1. Falls and fracture prevention
Dr Nicki Colledge
Liberton Hospital and
Royal Infirmary, Edinburgh

2. Why are falls important?

3. Injuries are frequent: Psychological impact:
High incidence:
30% of those over 65 report a fall each year
Rises to 60% of those in care homes
Sometimes fatal:
85% of deaths due to accidents at home are caused by falls in those over 65
Injuries are frequent:
Falls cause 1 million non-fatal injuries per year
Psychological impact:
Fear of falling is the most frequent reason given for a move to a care home
Expensive:
£909 million p.a. to the NHS

4. Falls and fractures Type of fracture
Percentage attributed to falls by older women
Wrist
Proximal humerus
Hip
Ankle
Pelvis
Face
Tibia/fibula
Vertebral 96 95 92 88 80 77 65 59
<25

5. Osteoporosis Estimated costs = £1.7 billion/year
>300,000 osteoporotic fractures p.a.
Estimated costs = £1.7 billion/year
47, 471 hip fractures p.a.
90% occur in people aged over 50
40% die within the next year
Estimated cost of treatment and care: £7.26million/year
Cost to the individual: 80% of women aged over 75 would rather die than have a hip fracture that led to admission to a nursing home
Normal bone
Osteoporotic bone

6. Why are old people so prone to falls?

7. Balance and Ageing: reaction times

8. Annual prevalence of falls in older women and number of simultaneous chronic diseases
Chronic diseases included
e.g. circulatory disease,
depression, and arthritis
Crude data adjusted for age,
each drug taken, BMI, alcohol
consumption, Hb concentration
and social class
Lawlor, D. A et al. BMJ 2003;327:
Copyright ©2003 BMJ Publishing Group Ltd.

9. Who is at risk of falling?

10. Relative risk ratio/Odds ratio
Risk factors for falls
Risk factor
Relative risk ratio/Odds ratio
Muscle weakness
History of falls
Gait deficit
Balance deficit
Walking aid use
Visual deficit
Arthritis
Impaired ADL
Depression
Cognitive impairment
Psychoactive drugs
Age >80
4.4
3.0
2.9
2.6
2.5
2.4
2.3
2.2
1.8
1.7
AGS et al. J Amer Geriatr Soc 2001

11. Cardiovascular disease and falls
Increased prevalence of falls in those with:
Intermittent claudication
Post-prandial hypotension
Lower standing systolic blood pressure
Overlap between symptoms of falls and syncope
Causal association identified with
Postural hypotension
Carotid sinus syndrome
Vasovagal syndrome

12. Environmental hazards
A third to a half of falls are due to environmental factors e.g. inappropriate footwear and walking aids
Falls cannot be predicted from the number of hazards present
Trips often occur on objects not assessed as hazardous

13. Falls risk factors increase the risk of fracture
Independent risk factors for # in those over 75 years:
↓muscle strength
visual impairment
neuromuscular impairments
↑postural sway
Nguyen et al. BMJ 1993
EPIDOS study. Lancet,1996

14. Can falls (and fractures) be prevented?

15. PROFET : Preventing falls in patients presenting to A&E
Patients aged > 65 attending A & E with a fall
184 randomised to medical and Occupational Therapy assessment
213 controls
Medical assessment and treatment of cause of fall
72% balance impairment
59% visual impairment
34% cognitive impairment
28% reduced muscle power
20% peripheral neuropathy
17% cardiovascular disorders
OT home visit: safety education and environmental adaptations
Close et al, Lancet 1999

16. PROFET: results 12 months later: 183 falls in intervention group
510 falls in controls (p=0.0002)
Outcome
Odds ratio (95% C.I.)
Reduction in any fall
0.39 ( )
Reduction in recurrent falls
0.33 ( )
Reduction in hospital admission
0.61 ( )
Close, J et al. Lancet 1999;353:93

17. Effective interventions for falls prevention
Cochrane Review Update 2004
1.Multidisciplinary, multifactorial risk factor screening and intervention
Population RR
95% C.I.
Unselected
0.73
History of falls or risk factors
0.86
In Residential care
0.60
Gillespie LD et al, The Cochrane Library, Issue 3, 2004.
Oxford Update Software. (

18. Effective interventions
2. Muscle strengthening and balance retraining
Individually prescribed
Delivered in patient’s home by a health professional
RR 0.80 (95% C.I )
3. Home hazard assessment and modification
Professionally prescribed
In those who have fallen (only)
RR 0.66 (95% C.I )

19. Effective interventions
4. Withdrawl of psychotropic medication
RR 0.34 (95% CI )
5. Cardiac pacing for fallers with Carotid Sinus Syndrome
WMD (95% CI )
6. Tai Chi group exercise intervention
RR 0.51 (95% CI )

20. Cataract surgery and falls
RCT of expedited cataract surgery (approx 4 weeks) vs routine wait (12 months)
306 women aged >70 randomised
Rate of falling: reduced by 34% in the early surgery group after 12 months (p<0.03)
Fractures: reduced from 8% in controls to 3% in the early surgery group (p<0.04)
Harwood et al, Br J Ophthalmol 2005

21. NICE guideline 21 : Assessment and prevention of falls in older people
Key priorities
Case/risk identification
Multifactorial Falls risk assessment
Multifactorial interventions
Encouraging older people to participate in these
Professional education
National Institute for Clinical Excellence
NICE.gov.uk

22. Case / Risk identification
Older people should be asked routinely if they have fallen in the past year.
+ frequency, context and characteristics of the fall(s)
Those who have fallen or who are considered at risk, should be observed for balance and gait deficits.
Get up and go test
NICE guideline 21

24. NICE guideline 21

25. Multifactorial intervention
Individualised to patient according to diagnosis, causes and risk factors
Most successful programmes include:
Strength and balance training
Home hazard assessment and intervention
Vision assessment and referral
Medication review and modification
NICE guideline 21

26. Applying the guidelines to the individual
Treat any acute illness that precipitated the fall
Treat specific conditions affecting balance
e.g Parkinson’s disease, osteoarthrosis, stroke
Correct postural hypotension or arrhythmia
Rationalise medication especially psychotropic agents
Correct visual impairment where possible
Physiotherapy: balance and strength training
OT: environmental hazard check, safety awareness
Commence osteoporosis treatment where indicated

27. Treatment of osteoporosis in older women
In those with ≥1 fragility fracture and/or +ve DEXA
Bisphosphonate: Alendronate or Risedronate
+ Vitamin D and Calcium
Not tolerated or contra-indicated
Raloxifene (or Strontium ranelate)
Further fractures or very severe osteoporosis
Teriparatide
NICE Technological Appraisal 87,
SIGN guideline 71,

28. Uncertainties

29. Falls prevention in hospitals and care homes
Meta-analysis of the evidence for strategies to prevent falls or fractures in
care home residents or hospital in-patients (Oliver et al BMJ 2007; 334:82)
Care homes:
Hip protectors reduced hip fractures by 0.67 (CI ) but…
Hospitals:
Multifaceted interventions reduced falls rate (0.82 (C.I )

30. Other interventions investigated:
Multifaceted interventions in care homes
Single interventions:
Physical restraint removal
Fall alarm devices
Exercise in care homes
Calcium and vitamin D in care homes
Changes in physical environment
Medication review in hospitals

31. Hip protectors Cochrane review 2006
Meta-analysis of 11 trials in care home settings:
Reduction in incidence of hip fracture (RR 0.77 (95% C.I ) (but weak cluster randomisation methodology in 7 trials)
Meta-analysis of 3 individually randomised trials in community settings: No reduction (RR 1.16 (95% C.I )
Poor acceptance (median 68%) and compliance rates (median 56%)
Conclusion: hip protectors are ineffective for those living at home and their effectiveness in an institutional setting is uncertain.
Parker et al. BMJ 2006

32. Falls prevention in dementia:
Multifactorial intervention in patients with cognitive impairment
RCT of those with MMSE of <24 found no benefit from multifactorial assessment and intervention after a fall which led to presentation to A&E
(Shaw et al, BMJ 2003:326:73)
Hospital and Care homes meta-analysis:
Meta-regression showed no significant association between effect size and prevalence of dementia or cognitive impairment

33. From guidelines to service delivery
England and Wales: Older People’s NSF Standard on Falls 2001:
NHS (with local councils) should take action to reduce falls and resultant injuries in their older populations
All who have fallen should receive effective treatment and rehabilitation, and advice through a specialised falls service
Response
Falls registers for those at risk
Falls specialist nurses
Falls service coordinators
Integrated Care Pathways
Consultant-led falls clinics
Exercise classes and safety advice

34. Scotland???
Falls have not been a National Executive or health board priority
Key challenges
Scale of problem: at least 15% of those over 65 years?
Delivery of annual check for falls
Follow up of A&E attenders with falls
Follow up of those helped up at home by emergency services
Bolting on osteoporosis management
Acceptability of programmes to older people
Cost effectiveness?

36. City of Edinburgh Falls and Fracture Prevention Pathway
WHO SHOULD BE REFERRED?
All those with more than one fall in the past year
All those who have presented to the medical services with a fall
All those who have had one fall in the past year and are unsteady on a Get up and Go test
Those whose “falls” are possible blackouts

37. City of Edinburgh Falls and Fracture Prevention Pathway
WHERE SHOULD THEY BE REFERRED?
RAPID RESPONSE TEAMS
Housebound
≧ 2 falls in the past month
Injury sustained due to fall
DAY HOSPITAL
(Liberton or Royal Victoria or Leith)
Blackouts
Unsteady with no obvious cause
Postural hypotension that is difficult to control
Patients who don’t fulfill RRT criteria
OPTHALMOLOGY: Cataracts

38. City of Edinburgh Falls and Fracture Prevention Pathway
WHAT INTERVENTIONS TAKE PLACE?
Full MDT assessment +
Physio: strength and balance training
OT: home hazard assessment and safety advice
Integrated Care pharmacist team: medication review
Osteoporosis risk assessment and referral for DEXA if needed
Postural blood pressure check
Referral back to GP where medication or blood pressure problems are identified or ?reason for poor balance.

39. Fracture prevention = Falls prevention + Osteoporosis treatment Next challenge: a comprehensive integrated service for all with falls and fractures

40. Measurement of Bone Mineral Density: Dual energy X ray absorptiometry (DEXA)
T score = no of SD by which patient differs from mean peak BMD for young normal subjects
Z score = no of SD by which patient differs from BMD in subjects of the same age
OSTEOPENIA: T-score -1 to -2.5
OSTEOPOROSIS: T-score < -2.5
Downloaded from: StudentConsult (on 10 September :19 PM)
© 2005 Elsevier

41. Non-pharmacological interventions
High intensity strength training
Low impact weight bearing exercise
Dietary intake of calcium = 1000mg/day
+ stop smoking
moderate alcohol intake
Scottish Intercollegiate Guidelines Network
SIGN 71: Management of Osteoporosis

42. Vitamin D and Calcium
Residents of care homes or specialist housing for the elderly
Non-vertebral fracture reduced by 32%
Hip fracture reduced by 43%
Those with previous fragility fractures living in the community
No reduction in fractures
?beneficial effects on neuromuscular function associated with falls
Chapuy MC et al. N Engl J Med Porthouse J et al. BMJ 2005
Grant AM et al. Lancet 2005

43. Hip protectors Cochrane review 2006
Meta-analysis of 11 trials in care home settings:
Reduction in incidence of hip fracture (RR 0.77 (95% C.I )
Meta-analysis of 3 individually randomised trials in community settings: No reduction in hip fracture (RR 1.16 (95% C.I )
Poor acceptance (median 68%) and compliance rates (median 56%)
Conclusion: hip protectors are ineffective for those living at home and their effectiveness in an institutional setting is uncertain.
Parker et al. BMJ 2006

44. I will now talk through the Pathway which is in your hand out.
This is designed to be used as an opportunistic screening tool by anyone who comes into contact with older people.
Ask everyone over 65 if they have had a fall.
If yes – GUAG.
Demonstrate GUAG
If NOT unsteady – hand out leaflets.
If unsteady –Follow pathway
Detailed history of their falls to establish the nature of their fall (we will come to this in more detail later).

45. My own role is as the Physio. In SC RR Team
My own role is as the Physio. In SC RR Team. As part of the falls pathway my role is shown on the yellow sheet.
At initial assessment we carry out a joint assessment with the OT. At this time we will gather information about their PMH, History of falls, DH and compliance, SH and assess their gait, balance, ROM, power, and function etc.
Thereafter a Rx. Prog. Using appropriate exercises from the Ortago and Agile exs. tailored to their individual needs will be started.
As part of our ongoing input we will take an erect and supine BP on all our falls patients whether they a symptomatic or not.
Should this show a drop we will report back to the GP
We will also refer onto the ICP if the pt. is on 4 or more meds.or if we suspect 1 in particular is causing problems.

46. Falls and fracture prevention
Balance and ageing
Risk factors for falls
Falls prevention: Evidence
Falls prevention: Guidelines
Applying the guidelines
National developments
Local services