Falls Specialist Intervention, Referral Pathways & Complex Case Management - AIGNA Masterclass 2016
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Presentation given by Dr Kieran O'Connor, Consultant Physician in Geriatric Medicine, Mercy Hospital, Cork
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Falls Specialist Intervention, Referral Pathways & Complex Case Management - AIGNA Masterclass 2016
- 1. Falls Specialist Intervention, Referral Pathways & Complex Case Management Dr Kieran Anthony O’Connor Consultant Physician in Geriatric Medicine
- 2. What I hope to cover • Introduction – impact of falls • Development of an integrated specialist falls service • Some cases • Falls prevention / assessment “toolkit”
- 3. Geriatric Giants* • Immobility • Incontinence • Instability (Syncope, Falls, Gait & Balance problems) • Intellectual Impairment *Bernard Issacs 1976
- 4. Everyday Story …. • One third of over 65’s fall each year • 15% fall more than once • 10-15% suffer serious injury • Leading cause of accidental death • Accounts for 10% – 20% of all A&E attendances
- 6. One reflects ... • Evidence many falls prevented • Real world often failure to implement • Falls prevention a neglected topic – Lack of clear idea what should be done – Not a priority – Lack of belief in the value of prevention – Daunting training gap Falls
- 9. Local Mapping Exercise • ~ 13,000 people falling in the over 65 age group each year • ~ 2,250 cases ambulance call outs • ~ 15.5% of all ED attendees • ~1000 people aged 65 and over hospitalised with falls and using 21,500 acute bed days • ~500 patients over 65 years admitted with a fall with a fracture Local Falls Services Mapping Exercise 2008 Ageing demography means all this will increase 50% by 2030
- 11. Principles • A whole-system approach to falls prevention & assessment • Timely and seamless transitions of care • Links between community/primary care and secondary care services • Bone health services should be operationally linked • Single point of contact • The assessments should be on a Do Once & Share Basis
- 12. Stepwise implementation Improve outcomes and improve efficiency of care after hip fractures – orthogeriatric services Fall & fracture patients Respond to the first fracture, prevent the second. Screening high risk – Specialist clinic High risk of falls & fractures e.g. non hip fracture # Screening in community & early intervention to restore independence – FRAC & primary screening Individuals with risk factors for further falls Prevent frailty, preserve bone health, reduce accidents. Active healthy later lifeOlder people Dream
- 13. Resilience & Persistence 2007: Falls Mapping Report 2012: Core group 2013: Falls stakeholder workshop 2014: Local falls steering group 2015: FRAC ATC MDT
- 14. Our project • The project has three main work streams: - building community capacity for falls risk assessment - re-engineering specialist falls services to improve access - standardising continuing care assessments and prevention strategies
- 16. Falls Risk Assessment Clinics (FRAC) • 3 clinics set up to date, • 4 by end of 2016, • 6 by end Q1 2017 Falls Risk Assessment Clinic Multidisciplinary (OT, Physio, Nurse) Validated assessment tool Training & coaching Administrative support Standardised documentation I like the fact that its MDT based and that there’s a steering group and that there’s funding, and that there are these things behind it… (health professional)
- 19. Syncope Clinic: complex falls & blackout 0 10 20 30 40 50 60 0 20 40 60 80 100 120 140 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Numberofpatientsseen WaitingTime(days) Number of patients seen Monthly average waiting time Waiting times/Patients seen in specialist syncope clinic (2014-2016) Bandon FRAC MDT assessment Mayfield FRAC
- 20. Integrated Falls Service • GP, ED, • Community Physio/ OT • Public Health Nurse Single Point of Referral Standardised referral form MDT triage meeting Falls Risk Assessment Clinic (FRAC) Community Rehab & Support Team (CR&ST) Specialist MDT Clinic +/- geriatric assessment Syncope Clinic Other specialist clinics & investigation Adults at risk of (recurrent) falls
- 22. Our service will… Improve integration between ED & Urgent care services, community services, GPs and Specialist Falls Service Single point of access Falls Service Office Coordinator based in ATC Standardised referral form Establish 6 new community-based fall risk assessment clinics (FRAC) 4 in Cork city, 2 outlying clinics (North and South of the city). Reengineer Specialist Falls Service Single referral pathway to specialist assessment in the ATC Incorporating existing service strands and a new a rapid access specialist clinic Monitoring and evaluate implementation. Activity metrics: case identification, waiting times for assessment, assessment outcomes/ onward referral Standardise falls management in continuing care Standardised plans & documentation for falls management Implementation lead Routine audit & feedback
- 23. Fall & Fracture At high risk of falls and/or fracture or injury Individuals with some risk factors for further falls Older people Just fallen & injury requiring immediate assistance / hospitalisation Acute or specialist care falls services
- 24. Specialist Falls Service • Complex falls & Blackout Clinic • Syncope testing • Community rehabilitation & Support (CR&ST) • Multidisciplinary assessment • Medical falls clinic • Acute medical unit • In-patient rehabilitation • Bone health
- 25. Specialist Service • Unexplained falls • Recurrent falls despite community management • All fallers that report of loss of consciousness or suspected blackouts • Falls associated with an ongoing medical problem not otherwise being managed • High risk of falling and/or sustaining a fracture
- 27. Weekly MDT
- 28. Integrated Falls Service • GP, ED, • Community Physio/ OT • Public Health Nurse Single Point of Referral Standardised referral form MDT triage meeting Falls Risk Assessment Clinic (FRAC) Community Rehab & Support Team (CR&ST) Specialist MDT Clinic +/- geriatric assessment Syncope Clinic Other specialist clinics & investigation Adults at risk of (recurrent) falls
- 33. “Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk” Morbidity from other causes Additional morbidity from fragility fractures Increasing falls rate Falls & Fractures – A long term condition
- 34. Falling – Visual Representation
- 35. Someone presenting with a fall ...
- 36. Ask Yourself … 1. Is there acute illness • Postural hypotension, dehydration, medication use... 2. Is there impairment or loss of consciousness • Hypotension, cardiac arrhythmias….. • Consider epilepsy 3. Is there impairment of gait or balance • Incorrect sensory input, impaired motor function…... More than one maybe positive Campbell AJ et al, 1995
- 38. Case 1 – 72 yr woman • Found at home on floor by her daughter • Admitted in emergency department by medical SHO • “Poor historian” • Incontinent, no focal neurology • Osteoarthritis, hypertension • Confused, MTS 4/10 • BP 145/84, WCC 6.4, CRP <5 • ECG – Normal sinus rhythm
- 39. Case 1 – 72 yr woman • Initial Diagnosis: – Collapse ? Cause – Possible UTI • Following Day: – More orientated – OT review • Functionally well at baseline • MMSE 19/30
- 40. Case 1 – 72 yr woman • Consult - 2 days later – Orientated MTS 10/10 – 3rd fall / collapse in 3 months – Preceding “dizziness” – One sitting, two standing – Prolonged confusion / amnesia • Diagnosis – Falls with loss of consciousness • Probable Seizures – Cerebrovascular disease – Known hypertension – Post-ictal confusion - improving – No UTI
- 41. Fall
- 42. Lessons • Establish the baseline cognition & function • Categorise falls – aids in diagnostic algorithm • Transient loss of consciousness – not always syncope
- 43. Acute illness & Falls Any condition which decreases “well being”, will increases sway, reduces stability, decreases judgement & compensatory mechanisms and will increases risk of falls
- 44. Case 2 - 84 year old male • Past medical history – Depression – Hypertension • Medications – Amitriptyline 50mg od – Amlodipine 5mg od
- 45. Case 2 - 84 year old male • Waiting to be served in restaurant • Blurred vision, “surreal feeling” • Got up to go outside • Fell, scalp laceration, loss of consciousness • Incontinent of urine • Definite limb jerking for ~ 20 seconds • Regained consciousness after 3 mins, “groggy” • Sat up, glass of water, apologising for commotion • After 20 mins, walked to GP surgery & gave coherent history
- 46. Case 2 - 84 year old male Q.What is the most likely diagnosis?
- 47. Case 2 - 84 year old male Q.What is the most likely diagnosis? A. Vasovagal syncope.
- 48. Fall
- 49. Categories of falls 1. Fall associated with acute illness 2. Fall with impairment or loss of consciousness 3. Fall with impairment of gait or balance Campbell AJ et al, 1995
- 50. Categories of falls 1. Fall associated with acute illness 2. Fall with impairment or loss of consciousness 3. Fall with impairment of gait or balance Campbell AJ et al, 1995
- 51. Impairment or Loss of Consciousness ESC Guidelines on the Management of Syncope. Europace 2004; 6: 467-537 Metabolic disorders hypoglycaemia, hypoxia, hyperventilation with hypocapnia Epilepsy Intoxication / overdose Vertebro-basilar transient ischaemic attack Psychogenic
- 52. Diagnostic plan ... Initial evaluation
- 54. Supine & Erect BP • Have patient rest supine for 5-10 minutes • Check blood pressure supine, ensure BP stable when supine • Once BP stable have patient stand up • Check blood pressure after standing up & then at one, two & three minutes while patient remains standing up
- 55. Summary of Syncope Causes Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 • VVS • CSS • Situational Cough Post- Micturition 2 • Drug-Induced • ANS Failure Primary Secondary 3 • Brady SN Dysfunction AV Block • Tachy VT SVT • Long QT Syndrome 4 • Acute Myocardial Ischemia • Aortic Stenosis • HCM • Pulmonary Hypertension • Aortic Dissection Neurally- Mediated DG Benditt, MD. U of M Cardiac Arrhythmia Center
- 56. Lessons • Vasovagal syncope is most common cause of syncope • Vasovagal syncope is a clinical diagnosis • If there is loss of consciousness, it is not a TIA • Limb jerking & incontinence do not reliably distinguish seizure from syncope • The best discriminating feature between syncope & seizure is the recovery time.
- 57. Case 3 – 84 year woman • Multidisciplinary falls clinic • Recurrent falls – 12-18 mths • “Dizziness” – dysequilibrium • Type II DM ~ 15 years • Osteoarthritis • Hypertension • Multiple medication
- 58. Case 3 – 84 year woman • Comprehensive Assessment – Reduced static & dynamic balance – Berg Balance Score – 34 – Fear of falling – Reduced visual acuity – Reduced contrast sensitivity – Early cataracts – Borderline asymptomatic orthostatic BP drop – Proximal lower limb weakness – Reduced proprioception & vibration sense in feet – MMSE 25/30
- 60. Case 3 – 84 year woman • Recurrent – non-syncopal falls - Multifactorial • Reduced vision - cataracts, diabetic eye disease • Peripheral neuropathy – diabetic • Orthostatic hypotension – autonomic neuropathy • Small vessel cerebrovascular disease – Dysequilebrium – “dizziness” – Reduced cognitive processing • Osteoarthritis • Foot deformity – severe hallux valgus, over-riding toes, claw toes • Proximal myopathy – vitamin D deficiency • Benzodiazepine use • Post fall syndrome - fear of falling
- 61. Categories of Falls 1. Fall associated with acute illness 2. Fall with impairment or loss of consciousness 3. Fall with impairment of gait or balance Campbell AJ et al, 1995
- 62. Fall
- 63. Multimorbidity
- 64. Sensory Input Central processing Effector Response Muscle strength Simplified Approach to Balance
- 65. Lessons • Comprehensive Geriatric Assessment • Problem list – individualised management plan • Multiple diagnosis – the norm • Balance – complex physiology • “Dizziness” – multiple causes
- 66. Case 4 – 74 year man • Attended falls clinic • “Walk has changed” • Recent falls • Good health usually • Unwell, hospitalised 6 months ago • Weight loss associated with EBV infection • Recovering • MMSE 30/30 • No medication
- 67. Case 4 – 74 year man
- 68. Case 4 – 74 year man • Non-syncopal falls– impairment of gait or balance • Left sided foot drop • Left common peroneal nerve palsy – External compression – weight loss – Mononeuritis – EBV
- 69. Lessons • Always watch the person walk • Always watch the person walk • Always watch the person walk
- 70. Walking • “Human walking is a unique activity during which the body step by step, teeters on the brink of catastrophe ….” – J Napier. The Antiquity of human Walking. 1967 • Get Up & Go Test – Sitting in a chair, stand up, walk 3 meters, turn around, walk back, and sit down
- 71. Gait Disturbances • Most gait disorders connected to a variety of underlying disorders • Prevalence: – 10-20% older, non-institutionalized adults – 40% in non-institutionalized ≥ 85yo – 60% in NH residents
- 72. Gait Disorders • Lower Level – Peripheral musculoskeletal problems – Peripheral sensory problems • Middle Level – Hemiplegia – Parkinson’s Disease • Higher Level – Gait Dyspraxia – Ignition, dysequilibrium, mixed – Diffuse central motor & postural issues – Diffuse small vessel cerebrovascular disease
- 74. The toolkit
- 76. Identification - Community • All older persons (aged 65 years and above) should be screened once a year for falls risk • Simple questions to identify those at high risk • Recurrent falls • Single falls with objective gait problems • Subjective gait & balance issues •Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. 2010
- 79. Assessment
- 82. “QuickScreen” - FRAC • Risk factors – Previous falls – Medication – Vision – Peripheral sensation – Balance Reaction Time – Bone health – FRAX • Risk factors – Cognition – Mini Cog – Fear of falling – Environmental Hazards – Nutrition – Continence
- 83. • Unexplained fallers • Falling despite appropriate community management
- 85. Self-assessment
- 88. Syncope testing – very selected
- 94. ED Pathway Patient Information Leaflets Story of my fall QuickScreen Falls Prevention Toolkit Falls - screening Home hazard Screen FRAX – Bone Health Lying & Standing BP Multifactorial assessment
- 95. Thank you • @AgeWellCork • @CorkFallService