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Falls in Older PeopleFalls in Older PeopleNational & International Research PrioritiesNational & International Research Priorities

Dr Jacqueline CT CloseDr Jacqueline CT ClosePrince of Wales Hospital,Prince of Wales Hospital,

Prince of Wales Medical Research Institute &Prince of Wales Medical Research Institute &University of New South WalesUniversity of New South Wales

OutlineOutline

What we knowWhat we knowWhat we donWhat we don’’t knowt knowWhat we doWhat we doWhat we need to doWhat we need to do

Absence of evidence Absence of evidence ≠≠ Evidence of absenceEvidence of absence

Published articles on falls in older Published articles on falls in older peoplepeople

050

100150200250300350400

1985 1990 1995 2000 2005

Year

Num

ber

Source - Medline

1st successful RCT 1994

The Community The Community

What we knowWhat we know

Successful RCTs in falls prevention

Emergency Department attendeesSingle InterventionsKenny, 2001 Multifaceted InterventionsClose, 1999 Davison, 2005

Hospital In-patientsSingle Interventions - NilMultifaceted InterventionsHaines, 2004 Healey, 2004

Care Home ResidentsSingle Interventions - NilMultifaceted InterventionsRay, 1997 Jensen, 2002 Schnelle, 2002Becker, 2003

Community dwelling populationsSingle InterventionsWolf, 1996 Campbell, 1999 Campbell, 1997 Buchner, 1997Cumming , 1999 Barnett, 2003 Lord, 2003 Robertson, 2001Nikolaus, 2003Harwood, 2005 Li 2005Skelton 2005Campbell 2005Multifaceted InterventionsTinetti, 1994 Hornbrook, 1994 Day, 2002 Clemson 2002Wagner, 1994

We knowWe knowHow to prevent falls in various at risk How to prevent falls in various at risk populationspopulationsThat interventions are defined by identified That interventions are defined by identified riskriskSingle and multifactorial interventions are Single and multifactorial interventions are effectiveeffectiveExercise is the most effective single Exercise is the most effective single intervention (in high risk populations)intervention (in high risk populations)Exercise must be of a certain typeExercise must be of a certain type

What we donWhat we don’’t knowt knowHow to systematically identify at risk How to systematically identify at risk populationspopulationsWhat level of assessment is required for What level of assessment is required for different populationsdifferent populationsThe true cost of the different approaches to The true cost of the different approaches to preventionpreventionHow to prevent falls in cognitively impaired How to prevent falls in cognitively impaired older peopleolder peopleCan preventing falls prevent fracturesCan preventing falls prevent fractures

What we doWhat we do

Opportunistic / sporadic case finding and Opportunistic / sporadic case finding and some pockets of good practicesome pockets of good practiceWork within Work within organisationalorganisational boundaries and boundaries and artificial constraintsartificial constraintsOver intervene / under investigateOver intervene / under investigateSet up new services and new teams without Set up new services and new teams without assessing existing demand and capacityassessing existing demand and capacityLargely bypass the GPLargely bypass the GP

What we need to doWhat we need to doQuantify need for our local populationQuantify need for our local populationAgree a mechanism for systematic Agree a mechanism for systematic identification of risk and clinical pathways identification of risk and clinical pathways for assessment and interventionfor assessment and interventionWork with GPsWork with GPsTarget interventions more effectivelyTarget interventions more effectivelyShare and replicate models of good practiceShare and replicate models of good practiceEvaluate services Evaluate services

EDED


What we knowWhat we knowEDsEDs are busy places and time is limited in EDare busy places and time is limited in EDED attendees are a high risk populationED attendees are a high risk populationEasily identifiedEasily identifiedIntervention needs to be multidisciplinaryIntervention needs to be multidisciplinarySpecialist Falls Services would collapse if all Specialist Falls Services would collapse if all ED fallers sent to Falls ClinicsED fallers sent to Falls ClinicsAmbulance services donAmbulance services don’’t bring all fallers to t bring all fallers to EDEDThose not conveyed are also high riskThose not conveyed are also high risk

What we donWhat we don’’t knowt knowWhich patients to refer for more detailed Which patients to refer for more detailed assessmentassessmentWhere and when should the assessment Where and when should the assessment happenhappenWhat level of assessment should we be doing What level of assessment should we be doing in ED and who should do themin ED and who should do themWhat should happen to those not conveyed What should happen to those not conveyed after a fallafter a fall


Fire fightFire fightPatch up the older personPatch up the older personOnward referral and assessment determined Onward referral and assessment determined by local service availability rather than needby local service availability rather than need

What we need to doWhat we need to doDevelop a screening/assessment tool to Develop a screening/assessment tool to quantify risk and direct referralquantify risk and direct referralConsider the role of ASET in assessing the Consider the role of ASET in assessing the older fallerolder fallerDevelop clinical algorithms to support safe Develop clinical algorithms to support safe nonnon--conveyanceconveyanceEvaluate alternate pathways for those not Evaluate alternate pathways for those not conveyedconveyedEnsure falls and bone health are addressed Ensure falls and bone health are addressed in fracture patientsin fracture patients

InIn--patientspatients



How to identify high risk fallersHow to identify high risk fallersMultidisciplinary assessment in aged care Multidisciplinary assessment in aged care wards can lead to a reduction in fallswards can lead to a reduction in fallsIt can be implemented in a real life settingIt can be implemented in a real life settingNSW Health are keen to reduce inNSW Health are keen to reduce in--patient patient fallsfallsNot all falls are on aged care wardsNot all falls are on aged care wards

What we donWhat we don’’t knowt know

Whether existing screening tools work on Whether existing screening tools work on non aged care wardsnon aged care wardsThe true cost of an inThe true cost of an in--patient fallpatient fallWhether all falls are the same Whether all falls are the same –– old versus old versus young, different departmentsyoung, different departmentsWhether alarm devices can reduce fallsWhether alarm devices can reduce fallsWhether different flooring types can alter riskWhether different flooring types can alter risk

What we doWhat we doFill in an IIMS report (with limited belief that it Fill in an IIMS report (with limited belief that it is worthwhile)is worthwhile)Use a fall as the trigger for future preventionUse a fall as the trigger for future preventionRarely share and use invaluable IIMS dataRarely share and use invaluable IIMS dataFocus on aged care wardsFocus on aged care wardsDonDon’’t discuss incidents in a timely mannert discuss incidents in a timely mannerUse mechanical restraints Use mechanical restraints Prescribe night time sedationPrescribe night time sedation

What we need to doWhat we need to do

Share and learn from IIMS data as a teamShare and learn from IIMS data as a teamScreen on low risk wards (validated scale)Screen on low risk wards (validated scale)Assess and intervene on high risk wardsAssess and intervene on high risk wardsTrial new devicesTrial new devicesLook at toileting practices on wardsLook at toileting practices on wardsReconsider use of mechanical restraintReconsider use of mechanical restraintStart treatments that will have benefits further Start treatments that will have benefits further down the linedown the line

Residential Aged CareResidential Aged Care


Falls can be prevented in those with MMSE Falls can be prevented in those with MMSE >19>19Simple measures such as regular toileting Simple measures such as regular toileting can alter riskcan alter riskVit D deficiency is almost universalVit D deficiency is almost universalVit D / Ca can prevent falls & fracturesVit D / Ca can prevent falls & fracturesBone health over under treatedBone health over under treated

What we donWhat we don’’t knowt knowHow to identify those at greatest riskHow to identify those at greatest riskHow to prevent falls in cognitively impairedHow to prevent falls in cognitively impairedThe effects of alarm devices, flooring types The effects of alarm devices, flooring types etcetcWhether increased physical activity Whether increased physical activity increases fallsincreases fallsWhy are there differences in falls rates Why are there differences in falls rates across countries / culturesacross countries / cultures


Not sureNot sure

What we need to doWhat we need to do

Weigh up falls prevention v physical Weigh up falls prevention v physical activity v activity v QoLQoLPrescribe Ca/Vit DPrescribe Ca/Vit DConsider bone healthConsider bone healthPilot alarm devices etcPilot alarm devices etc

If the MMSE is 20 or above, follow assessment and intervention protocols for cognitively normal fallers. Use clinical judgement in patients where MMSE does not accurately reflect overall cognitive and functional status.

Review of medication should be undertaken in all fallers, including thosewith cognitive impairment and dementia.

Orthostatic hypotension is a common risk factor for falls in older people with dementia. It is relatively easily assessed and has the potential for treatment.

Physical training programmes may be beneficial.Environmental recommendations may be applicable.Alarm devices may be appropriate it some circumstances.Calcium and Vitamin D replacement may have a role in fall prevention.

Recommendations for intervention Recommendations for intervention in cognitive impairmentin cognitive impairment

What research does tell usWhat research does tell us

What are the risk factors for fallsWhat are the risk factors for fallsWhat populations are at riskWhat populations are at riskWhat interventions can prevent fallsWhat interventions can prevent falls

What research doesnWhat research doesn’’t tell ust tell usHow we practically identify at risk populationsHow we practically identify at risk populationsWho will accept interventionsWho will accept interventionsWhat What motviatesmotviates an older person to accept and an older person to accept and comply with an interventioncomply with an interventionHow to develop a workforce fit for purposeHow to develop a workforce fit for purposeHow to deliver interventions in a real life How to deliver interventions in a real life settingsettingHow to evaluate outcomes and which How to evaluate outcomes and which outcomes represent successoutcomes represent success

ConclusionConclusionFalls are not an inevitable consequence of Falls are not an inevitable consequence of ageingageingWe know how to identify at risk populationsWe know how to identify at risk populationsWe know how to intervene and where we We know how to intervene and where we should be targeting interventionsshould be targeting interventionsThere are still gaps in the research evidenceThere are still gaps in the research evidenceNeed to acknowledge the complexities of Need to acknowledge the complexities of applying evidence in a real life contextapplying evidence in a real life contextHowever it shouldnHowever it shouldn’’t be a reason not to do it.t be a reason not to do it.

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