Cameron Swift, King’s College School of Medicine, London ... · PROVIDING AN EFFECTIVE FALLS...
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Transcript of Cameron Swift, King’s College School of Medicine, London ... · PROVIDING AN EFFECTIVE FALLS...
PROVIDING AN EFFECTIVE FALLS SERVICE
(26/04/16)
Cameron Swift, King’s College School of Medicine, London
KEYS TO AN EFFECTIVE FALLS SERVICE
1.1.1.1. Understanding the phenomenonUnderstanding the phenomenonUnderstanding the phenomenonUnderstanding the phenomenon
2.2.2.2. Adhering to the evidenceAdhering to the evidenceAdhering to the evidenceAdhering to the evidence
3.3.3.3. Coordinating across all boundariesCoordinating across all boundariesCoordinating across all boundariesCoordinating across all boundaries
4.4.4.4. Measuring the outcomeMeasuring the outcomeMeasuring the outcomeMeasuring the outcome
NICE GUIDANCE DEVELOPMENT ON FALLS
FALLS: The Assessment and Prevention of Falls in FALLS: The Assessment and Prevention of Falls in FALLS: The Assessment and Prevention of Falls in FALLS: The Assessment and Prevention of Falls in
Older PeopleOlder PeopleOlder PeopleOlder People
� CG 21 (2004): “Community dwelling” older CG 21 (2004): “Community dwelling” older CG 21 (2004): “Community dwelling” older CG 21 (2004): “Community dwelling” older
people. Insufficient evidence for guidance on people. Insufficient evidence for guidance on people. Insufficient evidence for guidance on people. Insufficient evidence for guidance on
inpatient settingsinpatient settingsinpatient settingsinpatient settings
� CG 161 (2013): CG21 unchanged: CG 161 (2013): CG21 unchanged: CG 161 (2013): CG21 unchanged: CG 161 (2013): CG21 unchanged:
�PLUS new guidance on inpatient settingsPLUS new guidance on inpatient settingsPLUS new guidance on inpatient settingsPLUS new guidance on inpatient settings
� QS 86 (2015): 6 Quality StatementsQS 86 (2015): 6 Quality StatementsQS 86 (2015): 6 Quality StatementsQS 86 (2015): 6 Quality Statements
(1) FALLS IN LATER LIFE – BINOCULAR VISION!
WHAT? WHAT?WHAT? WHAT?WHAT? WHAT?WHAT? WHAT?
A THREAT A SIGNALA THREAT A SIGNALA THREAT A SIGNALA THREAT A SIGNAL
WHY? WHY?WHY? WHY?WHY? WHY?WHY? WHY?
A PREVENTABLE THREAT A PRODUCTIVE SIGNALA PREVENTABLE THREAT A PRODUCTIVE SIGNALA PREVENTABLE THREAT A PRODUCTIVE SIGNALA PREVENTABLE THREAT A PRODUCTIVE SIGNAL
HOW? HOW?HOW? HOW?HOW? HOW?HOW? HOW?
IDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNALIDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNALIDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNALIDENTIFY AND PREVENT THE THREAT USE AND TREAT THE SIGNAL
FALLS IN LATER LIFE – A THREAT
1. 30% >65: 50%>80 fall at least once yearly
2. Injury, disability, dependency, mortality
3. NHS annual cost >£2.3bn
FALLS IN LATER LIFE: A SIGNAL
Commonly detectable:
1. Ageing processes (diminished physiological reserve)
2. Suboptimal physical fitness
3. Stable specific impairment (e.g. sensory, motor,
visual, CNS)
4. Unstable systemic illness (diagnosed or undiagnosed)
NEURAL CONTROL OF BALANCE AND FALLS (HORAK 2005)
EXAMPLES OF ATTRIBUTABLE MEDICAL
PROBLEMS IDENTIFIED - (80% +) (CLOSE ET AL, LANCET 1999)
� Cardiovascular/circulatory – (e.g. postural hyptension , Cardiovascular/circulatory – (e.g. postural hyptension , Cardiovascular/circulatory – (e.g. postural hyptension , Cardiovascular/circulatory – (e.g. postural hyptension ,
arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)arrhythmias, carotid sinus syndrome, pacemaker failure) (17%)
� Visual impairment (59%), poor stereoscopic vision (62%), Visual impairment (59%), poor stereoscopic vision (62%), Visual impairment (59%), poor stereoscopic vision (62%), Visual impairment (59%), poor stereoscopic vision (62%),
cataract (35%)cataract (35%)cataract (35%)cataract (35%)
� Decreased lower limb power (28%)Decreased lower limb power (28%)Decreased lower limb power (28%)Decreased lower limb power (28%)
� Peripheral neuropathy (20%)Peripheral neuropathy (20%)Peripheral neuropathy (20%)Peripheral neuropathy (20%)
� Measured strength/balance impairment (72%)Measured strength/balance impairment (72%)Measured strength/balance impairment (72%)Measured strength/balance impairment (72%)
� Measured cognitive impairment (34%), depression (18%)Measured cognitive impairment (34%), depression (18%)Measured cognitive impairment (34%), depression (18%)Measured cognitive impairment (34%), depression (18%)
� Undiagnosed malignancy (2%)Undiagnosed malignancy (2%)Undiagnosed malignancy (2%)Undiagnosed malignancy (2%)
(2) FALLS IN LATER LIFE – PREVENTABLE (CLOSE ET AL, LANCET 1999)
0
100
200
300
400
500
600
0-4mth 4-8mth 8-12mth Total
203
151 156
510
50 73 60
183
Control
Intervention
FALLS IN LATER LIFE – PREVENTABLE (LOGAN ET AL, BMJ 2010)
(7.68 vs 3.46 control vs intervention)
PREVENTING FALLS IN INPATIENTS
� Highest risk category
� Heterogeneous studies and settings (e.g. acute. non-acute, mixed)
� Inconsistent or negative findings with single factor or non-tailored interventions
� Risk factor prediction tools insufficiently sensitive or specific
� Some moderate evidence for multifactorialassessment and intervention strategies
EFFECT OF TARGETED RISK FACTOR REDUCTION
PROGRAMME ON INPATIENT FALLS (PER THOUSAND
OCCUPIED BED DAYS)(HEALEY ET AL, 2004)
0
5
10
15
20
25
Control Intervention
Pre
Post
CHARACTERISTICS IN COMMON OF UK
INTERVENTIONS WITH POSITIVE FINDINGS
� High risk groups (e.g. A&E attenders, ambulance callers)
� Organised, focused multidisciplinary assessment, diagnosis & intervention
� Strength & balance training, visual assessment, environmental assessment, medication review
� Effective interchange/collaboration: primary care – secondary care (Clinical Gerontology)
QS 86: SOME KEY ELEMENTS OF MULTIFACTORIAL
ASSESSMENT & INTERVENTION
� Falls history
� Gait, balance, mobility, muscle strength
� Functional ability & fear of falling
� Vision
� Cognition, neurology, cardiovascular,
continence, medication review
� Home hazards
“NEGATIVE” OR ATTENUATED INTERVENTION
FINDINGS
� Single interventions – untargeted group
exercise, cognitive/behavioural, vision
correction alone, Vit D (?), hip protectors (?)
� A&E based focus on cognitive impairment (Shaw et
al (2003)
� Unidisciplinary assessment with non-linked
primary care/social services referral (Lightbody et al,
2002; Spice et al 2009)
� Risk factor prediction tools in inpatients
(3) CG 161 GENERIC FALLS ASSESSMENT AND (3) CG 161 GENERIC FALLS ASSESSMENT AND (3) CG 161 GENERIC FALLS ASSESSMENT AND (3) CG 161 GENERIC FALLS ASSESSMENT AND
INTERVENTION ACTIVITY INTERVENTION ACTIVITY INTERVENTION ACTIVITY INTERVENTION ACTIVITY (UK EVIDENCE & FOCUS)(UK EVIDENCE & FOCUS)(UK EVIDENCE & FOCUS)(UK EVIDENCE & FOCUS)
CASE/RISK
IDENTIFICATION
MULTI-
FACTORIAL
ASSESS-
MENT
NETWORKED
FALLS SERVICE
INDIVIDUAL-
ISED SINGLE
OR MULTI-
FACTORIAL
INTERVEN-
TION &
FOLLOW-UP
BONE HEALTH
SERVICE
PRIMARY &
COMMUNITY
CARE
SECONDARY
CARE
Case / risk identified
at health screen
Case / risk identified
at presentation with
fall / other problem
Case / risk identified
at presentation with
fall / other problem
Presentation at A&E
with fall injury/
Inpatient >65 / or
Inpatient >50 with
known clinical risk
GENERIC FALLS SERVICE NETWORK –GENERIC FALLS SERVICE NETWORK –GENERIC FALLS SERVICE NETWORK –GENERIC FALLS SERVICE NETWORK –
AN OPPORTUNITY TO LEADAN OPPORTUNITY TO LEADAN OPPORTUNITY TO LEADAN OPPORTUNITY TO LEAD
PRIMARY & COMMUNITY
CARE
MAINSTREAM SECONDARY
CARE
ACCIDENT &
EMERGENCY
MEDICINE
POPULA
TION-BASED/
OPPORTUN-
ISTIC
SCREENING
HOME-BASED
EXERCISE
PROGRAMMES
DAY HOSPITAL,
OUTPATIENT
CLINICS &
REHABILITATION
NETWORKED
FALLS SERVICE (LINKED TO MEDICAL
GERONTOLOGY)
OTHER
MEDICAL &
SURGICAL
SPECIALITIES
TRAUMA, &
ORTHO-
PAEDICS
BONE
HEALTH
SERVICE
ACUTE
INPATIENT
MEDICAL
GERONTOLOGY
(4) RISK REDUCTION (CONTROL V INTERVENTION) USING
BASELINE ADJUSTED ODDS RATIOS
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Risk reduction
Falling
Recurrent falling
1+ Hosp admission
FALLS IN LATER LIFE – PREVENTABLE (DAVISON ET AL, 2005)
0
100
200
300
400
500
600
700
Intervention(n=159)
Control (n=154)
Falls*
Fallers (No)
Fallers (%)
Hospital Bed Days
CG 161: COST-EFFECTIVENESS OF INPATIENT
FALLS PREVENTION
EFFECT OF AN A&E-BASED MULTIFACTORIAL INTERVENTION
ON BARTHEL ADL INDEX (FROM DATA OF CLOSE ET AL, 1999)
16
16.5
17
17.5
18
18.5
19
19.5
Baseline 4 mth 8 mth 12 mth
Control
Intervention
CONCLUSIONS – RCP NATIONAL AUDIT 2011
� Unacceptable variation in the quality of falls and
fracture services
� Major gap between what organisations report and
actual services
� Patients with non-hip fragility fractures only 50%
assessment & management v hip # patients
� Important deficiencies remain in the commissioning,
organisation and provision of care
CONCLUSIONS – QS 86 UPTAKE 2013
Royal College of Physicians - Fracture Liaison Service Royal College of Physicians - Fracture Liaison Service Royal College of Physicians - Fracture Liaison Service Royal College of Physicians - Fracture Liaison Service Database (FLS-DB) Feasibility Study Summary ReportDatabase (FLS-DB) Feasibility Study Summary ReportDatabase (FLS-DB) Feasibility Study Summary ReportDatabase (FLS-DB) Feasibility Study Summary Report
� Proportion of index fractures that had evidence in the GP electronic records of a formal falls risk assessment = 3.9%
� Proportion of older people living in the community with a known history of recurrent falls reporting to their GP who are referred for strength and balance training = 0.8%
CONCLUSIONS
� FALLS DIAGNOSIS, MANAGEMENT AND
PREVENTION IS:
� VITAL, EFFECTIVE AND COST-EFFECTIVE
� SPECIALISED – INTEGRAL TO CLINICAL
GERONTOLOGY
� MULTIFACTORIAL AND MULTIDISCIPLINARY
� COORDINATED, FOCUSED & COMMISSIONED
� INSUFFICIENTLY IMPLEMENTED BUT ACHIEVABLE