Bone Health

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to community based service and has access to rapid diagnostic and intervention services. Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers. Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls. Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services. Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

Introduction

Fracture prevention is a key component in the care of frail patients who fall. Patients that have already fallen and suffered a fractured neck of femur are highly likely to fall again, and have proven themselves high risk for fracture. Bone protection is a priority, and recent guidelines recommend IV Bisphosphonates as an appropriate 1st line drug. Vitamin D level should be 50 or above before this is given.

Method: I audited the notes of 41 patients age 60 years or over who were admitted in 2022 with a fractured neck of femur. I reviewed their admission Vitamin D level, and whether they required loading with Vitamin D before IV Bisphosphonates could be given. I reviewed the loading regime used, and how many of the patients had received bone protection medication, either as an inpatient or post-discharge. I liaised with 3 other neighbouring trusts to find out their current Vitamin D loading regimens to compare to our own.

Results: The audit identified that 54% of those patients required Vitamin D loading before they could be given IV Bisphosphonates. 36% of those never had their loading regime prescribed, and of those that did all were prescribed a 7 week long regime. 1 patient was already receiving IV Bisphosphonates prior to admission, and continued on those. 4 Patients were prescribed PO Bisphosphonates. 4 patients were Fast-Track or EOL. 7 patients had low CrCl preventing use of bisphosphonates. Of those that remained, none got inpatient treatment.  I identified that the long loading regime was proving a barrier, and so drafted a new rapid loading guideline, similar to the practice of nearby trusts. Re-audit to assess the impact of this will be performed in July & August 2023 with results presented at conference

Abstract: Ageing is a complex biological process that is progressive in nature. There is a decline observed in the muscle mass and the sensorimotor systems which may contribute to decreased balance and stability while walking.Balance is one of the most crucial intrinsic risk factor for the occurrence of falls. Falls are the leading cause of fatal and non fatal injuries among the elderly.Multiple studies indicate that a structured exercise program helps in improving balance and reducing risk of falls.Exercises can be performed on land as well as in water.Thereby the need of the study to evaluate the effect of land vs aquatic exercises on balance in the elderly.

Method :A Randomised Control Trial with 40 elderly’s selected based on the inclusion criteria; randomly divided in 2 groups. Balance was assessed using Tinetti POMA scale. Exercises were done 3 times a week on alternate days. Below are the walking activities: Walking forward 11 feet. Marching forward 11 feet. Sidestepping without crossing legs 11 feet. Tandem walking 11 feet. Below are the exercise activities. Marching in place. Hip flexion/extension .Hip abduction/adduction. Toe raises/heel raises. Shallow knee bends. Sit to stand from chair in land group. Sit to stand from pool shelf in aquatic group.

Results :Wilcoxin pair signed rank test was used for within group pre and post analysis, for land exercise the two tailed p value <0.0001, which is extremely significant; for aquatic exercises the two tailed p values < 0.0001, which is extremely significant.For between group analysis Mann Whitney Test was used, the two tailed p value < 0.0001, which is extremely significant.

Conclusion:The results show that there is an improvement in balance post both land and aquatic exercises individually, but when compared between the two mediums aquatic exercises showed a better result.

Index terms : Land exercises, Aquatic exercises, Balance in elderly, reduce risk of fall

Introduction

Keeping our standing balance is a crucial capability in preventing falls. Nevertheless, older adults may focus attention internally to their movement mechanisms during stance, through conscious movement processing (CMP), when facing balance difficulties. However, this may interfere with movement automaticity that could cause balance problems. The primary aim of this pilot study is to examine the effects of attention focus balance training on CMP propensity in older adults at risk of falling.

Method

Twenty-four older adults (mean age = 79.92 ± 7.61) with moderate to high risk of falling were included in this preliminary analysis. Participants were randomly assigned to either the No Specific Attention Focus Balance Training Group (NBTG; n=8), External Attention Focus Balance Training Group (EBTG; n=8), or the Internal Attention Focus Balance Training Group (IBTG; n=8). Participants in different groups participated in twelve tailor-made 45-minute training sessions with different attention focus instructions during standing balance training. The primary outcome measure of the real-time (state) CMP propensity (T3-Fz Electroencephalogram (EEG) coherence) at the baseline (T0) and after completion of all balance training sessions (T1) was evaluated. A 3x2 Group (NBTG, EBTG, IBTG) x Time (T0, T1) mixed Analysis of Variance (ANOVA) was conducted.

Results

We discover a decreasing trend of the real-time (state) CMP propensity (T3-Fz EEG coherence) in the EBTG but an increasing trend of the T3-Fz EEG coherence in the IBTG from T0 to T1. The T3-Fz EEG coherence for the NBTG remains similar from T0 to T1.

Conclusion

This preliminary result suggests that the external attention focus balance training has a potential to mitigate the real-time (state) CMP propensity in older adults at risk of falling. Consequently, it could further benefit the standing balance of the at-risk older adults after their rehabilitation.

An 86-year-old lady, presented with an unwitnessed fall with no obvious head injury. Her Glasgow Coma Scale (GCS) was 15 on arrival. She denied precipitating factors, taking blood thinners or seizure medication. Her examination revealed tongue biting, suprapubic tenderness, and pain in both hips and arms. An X-ray of the possible affected joints was ordered. Bloods and venous blood gas (VBG) were unremarkable. Within a few hours, she had a witnessed tonic-clonic seizure with a swollen tongue, for which lorazepam and adrenaline were administered. Repeat VBG (post-ictal) revealed a high lactate with hypoxia and hypotension. Intravenous fluids and oxygen were administered with a full body trauma series and a Contrast-Enhanced Pulmonary Angiogram. This showed a large retroperitoneal haematoma, a comminuted fracture of the superior pubic ramus and an unstable thoracic fracture.  She was referred to surgeons and orthopaedics for further management.

Trauma in older patients with polymorbidities can be missed as they are poor historians with conflicting collateral histories and atypical presentations. The “Silver trauma” emphasises early diagnostics, intervention and outcome including rehabilitation, decreasing mortality and morbidity. (1) The most common trauma is a fall of less than two metres from standing. (2)  They should be searched for more than one injury (2) in this case, suprapubic tenderness. They can have atypical observations compared to younger people sustaining trauma. (1) Example, a higher baseline blood pressure due to significant aortic disease. Similarly, tachycardia can be masked by medications such as beta blockers.

They should be investigated for polytrauma following an unwitnessed fall with a low threshold for a full CT trauma series.

 Furthermore, early reversal of anticoagulation should be implemented with adequate pain relief hydration to prevent delirium. (2) Knowing local pathways for referral to specialist services, and considering of patient’s and relatives’ previous wishes are key for early mobilisation and discharge. (1)

Introduction:

The Older Person's Assessment Unit (OPAU) Physiotherapy team have been collaborating with Breathe Arts Health Research (BAHR) to provide ‘Dance for Strength and Balance’ (DSAB) classes for Older Adults as an alternative to traditional, long-established Strength and Balance Group (SABG). Previous preliminary data established DSAB to be safe and effective in falls risk reduction for participants.

The primary aim of this service evaluation was to determine if DSAB is at least as effective as SABG for improving outcomes and reducing falls risk for OPAU patients.

Methods:

46 DSAB patients were cross-matched to 46 SABG patients over a 3-year period (10^th October 2019 – 24^th November 2022). Only those with full data sets and at least 80% class adherence were included. Participants were matched by age, gender, ethnicity and functional level at class entry, including their Timed Up and Go (TUAG) scores. 

Intervention effect was measured by change in performance of outcome measures including TUAG, Gait Speed (GS), Sit to Stands in 1 minute (STS), Turn 180 and Falls Efficacy Scale (FES-I).

Data was analysed using two-tailed t-tests.

Results:

Median age of participants was 79.5 years (48-95).

DSAB and SABG were beneficial to participants, with falls risk reduction demonstrated across the range of outcome measures.

There was no significant difference between groups for changes in TUAG, Gait Speed, Turn 180 and FES-I, with p-values >0.05 for all.

There was a significant difference in STS 1min (DSAB 0.63, SD 5.17; SABG 7, SD 6.72); t=-5.1, p=0.00

Conclusion:

DSAB classes were as effective as traditional SABG in targeting outcomes known to impact falls risk. The difference in STS 1min between groups is likely due to repetition of this as an exercise in SABG, and worth incorporating into DSAB. DSAB should remain an option for older adults aiming to reduce falls risk.

Introduction: One of the key action areas of the World Health Organization (WHO) third Global Patient Safety Challenge ‘Medication Without Harm’ (WHO, 2017) is to reduce severe avoidable medication-related harm and address polypharmacy. NICE guidance on falls risk assessment and prevention also includes medication review as part of its recommended multifactorial risk assessment (NICE, 2013). Use of Falls Risk Increasing Drugs (FRIDs), along with polypharmacy and anticholinergic burden (ACB) are known to increase the risk of falls, particularly in older people.

Method:

This research quantitatively evaluates the impact of the intervention of a novel community falls pharmacist role on medicines optimisation, in relation to FRIDs in older people who have had a fall. We will present data on admission and discharge from the service in relation to:

• Number and type of FRIDs prescribed
• Calculation of Anticholinergic Burden score using the ACBcalc® (King and Rabino, 2022)
• Polypharmacy- number of medications prescribed
• The appropriateness of medicines prescribed
• Undertake measurement of lying/ standing manual blood pressure to identify potential postural drop in blood pressure, and hypertension.
• Undertake a Bone health review using an approved tool (FRAX)
• Outcome of pharmacist referral of appropriate patients for DEXA scan using a new direct referral system
• Measure the significance of clinical interventions (EADON graded)
• Calculate the cost avoidance of pharmacist interventions (ScHARR Tool) Results

Results:

Data was collected on 92 patients over 14 months. Results indicate a medicines review by the community falls pharmacist leads to a statistically significant reduction in polypharmacy (¯8%; p<0.05) and ACB (¯33%; p<0.05), an increased appropriateness of prescribing (MAI ¯56%; p<0.05), 317 clinically significant interventions, identification of blood pressure issues (22%) eg orthostatic hypotension, and identification of osteopenia (n=13) or osteoporosis (n=4) using a new pharmacist DEXA referral pathway. Amitriptyline was the most common FRID deprescribed (22%). Annual cost avoidance due to pharmacist interventions were in the range of £28160 – £62358 along with drug cost savings of £6041, amounting to total savings of £34201-£68400, and invest to save return of one to two pounds for every £1 invested. Benefit to the environment of reduced inappropriate prescribing amounted to almost 1 tonne of avoidable CO₂ emissions per year.

Conclusion:

Introduction of a community falls pharmacist role is an effective and cost efficient means to optimise medicines in older people who experience falls, as well as having a positive impact on the environment.

Introduction:

The number one reason for older people to be taken to hospital emergency departments is a fall¹.

An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

The objectives were to assess recruitment rate and feasibility of online survey delivery, and determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants and their role, with 5-point Likert scales of confidence.

Descriptive statistics and Chi-square analyses were used for quantitative data.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, and 53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there appeared to be significant variation between confidence levels relating to utilisation of hospital pathways and localities (p-value=.0045).

Length of experience in both frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion:

The overarching confidence of clinicians did not significantly vary around the region.

Locality of work had a relationship with confidence in utilising hospital avoidance pathways, however, did not relate to confidence in assessing this patient population.

Confidence was not found to increase for either total years providing healthcare, nor providing emergency frontline care.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf

Background

This healthcare evaluation focussed on the effectiveness of an orthoptic-led inpatient vision screening service at Nottingham University Hospitals for older adults admitted with a fragility hip fracture. The service was developed in response to national guidance, which recommended a multifactorial assessment, including a vision assessment for older adults presenting following a fall.

Method

Vision screening was carried out by orthoptists on eligible patients ≥65 years of age admitted to the Trauma and Orthopaedic wards with a hip fracture. Retrospective data for patients screened between 2015-2019 were analysed, including: patient demographics, screening eligibility and outcome, ophthalmology referrals made, ophthalmology appointment attendance and outcome.

Results

Of 3321 patients admitted with hip fracture between 2015-2019, 2033 (61%) were eligible for vision screening and 1532 (75%) of these were screened. 784 (51%) patients screened had an ocular abnormality requiring ophthalmology referral via their GP, or a sight test at an optician. Only 144/383 (38%) requiring ophthalmology referral were successfully referred and only 107/186 (58%) patients given appointments attended. 98/107 had pathology and cataracts was the most common finding (51%). 61/98 (62%) patients had treatable vision impairment. 

Conclusions

We found a large proportion of hip fracture patients who had impaired vision; much of which was easily treatable and could be detected effectively with orthoptic-led bedside screening. The most common eye problem in those referred to ophthalmology was cataracts. An internal referral pathway to ophthalmology is proposed. There is a need to investigate reasons for disengagement with eye care services in this population.

Introduction Older adults are at risk of falls, which increases further in care homes. Due to the complexity of care home residents’ conditions and an increasing ageing population, it is important for care staff to have knowledge and understanding in falls awareness, prevention, and management in order to support their residents. Literature searches identified that barriers to care staff implementing falls prevention strategies included limited knowledge of staff and insufficient resources (including lack of staff training). There is scarce research regarding methods to deliver training to care staff, however emerging research in Virtual Reality (VR) as a training method had promise due to increased knowledge retention, and application into practice. Stakeholder patient and public involvement and engagement determined that VR as a training method had potential value.

Methods The second study as part of a multi-phase project, including two research phases and one technology development phase. The second research study was a mixed methods pragmatic study exploring the feasibility of the VR proof-of-concept, across seven care homes across the North West (n=40).

Results Engagement, immersion and enjoyment were key factors for acceptability of a training method. The training suited the learning styles of care staff, and VR was accepted as a training method. Utilisation of a case study resident increased empathy for the resident experience. Feedback for development included additional locations, scenarios, and interactable items. Barriers and facilitators of acceptability and adoption were identified.

Conclusion Identifying a potentially effective method of training for a complex intervention may influence the creation of future training programmes for care homes: to assist in increasing care staff knowledge, retention of information, and application of knowledge into practice. This in turn may improve the quality of care delivered and resident outcomes. Additional research is required to develop the proof-of-concept further, and feasibility tested further.