Falls

Introduction:

Dizziness and vestibular symptoms are common in older adults. However, many older adults do not seek assistance for these symptoms. This study set out to explore the barriers and enabling factors to accessing healthcare in this population.

Method:

Semi-structured, one to one interviews were undertaken via video conference. Older adults (≥65 years old) were recruited organisations that support older adults, via purposeful sampling to recruit participants with a range of severity of vestibular symptoms (measured using the dizziness handicap inventory) alongside those who had and hadn’t sought help for their symptoms. Data was analysed using a reflective thematic analysis approach. Findings: 16 older adults (Mean age 74) were interviewed via zoom. The majority were female (76.5%) and White British (88.3%). The following themes were identified in the data set. 1) “Sometimes I feel dizzy if the vertigo is really bad” This theme describes the challenges with describing dizziness and vertigo, alongside the range of presentations experienced by participants. 2) Accessing Healthcare: This broad theme describes a range of personal and systemic barriers that participants experienced when accessing healthcare for their vestibular symptoms. This theme has been split into subthemes exploring the personal, service level and health professional barriers experienced by participants

Conclusion:

This study has highlighted that dizziness and vertigo are ambiguous terms and therefore clear communication is needed to ensure a shared understanding between health professionals and older adults. Barriers to healthcare exist at a personal, service level and health professional level for this population. Further work is needed to break down these barriers and improve access to healthcare for this population.

Introduction

Falls in older people are common and can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken by organisations to prevent deaths, but dissemination of the findings from these Prevent Future Deaths (PFD) reports remains poor, limiting their possibility to effect change. We set out to identify preventable fall-related deaths, classify coroners’ concerns, and explore organisational responses to these deaths.

Methods

A protocol for a retrospective case series of fall-related PFDs was pre-registered. A novel, openly available, computer code was created to download and read PFDs from the Courts and Tribunals Judiciary website from July 2013 to November 2022. Demographic information, coroners’ concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data.

Results

527 PFD cases (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (71%). A high proportion of cases experienced fractures, major bleeding, or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations most commonly produced new protocols, improved training, and commenced audits in response to PFDs.

Conclusion(s)

One in eight preventable deaths reported in England and Wales involved a fall. Adequately addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken at the local level. Wider dissemination and learning from PFD findings may help reduce preventable fall-related deaths nationally.

INTRODUCTION: In order to improve resident safety and reduce hospital admissions, the ‘Optimizing Bed Height Quality Improvement Study’ aims to raise awareness among healthcare professionals about the importance of ensuring optimal bed height to prevent falls and injuries in residents and to improve bed mobility.

The parameters from a 2015 study, ‘Analysis of the Influence of Hospital Bed Height on Kinematic Parameters Associated with Patient Falls During Egress', are taken into account when using intervention techniques.

METHODS: Residents aged 65 or over falling out of bed between January and June of 2022 were used as a pre-test measure. By maintaining a hip or knee angle just above 90 degrees, keeping the resident's feet flat on the floor, and ensuring that they can easily transition from sitting to standing and vice versa, the nurse and physiotherapist assessed the resident's mobility and determined the height of the resident's bed. An illustration of the ideal height is displayed on a poster that hangs on the wall above the headboard of the bed. Nurses visit each resident's room each day to ensure that the beds were in the ideal position and record this information in the monitoring system. The data obtained during the six-month period of intervention (July to December 2022) was compared with the pre-test results.

RESULTS: Results from a six-month intervention period (July to December 2022) were compared to those from a six-month pre-intervention phase (January to June 2022) with fourteen bed falls, there was a FIFTY PERCENT decrease in bed falls.

CONCLUSION: After a six-month clinical trial, the study revealed that older adults who had bed falls and trouble getting out of their beds had lower fall rates, suggesting that stakeholders' knowledge of the ideal bed height had increased.

Introduction: In the current European guidelines, sarcopenia is diagnosed on the basis of low muscle strength, with low muscle mass used to confirm diagnosis. The added value of measuring muscle mass is unclear. We performed a systematic review to assess whether muscle mass was independently associated with adverse outcomes in patients with hip fracture.

Method: The systematic review protocol was registered on the PROSPERO database (CRD42021274981). Electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL, Clinicaltrials.gov) were searched for observational studies of patients with hip fracture aged ≥60 who had muscle mass or strength assessment perioperatively. Two reviewers independently screened titles/abstracts for inclusion. The association of muscle mass or strength with postoperative outcomes (mortality, Barthel Index, mobility, physical performance measures, length of stay, complications) was recorded. Risk-of-bias was assessed using the AXIS or ROBINS-I tool as appropriate. Due to the degree of study heterogeneity, data were analysed by narrative synthesis.

Results: The search strategy identified 3,007 records. Ten studies were included (n=2281 participants), containing 27 associations between muscle mass assessment and hip fracture postoperative outcomes. Four studies had intermediate risk of bias; 6 studies had high risk of bias. Lower muscle mass was associated with higher mortality and worse physical performance measures in univariate analyses but there was no significant association between muscle mass and mobility, length of stay and postoperative complication scores in any included study. Six studies assessed both muscle mass and strength. Muscle mass was not a significant independent predictor of any adverse outcome in any included study after adjustment for muscle strength and other predictor variables.

Conclusion: Data on the clinical utility of muscle mass measurement in patients with hip fracture are limited in volume and quality, but available studies suggest muscle mass does not offer additional prognostic benefit to muscle strength measures.

INTRODUCTION   

Postural hypotension (PH) is an identifiable and potentially reversible cause of falls in elderly patients. The National Audit of Inpatient Falls recommends lying and standing blood pressure (LSBP) measurement for patients aged over 65. Our project aims to review current clinical practice and to develop a standardised approach to correctly investigate and manage PH in patients admitted following a fall to the geriatric department.  

METHOD:   

We performed two cycles of retrospective data collection across three geriatric wards, looking at percentage of patients investigated for PH and the use of correct technique for LSBP measurements as recommended by the Royal College of Physicians (RCP) guidelines. Between cycles, formal and informal educational strategies were implemented and the RCP LSBP measurement guidelines were displayed on doctors’ noticeboards and blood pressure monitoring devices. A PH sticker was designed to ensure correct technique was used and documented.  

RESULTS:    

Following the interventions, the percentage of patients who had LSBP measurements performed improved from 28% to 96% [p<.00001(x2 test)]. Introduction of the PH stickers improved use of correct technique from 12% to 37.5%. Performance and documentation of medication reviews for patients diagnosed with postural hypotension improved from 0% to 87.5% and lifestyle advice given and documented improved from 0 to 37.5%. 

CONCLUSIONS: 

Our study highlighted the need for further training on investigation and management of PH. Our results demonstrate that educational interventions and a standardised sticker to ensure clear documentation can significantly improve diagnosis of PH. The local Falls Prevention team are keen to promote use of the sticker across the Trust and we have produced patient information leaflets to ensure all patients receive lifestyle advice.

Introduction Predicting outcomes after hip fracture is important for identifying high-risk patients who may benefit from additional care and rehabilitation. Pre-operative scores based on patient characteristics are commonly used to predict hip fracture outcomes. Mobility, an indicator of pre-operative function, has been neglected as a potential predictor. We assessed the ability of pre-fracture mobility to predict post-operative outcomes following hip fracture surgery.

Methods We analysed prospectively collected data from hip fracture surgery patients at a large-volume trauma unit. Mobility was classified into four groups. Post-operative outcomes studied were mortality and residence at 30-days, medical complications within 30- or 60-days post-operatively, and prolonged length of stay (LOS, ≥28 days). We performed multivariate regression analyses adjusting for age and sex to assess the discriminative ability of the Nottingham Hip Fracture Score (NHFS), with and without mobility, for predicting outcomes using the area under the receiver operating characteristic curve (AUROC).

Results 1919 patients were included, mean age 82.6 (SD 8.2); 1357 (70.7%) were women. Multivariate analysis demonstrated patients with worse mobility had a 1.7-5.5-fold higher 30-day mortality (p≤0.001), and 1.9-3.2-fold higher likelihood of prolonged LOS (p≤0.001). Worse mobility was associated with a 2.3-3.8-fold higher likelihood of living in a care home at 30-days post-operatively (p<.001) and a 1.3-2.0-fold higher likelihood of complications within 30-days (p≤0.001). addition mobility improved nhfs discrimination for discharge location, auroc 0.755 [0.733-0.777] to nhfs+mobility 0.808 [0.789–0.828], los, 0.584 [0.557-0.611] 0.616 [0.590–0.643].

Conclusions incorporating assessment into risk scores may improve casemix adjustment, prognostication following hip fracture, identify high-risk groups requiring enhanced pre, peri post-operative care at admission. this implies that information available admission could facilitate prognostication, planning, bed management aversion, as well informing discussions between clinical teams patients about recovery.

Delirium in hip fracture patients admitted from home is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation and readmission to acute services: The IMPACT Delirium study

RS Penfold1,2, AJ Hall2,3,4, A Anand5, ND Clement2,4, AD Duckworth4,6, AMJ MacLullich1,2

1. Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK 

2. Scottish Hip Fracture Audit, Edinburgh, UK 

3. Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK 

4. Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK 

5. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK 

6. Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK 

Aim 

Delirium is associated with adverse outcomes following hip fracture, but specific associations in patients admitted directly from home are less well studied. Here we analysed relationships between delirium in patients admitted from home with: (i) mortality; (ii) total length of hospital stay; (iii) need for post-acute inpatient rehabilitation, and (iv) hospital readmission within 180 days. 

Methods 

This study utilised routine clinical data in a consecutive sample of hip fracture patients aged ≥50 years admitted to a single large trauma centre between 01/03/20-30/11/21. Delirium was prospectively assessed as part of routine care by the 4’A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, level of social deprivation, and American Society of Anesthesiologists grade.  

Results 

A total of 1821 patients (mean age 80.7 years; 71.7% female) were admitted, with 1383 (mean age 79.5; 72.1% female) directly from home. 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1734): 14.1% (189/1340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20 day longer total length of stay (p<0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (Odds Ratio (OR) 1.69, 95% Confidence Interval (CI) 1.13-2.54; p=0.013), requirement for post-acute inpatient rehabilitation (OR 2.82, CI 1.99-4.00; p<0.001), and readmission to hospital within 180 days (OR 1.77, CI 1.01-3.11; p=0.046). 

Conclusions 

Delirium affects 1 in 7 patients with a hip fracture admitted directly from home and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. 

Background: Foot pain in older adults may reduce physical activity, resulting in impaired mobility and an increased risk of falls. Orthotics, both with and without a metatarsal pad, may provide foot pain relief and improved stability. Objective: Compare the use of Aetrex orthotics with and without a metatarsal pad in decreasing pain and fear of falling in older adults. Methods: 206 participants over 60 years old were randomised into the intervention group, who received Aetrex L2305 Orthotics with a metatarsal pad, or the control group, who received Aetrex L2300 Orthotics with no metatarsal pad. At baseline and 6-week follow-up, musculoskeletal pain was reported via Numerical Rating Scales (NRS), foot pain and functionality via the Foot Health Status Questionnaire (FHSQ), and fear of falling via the Short Falls Efficacy Scale International. Results: Both groups reported significant improvements in pain in the back, hips, knees, ankles, and feet using the NRS (P < 0.001). Using the FHSQ, foot pain significantly improved in both the intervention (x̄= 18.47 ±20.58, P < 0.001) and control group (x̄= 17.21 ±18.74, P < 0.001). Function also improved significantly in both groups (x̄= 18.35 ±20.67, P < 0.001 and x̄ = 15.07 ±20.15, P < 0.001, respectively), as did fear of falling (x̄= 1.55 ±3.79, P < 0.001 and x̄= 1.23 ±3.53, P < 0.001, respectively). No statistically significant difference was observed between groups for any outcome (P > 0.05). Conclusion: Aetrex orthotics, with and without metatarsal pads, decrease pain and fear of falling in older adults.

Introduction Type 2 diabetes mellitus (T2D) is associated with poor health outcomes and tight glycaemic targets are questionable in those aged over 70 years. Methods The Older Persons Assessment Service (OPAS) is a local emergency department service which accepts patients on frailty criteria. The OPAS databank was retrospectively analysed for people with T2D admitted with a fall between June 2020-September 2022. We examined clinical outcomes relating to medication, age, Charlson co-morbidity index (CCI) and clinical frailty score (CFS). Results 1081 patients were included: 294 (27.2%) with T2D and a mean HbA1c of 53.9 (±15.8) mmol/mol [7.1%]. People with T2D had a similar mean CFS and age compared to those without T2D, but higher mean CCI (7.0±2.2 vs 5.9±2.1, p001 of those people with t2d, 175 (59.5%) and 240 (81.6%) had a hba1c ≤53 mmol />mol [7.0%] and ≤64 mmol/mol [8.0%], respectively. In total, 48 (16.3%) people with T2D were identified to have a capillary blood glucose below 4.0 mmol/L on admission to the emergency department. People with T2D treated with insulin and/or gliclazide had a greater mortality (36.6% vs 23.6%, p05 greater frequency of hypoglycaemia (35.4% vs 11.8%, p0.001), and hba1c (65.5±17.2 mmol />mol [8.2] vs 48.9±12.1 mmol/mol [6.6%]) compared to those who used other agents. People with T2D were not more likely to live in deprived areas. Conclusion Falls are a significant burden, and hypoglycaemia-inducing agents may contribute to the greater mortality observed in people with T2D. People with T2D had a similar CFS, were more likely to be male, prescribed more concomitant medicines and have greater deprivation. Clinician awareness can support de-prescribing for frail patients with HbA1c less than 64mmol/mol. There should be increased awareness of the impact of hypoglycaemia, especially in those using insulin or gliclizade.

Introduction: In Scotland, more than 18,000 older people are admitted to hospital after a fall each year. One in three people over the age of 65 experience a fall at least once each year (1). Neurological examination is an essential part of the initial assessment of these patients in hospital and can determine the cause of falls such as stroke, peripheral neuropathies and Parkinson’s disease. Local anecdotal evidence suggested that this was often not carried out, with the potential for delayed diagnosis and treatment.

Method: Baseline data was collected from clinical notes of admissions to the care of the elderly (COTE) wards at University Hospital Hairmyres (UHH) over a 1-month period. Multiple departmental education sessions were arranged to highlight to medical staff the importance of neurological examination in patients presenting to hospital following a fall. Following these sessions the data collection cycle was repeated. A poster has now been designed highlighting common causes of falls and in particular emphasising the importance of performing a neurological examination, with a further cycle of data collection planned.

Results: 36.8% of patients admitted to COTE wards in August 2022 were admitted with falls, with only 23% of patients having a neurological exam documented on admission. Following the initial intervention, 30 patients’ notes were reviewed in January 2023. 56.7% of patients were admitted with falls and frequency of documented neurological examination had increased to 58.8%.

Conclusion: Educational sessions resulted in a 156% increase in documented neurological examinations for patients admitted with falls. We hope this improvement will lead to earlier identification of causes of patients’ falls, allowing prompt management. Our project is ongoing, with planned implementation of posters as a secondary intervention, with further data collection in due course.

References: 1. NHS Inform. Why Falls Matter. Available from: https://www.nhsinform.scot/healthyliving/preventing-falls/why-falls-mat… (accessed 27 November 2022)