An Evaluation of the Greater Glasgow & Clyde Osteoporosis and Falls Strategy Dr Dawn Skelton & Fiona Neil, School of Health

The Process Jan 2008, Fiona Neil, OT within the Falls Service, was seconded to the GCAL 0.5 FTE for one year. Visits to representatives of all parts of the service (Jan 2008-Aug 2008) –Record current Protocols and Processes –Discuss and gather previous audits –Discuss potential data collection –Advise on relevant up to date guidelines/evidence base Any previously gathered audit or outcome information (for presentations at conferences etc) was collected as well as raw data where possible. Data blinded by the relevant service, permission sought from the Caldicott Guardian for NHSGGC. Some small audit projects and 2 Masters Project (GCU OT & PT student, with full NHS ethical approval)

CFPP Specialist falls service which aims to prevent further falls by providing a comprehensive falls screening, health education, exercise, rehabilitation and onward referral The service is available to individuals who are over 65, live at home and have had a fall in the last year 221 referrals a month in 2008 Telephone triage completed within 24 hours of receiving referral Home screening completed within 5 working days of triage

Onward referral Fall in past year. Community dweller. Aged 65+ Falls Admin centre- triage (within 24 hours) Open Referral Multi- factorial Falls Risk Screening Home visit within 5 working days. HFPP Physio assessment and falls exercise classes Pharmacy review 1to1 Physio at community site for musculoskeletal problem Community older peoples team (COPT) Dietician Podiatry OT Optician Sensory Impairment Dexa Scan GP/Audiology Community Alarms Handy Persons Benefits Advisor Social Work/Home Care Falls Clinic/ Medical review and gateway to day hospital Multifactoral interventions COPT/ IRIS/ DART Pathway Home Falls Prevention Programme Deliver

INTEGRATED PLANS Fracture Osteoporosis Falls > 95% hip fractures due to a fall > 90% of hip fractures due to osteoporosis Falls, Fragility & Fractures, Cryer & Patel, 2002

NICE Falls CG: specialist integrated service model, 2004

ABS/BGS Guidelines 2001 Assessment History of falls Medications & Medical Conditions Vision Gait and Balance Lower Limb Joints (assistive devices) Neurological (sensory) & Continence Cardiovascular Multifactorial intervention (as appropriate) Gait, balance and exercise programmes Medication modification Postural Hypotension Treatment Environmental Hazard Modification Cardiovascular disorder treatment AGS/BGS Guidelines J Am Geriatr Soc 2001; 49: 664 – 672.

Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Case/risk identification POSITIVE –Large number of referrals into CFPP. Telephone Triage followed by home visit and onward referral. –Linkages and communication with CHCPs, DART, IRIS & COPT to support case risk identification NEEDS WORK ON –Reducing refusals and non-responses to invite letters from CFPP. –DNAs to Falls Clinic. –Engaging GPs and A&E Depts to identify high risk fallers (eg. those who have presented with a fall) –FPCs work in Hospitals and Care Homes. Have identified issues and more work is needed to engage hospital AHPs and Care Home Staff

Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Multifactorial Falls Risk Assessment POSITIVE –Excellent links with Fracture Liaison Service and Direct Access DEXA Scan and Pharmacy to ensure bone health is also considered NEEDS WORK ON –Urinary Incontinence, Fear of falling, anxiety and depression and Vision assessment is minimal. –Roll out of DADS into Clyde

Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Multifactorial Interventions POSITIVE –Evidence based exercise delivery continuum. –Good OT input to CFPP interventions. –Excellent links with Fracture Liaison Service & Pharmacy NEEDS WORK ON –dedicated support time for CFPP (& Falls Clinics) Clinical Psychology –Hospital based OTs to ensure home visits before discharge –Equitable access to services across GG&C (eg syncope clinic for potential cardiac pacing). –long-term support of home exercise programmes and primary prevention programmes –No “tie-up” or follow up after interventions (Falls Clinics, CFPP, Little evidence of exercise or other multi-factorial interventions occurring in care homes (apart from FPCs currently raising awareness)

Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Patient Engagement POSITIVE –Evidence of patient satisfaction questionnaires in some parts of the service NEEDS WORK ON –Falls Clinics need to engage patients to understand reasons for DNAs

Comparison of current strategy with the NICE guidelines 21: Clinical protocol for prevention of falls Case/risk identification POSITIVE –Large number of referrals into CFPP. Telephone Triage followed by home visit and onward referral. –Linkages and communication with CHCPs, DART, IRIS & COPT to support case risk identification NEEDS WORK ON –Reducing refusals and non-responses to invite letters from CFPP. –DNAs to Falls Clinic. –Engaging GPs and A&E Depts to identify high risk fallers (eg. those who have presented with a fall) –FPCs work in Hospitals and Care Homes. Have identified issues and more work is needed to engage hospital AHPs and Care Home Staff

Comparison of current strategy with the AGS/BGS Guidelines Assessment History of falls Medications & Medical Conditions Vision Gait and Balance Lower Limb Joints (assistive devices) Neurological (sensory) & Continence Cardiovascular Multifactorial intervention (as appropriate) Gait, balance and exercise programmes Medication modification Postural Hypotension Treatment Environmental Hazard Modification Cardiovascular disorder treatment

Emergency admissions due to falls in the home by age group

Cumulative percentage of emergency admissions by age range

Percentage of emergency admissions due to falls

Number of admissions due to falls in relation the number of medical conditions diagnosed

Emergency admissions and bed days occupied from falls Injuries to Hip and ThighInjuries to the Head Emergency Admissions for falls (number) % total adm. for falls Bed Days (averag e number ) % total bed days for falls admissi ons Emergency Admissions for falls (number) % total adm. for falls Bed Days (averag e number ) % total bed days for falls admissi ons Greater Glasgow and Clyde % % % % Greater Glasgow % % % %

Relationship between emergency admissions and deprivation

Deaths due to falls by deprivation index

Emergency Admissions due to falls over a ten year period ( ) % change over 10 yrs Total admissions due to falls in % Admissions due to falls at home % Admissions due to falls in residential institutions % Admissions due to falls in the street/highway % Unspecified or unknown place %

Bed days, emergency admissions and mean stay due to falls in the home in the 65+ age group Greater Glasgow Greater Glasgow & Clyde Year Bed Days Number of admissions Mean Stay Bed Days Number of admissions Mean Stay % Change 1998 to %-36.9%-21.7% -49.0%-32.4%-24.5% % Change 2005 to %-8.5%-25.1% -30.2%-10.5%-22.1%

Number of emergency admissions due to falls in the home

Comparison with Scotland

Growth 5.6% per year

Bed days due to admission for falls in the home

Growth 1.7% per year

Hip fracture admissions in over 65s No change –0.4%

Growth 1.8% per year

In a bit more depth… CFPP referrals and interventions –Any parts of the process that need work? Strength and Balance Interventions –Do they improve balance? –Do they reduce fear of falling, improve balance confidence and quality of life? –Why do people not necessarily progress from rehab-led to instructor-led classes? Assessment of bone health in Falls Clinics –Can we use a “tool” and not do DEXA scans?

Compared to Other Falls Services SDO Report 2007 – services in England –231 services reported back - median new attendances p.a = 180 (range 10–1700) at a cost of £32 million! –116 Community based services Average cost £110k see on average 195 pts p.a –110 Acute based services Average cost £171k see on average 269 pts p.a –5 A&E based services Average cost £363k refer on average 1000 pts p.a to GP etc. CFPP GGC sees 2652 pts p.a – at unknown cost

CFPP Referrals

Audit (July-Sept 2008) of A & E attendee ’ s at the SGH 32% of all A & E attendee ’ s over the age of 65 have had a fall 65 had had a fracture and half of these had a history of falls 2 were referred to the CFPP direct from A&E! 66 ♂ (74.9 yrs) 155 ♀ (77.6yrs) 3 falls with multiple injury

CFPP appointments

CFPP workload

CFPP Interventions

Physiotherapy Intervention 12 Strength & Balance Classes Classes locally delivered Free transport service (70% utilise) week attendance Home Exercises Partnership working with Day hospital and Leisure services (Glasgow Culture & Sport)

Hospital Falls Clinics COPT/IRIS/DART (ref made by physiotherapist) CFPP Physiotherapy assessment Level 1 Day Hospital class Tinetti Physio led VITALITY community classes levels 1-4 Instructor led Level 2 CFPP community class Tinetti Physio led. Osteoporosis and Ozone classes for low risk fallers Referral Pathways for Exercise Classes– exit and entry routes

Strength & Balance Programmes Evidence based exercises –(Skelton 2005; Robertson 2001; Campbell 1999) Evidence based “deliverers” –Physiotherapists and trained Postural Stability Instructors (Skelton 2004) Evidence based duration –Dose of 50 hours of balance challenging exercise (Sherrington 2008)

Attendance at classes

Evaluation of effect N= 274 clients considered over a time period in Attended on average 11.9 (sd 3.8) weeks Outcome measures: –Duration of attendance –Functional tests Tinetti Mobility and Balance Score Timed Up and Go 180 degree turn Functional Reach Confidence in Maintaining Balance Tinetti’s Falls Efficacy Scale (FES) –Patient Satisfaction Questionnaires (N=91) Same assessor throughout - not all tests completed on all clients

Outcome measures Test Mean (sd) Number of clients Before exercise sessions After exercise sessions P-value Tinetti Balance Score (3.3)24.8 (3.1) deg turn (deg) (1.9)5.0 (1.6)0.000 Functional Reach (cm) (5.9)20.9 (6.9)0.000 TUAG (sec) (6.7)16.3 (5.9)0.000 ConFBal (3.9)16.9 (3.4)0.000 Tinetti FES (16.5)21.5 (11.6)0.0002

Balance improvements are duration dependent The Tinetti Mobility and Balance Score showed considerable improvement, but the change was dependent on duration of exercise attendance. Those attendees that drop out of sessions before 12 weeks are unlikely to see clinically significant changes in their balance. This is in line with the recent systematic review of exercise (Sherrington et al. 2008) where a dose of at less than 50 hours confers little benefit to fall risk reduction.

Client Satisfaction Satisfaction forms at week 10 of their exercise programme (n=117 issued). 91 patients returned the forms (response rate 78%). 85% had received information about the class before the sessions started and most (83%) found the pre-class information useful. Only 1% thought the class was not in a suitable location; the staffs were not helpful; the exercises were rushed, too short or not well explained (showing a high degree of satisfaction with facilities and delivery). 98% felt the exercise classes were beneficial and 94% thought the sessions were good or very good. Open response questions showed good improvements to wellbeing (see next slide) however, many people just wrote “enjoyed” in this section!

Open responses to feedback

Summary The CFPP exercise service to prevent falls in Glasgow does improve many of the known risk factors for falls The benefits are duration dependent –clients should be encouraged to adhere for at least 12 weeks, ideally to the maximum 18 weeks and then to move into normal community exercise sessions for older people to maintain the improvements High degree of client satisfaction (though questionnaire could have been designed better)

WHAT ARE THE EFFECTS OF THE GGC FALLS EXERCISE SESSIONS ON FEAR OF FALLING, BALANCE CONFIDENCE AND QUALITY OF LIFE IN GLASWEGIAN FALLERS? Gaynor McGrath MSc Rehabilitation Science Glasgow Caledonian University Submitted Oct 2009

Aims and Methods Objectives: To examine whether a 12 week strength and balance exercise class improved an individual’s perception of their fear of falling, balance confidence and quality of life and whether there was an inter-relationship between outcome measures pre and post the exercise intervention. Methods: Prospective cohort study. Participants: Female fallers (n=13) aged >=65 years Questionnaires specific to fear of falling (SFES-I), balance confidence (CONFbal) and quality of life (SF-12) were completed prior to and on completion of the 12 week exercise intervention.

Results and Conclusion Results: following completion of the 12 week exercise intervention there was a significant reduction in fear of falling (p<0.05) together with a significant improvement in balance confidence (p<0.05) and quality of life (p<0.05). However, the only significant inter-relationship between outcome measures was between fear of falling and balance confidence post exercise intervention (p<0.05). Conclusion: An exercise intervention is effective in reducing fear of falling whilst improving balance confidence and quality of life in community dwelling older females 65 years and older. It also improves the inter- relationship between fear of falling and balance confidence post intervention.

WHAT ARE OLDER PEOPLE’S VIEWS ON THEIR FORTHCOMING TRANSITION BETWEEN THE PHYSIOTHERAPY-LED FALLS PREVENTION EXERCISE CLASS AND THE INSTRUCTOR-LED FALLS PREVENTION EXERCISE CLASS? Aisling O’Connor MSc Rehabilitation Science Glasgow Caledonian University 31st January 2009

Falls Intervention Programme GG & C – tiered exercise programme: Physiotherapist-led community class (12-18 weeks) Postural Stability Instructor (PSI)-led class Benefits of Falls Prevention Exercise Programmes (Hauer et al., 2003; Skelton et al., 1995; Narici et al., 2004; Mazzeo & Tanaka, 2001) Exercise intervention greater than 6 months in duration is necessary (Skelton, 2007). PSI-led class: low uptake & high drop-out rates

Aims Explore older people’s views on falls exercise classes Transition from physiotherapist-led classes to PSI-led classes Motivators & Barriers to the uptake and adherence Increase attendance rates at PSI-led classes

Methods – Qualitative Research Design: Principles of grounded theory. Sample: 5 participants from physiotherapist-led class (saturation point reached) Recruitment: Visit by researcher to classes Data Collection: Semi-structured interviews: 7 open questions Analysis of data: Transcription of interviews -Open coding >> axial coding >> selective coding (+ memo writing)

Findings MOTIVATORS Benefits of Exercise (physical & psychological) Desire to Improve Social Interaction Confidence in Class Set-Up BARRIERS Knowledge of PSI-led Class Low Self Efficacy Low Outcome Expectations

New themes.…Motivator CONFIDENCE IN CLASS SET-UP -Not previously discussed in the literature -“...But I mean these people, whether it ’ s this class or the next advanced class, presumably they are experts in their own field. ” (P4, pg.10, L )

New themes….Barrier KNOWLEDGE OF PSI-LED CLASS Not previously discussed in the literature “…What’s this other class?” (P1, pg.1, L5-6) “...What time would it be? ” (P2, pg.3, L109) “...Where would I have to go in the first place? ” (P5, pg.11, L419)

Clinical Implications Lack of knowledge of PSI-led classes Increase awareness of Falls Prevention Services - booklet? - DVD? - reinforce information every week? Essential if attendance rates at PSI-led classes are to be increased and the risk of falling reduced

Future Research… …on the transition between classes with larger sample sizes & bigger geographical area …strategies to encourage older people with low self efficacy But most importantly… Effective strategy to inform older people of their options within Falls Prevention Programmes urgently needed!

How useful is the fracture Risk Assessment Tool (FRAX) in a falls clinic population? McCarthy C, Skelton DA, Gallacher S, Mitchell LE Abstract presented at 10 th National Conference on Postural Stability and Falls, Blackpool, 07/09/09

So what about case finding for bone fragility? Used to determine 10 year fracture risk in community dwelling adults – then NOGG suggests guidance on treatment

NOGG Advice based on FRAX

Research Questions What are the implications of using FRAX / NOGG in a falls clinic Setting? Can they identify those patients who would benefit from BMD assessment? Can they be used to determine treatment without the use of DEXA?

Methods 44 consecutive patients (33 F) attending a falls clinic –Mean age 78.0 (sd 6.0) years BMD measured –Lunar Prodigy, L2-L4 and neck of femur FRAX and NOGG assessed Statistics –Sensitivity, specificity, negative predictive values, positive predictive value, false negative and false positive rate for each FRAX cut off and NOGG advice to treat or not – before and after BMD measurement

Demographic Results After DEXA –Total 29.5% (n=13) had Osteoporosis (T < -2.5) –4 at hip and spine, 1 at spine alone, 8 at hip alone –A further 47% (n=21) had Osteopenia at spine and/or hip (T < -1) MeanSt Dev Tinetti (score) TUG (sec) FRAX score major OP (%) FRAX score hip (%) BMD at Spine BMD at hip

Results pre-DEXA NOGG advice (DEXA or treat) followed: –46% (n=6) of those with OP at either spine and/or hip would not be treated or advised a DEXA –Of those where DEXA was advised (n=18), 72% did not have osteoporosis (n=13) –Treatment advised in 2 patients both of whom had osteoporosis on subsequent DEXA

FRAX and NOGG not good in falls clinic at predicting need for DEXA and treatment Pre-FRAX NOGG Advice Sensitivity % Specificity % NPV % PPV % FP % FN % DXA advised and has OP DXA advised and has OP or OS

The Benefits ‘Loss leader’ that has led to a strong relationship –Access and willingness to work on research within various parts of the service Masters students data projects x 2 2 large NIHR outline bids, dementia and physical activity, visual impairment and falls –Memorandum of Agreement to increase research capacity within Specialist Registrars Footwear and balance in wards FRAX and BMD in Falls Clinic Attenders