Episode 1.5 Acute Management Following a Fall

MDTea Episode 5: Falls – Acute Management

Posted 15th March 2016

Presented by: Jo Preston & Iain Wilkinson, Geriatricians at Surrey and Sussex Healthcare NHS Trust.

Core Faculty Contributors: Sarah Jane Ryan, Physiotherapist at University of Brighton and Pam Trangmar, Physician Associate at Surrey and Sussex Healthcare NHS Trust.

This episode focuses on the acute management of falls. What causes them, how to approach managing them, and why they are important.

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Episode 5 Show Notes

Falls

Presented by: Dr Jo Preston & Dr Iain Wilkinson

Faculty: Sarah Jane Ryan – Physiotherapist

Pamela Trangmar – Physician Associate

Broadcast Date: 15th March 2016

Learning Outcomes

Knowledge:

• To understand the common causes of falls in older adults and outline the initial management.
• To be able to describe a management plan for patients following a fall.

Skills:

• To identify patients at high risk for falling
• To be able to instigate a falls prevention and management strategy for a patient who has fallen.

Attitudes:

• To view a fall as a potentially serious symptom of an underlying medical condition.

Definitions:

Formal / Scientific Definition:

“Inadvertently coming to rest on the ground or other lower level with or without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake, or overwhelming external force”

Close et. al, Lancet 1999

Practical Definition:

A syndrome not a diagnosis and a sign that one of many things are going wrong resulting in instability of a person, leading to a fall. It is often due to a combination of factors, rather than one alone and may be a marker of frailty.

Key Points from Discussion

Causes for falls can be divided into a few categories when diagnosing and considering a management plan:

• Intrinsic or extrinsic e.g. within the person or within their environment
• Transient or permanent e.g. a treatable or permanent condition
• Modifiable and non-modifiable e.g. to optimise or work around

Fear of falling can result in a cycle of worsening mobility that can be difficult to break. CBT can be helpful.

Effects of a multicomponent cognitive behavioural intervention on fear of falling and activity avoidance in community dwelling older adults: results of an RCT. Zijlstra et. al JAGS 2009 

Syncope in older adults is largely investigated and managed in the same way as their  younger counterparts.

European Society for Cardiology Syncope Guidelines: www.escardio.org

NICE Guidance on Transient Loss of Consciousness. CG109

Risk of falling increases with age due to accumulation of deficits which links into some theories of frailty. Thinking about falling in terms of thresholds in a similar way: the likelihood of falling increases as the number of deficits increases and compensatory mechanisms decreases. When an inter concurrent stressor occurs, it drops your reserves and you are more likely to fall. This stressor could be biological, social or psychological in origin.

There is conflicting evidence regarding the benefits of falls prevention measures. In one meta-analysis, no benefit was found.

Interventions for preventing fall in acute and chronic care hospitals: a systematic review and meta-analysis. Coussement et. al JAGS 2008

However, a cochrane review in 2012 showed that multifactorial interventions do reduce falls in hospitals. The evidence for exercise as part of this was inconclusive but this is likely due to the short duration, interconcurrent illness, and not looking at longer term outcomes.

Interventions for preventing falls in older people in care facilities and hospitals.  Cameron et. al, Cochrane Review 2012.

One of the perceived failures of many of these studies is the approach within which they are implemented. Either that the bundle itself was too complicated, contains too many components and / or is implemented all in one go, making it appear unachievable. The FALLSAFE project was more successful in implementing widespread change, by using Quality Improvement methodologies comprising staggered interventions with education and support. In this way, interventions are embedded in routine practice before another is introduced. The benefit was not seen necessarily from individual interventions but from the combination of them together.

FALLSAFE project

With anyone who you encounter with falls, consider

• Does this person need referral for CGA?
• Have they injured themselves, do they have a fracture?
• Do they have pain control needs?
• Do they need a bone health assessment?
• Do they need urgent medical review? E.g. palpitations, loss of consciousness, new neurological symptoms.

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 Service Improvement: Level 1 – 2
Foundation curriculum	7. Good Clinical Care 7.1 Diagnosis and clinical decision-making 7.9 Interactions with different specialities and professions 10. Patients with Long-term conditions
Core Medical Training	Common Competencies Decision making and clinical reasoning Team working and patient safety Evidence and guidelines Symptom Based Competencies Falls Other Important Presentations Immobility System Specific Competencies Geriatric Medicine
GPVTS program	Section 2.03 The GP in the Wider Professional Environment Core Competence: Managing medical complexity Section 3.03 Care of Acutely Ill People Core Competence: Managing medical complexity Section 3.05 – Managing older adults Core Competence: Clinical Management Core Competence: Managing medical complexity Core Competence: Working with colleagues and in teams Core Competence: Practising holistically and promoting health
ANP (Draws from KSF)	Sections 5, 6, 8 and 10 Section 7 – in particular 7.2 General deterioration in mobility, function and health 7.10 Falls, fractures and other injuries 7.20 Falls, dizziness, syncope 7.26 Immobility and declining mobility