This year’s well attended Falls and Postural Stability Conference was held in Wembley, London. BGS member Mary Ni Lochlainn reports back.
The first session at this year’s BGS Falls and Postural Stability Conference was opened by Professor Alice Nieuwbower, from University of Leuven, Belgium, who discussed falls in the context of Parkinson’s Disease (PD).
Patients with PD are twice as likely to fall, compared to healthy older adults. It seems wobbling is a major factor here with ‘sway’ more predictive of falls than ‘gait speed’ in this population. Sway-metrics (probably not as much fun as they sound) show increased sway in patients taking levodopa, leading to a therapeutic challenge for clinicians.
The not-so-sunny world of vitamin D was summarised by Dr. Terry Aspray of University of Newcastle-Upon-Tyne. Research is on-going on the correct thresholds of 25(OH)D, the recommended dose of vitamin D, and whether it should be given with or without calcium. High doses have actually been associated with increased falls and fractures. Interestingly, while vitamin D supplementation increases muscle strength in younger adults, this effect is not seen in studies of older people. We were told 80-90% of vitamin D intake should be from UV-B light and the remainder via dietary intake. Unfortunately, it is unlikely that British weather is satisfying these needs. Is food supplementation the answer?
Professor Dawn Skelton, of Glasgow Caledonian University, argues that we are in the midst of a deconditioning epidemic. Sedentary behaviour is associated with active bone and strength loss and has also been linked to depression. Grant (2010) showed patients in a rehab ward were in an upright position for only 70 minutes a day on average. Can we achieve less sitting?
We all know falls are more common in the winter; I had always attributed this to icy weather. Prof Skelton described a study which looked at the effect of sitting in a cold (15°) and hot (30°) room for 45 minutes. The cold room led to slower walking speed, slower sit-to-stand velocity and decreased muscle power. Older people living in cold homes in the winter will be susceptible to these changes. Sitting in the hot room resulted in a significant rise in blood pressure, increased postural hypotension and shorter 6 minute walk distances. Indeed, many hospital wards and care homes are often too warm and this too may be a contributor to falls.
For the late morning session, the focus was on falls in the cognitively impaired. Dr Jacqui Close, over from University of New South Wales, Australia, described her FOCIS and iFOCIS studies and Professor Rowan Harwood, of Nottingham University, summarised important work in this area such as the FINALEX trial done in Finland. Adherence was an issue throughout, and this was a recurring theme throughout the day. An average of ~50% was cited throughout the sessions. The take home message was that patients with dementia need to be considered as a dyad with their carer. Carers are likely to hold the key to the success of interventions in this population.
The afternoon led on to the choice of four parallel workshops and I attended the ‘Cardiovascular Causes of Falls’ session. Dr Sofie Jansen, of University of Amsterdam, The Netherlands, presented work she carried out during her PhD in Trinity College Dublin, working with The Irish Longitudinal Study of Ireland (TILDA), led by Professor Roseanne Kenny.
Dr Jansen presented a systematic review of the causes of falls as well as two original research papers, sparking hot debate in the audience. Interestingly orthostatic hypotension does not have a robust association with falls in the observational studies reviewed. This was revisited later by Ciaran Finnucane of TILDA, and heterogeneity in study design, definitions and measures used in a limiting factor in this area of research. The research papers focused on atrial fibrillation (AF) and its association with syncope/falls and impaired mobility respectively. In terms of the former, there is an increased prevalence of AF in patients with syncope vs. those without syncope. There is also a less pronounced association with falls. As for AF and impaired mobility, those with AF had slower gait speed and slower ‘timed up and go’ test speeds, even when adjusted for confounders. From age 70 onwards this became statistically significant and the difference widened with increasing age. This association and possible mechanisms of such warrant further research.
A recurring theme in the oral presentations was falls prevention programmes. A Cochrane review on multifactorial interventions to prevent falls showed a dearth of robust evidence and recommended further research. Dr. Anna Barker presented a large Australian randomised controlled trial (RCT) which looked at the 6-Pack Program to decrease fall injuries in acute hospitals. Approximately 40,000 patients were included. A massive change in practice was seen, however there was no effect on falls or on falls injuries. Dr. Julie Whitney described the ProF-Cog study, an RCT aiming to look at multifactorial intervention to prevent falls. Again, the intervention did not reduce falls and it did not improve balance. It seems that researchers will have to head back to the drawing board in terms of these interventions. Indeed Prof Skelton noted one RCT showed a 40% increase in falls following the exercise program so caution is needed in this area!
Going forward, innovative new research is being done such as that in Denmark on the use of a wii board for measuring isometric lower limb strength, as described by Dr. Martin Grønbech Jørgensen. On a European level the Prevention of Falls Network, ProfouND EU, aims to influence policy and increase awareness of falls and innovative prevention strategies amongst all sectors that work with older people.
Dr. Shelagh O’Riordan closed with the final session discussing the National Audit of Inpatient Falls (NAIF), the results of which we will be seeing soon. The results of this audit will tell us the falls per 1000 occupied bed days (OBD). One OBD is one bed occupied at midnight on that day. We will also learn the number of falls resulting in harm per 1000 OBDs. This information, as well as the rest of the data collected, will be invaluable in developing policies and strategies going forward.
The platform prize was awarded to Dr. Yvonne Morrissey for her presentation on the incidence of hypotension in older people on anti-hypertensives, and the poster prize was split between Dr. K. Alpantaki and Dr. A. Winfield for their projects entitled ‘In-Hospital Falls in the Elderly: A Pilot Prospective Study at the University of Crete, Greece’ and ‘Working Across Boundaries to Prevent Falls in Leeds: A Quality Improvement Project’ respectively.
This year’s Falls and Postural Stability Conference was a great success with heated debate, fantastic international speakers, and high quality scientific research. Clearly there is still a lot of work to be done in the management and especially, the prevention of falls.
Next on the BGS agenda is the launch of the Oncogeriatrics Special Interest Group on 18th September 2015 in London, followed by some sea air at the Autumn Meeting 14th-16th October in Brighton. The Autumn meeting this year includes a dedicated joint BGS/AGILE session focusing on orthogeriatrics and fracture management. Watch this space!