Falls

Background: Idiopathic Parkinson’s disease (IPD) increases fall risk and is associated with osteoporosis and fragility fractures (FF). Despite the high risk of adverse outcomes from untreated osteoporosis in IPD patients, bone health is clinically overlooked. This study aimed to evaluate the adequacy of bone health assessment among Aneurin Bevan University Health Board (ABUHB) patients.
Methods: This observational cohort study retrospectively analysed data from IPD patients at the ABUHB movement disorder clinic, between May 2022 and January 2024. Data collected included: demographics, disease severity, FF, FRAX® score, and bone protection. Clinic letters were also reviewed for mentions of bone health.

Results: The study included 57 patients with a mean age of 78.5 years; 70.2% were male. The mean Charlson Comorbidity Index was 5.1 and the mean Hoen and Yarh score was 2.3. Of these patients, 24.6% had osteopenia/osteoporosis, 36.8% had >0 FF, and 3.5% had fractures before PD diagnosis. The mean time from IPD diagnosis to the first FF was 3 years and 7 months. The mean duration of IPD diagnosis was 5.75 years, with those having FF showing a mean duration of 7.12 years compared to 5.21 years for those without FF. 75% of fractures were major osteoporotic fractures. Bone protection was used by 14% of patients: 100% of high-risk, 21.0% of moderate-risk, and 8.10% of low-risk patients (based on FRAX® scores). Bone health was mentioned in 22.8% of all clinic letters and in 33.3% of letters for those with >0 fragility fractures.
Conclusion: There is a positive correlation between the duration of IPD and the occurrence of  FF. The study highlights a need to improve bone health management in IPD patients, especially those at moderate risk of fractures, as only 21.0% of moderate-risk patients are receiving bone protection. Increased awareness of bone health in this cohort must be promoted.

Introduction

The importance of nutritional support has been extensively investigated in studies of people with hip and fragility fractures. Hospital nutritional assessments vary in quality, and this limits the extent to which risk assessment can be viewed as a meaningful indicator of nutritional support. Provision of supplements is an alternative measure, but only if known to have been consumed. For this reason, we developed a protocol to capture actual consumption of prescribed supplements. Methods Following nutritional risk assessment, the prescription and distribution of supplements was recorded on patients’ drug charts in the usual way. Our protocol required that when supplement cups were cleared, nurses should annotate the drug chart with the volume of supplement each patient had actually consumed. Following this protocol’s introduction, we conducted a point prevalence survey of patients’ supplement consumption in orthogeriatric rehabilitation wards in May 2024.  Results Of 25 inpatients with hip fracture, 21 (84%) had been identified as being at nutritional risk and prescribed Fortisip compact protein. Patients were recorded to have consumed between 50 and 100% of the supplement. This quantification of actual consumption allowed us to calculate that, on average, these patients with hip fracture had consumed an average of 188ml/day — which would provide an additional daily 27.4g of protein and 460 kcal of energy. Figures for 15 patients with other forms of orthopaedic injury indicated that 8 (53%) were at risk. These patients recorded similar levels of supplement consumption. Conclusion The prevalence of nutritional risk and malnutrition among patients with hip fracture would suggest that all should be considered ‘at risk’. A performance indicator might be constructed which starts with this assumption and measures whether such patients have actually consumed nutritional supplements. Our simple approach captures actual consumption, whilst reminding us of the importance of nutrition.

INTRODUCTION

People with Parkinson’s disease (PwPD) often report low levels of physical activity and poor health and 90% of PwPD will fall at least once[1]. Interventions to reduce falls in PwPD often involve physical therapy and exercise, however the environment is an independent risk factor for falls[2]. Exploring whether fall circumstances differ in PwPD due to health status and physical activity level will inform occupational health services and the design and development of environmental modifications.

METHODS

An online survey was developed to evaluate falls in adults ≥60y. Of 358 respondents, 117 were diagnosed with PD. The survey covered basic descriptors, fall history and contextual information about falls. Health (good/ average/ poor) and physical activity (active/ inactive) status were self-reported and used to stratify respondents.

RESULTS

68% of respondents with PD had fallen and of these 90% had poor health or were physically inactive. The 3 most problematic environments (steps/stairs, uneven/sloped surfaces and objects on the floor) and 4 most common pre fall activities (turning, walking, moving too quickly and transferring) were the same regardless of health or physical activity status, although more frequently reported by those with poor health or physically inactive.

Misjudging objects and falling over trip hazards was more common in PwPD of poor health than those of average/good health. Falls on steps and stairs were more common in physically inactive PwPD than those who were physically active.

CONCLUSION

This survey has highlighted several problematic aspects of the home environment contributing to falls in PwPD. Routine person-environment risk assessments are required to identify home hazards early. Research through co-design with PwPD and relevant stakeholders is required to develop novel home modifications targeting problematic environments so interventions may be prescribed effectively.

[1] Allen 2013 PMID:23533953 [2] van der Marck 2014 PMID:24484618

Introduction:

This audit was performed by the Northumbria-Healthcare NHS Foundation Trust (NHFCT) Falls and Syncope Service to inform the development of the NHFCT Integrated Falls Strategy (IFS).

Method:

From the opening of the Northumbria Specialist Emergency Care Hospital (NSECH) on 16/06/2015 all ED records were prospectively screened to identify the first 1000 patients aged 65 years and over that had attended with a fall. The 5-year outcome data was obtained from NHFCT electronic records.

Results:

Of the 1000 attends aged 65 years and over with a fall (13.7 attends daily), 55 were patients who reattended having had a further fall. Index characteristics of 945 fallers include: - 64% female, mean age 81.8+/-8.4 years, 79% resided at home, 47% attended with accidental falls, 26% attended with a fracture, 10% with a hip fracture. 5-year outcome data was available for 870 of 945 patients. Of these 870 patients, 28% died within one year and 64% died within 5 years. Men, those who lived in residential or nursing care, those who’s index fall was associated with a hip fracture, those that were admitted to hospital and those who initially presented with unexplained or recurrent falls were more likely to have died at 30 days, one year and 5 years. Of 870 patients, 51% reattended ED with a further fall (mean 2.4 reattends with a fall) and 17% with a subsequent fracture within 5 years. Women, those who lived in sheltered accommodation and those who initially presented with unexplained or recurrent falls were more likely to reattend with a further fall or fracture.

Conclusion:

If the NHFCT IFS aims to reduce further ED attends with a fall and fractures, then this data suggests that the focus should be on those who present with unexplained or recurrent falls and those who live in sheltered accommodation.

Background:

OPAL Team cares for elderly patients arriving at hospital front door. 80% of referrals to OPAL team are related to Falls. Early assessment and intervention reduce future risk of falls improving health outcomes. OPAL assessment proforma used for falls assessment varies widely depending on local resources. In our trust Multifactorial risk assessment (MFRA) is included in OPAL proforma to assess any patient presenting with a fall or has had two or more falls in the past six months or needs hospitalisation due to fall. Our MFRA includes assessment of Vision, Continence, Cognition, Footwear, Medication review, Lying Standing Blood Pressure (LSBP), Range of Movement (ROM), Strength, Gait, Balance, and Functional assessment.

Methods:

A retrospective review of health records of 100 patients seen by OPAL in June 2022 assessed compliance with MFRA. This revealed 100% compliance in documenting patients falls history but only 20% had vision assessment, 17% Footwear assessment and 40% has LSBP checked. Emphasis on adherence to proforma and regular departmental teaching targeted toward components of MFRA was held every month during this study period (June 2022-June 2023). The retrospective audit was repeated in June 2023 after these interventions.

Result: Visual assessment improved from 20% to 66%, footwear from 17% to 60%, LSBP increased from 40% to 53% but there was decrease in assessment of ROM 67% to 38%, Strength 71% to 44%, and Balance 71% to 60. While other components assessment was around average 75%.

Conclusion: Reduction in some MFRA risk factors is relating to time and space constraints in ED environment. A dedicated OPAL assessment area in ED is anticipated to improve these parameters. Reinforcement in MDT meetings, buddy system for fresh staff and adherence to proforma for documentation will help in achieving 100% in all components.

Introduction:

Inpatient falls are the most common adverse patient safety incidents in hospitals in the UK. The assessment and management following an inpatient fall is often the responsibility of the most junior doctor on call, particularly out of hours. Frequently, there are key omissions in the assessment of these patients, leading to missed diagnoses, poor management and avoidable patient harm. This study aimed to improve the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls.

Method:

31 patients were identified who had suffered ‘severe harm’ following an inpatient fall and a retrospective review of their notes was performed. A preliminary survey on self-perceived confidence levels on different areas of the assessment and management of inpatient falls was distributed to all foundation doctors at Ipswich Hospital. The key themes of the simulation scenario were subsequently determined by the areas of weakness identified in both the survey and documentation review. A total of 9 foundation doctors at Ipswich Hospital participated in a high-fidelity inpatient fall simulation with a patient actor. Pre- and post-simulation knowledge and confidence surveys consisting of ten multiple choice questions and Likert scales respectively were distributed using QR codes.

Results:

Post-simulation confidence levels improved in all domains measured (p < 0.05) with an overall increase in average confidence levels from 3.3/5.0 to 4.3/5.0 (p=0.007). Average post-simulation knowledge score increased from 4.6/10 to 7.4/10 (p= 0.01). Domains in which the greatest improvements in knowledge and confidence were seen included: moving & handling, neurological observations, assessment of suspected hip fractures and escalating concerns.

Conclusion:

The use of simulated patients improves the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls. The pilot project is due to be expanded with plans to incorporate this simulation scenario into the local foundation teaching programme.

Introduction: Concerns about falling (CaF) is a psychosocial concept, precipitating a spiral of increasing inactivity, social isolation and falls, and is common in those who have experienced, or are at risk of, a fall. One method of assessing CaF is the Falls Efficacy Scale International version (FES-I),with previous studies finding associations between higher FES-I scores and poor scoring on commonly used clinical assessments of functional mobility and balance (Gait speed (GS), Timed up and Go test (TUG), and Five time sit to stand (FTSS)). Using the FES-I to predict poor functional mobility and balance has the potential to identify those at risk before an initial fall, at which point an intervention may be provided.

Methods: A prospective study was carried out over 24 weeks, in which 119 participants were recruited from the North Tyneside Community Falls Prevention Service (NTCFPS). Participants completed questionnaires and underwent physical testing whilst attending the falls clinic (baseline) and at week 24, completing bi-weekly falls diaries throughout. Participants were users of the NTCFPS, and residents of North Tyneside.

Results: Findings showed (i) the FES-I had a limited ability to predict poor scores on GS, TUG and FTSS; (ii) attending referred Age UK strength and balance classes was significantly associated with improvements in FES-I score and FTSS; (iii) CaF at the outset of Age UK training was not significantly associated with clinically significant improvements in GS, FTSS and TUG.

Conclusions: Whilst the predictive capabilities of the FES-I were limited, the measure showed an ability to track improvements in participants CaF in the short to medium term. Further work is needed to explore the measures applications within the general population of community dwelling older adults, rather than a cohort of falls service users.

Introduction:

Osteoporosis is a known consequence of stroke, associated with an increased incidence of fractures and leading to further disability. The pattern of bone loss seen in stroke patients is different from that usually seen with postmenopausal osteoporosis. It depends on the degree of paresis, gait disability, and the duration of immobilisation.

Methods:

We retrospectively analyzed data from 20 patients admitted to the stroke ward. All patients with stroke aged more than 65 years were included in the data. Patients who were less than 65 years old, non-stroke patients, and patients who passed away during admission were excluded. Results: Fall risk assessment showed 25% of patients were low risk, 35% were medium risk, and 40% were high risk. Among them, 15% of the patients had a history of osteoporosis. Only 25% of patients had osteoporosis treatment before admission. 15% had a history of vertebral/femoral fracture in the past. We calculated the FRAX score for all patients (low risk in 44%, intermediate risk in 44%, and high risk in 12%). We compared the pre- and post-admission osteoporosis treatment (25% vs. 30%).

Proposed Plan:

Check vitamin D levels for all patients admitted to the stroke ward. Conduct falls risk assessments for all patients. Calculate FRAX scores for all patients under 90 years. Provide osteoporosis treatment if a previous vertebral fracture is found incidentally, unless contraindicated. If creatinine clearance is less than 30%, refer to the fracture liaison service or ask the GP to refer.

Conclusion:

This study highlights the high prevalence of osteoporosis and fall risk among stroke patients, emphasizing the need for routine osteoporosis screening and treatment in this population. Implementing systematic assessments and appropriate interventions can potentially reduce the risk of fractures and improve the overall quality of life for stroke patients.

 Introduction:

Maintaining good postural stability is considered important to prevent falls in the elderly. We evaluated factors associated with good postural stability.

Methods:

We evaluated 33 patients (6 males and 27 females) over 65 years old. The average age was 76.1 years old ranging 65 to 85. We measured Index of Postural Stability(IPS) using gravicoder GW-5000 manufactured by ANIMA. The IPS was advocated by Mochizuki in 2000. It was defined following this equation; IPS=log[(area of stability limit + area of postural sway)/area of postural sway). Larger IPS means better postural stability. The average IPS in each age was already known. IPS was calculated automatically through gravicoda. We divided these patients into two groups by the results of IPS. Group A with the patients whose IPS was larger, Group B with the patients whose IPS was smaller than the average in their age. We compared the following items between the two groups. Functional performance (gait speed, two-step test, one-leg standing test, five-repetition sit-to-stand test, grip strength), body composition (height, weight, BMI, limb circumference, skeletal muscle mass ), spino-pelvic parameters (Pelvic Incidence(PI), Lumbar Lordosis(LL), Pelvic Tilt(PT), Sagittal Vertical Axis (SVA)) using whole spine x-ray photograph.

Results:

Thirteen patients were classified into Group A and 20 patients were into Group B. Gait speed, two-step test, five-repetition sit-to-stand test, one-leg standing test, SVA were significantly different between the two groups. SVA was 6.39±31.0mm in Group A and 50.6±27.5 mm in Group B. SVA of less than 50 mm is known to be an important indicator of good posture.

Conclusion:

The results showed that SVA is related to postural stability as well as gait and balance ability. This suggests that good posture is likely one of the keys to fall prevention.

Introduction

The fall risk factors in older adults living in residential care homes for the elderly (RCHEs) are multifactorial. In Hong Kong, around 9.5% of RCHEs have a fall rate over 30% (Elderly Health Service, 2022)1. The objective of this survey is to identify the common fall risk factors among frequent fallers in RCHEs in biological, environmental, and behavioural domains, based on the World Health Organization (WHO)’s risk factor model for fall (World Health Organization, 2021)2.

Methods

197 frequent fallers from 67 RCHEs with fall prevalence over 30% in Hong Kong were included in this cross-sectional retrospective survey. Twenty fall risk factors in biological, environmental and behavioural domains were investigated through tailor-made questionnaires and staff interviews. The most common fall risk factors, the time period and places of fall of all fallers were identified. The fall management strategy including fall risk assessment and fall incident report of RCHEs were also examined and compared.

Results

In the biological domain, chronic illnesses, decreased mobility, gait instabilities, lack of physical activities and cognitive impairment are the most common fall risk factors. In the behavioural domain, unsafe behaviour such as over-estimation of self-ability and hesitation to seek assistance are the most prevalent. Key environmental fall risk factors include movable furniture and poor lighting. The most common places of falls are bedsides while the peak hours of falls occurs around meal times. Nearly 24% of RCHEs did not perform fall risk assessments for residents.

Conclusions

Behavioural and biological fall risk factors play a more important role than environmental risk factors in these frequent fallers, and many of them are modifiable. Large variations exist in the fall management of different RCHEs. Interventions to prevent falls in RCHEs should target at improving the fall management protocol and addressing the specific fall risk factors of frequent fallers.