation knowledge score increased from 4.6/10 to 7.4/10 (p= 0.01). Domains in which the greatest improvements in knowledge and confidence were seen included: moving & handling, neurological observations, assessment of suspected hip fractures and escalating concerns.

Conclusion:

The use of simulated patients improves the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls. The pilot project is due to be expanded with plans to incorporate this simulation scenario into the local foundation teaching programme.

Introduction: Concerns about falling (CaF) is a psychosocial concept, precipitating a spiral of increasing inactivity, social isolation and falls, and is common in those who have experienced, or are at risk of, a fall. One method of assessing CaF is the Falls Efficacy Scale International version (FES-I),with previous studies finding associations between higher FES-I scores and poor scoring on commonly used clinical assessments of functional mobility and balance (Gait speed (GS), Timed up and Go test (TUG), and Five time sit to stand (FTSS)). Using the FES-I to predict poor functional mobility and balance has the potential to identify those at risk before an initial fall, at which point an intervention may be provided.

Methods: A prospective study was carried out over 24 weeks, in which 119 participants were recruited from the North Tyneside Community Falls Prevention Service (NTCFPS). Participants completed questionnaires and underwent physical testing whilst attending the falls clinic (baseline) and at week 24, completing bi-weekly falls diaries throughout. Participants were users of the NTCFPS, and residents of North Tyneside.

Results: Findings showed (i) the FES-I had a limited ability to predict poor scores on GS, TUG and FTSS; (ii) attending referred Age UK strength and balance classes was significantly associated with improvements in FES-I score and FTSS; (iii) CaF at the outset of Age UK training was not significantly associated with clinically significant improvements in GS, FTSS and TUG.

Conclusions: Whilst the predictive capabilities of the FES-I were limited, the measure showed an ability to track improvements in participants CaF in the short to medium term. Further work is needed to explore the measures applications within the general population of community dwelling older adults, rather than a cohort of falls service users.

Introduction:

Osteoporosis is a known consequence of stroke, associated with an increased incidence of fractures and leading to further disability. The pattern of bone loss seen in stroke patients is different from that usually seen with postmenopausal osteoporosis. It depends on the degree of paresis, gait disability, and the duration of immobilisation.

Methods:

We retrospectively analyzed data from 20 patients admitted to the stroke ward. All patients with stroke aged more than 65 years were included in the data. Patients who were less than 65 years old, non-stroke patients, and patients who passed away during admission were excluded. Results: Fall risk assessment showed 25% of patients were low risk, 35% were medium risk, and 40% were high risk. Among them, 15% of the patients had a history of osteoporosis. Only 25% of patients had osteoporosis treatment before admission. 15% had a history of vertebral/femoral fracture in the past. We calculated the FRAX score for all patients (low risk in 44%, intermediate risk in 44%, and high risk in 12%). We compared the pre- and post-admission osteoporosis treatment (25% vs. 30%).

Proposed Plan:

Check vitamin D levels for all patients admitted to the stroke ward. Conduct falls risk assessments for all patients. Calculate FRAX scores for all patients under 90 years. Provide osteoporosis treatment if a previous vertebral fracture is found incidentally, unless contraindicated. If creatinine clearance is less than 30%, refer to the fracture liaison service or ask the GP to refer.

Conclusion:

This study highlights the high prevalence of osteoporosis and fall risk among stroke patients, emphasizing the need for routine osteoporosis screening and treatment in this population. Implementing systematic assessments and appropriate interventions can potentially reduce the risk of fractures and improve the overall quality of life for stroke patients.

 Introduction:

Maintaining good postural stability is considered important to prevent falls in the elderly. We evaluated factors associated with good postural stability.

Methods:

We evaluated 33 patients (6 males and 27 females) over 65 years old. The average age was 76.1 years old ranging 65 to 85. We measured Index of Postural Stability(IPS) using gravicoder GW-5000 manufactured by ANIMA. The IPS was advocated by Mochizuki in 2000. It was defined following this equation; IPS=log[(area of stability limit + area of postural sway)/area of postural sway). Larger IPS means better postural stability. The average IPS in each age was already known. IPS was calculated automatically through gravicoda. We divided these patients into two groups by the results of IPS. Group A with the patients whose IPS was larger, Group B with the patients whose IPS was smaller than the average in their age. We compared the following items between the two groups. Functional performance (gait speed, two-step test, one-leg standing test, five-repetition sit-to-stand test, grip strength), body composition (height, weight, BMI, limb circumference, skeletal muscle mass ), spino-pelvic parameters (Pelvic Incidence(PI), Lumbar Lordosis(LL), Pelvic Tilt(PT), Sagittal Vertical Axis (SVA)) using whole spine x-ray photograph.

Results:

Thirteen patients were classified into Group A and 20 patients were into Group B. Gait speed, two-step test, five-repetition sit-to-stand test, one-leg standing test, SVA were significantly different between the two groups. SVA was 6.39±31.0mm in Group A and 50.6±27.5 mm in Group B. SVA of less than 50 mm is known to be an important indicator of good posture.

Conclusion:

The results showed that SVA is related to postural stability as well as gait and balance ability. This suggests that good posture is likely one of the keys to fall prevention.

Introduction

The fall risk factors in older adults living in residential care homes for the elderly (RCHEs) are multifactorial. In Hong Kong, around 9.5% of RCHEs have a fall rate over 30% (Elderly Health Service, 2022)1. The objective of this survey is to identify the common fall risk factors among frequent fallers in RCHEs in biological, environmental, and behavioural domains, based on the World Health Organization (WHO)’s risk factor model for fall (World Health Organization, 2021)2.

Methods

197 frequent fallers from 67 RCHEs with fall prevalence over 30% in Hong Kong were included in this cross-sectional retrospective survey. Twenty fall risk factors in biological, environmental and behavioural domains were investigated through tailor-made questionnaires and staff interviews. The most common fall risk factors, the time period and places of fall of all fallers were identified. The fall management strategy including fall risk assessment and fall incident report of RCHEs were also examined and compared.

Results

In the biological domain, chronic illnesses, decreased mobility, gait instabilities, lack of physical activities and cognitive impairment are the most common fall risk factors. In the behavioural domain, unsafe behaviour such as over-estimation of self-ability and hesitation to seek assistance are the most prevalent. Key environmental fall risk factors include movable furniture and poor lighting. The most common places of falls are bedsides while the peak hours of falls occurs around meal times. Nearly 24% of RCHEs did not perform fall risk assessments for residents.

Conclusions

Behavioural and biological fall risk factors play a more important role than environmental risk factors in these frequent fallers, and many of them are modifiable. Large variations exist in the fall management of different RCHEs. Interventions to prevent falls in RCHEs should target at improving the fall management protocol and addressing the specific fall risk factors of frequent fallers. 
 

Background: Falls are common presenting complaints in older adults, particularly those aged 65 and above, with prevalence increasing with age. The risk of falls is multifactorial, and polypharmacy, defined as the use of five or more medications, is one of the significant modifiable risk factors. Inappropriate medication use, which occurs in 30-50% of cases in the elderly, exacerbates this risk.

Objective: This audit aimed to assess the impact of polypharmacy on fall risk among elderly patients and evaluate the effectiveness of medication reconciliation in reducing this risk. The study was conducted in an elderly ward at Maidstone Hospital.

Methods: The audit included patients on polypharmacy, assessing their fall risk and the appropriateness of their medication reconciliation. High-risk medications, such as diuretics, benzodiazepines, antidepressants, and antiparkinsonian drugs, were identified and analyzed for their contribution to fall risk. Tools used were EPR software to look at prescription orders, worksheets, documentation for falls risk, and medication reconciliation.

Results: 84% of patients were taking more than four medications. 80% of patients were on high-risk medications. 32% of patients had unreconciled medications, although pharmacists performed other reconciliations. Nearly 50% of patients had either medium or high fall risk.

Recommendations:

1. Conduct regular reviews of patients' medications, emphasizing the importance of medication reconciliation at admission and whenever prescriptions change.

2. Implement departmental teaching on polypharmacy and medication reconciliation for both doctors and pharmacists in the frailty department.

3. Utilize the START/STOPP criteria to review medications, ensuring compliance with NICE standards for medication reconciliation. These measures aim to reduce the risk of falls and other adverse effects associated with polypharmacy in the elderly.