Falls

Introduction

Substantial variations remain in hip fracture care delivery across the UK despite established standards and guidelines. We aimed to predict adverse patient outcomes following hip fracture from modifiable hospital-level organisational factors and develop implementation tools to improve national service delivery.

Method

We used a national record-linkage cohort of 178,757 patients (≥60 years) with a hip fracture in England and Wales (2016–19). We linked patient-level hospital admissions, National Hip Fracture Database and mortality data with 231 metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with patient outcomes: length of hospital stay, emergency 30-day readmission, 120-day mobility recovery, days in hospital and health costs over 365-days, and mortality (30- and 365-day) in 172 hospitals across England and Wales.

Results

Over one-year patients with mean (SD) age 83 (8.6) years, spent 31.7 (32.1) days in hospital, costing £14,642 (£9,017), and 50,354 (28.2%) died. We identified 46 key organisational factors independently associated with one or more patient outcome, of which 14 were (a) associated with cost and/or bed-day savings over one year, (b) consistently associated with other positive patient outcomes, and (c) potentially modifiable. Factors included weekend physiotherapy provision (mean saving per patient/year: £676 [95%CI:£67-1285]), orthogeriatrician assessment (£529 [£148-910]), direct admission to a hip fracture ward (3.4 [-0.36-7.07]days), regular dissemination of audit data to staff (0.85 [0.30-1.39]days). These data have informed the development of a hospital-specific cost-benefit calculator, with a model business case for service improvement, specialty checklists, audit and ‘how to’ guides for complex care delivery.

Conclusion

All hospitals should try to provide the best available hip fracture care equally across England and Wales. We identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture. Our practical and freely-available toolkit should help reduce variation in service delivery.

Introduction:

Mortality after a hip fracture increases compared to the general population. The main objective of this study is to examine the incidence, trends, and factors associated with mortality in patients with osteoporotic hip fractures.

Methods:

This is a retrospective cohort study from a South American hospital. Patients older than 65 years with osteoporotic hip fracture between 2015 and 2018 were identified. Demographic data and comorbidities were obtained. The incidence rate, standardized mortality rate, trend (Poisson regression), and risk (hazard ratio) were calculated.

Results:

A total of 304 patients admitted for osteoporotic hip fracture were found, 240 (79%) were women with a mean age of 81.3 years (SD 8.45) and 64 (22.1%) were men with a mean age of 85. .42 years (SD 10.08). The cumulative incidence of mortality was 72.5%. The annual mortality rate was 75.6/1000 patients/year (54.8 in men and 20.8 in women). The 1-year mortality rate increased significantly by 2% per year (HR 1.05, 95% CI 1.002–1.08). Median overall survival was 854 days (95%CI 802-906). The mortality probability density was 18% for women and 27% for men (first 90 days).

Conclusions:

A more significant increase in mortality was observed in men than in women. Institutionalization combined with comorbidities are associated with higher mortality.

Introduction The aim of this study was to examine the prevalence of vitamin D deficiency in elderly patients with fragility fractures of the hip by estimating 25-hydroxyvitamin D levels, whether low levels of Vitamin D at the time of admission affects the functional outcomes and mortality at 28 day and one year. Methods A retrospective study of all the patients admitted with a fracture neck of femur from Jan 2018 to March 2021 was carried out. The data was obtained from NHFD (National Hip Fracture Database) and Medway software. A total of 1221 patients were admitted during this period. Patient demographics including age, sex, fracture pattern, Vitamin D levels at the time of admission, function at 120 days, mortality at one month and one year were calculated. Results Of the 1221 patients, 106 patients did not have the Vit D levels checked at the time of admission. The average age was 81.91 (range-60 to 108). There were 845(70%) females and 376(30%) males. The serum Vit D levels were low in 611(55.3%) patients. The mobility in patients with Vit D deficiency 261(40.9%) has dropped significantly in the 3 months after surgery for fractures of proximal femurs. The 28 day and one year mortality was 6.74% and 30.3% compared to 4.7% and 27.3% for those with low and normal levels of vitamin D respectively. Patients with low Vit D levels at the time of admission with proximal femur fractures has got higher 28 day and one year mortality rates compared to those with normal levels. Conclusion Our study showed that low levels of Vitamin D at the time of admission with proximal femur fractures are associated with poor functional mobility, higher perioperative and one year mortality

Background:

Use of bisphosphonates following NOF fracture in patients over the age of 60 has extensive evidence showing up at a 50% relative reduction in fracture risk. However this is variably recorded on the immediate discharge letter (IDL) and subsequently poorly communicated to Primary Care via the emergency care summary (ECS).

Aim:

To review how often IV Zoledronate is used in hospital, documented in the IDL and on ECS, leading to an improvement of documentation and communication between primary and secondary/tertiary care and therefore the safer management and usage of medicines. Method: Retrospective analysis of inpatient administration of IV Zolendronate and its documentation in the IDL text, medication script and ECS for all patients with hip fracture admitted to RAH in October, November and December 2023. Exclusion criteria were patients who died during admission and those without an IDL completed.

Results:

There were 114 patients who met inclusion criteria. Only 25.4% received IV Zoledronate, 72.4% of these patients had this documented in the IDL text however only 6.9% on the IDL medication script. Where IV Zoledronate was on the medication script there was 100% transfer to a patients ECS.

Conclusion and discussion:

The data highlights that when IV Zoledronate is put on their discharge script this is transferred to ECS by community pharmacists, identifying a key part of the documentation pathway to target. On further review of the data we also looked at reasons why patients were not given IV Zoledronate e.g. CrCl <30, previous bisphosphonate course or alternative drug, pathological fractures and patients referred for dental review, accounting for a large portion of the data set, which going forward are other areas to target to increase use of IV Zoledronate. We have implemented a change and aim to re audit and assess whether this has led to any improvement.

Introduction

Stair falls cause approximately 230,000 injuries and 500 fatalities each year (Roys, 2001). Falls cost the NHS £4.6 million every day (AgeUK, 2010), and approximately £2 billion each year (GOV.UK, 2022), with falls on stairs accounting for the majority of these costs. However, the evidence about how to reduce stair falls is unclear. The aim of this systematic review was to establish which interventions are effective or show greatest potential to improve safety on stairs and reduce falls.

Methods

Five databases were searched: Medline, Scopus, Web of Science, PubMed and CINAHL. Papers were included if they were interventions or provided proof-of-principle to inform an intervention design. Papers were excluded if participants were under the age of 18, or were diagnosed with any clinical condition (disease outside that which we can expect from healthy ageing).

Results

No study reported fall occurrence as an outcome measure. Step-edge highlighters were the only intervention tested in real-world environments, as well as laboratories, and showed good proof of principle, feasibility and acceptability. Five intervention types were found that reduced fall risk in laboratory trials: lighting, horizontal-vertical illusions in ascent, stair dimensions (riser, going and pitch), avoiding multi-tasking and handrail use. These were successful in reducing mechanical demand (reducing or redistributing joint moments) and improving stepping behaviours associated with fall risk (reductions in magnitude and variability of foot clearances and overhang on the step).

Conclusion

This review has established there is no definitive evidence that any intervention reduced fall rates, but that some interventions show good proof-of-principle and feasibility: step-edge highlighters flush to the step edge, increased lighting levels, horizontal-vertical illusions in ascent, use of handrails, avoiding multi-tasking, riser heights 10.2-19cm, going lengths 22.5-32.5cm and reduced pitch angles. Future research must translate these interventions into real world settings and evaluate effectiveness to reduce fall rates.

BACKGROUND

Counter-intuitively, a systematic review identified general walking aid use to be a risk factor for falling; some research even linked falls directly to use of walking aids. Hence walking aids’ effectiveness remains suboptimal. Yet a lack of innovation, especially with regard to indoor walking frames, persists: the front-wheeled Zimmer frame has not changed in design for decades. It was the aim of this work to completely re-think and innovate indoor walking frame design for enhanced user stability and mobility. New features include: 1) swivel wheels at the front to help turning, but which self-align straight during straight line walking, 2) glider feet at the rear to go over thresholds, 3) brakes inside the glider feet to prevent the frame from “running away”.

METHODS

Four proof-of-concept studies investigated the standard versus the new frame design:

Study 1. A gait lab-based study quantified stability (9 healthy older adults, walking repeated trials).

Study 2. A care-home based study investigated unstable usage patterns and body weight transfer (9 older frame users).

Study 3. An interview study investigated perceptions of 7 frame users regarding usability and safety.

Study 4. A clinical trial assessed safety and efficacy of use (10 clinicians, 10 inpatients, 8 outpatients, use of a questionnaire).

RESULTS

The novel frame increased stability during performance of complex everyday tasks (p<0.05). It also facilitated safer usage patterns whilst providing greater and more continuous body weight support. Users found the new design enjoyable; “That’s better than what I am using at the moment” and “I enjoyed using this one {new frame} compared to the other.” and clinicians perceived it to be safe and effective and hence more usable.

CONCLUSIONS

The four studies combined let us conclude that the new frame design is an improvement on the status quo.

Introduction: Turning is essential to mobility, constituting 35-45% of all daily steps. Falls during turning are more severe with 7.9x greater risk of hip fracture. Reduced quality of turning has been observed in people with Parkinson’s disease (PwP). Findings suggest head and trunk control during turning are different in PwP compared to controls, however it is unclear how this relates to clinical measures. Methods: 36 PwP completed an intermittent walking task with 180 degree turns (ICICLE-Gait). An inertial measurement unit attached to the head evaluated head rotations (>30 degrees). Turning features were extracted using a validated algorithm. Spatiotemporal (duration, velocity) and signal-based features reflecting movement intensity (root mean square [RMS] in the mediolateral [ML], anterior-posterior [AP] and vertical [VT] planes from the gyroscope) were extracted. Relationships between turning and clinical measures (Activities of Balance confidence (ABC), Mini Mental State Exam (MMSE), Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) II and III, Levodopa Equivalent Daily Dose (LEDD)) were evaluated using Spearman’s rho. Results: There were 2/6 spatiotemporal and 13/25 signal features with weak-to-moderate correlations with clinical measures. Lower cognition and reduced balance confidence were associated with slower head rotations (rho=0.416-465, p<.05) and lower head movement intensity (lower rms: rho=0.340, p<0.05). higher disease severity (higher mds updrs-ii, iii scores) was associated with slower rotations (rho="-0.322:-0.436," p<0.05) increased ledd greater conclusion: rotation velocity are important features of turning that correlate clinical outcomes relevant in parkinson’s. places a demand on sensory, cognitive motor systems which affected pwp. further analysis will explore whether correlations exist for other segments during (i.e. torso), (such as axial rigidity), gait. 

One in four seniors fall annually, leading to unnecessary hospitalizations and decreased independence, with existing in-person fall prevention programs limited by access, scheduling, and cost. KINIMA Seniors is a newly developed automated interactive exercise and movement app providing real-time visual and audio feedback to assess and reduce risk of falls in seniors, using our proprietary augmented reality motion capture system. KINIMA Seniors introduces an innovative, scalable solution through a mobile app, assessing and reducing fall risks without the need for on-body sensors. It allows seniors to engage in exercises that enhance strength, balance, and gait, displayed alongside a virtual trainer with visual and audio cues for improving physical performance.

Methods:

20 sessions lasting 45 minutes were conducted over 10 weeks in 4 US Senior Centers using the KINIMA Seniors interactive movement platform. During the 1st and last sessions, the KINIMA system's computer vision data capture technology was employed to assess our 4 measures related to the risk of falls, and these measurements were compared with human observer-derived data in both the initial and final assessments. 26 participants completed the sessions with 4 dropouts. Assessment measures were: 1) One-Legged Stance test (left and right), 2) # of Leg Lifts in 30 seconds (left and right), 3) # of Sit to Stand repetitions in 30 seconds, 4) Timed Up and Go.

Results:

This study demonstrated improved fall risk outcomes were achieved in pre/post measures, technical feasibility, likeability of our automated exercise features, and accuracy of automated fall risk measures.

Conclusion:

KINIMA Seniors can deliver a cost-effective and scalable offering for fall prevention targeting enterprises that cater to seniors, such as senior day centers, senior living, and physical therapy. This technology facilitates independent aging in place and also offers a personalized exercise regimen with performance tracking to significantly enhance quality of life. 

Background Osteoporosis is a global health concern that is likely to increase with a rapidly ageing world population. It affects one in three women and one in five men over the age of 50. Although there is a large body of qualitative research exploring the experience of living with osteoporosis, far fewer studies have focused on men. We aim to explore the meaning making processes of men with osteoporosis. Methods We interviewed 13 White British men aged 63 to 94 with an osteoporotic vertebral fracture We used the six stages of reflexive thematic analysis: familiarisation with the data; coding ; generating initial themes; developing and reviewing themes through discussion; refining and naming themes; writing up. Results We developed six themes giving insight into the existential losses of men with osteoporosis: there has been a step changed coming; I am no longer what I once was; the change in me is de-meaning; I want to know where I am heading; I want to know why this happened to me; I want to know what’s wrong and how to fix it? We describe moral narratives used in defence of self. Conclusions Our findings highlight the challenge of deciphering the symptoms of osteoporosis and age-related changes. We also see the impact on self and a struggle to repair self. Healthcare providers are in a unique and privileged position to accompany their patients at points of Existential Crisis. As such, they attend to the repair of both identity and body. This comes with an ethical responsibility and has implications for clinical education. Health professionals should feel equipped to be alongside people facing existential losses. Qualitative Research and can give valuable insight into the phenomenology of illness and contribute to improvements in care pathways.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.