Nazia Mumtaz & Sairah Naeem

GPST3’s in General Practice

Tuesday 18th September 2012

Epidemiology Risk assessment Falls assessment Primary prevention Secondary prevention What NICE does/doesn’t recommend Patient education How to refer for falls assessment

The leading cause of mortality resulting from injury in people aged > 75 years

400,000 older people attend A&E each year for falls

14000 die due to osteoporotic hip fractures each year

1 in 3 people > 65 years fall at least once per year

1 in 2 people >80 years fall at least once per year

5% of these need hospitalisation (Royal society for the Prevention of Accidents)

History- how, ?LOC, injuries, pain, loss of function, headache, carers re behaviour, long lie

Examination- temperature, MMSE, bruising, reduced function, confusion, postural BP, pulse, neurology, fundi, vision testing

Investigation- risk factors, bloods (FBC, U&Es, LFTs, TFTs, Vitamin B12, glucose), urinalysis, ECG, ECHO, specialist assessment (optician, neuroimaging etc)

Treat- fractures- Colles’/NOF, subdural haematoma, pneumonia, hypothermia, UTI, dehydration

Referral:

A&E- significant HI, ?fracture, other injuries- lacerations

Acute elderly admission- acute medical cause, unable to cope

Outpatient referral elderly- unclear cause recurrent falls, possibility of further falls, not coping well

Falls history Gait, balance, mobility, muscle weakness Osteoporosis risk Perceived functional ability Fear of falling, perceived functional ability Visual impairment Cognitive impairment Neurological exam Continence Home hazards Cardiovascular exam Medication review

Falls are usually MULTIFACTORIAL

Previous falls Female 2:1 in >75 years Age > 80 years Disorders of gait/balance/co-ordination Visual impairment Cognitive impairment/confusion Low morale/depression High level of dependency with ADLs Reduced mobility Foot problems/inappropriate footwear Arthritis Lower limb weakness Stroke/Parkinson’s Polypharmacy Alcohol Environmental factors Infection Use of walking aids, e.g. Walking stick

Loose rugs/electric leads Wet surfaces- spills, bathroom Poor lighting Ice High winds Use of ladders Too low/too high- chair/bed

Stroke Parkinson’s- abnormal posture, freezing,

frontal impairment, poor leaning balance, leg weakness

Neuropathy- diabetes Proximal myopathy e.g. thyrotoxicosis,

Cushing’s syndrome- esp rising from sitting

Cognitive impairment

Syncope seizures Dizziness Arrythmias

Tachyarhythmias- broad/narrow complex tachycardias

Bradycardias AF

Cardiovascular Carotid sinus disease TIAs Orthostatic hypotension

Psychotropic drugs- phenothiazines, tricyclic antidepressants

Levodopa Bromocriptine Sedatives Diuretics Betablockers ACE inhibitors Alpha blockers Diabetic medications- insulin,

sulphonylureas

Rule out possibility of elder abuse

-what we have just done

Ask elderly people routinely whether they have fallen in last year

Older people reporting a fall or considered at risk of falling

Timed up and go test- ‘rise from chair without support of arms, walk 3 metres, turn around and sit again’. (NB- can use walking stick. Look for

unsteadiness/difficulty)

Turn 180’ test-’stand up and step around until facing the opposite direction’. (NB- further assessment if >4 steps

needed)

What is available???????????

*Multicomponent programmes

According to NICE: Strength and balance training (Tai Chi) Home hazard assessment and

intervention Medication review Cardiac pacing as indicated Visual assessment and referral

Not at all- brisk walking

Insufficient evidence- low intensity exercise + incontinence

programmes group exercise cognitive/behavioural interventions referral for correction of visual impairment

on its ownvitamin D hip protectors

How to cope with a fall What changes are they willing to make? Motivation/fear of falling Measures to prevent falls Preventable nature of some falls Physical/psychological benefits of

modifying risk Further advice and assistance

Falls awareness week (Age UK:18-22 June 2012- http://www.ageuk.org.uk)

Standard 6:

Establishment of MDTs to deal with management of falls

Through district nurses Falls clinics Multidisciplinary falls teams

AKT question Which of the following, on their own, is

recommended by the NICE 2004 guidelines on the assessment and prevention of falls as an intervention?

Brisk walking Referral for correction of visual

impairment Cardiac pacing Group exercise Hip protectors

Patient.co.uk. Prevention of falls in the elderly:http://www.patient.co.uk/doctor/Prevention-of-Falls-in-the-Elderly.htm

NICE clinical guideline 21: The assessment and prevention of falls in older people, November 2004. http://www.nice.org.uk/CG021

Simon C, Everitt H, Van Dorp F. Oxford handbook of general practice, 3rd ed. Oxford. 2010. p210