1. Falls Dr. Fiona Shaw Consultant Geriatrician Rehabilitation and Intermediate Care Services

2. Overview  Background  Evidence  Risk factors and causes of falls  GP interventions  Orthostatic hypotension  Case  Services - current  Proposed service improvements  New guidelines etc.  Websites

3. Background  Less than 1 in 50 older people recorded as having a high risk of falling has a recorded referral to a falls service or exercise programme  ….in part due to not entering data….  ….workload of falls services would increase substantially…… QRESEARCH Evaluation of standards of care for osteoporosis and falls in primary care, 2007

4. Local background  35 – 65 % fall pa  5% fracture Fractures in A&E: Fallers seen by services:  14, 525 – 24,900  726 – 1245  1710 (age > 50)  1500 Newcastle population age > 65 = 41,500 Actual figures 2007

5. Reactions? aOh gosh! I must refer more patients to falls clinics bThe falls services couldn’t possibly cope with those numbers – don’t be silly! cI would refer more patients with falls if there were more appropriate services dThere’s no evidence for falls clinics so why would I waste money sending more patients there?

6. Falls clinics – negative press  ‘The evidence indicates falls clinics have negligible clinical effect’ Scoping exercise on fallers clinics SDO 2008  Actually didn’t have data to comment  BMJ article ‘Multifactorial falls assessment and intervention’ Lamb et al 2008 Only 6 of 19 trials were of multifactorial assessment and intervention ‘High intensity interventions’ successful Contrast Campbell and Robertson 2007 and Chang et al 2004 and NICE 2004

7. What is the evidence?  Good evidence: Multi-factorial assessment and intervention provided by MDT Targeted strength and balance exercise (community populations)  Some evidence Home hazard assessment alone Medication review alone Correction of visual impairment alone

8. Multifactorial assessment and intervention  Assessments and interventions delivered by MDT: Campbell 2007: 6 RCTs: RR 0.78 (0.68 – 0.89) Chang 2004: 8 RCTs: RR 0.82 (0.72 – 0.94) Gates 2008: higher intensity int: RR 0.84 (0.74 – 0.96) Chang 2004: falls / month: 0.63 (0.49 – 0.83) Chang 2004: NNT to prevent 1 person falling/year = 11  There is lots of evidence to support multifactorial assessment and intervention delivered by a multidisciplinary team

9. What should be included?  Medication review  Orthostatic blood pressure  Gait, balance, strength  Environmental hazards  Vision  Cardiovascular  Education Research base: Agrees with NICE – added a few more

10. Targeted balance and strength exercises  Meta-analyses: Chang 2004: 13 RCTs: RR 0.86 (0.75 – 0.99) Gillespie 2003: RR 0.80 (0.66 – 0.98)  Individual result (FaME, Skelton 2005): 30% reduction in falls over 18 months 32% reduction in death or move to institutional care at 3 years  Again good evidence to support targeted balance and strength exercises as per NICE

11. So in summary….  multifactorial assessment and intervention delivered by MDT and  targeted strength and balance exercises in community populations as a single intervention Robust evidence to support:

12. Risk factors & causes of falls How many can you name in 2 minutes?

13. Risk factors & causes of falls  General medical problems e.g. UTI, anaemia  Visual impairment  Medication  Depression  Specific diagnoses e.g. Parkinson’s Stroke  Cognitive impairment / dementia  Gait and balance impairments  Muscle weakness  Inappropriate footwear  Inappropriate aids  Feet  Environment  Low blood pressure  Orthostatic hypotension  Vasovagal syncope  CSH  Cardiac arrhythmia  Drop attacks  BPPV  Acute vestibular problems  Cerebrovascular disease  Epilepsy  Narcolepsy  Vertebrobasilar insufficiency  Psychogenic  etc…..

14. What should the GP be doing? Your views?

15. What do I think the GP should be doing?  Looking for underlying general medical problems – UTI, chest infection, anaemia, malignancy, etc  Checking for injuries  Reviewing medication – esp recent changes  Checking pulse, BP, orthostatic hypotension  Assessing (briefly) mobility, gait and balance  Thinking about osteoporosis  Looking at others issues e.g. safety at home  Referring to falls services

16. Measuring orthostatic blood pressure What’s the physiology? How do you do it?

17. Orthostatic hypotension  Mechanism – venous pooling on standing  Contributing mechanisms – impaired heart rate response, volume depletion, impaired cerebral circulation and autoregulation, medication, other diseases  Result: Falls or Syncope  Measurement GP: LYING (10 mins!?) and standing at / within 2 minutes, should be in the morning  Measurement Falls Clinic: 10 minutes supine rest, beat to beat blood pressure reading recording at 30 secs, 1 min, 90 secs, 2 mins, in the morning

18. Falls case  Female – 88 years old – independent  2 falls – tripped on paving stones  Lightheaded but Bp 160/70, no postural drop  PMH – MI 1998  Medications: Atenolol 50mg od, Aspirin 75mg od, Lisinopril 10 mg od, Zopiclone 7.5 mg nocte  What did we do for our initial assessment?  What did we find?

19. Falls case  History – lightheaded esp mornings, standing quickly, up from bending  Exam – unsteady initial standing, blind L eye  Bloods – normal  12 lead ECG – SR 62 / min (rate 48 / min 2007)  Active stand – No OH  DXA – osteoporosis – treatment commenced  Physio  Do we need to do anything else?

20. Falls case  24 hour ECG SR 51 - 82  24 hour Bp  Lisinopril stopped (kept Atenolol – not too bradycardic, previous MI, good history OH)

21. If the history is good, think of OH and low BP in spite of surgery readings Beware white coat hypertension

22. Current falls services  Falls and Syncope Service, RVI  Belsay and Melville Day Hospitals, NGH & FRH  Community Resources Teams (North, East, West)  Osteoporosis Service, FRH

23. Who do we want to see?  3 or more falls in past year  1 or 2 falls and unsteady walking  Unsteady walking and other risk factor – inc 4 or more medications  Fall presenting to medical attention

24. What can you expect? Multifactorial falls assessment and intervention Hx, Ex, ECG, AS, OPx, PT FASS Prolonged cardiac & Bp monitoring CSM, HUT Specialist vestibular OT Day Hospital / CRT for MDT Day Hospitals Prolonged cardiac & Bp monitoring Basic vestibular Vestibular rehab Full MDT Falls Groups FASS for CSM / HUT CRT MDT at home Day Hospital for other

25. Interventions provided  Medication changes  Physio gait, balance and strength exercises  Treatment for OH  General medical  Podiatry  OT  Treatment for VVS  Vestibular rehabilitation  Driving advice  SW  PPM (via cardiology) – CSH, bradyarrhythmia  Psychiatry (psychology) referral  Referral to: ENT, neurology, specialist bone, ophthalmology

26. Proposed service improvements  Expand referral criteria – any fall (or blackout)  Simplify referral mechanism – FAB hotline  Fill some gaps - Staying Steady exercise groups CommFASS  Joint standards of working across all services and more explicit joint working  Expansion and better profile for existing services  DXA scanning West of City (Belsay)  Improved links with others – orthopaedics, ENT, A&E

27. New guidelines etc.

28. A new ambition for old age (2006)  To extend initiatives to improve exercise, balance, medicines management & footwear  To improve emergency response  To have a falls assessment service for people with recurrent falls  To increase capacity in osteoporosis  To improve rehabilitation services for people who have lost functional ability or confidence after a fall

29. RCP Falls & Bone Health (2007)  Most patients returning from A&E after a low impact fracture were not offered multidisciplinary falls risk assessment  Only 22% were referred for exercise training  After 3 months only 20% on appropriate treatment for osteoporosis  For the minority of patients who attended a falls clinic, falls and fracture risk assessments and treatments were better www.rcplondon.ac.uk

30. Useful web links  www.shef.ac.uk/FRAX  www.helptheaged.org.uk  www.rcplondon.ac.uk  www.ic.nhs.uk  www.profane.eu.org