Episode 2.09 – Falls Prevention

December 10, 2016

MDTea Episode 2.09 – Falls Prevention

In this episode we will cover the evidence base for falls prevention, particularly community based programmes designed to improve balance and mobility

Broadcast date: 13th December 2016

Presented by: Jo Preston (Consultant Geriatrician at St George’s Hospital, London) and Iain Wilkinson (Consultant Geriatrician at East Surrey Hospital).

Core Faculty: Sarah Jane Ryan (Physiotherapy Lecturer at University of Brighton)

Guest Faculty: Alun Cooper (GP in Surrey and Clinical Lead for Fracture Liaison Service in Crawley) and Amy Heskett (Community Geriatrician in Kent).

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Episode 2.09: Falls prevention – Show Notes

You can download these show notes here.

Learning Outcomes

Knowledge:

  • To understand the role of falls prevention programmes and their potential
  • When to perform a falls risk assessment

Skills:

  • Identify the components of a falls risk assessment
  • Be able to perform a basic timed ‘up and go’ test

Attitudes:

  • To appreciate that falls are a symptom and not a diagnosis in themselves
  • Understand that falls may lead to a fear of falling

Definitions:

 

The scale of the problem

  • 28-35% of people >65 years old fall each year
  • 68% of these had an injury and 24% of these injuries required intervention from a healthcare professional
  • 35% of those who have a fall have a subsequent decline in function
    • this may affect someone’s ability to stay within their own home, to manage without carers or indeed their chance of enjoying activities.
  • After a first fall people have a 66% chance of having another fall within a year.

WHO Factsheet

Falls prevention programmes do work

  • NNT (number needed to treat) to reduce falls from strength and balance training is only 11.
  • Group and home-based exercise programmes, and home safety interventions reduce both rate of falls and risk of falling.
  • Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.
  • Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

Interventions for preventing falls in older people living in the community.

Gillespie et al. 2012

Key Points from Discussion

Falls risk assessment

A recent (2016) article in the BMJ reviewing falls prevention in community dwelling older people highlights that falls result from interactions between multiple individual and environmental risk factors – for example:

        • Frailty
        • Polypharmacy
        • Gait and balance
        • Co-morbid conditions

Extensive research has identified many risk other factors in older people in the community, including:

  • Previous falls
  • Pain – e.g. lower limb or foot
  • Cognitive impairment – reduction in verbal ability, processing speed and immediate memory
  • Urinary incontinence – rushing to the toilet at night

Gillespie et al. 2012

Key point: You may not think of yourself as someone who ‘sees patients that fall’ (eg podiatry, continence services etc.) but in reality patients may present to a number of different services, and you may be the person that triggers the more detailed assessment. The management of older people is multifactorial and needs Comprehensive Geriatric Assessment.

 

The BMJ paper suggested a strategy for falls risk assessment based around:

1) History and examination

2) Drug review  – involve the patient’s GP and/or pharmacist here

3) Specific review of medical risk factors:

  •     Vision
  •     Syncope
  •     Cardiovascular
  •     Cerebrovascular
  •     Diabetes

4) Functional and mobility assessment

5) Psychological effects of the fall

  • May reduce mobility to decrease risk of fall but this may cause muscle weakness and joint stiffness
  • It is therefore important to encourage or develop techniques to assist with coping with anxiety.

Essentially a CGA! (See episode 1.01- CGA)

Prevention of falls in older people living in the community

Vieira et al,  BMJ 2016

Falls prevention exercise programmes

A systematic review provides evidence that fall prevention exercise programmes for older people not only reduce the rates of falls but also prevent injuries.

  • The protective effect seems most pronounced for the most severe fall related injuries: estimated reduction is 37% for all injurious falls, 43% for severe injurious falls, and 61% for falls resulting in fractures.
    • Many of the risk factors for falls injuries are similar. These factors are correctable by well designed exercise programmes, even in the very old and frail.
  • All exercise programmes that have proved to be effective for fall prevention (and all trials included in this review) emphasise balance training, and there is now ample evidence that this improves balance ability. However, most programmes are multi component—that is, also include other types of exercise such as gait and functional training, strengthening exercises, flexibility, and endurance.
    • There is evidence that these types of interventions can improve reaction time, gait, muscle strength, coordination, and overall physical functioning as well as cognitive functions, especially executive function.
    • It is therefore thought that exercise prevents injurious falls not only by improving balance (e.g Tai Chi and Otago) and decreasing the risk of falling, but also by improving cognitive functioning, and the speed and effectiveness of protective reflexes (such as quickly extending an arm or grabbing nearby objects) or the energy absorbing capacity of soft tissues (such as muscles), thereby diminishing the force of impact on the body.

Systematic review of falls prevention programs

El-Khoury et al, BMJ 2013

Otago home exercise programme

Administered to 1000 people living at home, aged 65-97. Falls reduced equally in men and women and by 35% overall.

Highest impact was seen in those >80yrs with a previous fall.

  • The programme was designed specifically to prevent falls. It consists of a set of leg muscle strengthening and balance retraining exercises progressing in difficulty, and a walking plan.
  • The exercises are individually prescribed and increase in difficulty during a series of five home visits by a trained instructor.
  • Each person receives a booklet with instructions for each exercise prescribed and ankle cuff weights (starting at 1kg) to provide resistance for the strengthening exercises.
  • The exercises take about 30 minutes to complete. Participants are expected to exercise three times a week and go for a walk at least twice a week.
  • Support and motivation program is provided alongside.
  • Participants record the days they complete the programme and the instructor telephones them each month between home visits.
  • Follow-up home visits are recommended every six months.

Otago exercise programme

  • This is echoed by the AGILE guidelines which recommend:
    • Exercise programmes to reduce falls should be high dose (> 50 hours over 6 months)
    • Exercise programmes to reduce falls should have a high balance challenge component.
    • They also make the point that people at risk of falling should be asked if they can get up from the floor – and if not be taught strategies to do this.

 

Consider a home visit

A RCT of 842 houses showed that modifications to a home reduced the rate of injuries from falls by 39% compared with those on a waiting list control group.

Home environment assessment checklists are available,and they are designed to identify:

  • Environmental hazards that can be removed or avoided, including tripping obstacles such as cords, rugs, and furniture; slippery surfaces; and poorly illuminated areas
  • Accessories that can be installed and furniture that can be modified to facilitate transfer or walking including ramps, proper height toilet seats and beds, grab bars next to the toilet and shower, and railings along walking pathways
  • The need and opportunities for use of assistive gadgets and devices, such as extended reaching gadgets, falls monitoring devices, medical staff or rescue alert systems.

Home modifications to reduce injuries from falls in the home injury prevention

intervention (HIPI) study: a cluster-randomised controlled trial.

Keall et al. 2015

Assessing balance

There are many different tests but the two detailed in this episode are:

  1. Timed Up and Go (TUG) test

This is a useful test as it can easily be done in someone’s home. Measure time taken to rise from a chair, walk 3m, turn around and navigate back to the original starting chair.

  • TUG time > 12 seconds is associated with an increased risk of falls.
  • Sensitivity 80%
  • Specificity 100% – a good test to identify those unlikely to fall

 

2. 180 degree turn

If this takes more than 4 steps, further assessment should take place

(Both TUG and 180 are in NICE falls risk assessment)

 

 

Vitamin D supplementation:

Thought to be important because low vit D can be associated with proximal myopathy and therefore falls. A meta-analysis in 2012 showed that supplementation didn’t reduce the overall rate of falls but that it was helpful in certain subgroups.

  • Particularly helpful in those with a low vitamin D; fewer people who received vitamin D supplements in this group fell (rel risk 0.70, 0.56-0.87).
  • Cochrane review ? helpful for care home residents.
  • Useful for bone health in people who fall

 

 

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

Curriculum Area
NHS Knowledge Skills Framework Suitable to support staff at the following levels:

  • Personal and People Development: Levels 1-3
  • Health, safety and security: Levels 1-3
  • Quality improvement: Levels 1-2
Foundation Curriculum 2012 2.1 Patient as centre of care

6.1 Lifelong learning

6.2 Evidence, guidelines, care protocols and research

10.1 Manages patients with long term conditions

10.2 Supporting patient decision making

10.5 Health promotion, patient education and public health

Foundation Curriculum 2016 2. Patient as centre of care

4. Self-directed learning

6. Interface with other healthcare professionals

10. Support for patients with long term conditions

16. Demonstrates understanding of the principles of health promotion and illness prevention

Core Medical Training Common competencies:

  • The patient as central focus of care
  • Managing long term conditions and promoting self-care
  • Health promotion and public health
  • Evidence and guidelines

 

Symptom based competencies:

  • Falls

 

System specific competencies:

  • Geriatric medicine
GPVTS program Section 2.03 The GP in the Wider Professional Environment

  • Core Competence: Managing medical complexity

Section 3.01 – Healthy people: promoting health and preventing disease

Section 3.05 – Managing older adults

  • Core Competence: Managing medical complexity
  • Core Competence: Working with colleagues and in teams
  • Core Competence: Practising holistically and promoting health
ANP (Draws from KSF) 7.10 Falls, fractures and other injuries

7.20 Falls, dizziness, syncope

7.26 Immobility and declining mobility

20.  Patient as central focus of care

22. Team working and patient safety

PA curriculum 2.3.18 Public health

2.6.3 Patient presentations: Falls

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Check out our cool infographic A sip of… summarising key points on falls prevention. It’s made for sharing!


 

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