Preventing Falls in Older People: Core Elements and Effective Strategies
Falls in older individuals represent a significant health concern, with intrinsic and extrinsic factors contributing to increased risk. This discussion covers key concepts, evidence on preventability, and effective strategies in falls prevention services. Understanding the signal of falls in later life is crucial for developing targeted interventions and improving outcomes.
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Preventing Falls in Older People Preventing Falls in Older People Friday 28 Friday 28th thApril, 2023 April, 2023 Cameron Swift, King s College School of Medicine, London Cameron Swift, King s College School of Medicine, London FALLS PREVENTION SERVICES FALLS PREVENTION SERVICES CORE ELEMENTS, NATIONAL AND INTERNATIONAL DEVELOPMENTS NATIONAL AND INTERNATIONAL DEVELOPMENTS CORE ELEMENTS,
KEYS TO AN EFFECTIVE FALLS SERVICE KEYS TO AN EFFECTIVE FALLS SERVICE 1. Concept 1. Concept an age associated an age associated syndrome syndrome 2. Evidence 2. Evidence positive and negative positive and negative 3. Structure and delivery 3. Structure and delivery - - crossing all boundaries boundaries crossing all 4. Audit 4. Audit - - measuring process and measuring process and outcome outcome
(1) CONCEPT: FALLS IN LATER LIFE: A SIGNAL (1) CONCEPT: FALLS IN LATER LIFE: A SIGNAL AS WELL AS A THREAT AS WELL AS A THREAT Commonly detectable (Intrinsic / Extrinsic): Commonly detectable (Intrinsic / Extrinsic): 1. 1. Ageing processes Ageing processes (diminished physiological reserve) (diminished physiological reserve) 2. 2. Suboptimal physical fitness Suboptimal physical fitness 3. 3. Stable specific impairment Stable specific impairment (e.g. sensory, motor, visual, CNS) visual, CNS) 4. 4. Unstable systemic illness Unstable systemic illness (diagnosed or undiagnosed) undiagnosed) 5. 5. Environmental risk factors Environmental risk factors (e.g. sensory, motor, (diagnosed or
(2) EVIDENCE (2) EVIDENCE - - POSITIVE: FALLS IN LATER LIFE POSITIVE: FALLS IN LATER LIFE PREVENTABLE PREVENTABLE (CLOSE ET AL, LANCET 1999) (CLOSE ET AL, LANCET 1999) 600 510 500 400 Control Intervention 300 203 183 156 151 200 73 60 50 100 0 0-4mth 4-8mth 8-12mth Total
(2) EVIDENCE (2) EVIDENCE - - POSITIVE : MEDICAL PROBLEMS IDENTIFIED - - (80% +) POSITIVE :- - EXAMPLES OF ATTRIBUTABLE EXAMPLES OF ATTRIBUTABLE MEDICAL PROBLEMS IDENTIFIED (80% +) (CLOSE ET AL, LANCET 1999) (CLOSE ET AL, LANCET 1999) Cardiovascular/circulatory Cardiovascular/circulatory (e.g. postural (e.g. postural hypotension , arrhythmias, hypotension , arrhythmias, carotid sinus syndrome, carotid sinus syndrome, pacemaker failure) (17%) pacemaker failure) (17%) Visual impairment (59%), Visual impairment (59%), poor stereoscopic vision poor stereoscopic vision (62%), cataract (35%) (62%), cataract (35%) Decreased lower limb Decreased lower limb power (28%) power (28%) Measured Measured strength/balance strength/balance impairment (72%) impairment (72%) Measured cognitive Measured cognitive impairment (34%), impairment (34%), depression (18%) depression (18%) Peripheral neuropathy Peripheral neuropathy (20%) (20%) Undiagnosed malignancy Undiagnosed malignancy (2%) (2%)
(2) EVIDENCE (2) EVIDENCE - - POSITIVE: FALLS IN LATER LIFE FALLS IN LATER LIFE PREVENTABLE POSITIVE: PREVENTABLE (LOGAN ET AL, BMJ 2010) (LOGAN ET AL, BMJ 2010) (7.68 vs 3.46 control vs intervention)
(2) EVIDENCE (2) EVIDENCE - - POSITIVE: FALLS IN LATER LIFE POSITIVE: FALLS IN LATER LIFE PREVENTABLE PREVENTABLE (DAVISON ET AL, 2005) (DAVISON ET AL, 2005) 700 600 500 Falls* Fallers (No) Fallers (%) Hospital Bed Days 400 300 200 100 0 Intervention (n=159) Control (n=154)
(2) EVIDENCE: BROADER OUTCOMES (2) EVIDENCE: BROADER OUTCOMES - - EFFECT OF AN A&E MULTIFACTORIAL INTERVENTION ON BARTHEL ADL INDEX MULTIFACTORIAL INTERVENTION ON BARTHEL ADL INDEX (FROM DATA OF CLOSE ET AL, 1999) EFFECT OF AN A&E- -BASED BASED 19.5 19 18.5 18 Control Intervention 17.5 17 16.5 16 Baseline 4 mth 8 mth 12 mth
(2) EVIDENCE (2) EVIDENCE - - EXERCISE IN OLDER PEOPLE LIVING IN THE EXERCISE IN OLDER PEOPLE LIVING IN THE COMMUNITY (COCHRANE REVIEW 2019) COMMUNITY (COCHRANE REVIEW 2019) (SHERRINGTON ET AL) (SHERRINGTON ET AL) 108 RCTs with 23,407 participants living in the community in 108 RCTs with 23,407 participants living in the community in 25 countries. 25 countries. Most trials had unclear or high risk of bias Most trials had unclear or high risk of bias 81 trials (19,684 participants) compared exercise (all types) 81 trials (19,684 participants) compared exercise (all types) with control with control Exercise reduces the rate of falls by 23% and number of Exercise reduces the rate of falls by 23% and number of people experiencing one or more falls by 15% people experiencing one or more falls by 15% Findings for other outcomes are less certain Findings for other outcomes are less certain
GtACH MULTICENTRE CLUSTER RCT from Logan et al BMJ Dec 2021 Fall Rate per Fall Rate per participant participant [mean(sd)] 0 3 months 3 6 months* 6 9 months 9 12 months GtACH GtACH Usual Care Usual Care Adjusted Adjusted Ratio ** Ratio ** 0.74 0.63 0.91 0.93 p p 0.55 0.55 (1.36) (n=708) 0.49 0.49 (1.13) (n=630) 0.60 0.60 (1.29) (n=547) 0.55 0.55 (1.14) (n=502) 0.88 (2.37) (n=826) 0.89 (2.60) (n=712) 0.73 (1.85) (n=633) 0.79 (2.37) (n=573) <0.01 <0.001 n.s. n.s. Fall Rate per 1000 Fall Rate per 1000 resid resid. Days ( . Days (m+sd 0 3 months 3 6 months* 6 9 months 9 12 months GtACH GtACH Usual Care Usual Care m+sd) ) 6.93 6.93 (20.56) 6.04 6.04 (14.02) 7.28 7.28 (16.67) 6.22 6.22 (12.88) 10.24 10.24 (27.26) 10.38 10.38 (29.52) 9.21 9.21 (28.77) 9.22 9.22 (27.36) * Primary outcome ** Includes both outcome variables
(2) EVIDENCE: FALLS IN INPATIENTS (2) EVIDENCE: FALLS IN INPATIENTS Heterogeneous studies Heterogeneous studies and settings (e.g. acute. and settings (e.g. acute. non non- -acute, mixed) acute, mixed) Highest risk category Highest risk category Inconsistent or negative Inconsistent or negative findings with single factor findings with single factor or non or non- -tailored tailored interventions interventions Risk factor prediction Risk factor prediction tools insufficiently tools insufficiently sensitive or specific sensitive or specific Some moderate/low Some moderate/low evidence for multifactorial evidence for multifactorial assessment and assessment and intervention strategies intervention strategies More research needed More research needed
(2) EVIDENCE (2) EVIDENCE - - POSITIVE: EFFECT OF TARGETED RISK POSITIVE: EFFECT OF TARGETED RISK FACTOR REDUCTION PROGRAMME ON INPATIENT FACTOR REDUCTION PROGRAMME ON INPATIENT FALLS FALLS (PER THOUSAND OCCUPIED BED DAYS) (PER THOUSAND OCCUPIED BED DAYS) (HEALEY ET AL, 2004) 25 20 15 Pre Post 10 5 0 Control Intervention
FALLSAFE FALLSAFE CARE BUNDLE KEY ELEMENTS CARE BUNDLE KEY ELEMENTS [RCP 2015] 2015] [RCP Cognitive assessment* Bed-rail/Ultra-low bed strategy* Delirium screen* Lying & standing blood pressure & pulse* Medical & medication review* Basic visual check* Tailored on-ward (v 2-hr) observation regimen
NICE CG 161: COST NICE CG 161: COST- -EFFECTIVENESS OF INPATIENT EFFECTIVENESS OF INPATIENT FALLS PREVENTION FALLS PREVENTION
(2) EVIDENCE:NEGATIVE , UNCERTAIN OR (2) EVIDENCE: NEGATIVE , UNCERTAIN OR ATTENUATED INTERVENTION FINDINGS ATTENUATED INTERVENTION FINDINGS Single interventions Single interventions untargeted group exercise, cognitive/behavioural, untargeted group exercise, cognitive/behavioural, vision correction alone, Vit D (?) vision correction alone, Vit D (?) Focus on cognitive impairment (A&E /Care home) (e.g. Shaw et al, 2003, Focus on cognitive impairment (A&E /Care home) (e.g. Shaw et al, 2003, Whitney et al, 2017) Whitney et al, 2017) Unidisciplinary assessment with non Unidisciplinary assessment with non- -linked referral (Lightbody et al, 2002; linked referral (Lightbody et al, 2002; Spice et al 2009) Spice et al 2009) Risk factor prediction tools in inpatients [e.g. Barker et all (6 Risk factor prediction tools in inpatients [e.g. Barker et all (6- -Pack), 2015] Pack), 2015] Risk factor prospective postal screening intervention in primary care (Bruce et Risk factor prospective postal screening intervention in primary care (Bruce et al, 2021)( al, 2021)(PreFIT PreFIT) ) Assistive technology Assistive technology
THE 6 THE 6- -PACK (RISK PREDICTION TOOL BASED) PACK (RISK PREDICTION TOOL BASED) STUDY STUDY [BARKER [BARKER et al et al; ; BMJ BMJ (2016) 352; (2016) 352;h h6781] 6781]
P Pre reFIT FIT Cluster RCT Cluster RCT (Bruce et al, 2021) (Bruce et al, 2021)
(2): NATIONAL EVIDENCE (2): NATIONAL EVIDENCE- -BASED GUIDANCE GUIDELINE ON FALLS (CG161) GUIDELINE ON FALLS (CG161) (2013 BASED GUIDANCE - - NICE NICE (2013- -DATE: REVIEW 2024) DATE: REVIEW 2024) Case/risk identification (opportunistic case Case/risk identification (opportunistic case- -finding) Multifactorial falls risk assessment/diagnosis Multifactorial falls risk assessment/diagnosis Falls history Falls history Assessment of: Assessment of: gait, balance and mobility, and muscle weakness gait, balance and mobility, and muscle weakness osteoporosis risk osteoporosis risk perceived functional ability and fear relating to falling perceived functional ability and fear relating to falling visual impairment visual impairment cognitive impairment and neurological examination cognitive impairment and neurological examination urinary continence urinary continence environmental hazards environmental hazards Cardiovascular examination and medication review Cardiovascular examination and medication review Individualised multifactorial interventions Individualised multifactorial interventions finding)
CG 161 GENERIC FALLS ASSESSMENT AND CG 161 GENERIC FALLS ASSESSMENT AND INTERVENTION ACTIVITY INTERVENTION ACTIVITY (UK EVIDENCE & FOCUS) (UK EVIDENCE & FOCUS) CASE/RISK IDENTIFICATION NETWORKED FALLS SERVICE Case / risk identified at routine health screen INDIVIDUAL- ISED SINGLE OR MULTI- FACTORIAL INTERVEN- TION & FOLLOW-UP MULTI- FACTORIAL ASSESS- MENT PRIMARY & COMMUNITY CARE Case / risk identified at presentation with fall / other problem Case / risk identified at presentation with fall / other problem SECONDARY CARE Presentation at A&E with fall injury/ Inpatient >65 / or Inpatient >50 with known clinical risk BONE HEALTH SERVICE
(2) INTERNATIONAL CONSENSUS: World Guidelines for Falls Prevention and Management for Older Adults (Montero- Odasso M et al, 2022) Major evidence Major evidence- -linked consensus statement linked consensus statement 57 co- authors from 72 institutions; 96 Expert participants; 39 countries; 5 continents (low on Africa); 36 Societies; 249 references. Modified Modified GRADE GRADE evidence assessment (1-2; A-C; E) and Modified Delphi consensus process Modified Delphi consensus process Comprehensive, detailed recommendation statements Comprehensive, detailed recommendation statements (including available validated measurement options) on: Fall risk stratification Assessment * * Personalised management and intervention * *
(2) INTERNATIONAL CONSENSUS: World Guidelines for Falls Prevention and Management for Older Adults (Montero- Odasso M et al, 2022) Risk stratification Risk stratification (Low; Intermediate; High)(see Algorithm) Opportunistic case-finding * * Presentation with falls/related injuries * * Multidomain Assessment & Interventions Multidomain Assessment & Interventions *(High Risk);(Perception of older adult throughout) Low Risk Low Risk (Fitness advice) and and Intermediate Risk (Exercise Regimens) M Management anagement Inpatient Inpatient * *, Care Home & LMI National settings , Care Home & LMI National settings Intermediate Risk
(2) INTERNATIONAL CONSENSUS: World Guidelines for Falls Prevention and Management for Older Adults (Montero- Odasso M et al, 2022)
(2) INTERNATIONAL CONSENSUS: World Guidelines for Falls Prevention and Management for Older Adults (Montero- Odasso M et al, 2022) MULTIFACTORIAL ASSESSMENT MULTIFACTORIAL ASSESSMENT: Mobility Mobility * *: Balance; Gait; Muscle strength; Aids; Feet & footwear; Concerns re falling Sensory function Sensory function * *; Dizziness/vestibular; Vision; Hearing Activities of daily living Activities of daily living * *; Functional ability Cognition Cognition * *; Cognitive ability; Delirium Autonomic Autonomic * *: Orthostatic hypotension; Urinary incontinence Disease occurrence Disease occurrence * *; (CGA); Cardiovascular; Other contributory conditions; #Risk; PD; Depression; Medication Medication * * Nutritional status Nutritional status; Vit D * * Environmental Environmental * *
(3) STRUCTURE & DELIVERY (3) STRUCTURE & DELIVERY - - COORDINATING ACROSS BOUNDARIES: GENERIC FALLS SERVICE NETWORK BOUNDARIES: GENERIC FALLS SERVICE NETWORK AN OPPORTUNITY TO LEAD OPPORTUNITY TO LEAD COORDINATING ACROSS AN PRIMARY & COMMUNITY CARE MAINSTREAM SECONDARY CARE ACCIDENT & EMERGENCY MEDICINE NETWORKED FALLS SERVICE (LINKED TO MEDICAL GERONTOLOGY) POPULA TION-BASED/ OPPORTUN- ISTIC CASE- FINDING INCL. 1ST RESPONSE ACUTE INPATIENT MEDICINE & GERONTOLOGY TRAUMA, & ORTHO- PAEDICS OTHER MEDICAL & SURGICAL SPECIALITIES DAY HOSPITAL, OUTPATIENT CLINICS & REHABILITATION HOME-BASED EXERCISE PROGRAMMES INCL 3RD SECTOR BONE HEALTH SERVICE
(3) STRUCTURE (3) STRUCTURE - - IMPROVING IMPLEMENTATION IMPROVING IMPLEMENTATION (RCP 2017) (RCP 2017) MANAGEMENT LEVEL MANAGEMENT LEVEL CLINICAL CLINICAL Organisation Organisation- -wide Patient Safety Group wide Patient Safety Group Structured rapid assessment procedures Structured rapid assessment procedures (including standardised delirium tools) (including standardised delirium tools) Robust data and reporting on falls & Robust data and reporting on falls & fractures fractures Multi Multi- -D Falls Working Group auditing v QS D Falls Working Group auditing v QS 86 86 Audit of Postural BP, Visual, Medication and Audit of Postural BP, Visual, Medication and Walking Walking- -aid use review and provision aid use review and provision
(4) AUDIT (4) AUDIT - - INPATIENT IMPLEMENTATION & OUTCOME INPATIENT IMPLEMENTATION & OUTCOME MEASUREMENT MEASUREMENT FALLSAFE FALLSAFE QI EVALUATION QI EVALUATION [HEALEY ET AL 2014] [HEALEY ET AL 2014]
4: LOCAL AUDIT/QI: INPATIENT FALLS PER 1,000 BED DAYS AT NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST 2013 2020. (Richardson et al., 2020)
(4) NATIONAL AUDIT (4) NATIONAL AUDIT - - QS 86 2017 UPDATE STATEMENTS QS 86 2017 UPDATE STATEMENTS 1 Older people are asked about falls when they have routine assessments and 1 Older people are asked about falls when they have routine assessments and reviews with health and social care practitioners, and if they present at hospital. reviews with health and social care practitioners, and if they present at hospital. 2. Older people at risk of falling are offered a multifactorial falls risk assessment. 2. Older people at risk of falling are offered a multifactorial falls risk assessment. 3. Older people assessed as being at increased risk of falling have an individualised 3. Older people assessed as being at increased risk of falling have an individualised multifactorial intervention. multifactorial intervention. 4.Older people 4.Older people who fall during a hospital stay who fall during a hospital stay are checked for signs or symptoms of fracture and potential for spinal injury before they are moved. fracture and potential for spinal injury before they are moved. 5. Older people 5. Older people who fall during a hospital stay who fall during a hospital stay and have signs or symptoms of fracture or potential for spinal injury are moved using safe manual handling fracture or potential for spinal injury are moved using safe manual handling methods. methods. 6. Older people 6. Older people who fall during a hospital stay who fall during a hospital stay have a medical examination 7. Older people 7. Older people who present for medical attention because of a fall who present for medical attention because of a fall have a multifactorial falls risk assessment. multifactorial falls risk assessment. 8. Older people living in the community 8. Older people living in the community who have a known history of recurrent falls who have a known history of recurrent falls are referred for strength and balance training. are referred for strength and balance training. 9. Older people 9. Older people who are admitted to hospital after having a fall who are admitted to hospital after having a fall are offered a home hazard assessment and safety interventions. hazard assessment and safety interventions. are checked for signs or symptoms of and have signs or symptoms of have a medical examination. . have a are offered a home
(4) NICE QS 86 ADHERENCE NICE QS 86 ADHERENCE (NAIF AUDIT) (RCP 2020)
(4) NATIONAL AUDIT (4) NATIONAL AUDIT SNAPSHOT DATA INPATIENT FALLS 2017 ( INPATIENT FALLS 2017 (v v 2015) (RCP 2019) SNAPSHOT DATA - - 2015) (RCP 2019)
(4) 30-DAY HIP FRACTURE MORTALITY, 2011-2018 (NHFD 2019)
NHFD 6 KPIS FOR INPATIENT & NHFD 6 KPI S FOR INPATIENT & NON NON- -INPATIENT HIP FRACTURE INPATIENT HIP FRACTURE [NHFD 2022] [NHFD 2022]
(4) NATIONAL AUDIT OF INPATIENT FALLS (NAIF) 2018-21 (RCP 2021) DATA regularly updated, openly accessible GUIDANCE e.g. Vision assessment Postural blood pressure measurement Post-fall management* Gaining insight (v. incident review only)* Hot debrief (immediate info collection) After action review (MDT learning) *In development
KEYS TO AN EFFECTIVE FALLS SERVICE KEYS TO AN EFFECTIVE FALLS SERVICE 1. Concept 1. Concept an age associated an age associated syndrome syndrome 2. Evidence 2. Evidence positive and negative positive and negative 3. Structure & Delivery 3. Structure & Delivery - - crossing all boundaries boundaries crossing all 4. Audit 4. Audit - - measuring process and measuring process and outcome outcome
