Prevention and Management of Falls and Fragility Fractures in Older People

1. Training for Healthcare Support Workers Prevention and Management of Falls and Fragility Fractures in Older People

2. Learning Outcomes By the end of the session the candidate should be able to 1 Advise and inform the older person and carers about falls and fragility fracture prevention to support self management 2 Identify, record and report risks and physical and psychological consequences of falls and fragility fractures for older people and their carers 3 Understand the range of solutions available to help reduce risks, including steps to be taken to enable self management

3. Definition of a Fall An event which results in a person coming to rest inadvertently on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects 2

4. Osteoporosis A disease characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk8

5. Risk Factors for Fragility Fractures Can be divided into 2 factors • Increased prevalence of falls • Changes in bone density A person is at greater risk of fracturing a bone when they fall if they have osteoporosis

6. The Scale of the Problem • Approximately one third of people over the age of 65, and half of people over the age of 80 fall every year • Falls are the leading cause of injury deaths among people aged 65 and over • 95% of hip fractures are caused by falls • 75-80% of non injurious falls are not reported to a health professional3 • Half of people who have a fall will fall again within the next 12 months11

7. The Scale of the Problem(2) • 1 in 3 women and 1 in 12 men will suffer an osteoporotic fracture over the age of 50 years14 • Approx 5% of falls result in fracture3 • Approx 1% of falls result in hip fracture6 • There are over 6000 hip fractures in Scotland every year4 • Over 200 hip fractures per annum in Dumfries and Galloway

8. The Ageing Population of Scotland • The ageing of Scotland’s population is a particular challenge to health. In the next 25 years the proportion of the population over 65 will increase to 1 in 415 • In Dumfries and Galloway the number of residents aged 90 years or over is projected to increase from 1,134 in 2008 to 4,425 in 2033 • The over-65s population in D&G is likely to grow by 25% by 2018 and 56% by 2033 16

9. Financial Consequences of Falls and Fragility Fractures • The direct cost of a hip fracture is £12000 (mostly accounted for by length of stay) • The estimated hospital cost of hip fracture to NHS Scotland is £ 73 million per annum4 • Average additional costs for health and social aftercare are £13ooo in the first 2 years12

10. Risk Factors for Falls • What are the risk factors for falls in older people? • State whether you think each is modifiable or non modifiable

11. Most Common Risk Factors for Falls • Muscle Weakness • History of falls • Abnormality of gait/balance • Visual Deficit • Arthritis • Impaired Activities of Daily Living • Depression • Cognitive impairment • Age>80 years13

12. The more risk factors present the greater the risk of falling • One study showed that the percentage of older people falling increased from 27% for those with no or one risk factor to78% for those with four or more risk factors7

13. Osteoporosis risk factors • Strongest risk factors Female sexAge > 60 yearsFamily history of osteoporosis Other significant risk factorsEarly menopause Caucasian OriginLow BMISmokingSedentary lifestyleLong term (>=3 months) corticosteroid use14

14. Physical/Psychological Consequences of Falls What are the consequences of an older person having a fall 1 On the older person themselves 2 On their family/carers Divide into 2 groups. One group consider physical consequences, and one group consider psychological consequences. Feed back to the main group

15. Physical Consequences of a Fall Bruising Pressure Sores Dislocation Soft Tissue Injury Fractures PhysicalDehydration HypothermiaPneumonia/Chest Infection Muscle Wasting Head Injury DEATH

16. Psychological Consequences of a Fall Fear of further falls Social Isolation Embarrassment Low self esteem Psychological Loss of Confidence Depression Guilt(carers/family) Stress Worry/anxiety for carers Dependency

17. However........ • Falls are not an inevitable consequence of old age; rather they are nearly always due to one or more underlying risk factors. Recognising AND MODIFYING these risk factors is crucial in preventing falls and injuries11 • Glasgow Falls service demonstrated 32% reduction in hospital admissions due to falls • Evidence shows that falls can be reduced with implementation of appropriate interventions and in one study were reduced by 55%5

18. How Do We Reduce Falls Rates? 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)1 NICE(2004)

19. Risk Assessments Level 1 Screening/Basic Risk assessment Aim: to identify an older person who has fallen/is at risk of falling and may benefit from further intervention. Next steps include informing a senior colleague of the risks, implementing any interventions within your remit Examples: FRAT-may under/over predict the risk of a fall Cambridgeshire Falls Prevention Assessment

20. For example…Cambridgeshire Falls Prevention Services Level 1: Initial risk identification Provided by Jackie Riglin, Falls Prevention Co-ordinator, Southern Cambridgeshire Falls Prevention Service

21. Risk Assessments Level 2 Multifactorial Assessment Aim: To identify SPECIFIC risk factors for falling/sustaining a fracture, in order to guide which interventions the individual requires. It is more complex than the level 1 assessment and leads on to addressing specific risk factors Contains a checklist of risk factors, interventions and clear onward referral guide/action plan

22. Risk Assessment(Cont) Level 3 Specialist Assessment Aim: To investigate further the risk factors identified with a view to providing tailored interventions to reduce the risk Eg: Balance/gait assessment by a physiotherapist, continence assessment, medication review by a GP

23. What Can be Done?-Falls Prevention • Adaptation or modification of home environment • Withdrawal or minimization of psychoactive medications • Withdrawal or minimization of other medications • Management of postural hypotension • Management of foot problems and footwear • Exercise, particularly balance, strength, and gait training9

24. Environmental Modification Consider: Floor Coverings Cables/cords Lighting(including the lighting on stairs) Slip resistant mats in bathroom Height of bed/chair/toilet Equipment-handrails, toilet/chair raise, bannister on stairs/bed rail Clutter Spills-kitchen/bathroom

25. Medication May contribute to falls eg anti-hypertensives (egDoxazosin) sedatives (egnitrazepam) analgesics (egtramadol) anti-depressants (egamytriptyline) diuretics (egfurosemide) anti-epeleptics (eg sodium valporate) May be prescribed to treat osteoporosis eg calcium/ vitaminD alendronate ibandronate

26. Footwear/Foot Care • Identification of foot problems and appropriate treatment should be included in fall risk assessments and interventions • Older people should be advised that walking with shoes of low heel height and high surface contact area may reduce the risk of falls9 • Mule type slippers and shoes are best avoided • Check footwear regularly for signs of wear

27. Vision • An older person should be advised not to wear multifocal lenses while walking, particularly on stairs9 • Make sure the older persons glasses are CLEAN • Ensure adequate lighting within the home and the immediate vicinity • GPs can refer to Low Vision Clinic • Vision assessment should be carried out as part of a multifactorial assessment

28. Staying Active • An exercise programme that targets strength, gait and balance, such as Tai Chi or physical therapy, is recommended as an effective intervention to reduce falls • Exercise may be performed in groups or as individual(home) exercises as both are effective in preventing falls9 • Home exercise programmes can be supported by support workers

29. Local Exercise Opportunities In Dumfries and Galloway 12/52 Community Based Classes run by physiotherapy staff target strength, balance, co-ordination and gait. Guest speakers give talks on aspects of falls and fracture prevention Home Based Exercise Programmes supported by Physiotherapy staff 12/52 attendance at local rehabilitation unit where progressive balance and strengthening programmes are undertaken Local Community based therapists have been trained to deliver Tai Chi

30. The Multidisciplinary Team • GP-multifactorial assessment(medication, BP, vision) • Physiotherapist-provision of walking aid/exercise programme • OT-provision of equipment/environmental modification/review of ADL • Podiatrist-Footcare/advice on footwear • Optician-regular vision checks • Social Worker-assessment for care package/telecare • Pharmacist-medication review • District Nurse-monitor ly/st BP

31. Multidisciplinary Team(cont) Support Workers can • Encourage use of walking aids where they have been issued • Check walking aids for safety • Ensure the environment is safe • Encourage activity/exercise • Encourage the older person to eat a healthy rich in calcium/ vit D and leafy green vegetables • Ensure medication is taken as prescribed(including that for bone health) • REPORT FALLS/NEAR MISSES/CLIENTS AT RISK OF FALLS

32. Falls Reporting • Incident Report to be completed for any witnessed falls • Report to senior member of staff any reported falls • Falls reporting should include date, time of day, area where the fall occurred, loss of consciousness, injuries sustained, whether witnessed or not