Nazia Mumtaz & Sairah Naeem GPST3’s in General Practice Tuesday 18 th September 2012

 Epidemiology  Risk assessment  Falls assessment  Primary prevention  Secondary prevention  What NICE does/doesn’t recommend  Patient education  How to refer for falls assessment

 The leading cause of mortality resulting from injury in people aged > 75 years  400,000 older people attend A&E each year for falls  die due to osteoporotic hip fractures each year  1 in 3 people > 65 years fall at least once per year  1 in 2 people >80 years fall at least once per year  5% of these need hospitalisation (Royal society for the Prevention of Accidents)

 History- how, ?LOC, injuries, pain, loss of function, headache, carers re behaviour, long lie  Examination- temperature, MMSE, bruising, reduced function, confusion, postural BP, pulse, neurology, fundi, vision testing  Investigation- risk factors, bloods (FBC, U&Es, LFTs, TFTs, Vitamin B12, glucose), urinalysis, ECG, ECHO, specialist assessment (optician, neuroimaging etc)  Treat- fractures- Colles’/NOF, subdural haematoma, pneumonia, hypothermia, UTI, dehydration

 Referral:  A&E- significant HI, ?fracture, other injuries- lacerations  Acute elderly admission- acute medical cause, unable to cope  Outpatient referral elderly- unclear cause recurrent falls, possibility of further falls, not coping well

 Falls history  Gait, balance, mobility, muscle weakness  Osteoporosis risk  Perceived functional ability  Fear of falling, perceived functional ability  Visual impairment  Cognitive impairment  Neurological exam  Continence  Home hazards  Cardiovascular exam  Medication review

 Falls are usually MULTIFACTORIAL

 Previous falls  Female 2:1 in >75 years  Age > 80 years  Disorders of gait/balance/co-ordination  Visual impairment  Cognitive impairment/confusion  Low morale/depression  High level of dependency with ADLs  Reduced mobility  Foot problems/inappropriate footwear  Arthritis  Lower limb weakness  Stroke/Parkinson’s  Polypharmacy  Alcohol  Environmental factors  Infection  Use of walking aids, e.g. Walking stick

 Loose rugs/electric leads  Wet surfaces- spills, bathroom  Poor lighting  Ice  High winds  Use of ladders  Too low/too high- chair/bed

 Stroke  Parkinson’s- abnormal posture, freezing, frontal impairment, poor leaning balance, leg weakness  Neuropathy- diabetes  Proximal myopathy e.g. thyrotoxicosis, Cushing’s syndrome- esp rising from sitting  Cognitive impairment

 Syncope  seizures  Dizziness  Arrythmias Tachyarhythmias- broad/narrow complex tachycardias Bradycardias AF

 Cardiovascular  Carotid sinus disease  TIAs  Orthostatic hypotension

 Psychotropic drugs- phenothiazines, tricyclic antidepressants  Levodopa  Bromocriptine  Sedatives  Diuretics  Betablockers  ACE inhibitors  Alpha blockers  Diabetic medications- insulin, sulphonylureas

 Rule out possibility of elder abuse

-what we have just done

 Ask elderly people routinely whether they have fallen in last year  Older people reporting a fall or considered at risk of falling

 Timed up and go test- ‘rise from chair without support of arms, walk 3 metres, turn around and sit again’.  (NB- can use walking stick. Look for unsteadiness/difficulty)  Turn 180’ test-’stand up and step around until facing the opposite direction’.  (NB- further assessment if >4 steps needed)

 What is available???????????

*Multicomponent programmes According to NICE:  Strength and balance training (Tai Chi)  Home hazard assessment and intervention  Medication review  Cardiac pacing as indicated  Visual assessment and referral

 Not at all-  brisk walking  Insufficient evidence-  low intensity exercise + incontinence programmes  group exercise  cognitive/behavioural interventions  referral for correction of visual impairment on its own  vitamin D  hip protectors

 How to cope with a fall  What changes are they willing to make?  Motivation/fear of falling  Measures to prevent falls  Preventable nature of some falls  Physical/psychological benefits of modifying risk  Further advice and assistance

 Falls awareness week (Age UK:18-22 June

Standard 6:  Establishment of MDTs to deal with management of falls

 Through district nurses  Falls clinics  Multidisciplinary falls teams

 Which of the following, on their own, is recommended by the NICE 2004 guidelines on the assessment and prevention of falls as an intervention?  Brisk walking  Referral for correction of visual impairment  Cardiac pacing  Group exercise  Hip protectors

 Patient.co.uk. Prevention of falls in the elderly: evention-of-Falls-in-the-Elderly.htmhttp:// evention-of-Falls-in-the-Elderly.htm  NICE clinical guideline 21: The assessment and prevention of falls in older people, November  Simon C, Everitt H, Van Dorp F. Oxford handbook of general practice, 3 rd ed. Oxford p210