Falls, fracture
prevention and
bone health
Jane Reddaway
(Falls prevention lead TCT)
Fracture Prevention
Osteoporosis
To achieve
Fracture
Reduction
Falls
Force
What is a fall?
‘Unexpected event in which the
participant comes to rest on
the ground, floor or other lower
level than intended’
(Lamb et al 2005)
• Includes falling out of bed or a chair, slipping in
the bath.
• Excludes tripping and correcting self, banging
into a wall, being pushed or knocked over, lying
on floor intentionally.
Falls Guidance
• National Service Framework for Older People (2001)
• AGS/BGS Guidelines (2010)
• NICE Guidance: Falls (2004)
• NICE Guidance: Osteoporosis (2004)
• RCP National Audit for falls and bone health 2006
• NPSA slips trips and falls in hospital 2007
• WHO global report on falls prevention 2007
• SW Strategic Health Authority ambitions 2009
Categories of Falls
• Explained fall:
a simple slip or trip
• Explained loss of consciousness (LOC):
When the diagnosis of LOC is made at the time
of the fall or within 7 days. ie MI, CVE.
• Unexplained LOC:
No cause found even after routine assessment
and investigations
Unexplained fall / Recurrent falls:
no apparent cause or explanation for the fall
Identify risk factors:
Personal and/or Environmental
Can be summarised as:
D.A.M.E
DRUGS
AGEING
MEDICAL CONDITIONS
ENVIRONMENTAL
Drugs:
• Side effects/out of date drugs
• Poly-pharmacy (more than 4
medications)
• Culprit groups: sedatives, diuretics, antihypertensives, hypnotics, antidepressants, and
benzodiazepines
• Alcohol/recreational drugs
• Compliance/over dosing
• Alternative therapies
Ageing:
• Impaired vision
• Hearing/vestibular problems
• Reduced strength, balance, gait, bone
density
• Cognitive impairment, dependence
• Housing type, living alone,
bereavement
• Fear of falling/reduced confidence
Medical Conditions:
• CVE/TIA (stroke), Parkinson’s disease, epilepsy,
dementia
• Cardiac arrythmias, myocardial infarction (heart
attack), chronic heart failure, postural hypotension
• Arthritis, osteoporosis
• Incontinence, alcoholism
• Infection (chest/UTI etc)
• Diabetes, hypothyroid
• Dehydration
Environmental Hazards:
• Lighting full spectrum light • Inaccessible lights,
bulbs
windows, sockets
• Stairs
• Pets, clutter
• Loose carpets, rugs,
• Weather
slippery floors
• Unfamiliar
• Ill-fitting footwear
environment
• Lack of safety
• Other people
equipment or
• Uneven surfaces
adaptations in the
home.
Instant
Ageing
Interventions that
demonstrate good evidence
• Exercise programme - Balance, gait and
lower limb strength training-either 1:1 or
group(A)
• Minimise use of Psychoactive medication(B)
• Reduce total no. of meds(B)
• Expedite cataract surgery (B)
• Vit D supplements<800IU/day for proven Vit
D deficiency (A)
• Home environment interventions (A)
AGS/BGS 2010
Osteoporosis
Normal bone
Osteoporotic bone
Osteoporosis literally means
“porous bones”
What are the risk factors
for osteoporosis?
• Low trauma fracture.
• Oral steroid exposure
(any dose for > 3/12).
• Hysterectomy or
premature menopause
< 45 years of age.
• Amenorrhoea > 1 year
• Family history of hip
fracture.
• Anti-convulsants
• Some medical
conditions eg.
malabsorption of
calcium,
hypogonadism.
• Low BMI <19kg/m2
• Kyphosis
• X ray evidence of
vertebral deformity or
osteopenia
Calcium & Vitamin D
Supplementation
• 37% of older people in institutional care are vitamin
D deficient
• High dose calcium and vitamin D prevents hip
fracture in institutionalised elderly people by up to
43%
• Reduces body sway and improves balance
• Available as a sachet dissolved in water
Calcichew D3, Caplet; Calfovit, drink once daily,
Cacit D3 2 x daily drink or a chewable tablet, Adcal
D3 1 tablet twice daily (Ask GP for alternative if non-compliant)
• Few side effects – mainly gastrointestinal.
Fracture Prevention
•Diet
•5 a day fruit and veg
•1200 mg calcium
•800iu Vitamin D
•Avoid fizzy drinks, caffeine and excess alcohol
•Exercise
•Bone loading
•Strength training
•Site specific (hip/wrist/spine)
•Avoid smoking
•Plus falls prevention strategies
This healthy
tortoise had a
well balanced,
calcium rich
diet
This tortoise was
raised on a high
protein, calcium
deficient diet. This is
a terrible example of
poor diet resulting in
extreme deformity.
Fragility fracture through the life span1
Osteoporosis + falls = fragility fractures
Additional
morbidity
from fragility
fractures
Morbidity
from other
causes
“Hip fracture is all too often the final destination of a 30 year journey
fuelled by decreasing bone strength and increasing falls risk”2
1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell
2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ
The Falls register
Benefits
• Identifies those at risk (3/3+)
• Informs the GP surgery their patient
has had a fall.
• Should lead to further assessment if at
risk
Falls Pathway
Complete the Falls register
01803 219700
Including falls risk assessment (FRAT) tool
PARIS (IT system for Torbay Care Trust) holds the
falls register and will send the details to the GP
practice
(proforma emails Hdrive/useful resources/forms_templates/falls)
The GP practice should ‘Read Code’ the
fall: 16D
Falls Risk Assessment Tool (FRAT)
1*
Ask the person is there a history of any fall in the previous year (include
this fall)?
Number of falls in previous 12 months =
2
Is the patient/client on four or more medications per day?
Identify number of prescribed medications.
3
Does the patient/client have a diagnosis of stroke or Parkinson’s Disease?
4
Does the patient/client report any problems with their balance?
5
Is the patient/client unable to rise from a chair of knee height?
Ask the person to stand up from the chair of knee height without using
their arms/ask person to describe how they rise from the chair
YES
*If the answer is YES to question 1 complete falls register
3 or more positive (YES) responses = at risk of falls
If scores >3: complete falls register if not already done and carry out a
personal and environmental (multifactorial) risk assessment
If scores <3 suggest: giving patient information on falls prevention
Telephone the falls register to report each fall:
01803 219700
NO
What should happen next?
If low risk:
scores <3 on
FRAT : send
‘Staying Steady’
falls prevention
leaflet
If at risk: scores >3
on FRAT: Should
lead to further
assessment:
Multifactorial falls assessment
Falls In Hospital
NSPA 2007 identified the following risks as most
significant in hospital:
• Walking unsteadily
• Being confused
• Being incontinent/needing the toilet
frequently
• Previous falls
• Taking sedatives
Falls the Future
Falls, fracture prevention and bone
health clinical commissioning
group
If you would like to join the falls special
interest group that meets quarterly email
your details to jane.reddaway@nhs.net
Useful Contacts
• Chris Dixon, Lead Nurse, Osteoporosis.
Tel: 01803 655603
chris.dixon2@nhs.net
• Jane Reddaway, Lead OT,
Osteoporosis/Falls. Tel: 07776 207358
Jane.reddaway@nhs.net
Map Of Medicine
• The national falls care pathway is
available to you on the internet
http://www.mapofmedicine.com
This outlines the evidence behind falls
interventions and what effective
interventions can be employed to modify
falls risks
Resources
• NSF for Older People, Standard Six Falls
(www.doh.gov.uk)
• National Osteoporosis Society
(www.nos.org.uk)
• Age UK (previously Help the Aged and Age Concern)
(www.ageuk.org.uk)
• Nice guidelines for Falls
(www.nice.org.uk)
• Hip protectors:
– Promedics
01254 619000
– BSN medical
01482 670100
email: orders.uk@bsnmedical.com
– Win Health
01835 864866
Measuring Postural Drop
• Lie patient flat for 5 minutes (in silence)
then take blood pressure (BP)
• Stand patient and repeating BP
• Repeat at 3 minutes
Orthostatic hypotension- systolic fall more that
20mmHg, diastolic more than 10mmHg
Resources
• National Patient Safety Agency
www.npsa.nhs.uk
• Royal College of Physicians National Audit
for falls and bone health 2006
www.rcplondon.ac.uk.
Leaflets for service users
• Torbay Active Ageing leaflet 01803 208840
• What is Postural Hypotension? 01803 219745
• Having Falls?
01803 219745
Exercise Resources
Age UK DVDs –’Be Strong, Be Steady’
‘Step to the Future’
£12 each + p&p
www.ageuk.org.uk
Thank you
Any questions?