Preventing further falls for older people presenting to an Emergency Department after a fall Developed by: National Ageing Research Institute For further information, contact Pauline Galvin – Funded by the Australian Government Department of Health and Ageing Preventing further falls for older people presenting to an Emergency Department after a fall Developed by: National Ageing Research Institute For further information, contact Pauline Galvin – Funded by the Australian Government Department of Health and Ageing

Frequency of falls in older people (Australia) Approximately 30% of community dwelling people aged 65+ experience one or more falls in a 12 month period Approximately 30% of community dwelling people aged 65+ experience one or more falls in a 12 month period 2/3 of fallers presenting to an ED have fallen in the preceding 12 months 2/3 of fallers presenting to an ED have fallen in the preceding 12 months Falls risk and injury risk increases with age Falls risk and injury risk increases with age –9 times risk of hospitalisation for 85+ compared to years –40 times risk of death from accidental fall for 85+ compared to years With our ageing population health costs are expected to triple by 2050 if current rates remain unchanged With our ageing population health costs are expected to triple by 2050 if current rates remain unchanged –Requiring 2500 additional hospital beds and 3320 more nursing home places

Definition of a fall Need for a standard definition: A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower levelA fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level (World Health Organisation) Includes all slips, trips, faints, not concentrating & accidents that fit in the definition.

Major causes of injury related ED presentations in Victoria 2001 among persons aged 65+ Source: VEMD and VISAR, Autumn 2003 Falls

Why target falls prevention in the ED? (1) 14% to 26% of all presentations to hospital EDs are people aged over 65 years 14% to 26% of all presentations to hospital EDs are people aged over 65 years At one large Melbourne Hospital in 2000: At one large Melbourne Hospital in 2000: 11,500 aged 60+ presented 11,500 aged 60+ presented 900 had a fall recorded as the primary diagnosis 900 had a fall recorded as the primary diagnosis 57% were sent directly home (516 people) 57% were sent directly home (516 people) In Victoria in 2006: In Victoria in 2006: 19,933 aged 65+ presented with an injury due to a fall 19,933 aged 65+ presented with an injury due to a fall 50% were discharged home plus 21% discharged back to their residential care facility 50% were discharged home plus 21% discharged back to their residential care facility Source: VEMD data for 2006

Falls Risk Factors Usually a combination of factors Usually a combination of factors –Intrinsic – health problems affecting balance performance (includes medications) Balance problems Balance problems Chronic health problems (stroke, PD) Chronic health problems (stroke, PD) Cognitive impairment Cognitive impairment Vision impairment, etc Vision impairment, etc Continence Continence –Extrinsic – environmental hazards, and activities associated with high falls risk Poor lighting Poor lighting Uneven or slippery surfaces Uneven or slippery surfaces Obstacles on floor Obstacles on floor

Older people presenting to an ED following a fall usually exhibit multiple risk factors Older people presenting to an ED following a fall usually exhibit multiple risk factors These people are at high risk of subsequent falls These people are at high risk of subsequent falls Some evidence that ED management for older people presenting with a fall focuses on management of injuries, but not on identifying and managing causes of the falls presentation Some evidence that ED management for older people presenting with a fall focuses on management of injuries, but not on identifying and managing causes of the falls presentation Why target falls prevention in the ED? (2)

Research evidence – effective approaches to preventing falls (community setting) There is good research evidence that a number of single interventions can reduce falls: There is good research evidence that a number of single interventions can reduce falls: »exercise (home exercise; Tai Chi, group exercise) »cataract extraction »psychotropic medication withdrawal »home visits by Occupational Therapists »vitamin D and calcium supplementation, can also reduce falls injuries There is good research evidence that multiple interventions, including those based on a falls risk assessment have also been shown to be effective, even in high risk groups such as people presenting to an ED after a fall There is good research evidence that multiple interventions, including those based on a falls risk assessment have also been shown to be effective, even in high risk groups such as people presenting to an ED after a fall

Cognitive Impairment Falls prevention strategies may need to be different for people with cognitive impairment. Falls prevention strategies may need to be different for people with cognitive impairment.

Client Perspectives Older people can have ambivalent attitudes to falls prevention advice. Older people can have ambivalent attitudes to falls prevention advice. Maintaining independence, rather than falls prevention, may be a more acceptable approach to older people. Maintaining independence, rather than falls prevention, may be a more acceptable approach to older people.

Best practice falls prevention in the ED Clear policy and procedures for screening, assessment and referral Clear policy and procedures for screening, assessment and referral Staff education Staff education Evidence based falls risk screening procedure applied Evidence based falls risk screening procedure applied If high levels of falls risk identified, actions are implemented to support further assessment and management (eg referrals) If high levels of falls risk identified, actions are implemented to support further assessment and management (eg referrals) Consider osteoporosis screen and Vitamin D supplements for people with high falls risk Consider osteoporosis screen and Vitamin D supplements for people with high falls risk

Screening of risk is a key component Identifies those at greatest risk of further falls Identifies those at greatest risk of further falls Can be used to determine: Can be used to determine: –those in need of detailed falls risk assessment (either by ED staff member, or referral) –Presence of some important risk factors, which can be used to initiate treatment referrals

An evidence based falls risk screening tool (1) 1. History of falls (0 – 3 points) SCORE Number of falls in the past 12 months? …….. Nil in 12 months (0) 1 in the last 12 months (1) 2 or more in 12 months (2) 1 or more requiring hospitalisation in the past 12 months (3) [ ] 2. Sensory loss (0 – 1 points) Does the client have an uncorrected vision deficit that limits their functional ability? No (0) Yes (1) [ ] Developed from data from a study of 700 older people presenting to Melbourne EDs after a fall (project funded by Department of Veterans Affairs / Department of Human Services (Vic)

An evidence based falls risk screening tool (2) 3. Balance (0 - 3 points) SCORE When walking and turning, does the person appear unsteady or at risk of losing their balance? (NOTE: Rate with usual walking aid. If level fluctuates, tick the most unsteady rating) No unsteadiness observed (0) Yes, minimally unsteady (1) Yes, moderately unsteady (needs supervision) (2) Yes, consistently and severely unsteady (needs constant hands on assistance) (3) [ ] Total Risk Score [ ] Developed from data from a study of 700 older people presenting to Melbourne EDs after a fall (project funded by Department of Veterans Affairs / Department of Human Services (Vic)

An evidence based falls risk screening tool (3) Grades for Overall Falls Risk o Low falls risk - total score 0 – 2 Recommendations: Implement actions for identified individual risk factors and recommend health promotion behaviour to minimise future ongoing risk (e.g. increased physical activity) o High falls risk - total score 3 – 7 Recommendations: Implement actions for identified individual risk factors and implement additional actions for high falls risk

Case study – low falls risk 88 year old man, presents to ED after a fall, moderate bruising to face and knees, shaken up by fall. 88 year old man, presents to ED after a fall, moderate bruising to face and knees, shaken up by fall. Reasonably active man, fell while carrying 2 bags of shopping home, tripped on uneven footpath. Reasonably active man, fell while carrying 2 bags of shopping home, tripped on uneven footpath. Past history of hypertension, type 2 diabetes (diet controlled), left total hip replacement (good recovery). Past history of hypertension, type 2 diabetes (diet controlled), left total hip replacement (good recovery). Feels eyesight has deteriorated in past few years, hasnt had a review for 5 years. Feels eyesight has deteriorated in past few years, hasnt had a review for 5 years. No other falls in past 12 months. No other falls in past 12 months. Steady on his feet Steady on his feet Falls risk screen scores: History of previous falls1 Sensory loss (vision) 1 Balance 0 TOTAL SCORE 2 Recommended actions: Vision – advise to see an optometrist for review of vision Overall risk – low (total score = 2) – no other actions recommended

Case study – high falls risk 83 year old lady, presents to ED after a fall causing moderate bruising to left hip. Fall occurred on rear steps at home. 83 year old lady, presents to ED after a fall causing moderate bruising to left hip. Fall occurred on rear steps at home. Past history of moderate osteoarthritis in knees, cataracts, peripheral neuropathy. Past history of moderate osteoarthritis in knees, cataracts, peripheral neuropathy. Has had 2 other falls at home in past 12 months, no serious injuries. Has had 2 other falls at home in past 12 months, no serious injuries. Is a little unsteady when standing from sitting Is a little unsteady when standing from sitting Falls risk screen scores: History of previous falls2 Sensory loss (vision) 1 Balance1 TOTAL SCORE 4 Recommended actions: Vision – advise to see an optometrist for review of vision. Balance – referral to physio for review and possible balance training. High risk (total score = 4) – letter to GP highlighting high risk identified. Further assessment including consideration of an OT referral.

Where to refer for further assessment / treatment (examples) Options will vary depending upon your area Emergency Dept General Practitioner Community Rehabilitation Physiotherapist Occupational Therapist Optometrist / ophthalmologist Vision Australia Falls Clinic HARP program Community Exercise Group Dietitian Podiatrist District Nursing Service Community Health Service

Summary Older people presenting to the ED after a fall are at increased risk of further falls Older people presenting to the ED after a fall are at increased risk of further falls A screening tool can help identify those at high risk of recurrent falls, A screening tool can help identify those at high risk of recurrent falls, ED can help in risk identification and referral for assessment and treatment ED can help in risk identification and referral for assessment and treatment

Further Information Information on Falls Prevention is available from Department of Human Services Department of Human Services Australian Commission on Safety and Quality in Healthcare Australian Commission on Safety and Quality in Healthcare