1. Definitions and Evidence Base Dr Karl Davis Cardiff and Vale UHB

2. Prudent Healthcare

3. Definitions

4. Falls Prevention - NICE Primary prevention – interventions that are targeted at those at risk or high risk of a fall. ‘The key issue of concern is not simply the high incidence of falls in older people – since children and athletes have a very high incidence of falls – but rather the combination of a high incidence and a high susceptibility to injury (Rubenstein 2001).’

5. Falls and risk of falling Physical (in)activity ContinenceOut-patients Wider determinants Air pollution / quality RTCs Climate Change Fuel Poverty Public transport Frailty CO poisoning Concussion / TBI Hot / cold weather Physical / built environment Awareness raising Epidemiology NERS Falls Brief Intervention / Timed Up and Go Primary care Secondary care Unscheduled care / ED Communit y care Care & Repair Fire and Rescue Services Pharmacy Optometry Podiatry What works – updated; What doesn’t work Current activity Individual v population level Outcomes; falls v injury falls; injury falls v # falls; medically treated – ED v IP Measuring effectiveness Falls services NICE guidance Cochrane Review Hydration WAST Strength & balance Steady on, Stay Safe Stay on your feet Get up and go Age Cymr u Dizziness Hearing loss Alcohol misuse High blood pressure LLTIPoor footwear Malnutrition RoSPA – Stand Up, Stay up Evaluatio n Best practice v effective practice Social services Housing Loss of independence Social exclusion Bed pressures Hospital admission MF risk assessment In-patient falls Home environment / home hazard assessment Fear of falling Bone density Cognitive impairment Foot problems Use of mobility aids increasing risk Bed pressures Medications / poly- pharmacy Whole system Health Boards Annual GP check WG Primary, secondary, tertiary prevention Physiotherap y OT Health Protection inc vacc and imms Comms Health improvement Nursing 3Es – Education, engineering, enforcement Single v multi factor int Haddon matrix Nuffield ladder Data collection Data quality

6. The Scale of Falls

7. Estimated burden (2009 data on falls) 252 deaths –(25% of inj deaths coded X59 (unspec) & linked to fall IP admission) 20,058 admissions 44,257 ED attendances 252 Deaths 20,058 In-patient admissions 44,257 Attendances at Emergency Department

8. Epidemiology of falls Summary of falls epidemiology, adapted from Rubenstein and Josephson (2002), Cummings and Melton (2002), Peel et al (2002)

9. Wales Epidemiology20102015 ? 765,200 people aged over 60 230,000 to 460,000 suffer a fall each year 11,500 to 45,900 suffer fracture, head injury, serious laceration 115,000 to 230,000 fall more than once 824,100 people aged over 60 247,200 to 494,5000 suffer a fall each year 12,400 to 49,400 suffer fracture, head injury, serious laceration 123,600 to 247,200 fall more than once 100 community dwelling older people 30 to 60 suffer a fall each year 2 to 6 suffer fracture, head injury, serious laceration 15 to 30 fall more than once

10. The Evidence for Preventing Falls Published by NICE

11. Falls in older people: assessing risk and prevention NICE guidelines [CG161] Published date: June 2013 Preventing falls in older peopleolder people Case/risk identification Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. [2004]Older people Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed in section 3.3 of the full guideline.) [2004]full guideline

12. Multifactorial falls risk assessment Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. [2004]multifactorial falls risk assessment multifactorial intervention

13. Multifactorial assessmentMultifactorial assessment may include the following: identification of falls history assessment of gait, balance and mobility, and muscle weakness assessment of osteoporosis risk assessment of the older person's perceived functional ability and fear relating to falling assessment of visual impairment assessment of cognitive impairment and neurological examination assessment of urinary incontinence assessment of home hazards cardiovascular examination and medication review. [2004]

14. Multifactorial interventions All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. [2004] In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):multifactorial intervention strength and balance training home hazard assessment and intervention vision assessment and referral medication review with modification/withdrawal. [2004] Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function. [2004]

15. Strength and balance training Strength and balance training is recommended. Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional. [2004]older people living in the community

16. Exercise in extended care settings Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling. [2004]Multifactorial interventionsextended care

17. Home hazard and safety intervention Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer, and appropriate members of the health care team. [2004] Home hazard assessment is shown to be effective only in conjunction with follow-up and intervention, not in isolation. [2004]

18. Psychotropic medications Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling. [2004]

19. Cardiac pacing Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls.

20. Encouraging the participation of older people in falls prevention programmes To promote the participation of older people in falls prevention programmes the following should be considered. Healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls. Information should be relevant and available in languages other than English. Falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant. Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants' different needs and preferences and should promote the social value of such programmes.

21. Education and information giving All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention. Individuals at risk of falling, and their carers, should be offered information orally and in writing about: –what measures they can take to prevent further falls –how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components –the preventable nature of some falls –the physical and psychological benefits of modifying falls risk –where they can seek further advice and assistance –how to cope if they have a fall, including how to summon help and how to avoid a long lie.

22. Ideas Stand up against falling down –Population level understanding that falls can be prevented Stop never fallers from becoming ever fallers –Population level exercise Take a proactive approach to risk assessment –Primary care ‘screening’ Ensure that current practice is good practice

23. Frailty : Falls Prevention & Prudent Healthcare

24. Prudent Healthcare

26. Wrexham Strength and Balance Classes

27. The Opportunity to Further Increase The Impact of Our Services 1000 Lives Improvement programme will create a national public service task force to change the way the falls programme is delivered across Wales. Creation of new regional partnership boards, as part of the Social Services and Well-being (Wales) Act 2014, from April 2016. Intermediate Care Fund will develop services to support older people to maintain their independence at home. Quality improvement programme to support innovation and integration in primary care.