An Evaluation of the Greater Glasgow & Clyde Osteoporosis and Falls Strategy

1. An Evaluation of the Greater Glasgow & Clyde Osteoporosis and Falls Strategy Dr Dawn Skelton & Fiona Neil, School of Health

2. The Process • Jan 2008, Fiona Neil, OT within the Falls Service, was seconded to the GCAL 0.5 FTE for one year. • Visits to representatives of all parts of the service (Jan 2008-Aug 2008) • Record current Protocols and Processes • Discuss and gather previous audits • Discuss potential data collection • Advise on relevant up to date guidelines/evidence base  • Any previously gathered audit or outcome information (for presentations at conferences etc) was collected as well as raw data where possible. • Data blinded by the relevant service, permission sought from the Caldicott Guardian for NHSGGC. • Some small audit projects and 2 Masters Project (GCU OT & PT student, with full NHS ethical approval)

3. CFPP Specialist falls service which aims to prevent further falls by providing a comprehensive falls screening, health education, exercise, rehabilitation and onward referral The service is available to individuals who are over 65, live at home and have had a fall in the last year 221 referrals a month in 2008 Telephone triage completed within 24 hours of receiving referral Home screening completed within 5 working days of triage

4. Pathway Fall in past year. Community dweller. Aged 65+ Multifactoral interventions Falls Admin centre-triage (within 24 hours) Falls Clinic/ Medical review and gateway to day hospital COPT/ IRIS/ DART HFPP Physio assessment and falls exercise classes Onward referral Pharmacy review Deliver 1to1 Physio at community site for musculoskeletal problem Multi-factorial Falls Risk ScreeningHome visit within 5 working days. Community older peoples team (COPT) Dietician Podiatry OT Home Falls Prevention Programme Open Referral Optician Sensory Impairment Dexa Scan GP/Audiology Community Alarms Handy Persons Benefits Advisor Social Work/Home Care

5. INTEGRATED PLANS Fracture OsteoporosisFalls > 95% hip fractures due to a fall > 90% of hip fractures due to osteoporosis Falls, Fragility & Fractures, Cryer & Patel, 2002

6. NICE Falls CG: specialist integrated service model, 2004

7. ABS/BGS Guidelines 2001 Assessment History of falls Medications & Medical Conditions Vision Gait and Balance Lower Limb Joints (assistive devices) Neurological (sensory) & Continence Cardiovascular Multifactorial intervention (as appropriate) Gait, balance and exercise programmes Medication modification Postural Hypotension Treatment Environmental Hazard Modification Cardiovascular disorder treatment AGS/BGS Guidelines J Am Geriatr Soc 2001; 49: 664 – 672.

8. Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Case/risk identification • POSITIVE • Large number of referrals into CFPP. Telephone Triage followed by home visit and onward referral. • Linkages and communication with CHCPs, DART, IRIS & COPT to support case risk identification • NEEDS WORK ON • Reducing refusals and non-responses to invite letters from CFPP. • DNAs to Falls Clinic. • Engaging GPs and A&E Depts to identify high risk fallers (eg. those who have presented with a fall) • FPCs work in Hospitals and Care Homes. Have identified issues and more work is needed to engage hospital AHPs and Care Home Staff

9. Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Multifactorial Falls Risk Assessment • POSITIVE • Excellent links with Fracture Liaison Service and Direct Access DEXA Scan and Pharmacy to ensure bone health is also considered • NEEDS WORK ON • Urinary Incontinence, Fear of falling, anxiety and depression and Vision assessment is minimal. • Roll out of DADS into Clyde

10. Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Multifactorial Interventions • POSITIVE • Evidence based exercise delivery continuum. • Good OT input to CFPP interventions. • Excellent links with Fracture Liaison Service & Pharmacy • NEEDS WORK ON • dedicated support time for CFPP (& Falls Clinics) Clinical Psychology • Hospital based OTs to ensure home visits before discharge • Equitable access to services across GG&C (eg syncope clinic for potential cardiac pacing). • long-term support of home exercise programmes and primary prevention programmes • No “tie-up” or follow up after interventions (Falls Clinics, CFPP, Little evidence of exercise or other multi-factorial interventions occurring in care homes (apart from FPCs currently raising awareness)

11. Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Patient Engagement • POSITIVE • Evidence of patient satisfaction questionnaires in some parts of the service • NEEDS WORK ON • Falls Clinics need to engage patients to understand reasons for DNAs

12. Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Case/risk identification • POSITIVE • Large number of referrals into CFPP. Telephone Triage followed by home visit and onward referral. • Linkages and communication with CHCPs, DART, IRIS & COPT to support case risk identification • NEEDS WORK ON • Reducing refusals and non-responses to invite letters from CFPP. • DNAs to Falls Clinic. • Engaging GPs and A&E Depts to identify high risk fallers (eg. those who have presented with a fall) • FPCs work in Hospitals and Care Homes. Have identified issues and more work is needed to engage hospital AHPs and Care Home Staff

13. Comparison of current strategy with the AGS/BGS Guidelines Assessment History of falls Medications & Medical Conditions Vision Gait and Balance Lower Limb Joints (assistive devices) Neurological (sensory) & Continence Cardiovascular Multifactorial intervention (as appropriate) Gait, balance and exercise programmes Medication modification Postural Hypotension Treatment Environmental Hazard Modification Cardiovascular disorder treatment

14. Emergency admissions due to falls in the home by age group

15. Cumulative percentage of emergency admissions by age range

16. Percentage of emergency admissions due to falls

17. Number of admissions due to falls in relation the number of medical conditions diagnosed

18. Injuries to Hip and Thigh Injuries to the Head Emergency Admissions for falls (number) % total adm. for falls Bed Days (average number) % total bed days for falls admissions Emergency Admissions for falls (number) % total adm. for falls Bed Days (average number) % total bed days for falls admissions Greater Glasgow and Clyde 376 35.6% 33.5 51.1% 178 16.8% 10.5 7.6% Greater Glasgow 271 36.7 % 32.8 52.6% 128 17.3% 11.7 8.8% Emergency admissions and bed days occupied from falls

19. Relationship between emergency admissions and deprivation

20. Deaths due to falls by deprivation index

21. 1998 2008 % change over 10 yrs Total admissions due to falls in 65+ 3939 4240 + 7.6% Admissions due to falls at home 1567 1059 -32.4% Admissions due to falls in residential institutions 309 205 -27.2% Admissions due to falls in the street/highway 330 199 -39.7% Unspecified or unknown place 1561 2074 +32.9% Emergency Admissions due to falls over a ten year period (1998-2008)

22. Greater Glasgow Greater Glasgow & Clyde Year Bed Days Number of admissions Mean Stay Bed Days Number of admissions Mean Stay 1998 34248 1173 29.2 48261 1567 30.8 2008 16909 740 22.9 24624 1059 23.3 % Change 1998 to 2008 -50.6% -36.9% -21.7% -49.0% -32.4% -24.5% % Change 2005 to 2008 -31.5% -8.5% -25.1% -30.2% -10.5% -22.1% Bed days, emergency admissions and mean stay due to falls in the home in the 65+ age group 1998-2008

23. Number of emergency admissions due to falls in the home

24. Comparison with Scotland

25. Growth 5.6% per year

26. Bed days due to admission for falls in the home

27. Growth 1.7% per year

28. Hip fracture admissions in over 65s No change –0.4%

29. Growth 1.8% per year

30. In a bit more depth… • CFPP referrals and interventions • Any parts of the process that need work? • Strength and Balance Interventions • Do they improve balance? • Do they reduce fear of falling, improve balance confidence and quality of life? • Why do people not necessarily progress from rehab-led to instructor-led classes? • Assessment of bone health in Falls Clinics • Can we use a “tool” and not do DEXA scans?

31. Compared to Other Falls Services • SDO Report 2007 – services in England • 231 services reported back - median new attendances p.a = 180 (range 10–1700) at a cost of £32 million! • 116 Community based services • Average cost £110k • see on average 195 pts p.a • 110 Acute based services • Average cost £171k • see on average 269 pts p.a • 5 A&E based services • Average cost £363k • refer on average 1000 pts p.a to GP etc. • CFPP GGC sees 2652 pts p.a – at unknown cost

32. CFPP Referrals

33. CFPP Referrals

34. Audit (July-Sept 2008) of A & E attendee’s at the SGH32% of all A & E attendee’s over the age of 65 have had a fall65 had had a fracture and half of these had a history of falls2 were referred to the CFPP direct from A&E!

35. CFPP appointments

36. CFPP workload

37. CFPP Interventions

39. Physiotherapy Intervention • 12 Strength & Balance Classes • Classes locally delivered • Free transport service (70% utilise) • 12-18 week attendance • Home Exercises • Partnership working with Day hospital and Leisure services (Glasgow Culture & Sport)

40. COPT/IRIS/DART (ref made by physiotherapist) CFPP Physiotherapy assessment Hospital Falls Clinics Level 1 Day Hospital class Tinetti 15-18 Physio led Level 2 CFPP community class Tinetti 19-28 Physio led. VITALITY community classes levels 1-4 Instructor led Osteoporosis and Ozone classes for low risk fallers Referral Pathways for Exercise Classes– exit and entry routes

41. Strength & Balance Programmes • Evidence based exercises • (Skelton 2005; Robertson 2001; Campbell 1999) • Evidence based “deliverers” • Physiotherapists and trained Postural Stability Instructors (Skelton 2004) • Evidence based duration • Dose of 50 hours of balance challenging exercise (Sherrington 2008)

43. Attendance at classes

44. Evaluation of effect • N= 274 clients considered over a time period in 2007. • Attended on average 11.9 (sd 3.8) weeks • Outcome measures: • Duration of attendance • Functional tests • Tinetti Mobility and Balance Score • Timed Up and Go • 180 degree turn • Functional Reach • Confidence in Maintaining Balance • Tinetti’s Falls Efficacy Scale (FES) • Patient Satisfaction Questionnaires (N=91) • Same assessor throughout - not all tests completed on all clients

45. Outcome measures

46. Balance improvements are duration dependent • The Tinetti Mobility and Balance Score showed considerable improvement, but the change was dependent on duration of exercise attendance. • Those attendees that drop out of sessions before 12 weeks are unlikely to see clinically significant changes in their balance. • This is in line with the recent systematic review of exercise (Sherrington et al. 2008) where a dose of at less than 50 hours confers little benefit to fall risk reduction.

47. Client Satisfaction • Satisfaction forms at week 10 of their exercise programme (n=117 issued). • 91 patients returned the forms (response rate 78%). • 85% had received information about the class before the sessions started and most (83%) found the pre-class information useful. • Only 1% thought the class was not in a suitable location; the staffs were not helpful; the exercises were rushed, too short or not well explained (showing a high degree of satisfaction with facilities and delivery). • 98% felt the exercise classes were beneficial and 94% thought the sessions were good or very good. • Open response questions showed good improvements to wellbeing (see next slide) however, many people just wrote “enjoyed” in this section!

48. Open responses to feedback

49. Summary • The CFPP exercise service to prevent falls in Glasgow does improve many of the known risk factors for falls • The benefits are duration dependent • clients should be encouraged to adhere for at least 12 weeks, ideally to the maximum 18 weeks and then to move into normal community exercise sessions for older people to maintain the improvements • High degree of client satisfaction (though questionnaire could have been designed better)

50. WHAT ARE THE EFFECTS OF THE GGC FALLS EXERCISE SESSIONS ON FEAR OF FALLING, BALANCE CONFIDENCE AND QUALITY OF LIFE IN GLASWEGIAN FALLERS? Gaynor McGrath MSc Rehabilitation Science Glasgow Caledonian University Submitted Oct 2009