The Other “F” Word: Is upstream prevention the way forward for falls?

Steve Parry works in acute medicine and older people’s medicine. He has a special interest in investigation and treatment of falls and blackouts in adult patients of all ages. He is BGS Vice President – Academic and Research.

Since those heady days in the late 90s when our local falls service was started by Rose Anne Kenny, falls services have moved from novelty to mainstream in the UK’s care of older people landscape. But has this service ubiquity made a difference?

Probably. Possibly. Or perhaps not. It’s almost impossible to say. Falls are notoriously poorly recorded and coded, though falls surrogates like hip fracture, the tip of the falls iceberg, provide at least a hard outcome measure universally recorded. Here, however, despite a decade and a half of falls and bone health services, the news is not good.

We talk a lot about delirium after hip fracture, but what can we do about it?

Dr. Susan Freter is an Associate Professor of Medicine at Dalhousie University, and a staff geriatrician at the Nova Scotia Health Authority in Halifax, Canada.  She has a special interest in delirium prevention and management in orthopaedic patients.  

Geriatricians talk a lot about post-operative delirium.  It is common after surgeries, especially in people with a lot of risk factors (or we could say, especially in the presence of frailty), and even with recovery it makes for a bad experience.  The occurrence of hip fracture, which mostly befalls patients who are older and frail, demonstrates this routinely.  We know that taking extra care with at-risk patients can help to prevent delirium.  Taking extra care can manifest in different forms: educating the caregivers, paying attention to hydration (is the patient actually drinking the cup of water that is plonked down in front of them?), paying attention to constipation (preferably before a week has gone by), making sure hearing aids are in the ears, and using medication doses that are geared for frailty, rather than for strapping 20 year olds. But how can what we talk about be translated into what we do? Does the ‘doing’ actually work in practice?

The Importance of Preventing Hip Fractures in Senior Women

Jess Walter is a freelance writer and mother. She loves the freedom that comes with freelance life and the additional time it means she gets to spend with her family and pets.

Hip fractures are tremendously dangerous for seniors, but they can be even more insidious and difficult to prevent in women. This type of injury can very quickly have deadly consequences. You or your loved one may require extensive surgery to repair the damage, and this may lead to a host of long term or even potentially deadly medical complications. These can include an increased chance of acquiring aspiration pneumonia, blood clots on the legs, increased difficulty walking after surgery, infections at the point of surgery, or acquiring a serious, antibiotic resistant hospital infection such as MRSA.

How do geriatricians improve outcomes after hip fracture?

Jenny Neuburger is a Senior Research Analyst at the Nuffield Trust  (@NuffieldTrust) and a Visiting Research Fellow at the London School of Hygiene & Tropical Medicine. She and her co-authors have recently published research in Age and Ageing journal.

We have just published a paper showing that geriatrician involvement in hip fracture care can improve patient outcomes.  Patients treated on wards with higher numbers of geriatrician hours tended to have lower mortality within the 30 days after presentation.

We measured geriatrician hours worked in orthopaedic departments using data collected via the National Hip Fracture Database annual survey each year from 2010 to 2013 for English hospitals.  Over this period, geriatrician hours increased from 1.5 to 4.0 hours per patient, reflecting investments made in response the financial incentives introduced under the Best Practice Tariff scheme.

Hip fracture patients treated at orthogeriatric units received better quality of care and have a lower mortality.

Pia Kjær Kristensen is a PhD student at Aarhus University Denmark. Her study on orthogeriatric care among hip fracture patients is published in Age and Ageing. She tweets at @pia_kjar 

Each year, 70-75,000 older people suffer a hip fracture that requires surgery in the UK. These hip fracture patients have a high risk of in-hospital mortality – a risk that clearly exceeds that of elective total hip replacement even accounting for differences in age, sex and comorbidity.

Who is at greatest risk of dying after a broken hip?

Toby Smith is a Lecturer in Physiotherapy at the Faculty of Medicine and Health Sciences, University of East Anglia. His recent paper published in Age and Ageing has identified those people who are at greatest risk of dying following a broken hip. He tweets at @tobyosmith.

Hip fracture is a major challenge for health services worldwide, and can be catastrophic for the individual who experiences it, in addition to their friends, family and carers. The consequences of a broken hip can range from physical disability through reduced mobility and loss of independence, to death. It has been estimated that approximately 25% to 40% of people following a hip fracture die within the first 12 months after their injury. This has been, in part, attributed to the fact that many of these people are older and have numerous medical conditions which place them at greater risk of death irrespective of their hip fracture.

Given this high risk and the large number of people who experience a hip fracture annually, our team aimed to identify characteristics which could predict who would be at greatest risk of dying following a hip fracture.

NHFD national report shows care for hip fracture patients is improving

The National Hip Fracture Database is a joint venture of the British Geriatrics Society and the British Orthopaedic Association, and is designed to facilitate improvements in the quality and cost effectiveness of hip fracture care.  Follow it on Twitter @NatHipFracData 

Hip fracture is a common, serious and costly injury affecting mainly older people. It usually results from the combination of osteoporosis and a fall from standing height or less.  Care is complex and involves surgical, medical and rehabilitation interventions.

The National Hip Fracture Database 2013 report covers casemix, care and outcomes of 61,508 cases submitted between 1 April 2012 and 31 March 2013 by 180 hospitals in England, Northern Ireland and Wales.

Preventing falls in care homes: a question of balance

Ahead of her session at the BGS Falls and Postural Stability Conference in September, Kate Robertson writes with Alex Macdonald for the Geriatric Medicine blog about falls in care homes.

Falls in older adults are common and the rate is three
times higher in people in care homes than in those living in their own homes. Falls in care homes are associated with considerable mortality and morbidity-hip fractures are significantly more prevalent than in community-dwelling older people, with rates in female care home residents estimated as high as 50.8 hip fractures per 1000 person-years.1

Healthcare professionals come together for the BGS Falls Symposium

We finish our coverage of falls awareness week with a blog by Bryony Elliott, Geriatric Trainee in Nottingham. She tweets at @BryonyBryboss.

On Friday the 7^th June interested health care professionals from around the country assembled at Nottingham City Hospital to learn about Falls. It was the Trent BGS Falls Symposium.

What struck me first was the diverse group of professionals in the lecture theatre. Looking at the delegate list there were consultants and trainees in geriatric medicine, physios, occupational therapists, nurse specialists, and from all across the country too. A variety of people with a lot of enthusiasm, which was great to behold.

All down to numbers?

Dr Frances Healey is a registered nurse who is Associate Director for Patient Safety at NHS England and a Research Associate at Newcastle University. Follow her @FrancesHealey

In our paper in Age and Ageing, Terry Haines and I present findings on the predictive values of the Morse Falls Risk Score, using data drawn from routine clinical practice in an acute hospital setting. However the data were cut, we found no clearly clinically useful predictive values, and the threshold score most commonly used to indicate a patient at risk of falls performed no better than tossing a coin. As we discuss, our findings are not new, but echo a series of studies carried out over the past two decades on all versions of falls risk scores. Concerns about falls risk scores relate not only to their predictive value, but for the potential for scoring to become a substitute for action, for scoring to override common sense, and for scoring to lead to a ‘one size fits all’ approach, despite the differing needs and wishes of individual patients.