Empowering service users and supporting self-management Laura Halcrow 29/01/14

The facts: Definition a fall An event which results in a person coming to rest inadvertently on the ground or lower level

Who is at risk of falls?

Falls represent the most frequent type of accident in the over 65’s Just under 295,00 people over 65 fall each year in Scotland.

In the UK, one person fractures their: 1 in 3 fall each year 65+ yrs 1 in 2 fall each year 85+ yrs In the UK, one person fractures their: Hip every 10 minutes, Wrist every 9 minutes Spine every 3 minutes 3% of people who fall are admitted as in-patient 15% (3,514) of fallers will attend an A&E department. 15% (3,514) of fallers will call the ambulance service. 7% (1,640) will sustain a fracture, 2% (468) to the hip. Based on: Falls and fractures: effective interventions in health and social care (DoH 2009)

What % of falls result in a serious injury?

10% One in ten! 7% (1,640) will sustain a fracture, 2% (468) to the hip.

What % of falls are reported to a health professional?

Makes prevention challenging! 20-25% are reported Only around 10% receive assessment Makes prevention challenging!

What is the biggest indicator that a person will have a fall? (i.e. the greatest risk factor) ?

Half of all people who fall will fall again within the following year A previous fall Repeat or multiple falls increase the risk of having an injurious fall. Half of all people who fall will fall again within the following year Half of people who have a fall will fall again within the next 12 months11

Why do we fall?

Biological reasons (Person-related): Why do we fall? Biological reasons (Person-related): Previous history of Falls Medical History - e.g. Parkinsons, dizziness, postural hypotension 4 or more medicines Pain Balance, gait or mobility problem Loss of muscle power Fear of falling Confusion Visual impairment Continence Intrinsic factors are ‘person related’ If a person has a history of falls then this increases their risk of future falls. Medical History of Parkinsons Disease, Stroke, Arthritis, Cardiac Abnormalities There are other medical conditions such as dizziness, syncope and postural hypotension – these all contribute to falls. Syncope is defined as a transient loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. Syncope affects about 30% of adults at some point in their life. There can be a range of reasons for syncope to occur the most common being a vasovagal attack or common faint. Other reasons include orthostatic hypotension, cardiac arrhythmias, structural cardiac or cardio pulmonary disease. These are normally your unexplained fallers who just go down for no reason and blackout. Your typical patient with postural hypotension will get up quickly to answer the telephone and just go down. Normally when we stand up your blood pressure should rise but with postural hypotension your blood pressure goes down. Another area to be aware of is Palliative care, where due to the nature of the persons condition they can become more likely to fall. Certain drugs can increase the risk of falls for example sedatives. Literature suggests that if you are on 4 or more medications then you are more likely to fall. However one medication can be enough to increase falls risk depending on the type of medication. Take a high dose of frusemide where a person has to toilet frequently. Atenolol for BP – if patients are on this long term it can cause a postural drop in BP.

Why do we fall? Behavioural reasons: Sedentary lifestyle Poor nutrition and hydration Alcohol Footwear Refusal to use assistive devices The behavioural risk factors to falls are those that are activity based. And as such they are the most challenging to tackle in terms of reducing risk. Certain things need a magic wand! Dehydration can cause dizziness and fainting, so staying hydrated is vital. Our patients are particularly vulnerable of dehydration because of deteriorating kidney function, changes in thirst responses and taking medication such as diuretics.  Alcohol is a major contributor to falls as obviously it impairs your judgment. Long term alcoholism can lead to neuropathy. When folks are detoxing and in the DTs -they are very vulnerable to falls. There is often no point in rehab (particualry the younger neuropathy patients unless they are also signed up to an alcohol reducing programme. However it is important to note that ‘falling’ can’t always be blamed by alcohol – it could be masking an underlying medical condition Over the counter medications can interact with prescribed medications. For example many patients take things like Benalin Cough syrup, or night nurse habitually to help them sleep and are unaware that these interact with their prescribed meds – many use over the counter medicines in various very inapproriate ways. CLICK Footwear should be supportive and well fitting otherwise it is a falls risk. Balance receptors are in our feet and if these are not supported this can cause an increased risk of falls.

Why do we fall? Environmental hazards account for about 25 to 45% of the causes of Falls in older people. Environmental hazards account for about 25 to 45% of the causes of Falls in older people.

Summary: consequence of falling

Human Cost of a Fall Muscle wasting Death Immobility From immobility Incontinence Fractures Hypothermia Dehydration PHYSICAL Soft tissue damage Pressure sores/ Leg ulceration Pneumonia/Chest Infection Dislocation Sub-dural haematoma We know that the physical cost of a fall may be vast… and consequences are well documented in the literature. This list is by no means exhaustive.

Human Cost of a Fall Feelings of Uselessness Increased Dependency Carer Stress Emotional Distress Loss of confidence Loss of control Anxiety/Depression PSYCHOLOGICAL Social Isolation/Withdrawal Embarrassment Low self esteem Fear of Further falls There is also a psychological human cost to falls with people loosing their confidence, becoming frightened, avoiding activities and becoming socially isolated and depressed. There is a condition – a psychological condition termed ‘the fear of falling’ – this affects 50 -75 % of fallers. And leads to a vicious circle of dependency. People limit their activities because they are frightened of falling. As a consequence, they loose muscle power and strength and in turn their mobility – which of course puts them at an even greater risk of future falls. In rehabilitation the ‘fear of falling through mobilising’ is a real phenomenon – A considerable amount of rehab is undertaken by assistant staff who are amazing at coping with client/patient fear issues and helping them through these real psychological issues. However, we all know how often a client/patient has been classed as difficult, i.e. refusing to move, wt bear, etc… and none of us are particularly good at acknowledging the very real psychological issues some people have regarding their ‘fear of falling’. We could all do with some training in this area!

Falls are not an inevitable consequence of old age Falls are nearly always due to one of more underlying risk factors. Recognising and modifying these risk factors is crucial in preventing falls and injuries. Multi-factorial, individualised interventions, based on risk assessment, can reduce falls by up to 30%. From: Falls and fractures: developing a local joint strategic needs assessment. (DoH 2009)

Multi factorial Risk factors Simples! Biological risk factors Behavioural Risk factors Environmental Risk factors Multi factorial Risk factors

Do you think we can stop all falls?

The risk of falling can never be completely removed, but by carrying out a falls risk assessment on an individual, risk factors can be identified and action taken to remove or alter risk where possible There will be cases when an individual remains at high risk of falling despite thorough assessment and management, however, the focus should be on anticipating and preventing problems before they occur.

Prevention: the evidence Early identification and individualised intervention, based on risk assessment Can reduce falls by up to 30% Sustained strength & balance training Home environment assessment & intervention Multifactorial, individualised interventions, based on risk assessment, can reduce falls by up to 30%.

Self management Not all people want or need assessment by health and social care staff. Health and social care services are changing to become more person centred and proactive. It involves giving individuals an active role in their own care. It is about giving the person the information and support to make their own decisions and plans to manage their health.

Do you have access/use a PC, tablet or smart phone to access the internet?

Why use technology? Surveys have shown that 26% of people over 65 use the internet. This rises to 63% for those between 55-63. People are becoming more reliant on technology. Good medium to reach a lot of the public with health information.

What are we planning? An internet based self assessment measure to reduce your falls risk. This will include answering a series of questions and completing activities about your general health, mobility and environment etc. Once completed this will give you an individualised personal action plan which will aid you to self manage your falls risk.

The Evidence There has been a web site developed by Dr S Nyman to give tailored advice regarding balance exercise activities. This has been proven through studies to be an acceptable and effective method of giving advice to elderly people regarding exercise to prevent falls. There are some websites that offer falls prevention advice. Currently there are no web sites that allow the user to self assess their own falls risk and get information/advice relevant to them.

What will it look like?

How will it work?

Spot the hazard!

Spot the hazard answers Rug Wires Clutter Bed Clothes Not much space for access Position of sockets Lighting

Think about your own bedroom Do you have any of these hazards? For example if we identify trailing wires as an issue. The process that will happen through the web site is shown by the diagram. Click on wires Advice re cable ties/fix to skirting board Signposted on to local handyman services.(Care and Repair)

Please give us your feedback What do you think? Would you use this? Are you interested in being involved with the design/testing of this?