(image source: brunelcare.org.uk)

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1 (image source: brunelcare.org.uk)

2 Falls in Older people Sue Bell S.R.N. Cert.Ed. M.Sc. Falls Prevention Project Lead/Practitioner

3 Learning Outcomes In this brief introduction to Falls Management we will explore: the scale of the falls problem how many people fall each day the cost of fractures risk factors which increase the likelihood of a fall assessing people at risk of falls : multifactorial assessment, TUG Test. maintaining balance strength and mobility : current recommendations the Shropshire Falls Prevention and Management Project skills manual handling trainers, activities co-ordinators and senior carers can develop to become actively involved on a daily basis in helping a resident to maintain their mobility

4 The scale of the falls problem : National Facts & Figures(England) 76,000 people fall and fracture a hip in England each year 1 in 3 have a herald fracture first (a previous fracture) 200,000+ other fragility fractures: wrist, pelvis, shoulder 50% lifetime risk of a fragility fracture. (Cost of fragility fracture care: 2 billion yearly) 30% mortality in the year following a hip fracture More women over 50 have a hip fracture than breast cancer Falls are the major reason for hospital attendance and admission, ambulance call out and admission to long term care in England. Falls are estimated to increase by 50% nationally by 2020 (Dept. of Health 2009) call outs in Shropshire last year were to pick people up off the floor

5 Local Figures : Shropshire statistics Shropshire has approximately 63,400 people over 65yrs of age (2011 Census). Telford and Wrekin has 38,000 people over 65 One in 3 people over 65yrs of age will fall each year One in two people over 80 will fall each year In the over 75s, falls are the leading cause of death resulting from injury Over 80 s are more likely to suffer a spine or hip fracture following a fall. Did you know? The County of Shropshire has a HUGE older population - ABOVE NATIONAL AVERAGE

6 The number of falls in hospitals (source: National Patient Safety Agency Rapid Response Report 2011) In Acute Hospitals 208,000 falls per year In Mental Health Units 36,000 falls per year In Community Hospitals 38,000 falls per year. A significant number resulted in severe or moderate injury including: 840 Hip fractures 550 Other types of fracture 30 Intracranial injuries MOST FALLS ARE UNWITNESSED

7 Cost of fractures Hip fracture: 1 every 10 minutes 12-15,000 each Wrist fracture: 1 every 9 minutes each Fragility fractures 2 billion a year Who bears the biggest cost?

8 An older person who has a fall is likely to fall again (image source:

9 Is falling an inevitable part of aging? What do you think? Let s look into why people fall

10 Risk factors for falls Intrinsic factors are those changes within our body which we cannot change, such as the changes associated with the aging process, or chronic illnesses/diseases such as COPD or insulin dependent diabetes. These factors are non-modifiable. Extrinsic factors are those factors within the environment which can be changed or modified, for example a chair obstructing our pathway can be removed, or a doorway made wider. (Some may be non-modifiable, such as removing the upper floor of a care home so people do not have to use stairs or a lift)

11 Any extrinsic risk factors in this picture? (image source: Bing Licensed images)

12 What are the modifiable risk factors in this picture? (image source: Bing Licensed images)

13 Why falls are more common as we age poor leg strength impaired balance acute illness especially infection long term medical conditions diseases/ conditions which affect the nervous system eyesight, hearing and other sensory problems loss of sensation in the extremities nutritional deficiencies resulting in poor bone health side effects from medicines hazards in the environment.

14 Changes to our body Physical Decreased strength, and power Decreased flexibility Reduced mobility Decreased joint mobility Reduced balance (due to changes in muscle tone and power, changes in joints and spine) Reduced endurance e.g. ability to stand or walk for long periods of time Decreased neck mobility Sensory: Eyes and Ears Reduced hearing Deterioration in vision Skeleton Postural changes Gait changes Reduced bone density osteoporosis Muscle wasting : disease or lack of exercise Skin Becomes thinner, prone to bruising and skin tears Heart, Blood Vessels, Lungs Irregular heart beat, heart valve disease Arteries lose elasticity Less able to tolerate fluctuations in blood volume Lung tissue loses elasticity, chest wall more rigid. Kidneys and Bladder Kidney function: not as effective at forming urine Loss of Bladder tone/ increased bladder tone Bowel Less gut motility: Risk of constipation/incontinence Brain Brain shrinks meaning more space to move around within the skull Reduced reaction times Reduced co-ordination Slower at processing information Nervous system Altered sensation

15 Changes in Posture in women are associated with hormonal changes (image source:

16 Loss of height Due to postural changes (image source: As we age we may develop problems associated with discs in the spine (image source:

17 Changes to our bones: Osteoporosis Osteoporosis : a significant reduction in bone mass (density of bone structure). Affects 1 in 2 women. Affects 1 in 5 men over 50yrs old. Almost 50% of all women will experience an osteoporotic fracture by the age of 70yrs. Bones store calcium, deficiency leads to osteoporosis, resulting in loss of bone density and strength. Exposure to sunlight helps calcium absorption from the diet.

18 The Unwanted Effect of Medicines There are a range of medicines commonly prescribed for conditions many elderly people have which are known to increase the risk of falls: Examples are: Risperidone an anti-psychotic, cause slow reflexes, orthostatic hypertension and sedation Mirtazepine an anti-depressant doubles the rate of falling Doxazosin an anti-hypertensive commonly causes SEVERE orthostatic hypertension In addition some drugs can adversely interact with each other Alcohol heightens the effect of medicines And then there s the problem with caffeine

19 The problem with caffeine! Excessive caffeine consumption is known to lead to harmful effects including reduced bone strength and increased blood pressure. Too much caffeine can be risky for the elderly because of the increased threat of osteoporosis, which is marked by brittle bones and spinal problems. Caffeine can lead to dehydration from additional urination, but only if a person consumes more than 500 to 600 milligrams a day (about 5 to 7 cups of coffee). Older adults are more susceptible to fluctuations in body fluids, so dehydration caused by too much caffeine can lead to lightheadedness and potential falls. Caffeine also can make a person jittery, anxious and struggle with sleeplessness.

20 Changes in Gait (i.e the way we walk) For the elderly, walking, standing up from a chair, turning and leaning are necessary for independent mobility Gait speed, chair rise time and the ability to do tandem stance ( i.e standing with one front of the other a measure of balance) are independent predictors of the ability to perform activities of daily living and of the risks of care home admission and death. Walking without assistance requires adequate attention, muscle strength and effective motor control (motor nerves are the nerves which carry messages from the brain telling the muscles to contract enabling us to move ) We also need to co-ordinate sensory information (i.e information we receive from outside our body as well as from the sensory organs such as the eyes and ears) to be able to walk without assistance

21 Gait velocity (i.e how fast we walk) Knowing a person s walking speed can help you determine their current level of mobility, and thus, frailty. Frailty is defined as a group of characteristics - unintentional weight loss, reduced muscle strength reduced gait speed self reported exhaustion and low energy; Individuals with three or more of these characteristics are described as having frailty Speed of walking remains stable until about 70 yrs of age After 70 speed declines at 15% per decade for usual gait, and 20% for fast walking gait. Gait velocity is a powerful predictor of mortality; as powerful as the elderly person s number of chronic medical conditions and number of times admitted to hospital

22 Frailty There are two broad models of frailty. The Phenotype model: In this model frailty is defined as a group of characteristics - unintentional weight loss, reduced muscle strength reduced gait speed self reported exhaustion and low energy; Individuals with three or more of these characteristics are described as having frailty The Cumulative deficit model: In this model assumes an accumulation of deficits ranging from symptoms such as loss of hearing, low mood signs such as tremor through to various diseases such as dementia, which can occur with aging and which combine to increase their frailty index A central feature of physical frailty is loss of skeletal muscle function and in terms of modifiable influences the most studied is physical activity, particularly resistance exercise which is beneficial in terms of treatment and porevention of the physical performance component of frailty.

23 Risk Factor Assessment Multifactorial assessment undertaken with the person at risk of falling or who has had a fall, is recommended best practice ( Frase : Falls Risk Assessment Tool for the Elderly is now obsolete) Multifactorial assessment includes: falls history assessment of gait, balance and mobility, and muscle weakness assessment of osteoporosis risk assessment of the older person's perceived functional ability and fear relating to falling assessment of visual impairment assessment of cognitive impairment and neurological examination assessment of urinary incontinence assessment of home/ environmental hazards cardiovascular examination and medication review Multifactorial interventions discussed with the person are the basis of a person centred care plan

24 Now we know the scale, causes and risk factors for falls, what can be done about it

25 1) The Falls Prevention & Management Project SPIC received a 12 months grant from Shropshire Clinical Commissioning Group (CCG) and Shropshire Council to deliver Falls Prevention & Management Training and support the implementation of Falls Prevention and management Strategies in Shropshire Care Homes. The funding enabled SPIC to appoint a Falls Prevention Project Lead/Practitioner to provide on-going training and if requested post training visits to care homes to support staff implementing the project in their care home.

26 2) Providing training and support to care homes Previously one day training sessions held at SPIC were delivered by a physiotherapist from the Shropshire Community Health Falls Prevention Service which does not offer Falls Services to Care Homes Now, to meet specific needs, there are two days: one for managers one for nurses, care staff and falls champions (who implement the project into the home on behalf of the manager) Post training visits to care homes (on request) Refresher days to revisit previous learning and keep up with new developments

27 3) Improving assessment and record keeping The Shropshire Falls Bundle includes specific documents for Pre admission falls assessment Multifactorial Risk Factor Assessment Post Fall Flow chart to aid decision making Post fall incident form to improve record keeping Head injury guidance to assist decision making and head injury observation record Feedback from Shropdoc is that the quality of information provided to them by staff using these documents is more specific and meaningful and aids their decision making Collecting falls data and providing quarterly progress reports to the CCG to demonstrate the impact this project is having on the incidence of falls in Care Homes.

28 4) Assessing the impact of the project The project is funded by the CCG To demonstrate the impact this project is having on the incidence of falls in Care Homes SPIC are required to collect the number of falls (and other information) which have occurred in individual As part of the funding agreement SPIC are required to collect the number of falls (and other information) which have occurred in individual care homes over a three month period and provide a report to the CCG (care homes are NOT named in the report) The next report is due to be submitted in January 2017

29 Ambulance Service Data In 2015/16 full year: 357 ambulance calls to care homes and 238 conveyances to Hospital. From April to Oct 2016: 17 ambulance calls to care homes and 6 conveyances to Hospital Meaning 95% reduction in ambulance calls for falls 98% reduction in conveyances to hospital by ambulance for falls However, we are not yet aware if the training has accounted for this through increased knowledge, or whether the ambulance data collection method has changed.

30 What you can do to help : Physical activity & Exercise for residents in care homes The Chief Medical Officer has issued guidance relating to physical activity and exercise for older people. The recommendations are 150 minutes per week at moderate intensity, and can be performed in 10 minute bouts PLUS specific strength and balance exercises on two days per week. The type of physical activity should be focused on improving muscle strength and balance. This is where Manual Handling trainers and Activities co-ordinators can get involved in maintaining a person s level of mobility and balance through: Carrying out tug tests Supporting a person through their daily strength and balance exercise routines

31 The TUG test! The timed Up and Go test ( TUG test) is a simple effective way to assess a person s current level of mobility. The test involves timing, and observing a person from the starting point of sitting in a chair, rising unaided, walking a pre-determined distance without physical assistance from another person (however, the person can use a walking cane or frame if they usually do) and returning to a sitting position. The test can be repeated regularly to determine if the person s mobility level is increasing, decreasing, or has stayed the same. Minimal equipment is require: arm chair, tape measure, tape to mark the floor at determined distance, stop watch, record chart *** The test is not recommended for individuals with hypotension/orthostatic hypotension.

32 The assessment : Timed Up and Go No special training required enables you to determine the person s walking speed and level of mobility can be used as part of the assessment process when assessing a potential new resident. and to assess current level of mobility should always be carried out prior to the person participating in exercise programs is not recommended for a person with known postural hypotension

33 How to determine a person s current mobility level (image source: www,pinterest.com) The TUG Test: Takes less than 3 minutes to do Requires a chair, a stopwatch, a measured distance of 3 metres and a recording/scoring chart The results tell you the person s current mobility level From this you need to plan how you can maintain or improve

34 And finally. The TUG Test : Three training dates are available for those who are qualified Manual Handling Trainers, Activities Co-ordinators and Senior Carers: Tuesday 14 th February pm, Tuesday 28 th February pm Tuesday 14 th March pm. Contact Sophie Price for a booking form: Tel: The aim is to develop skills to: be able to carry out the Test to assess a person s current mobility level develop observation skills while the person is doing the test & record findings identify what daily mobility strategies and exercise routines can be introduced for the individual to maintain or improve their current level of mobility work with individual residents on a daily basis in accordance with current exercise recommendations