Kawa AminConsultant Geriatrician HMC

Falls Assessment

Disclosures

I have no conflict of interest or disclosure in relation to this

presentation

Learning Objectives

NICE March 2015 QS86

Inpatient falls bundle

Complaint NICE June 2013 (CG161) & QS86 March 2015

• All people aged 65 or older need to receive fall risk assessment

• People aged 50 to 64 who are admitted to hospital and are judged by a clinician to be at higher risk of falling because of an underlying condition

• All patient who experienced fall need to be reviewed within 12 hours and ½ hour in case of suspected severe impact [#NOF, Spinal injury].

• All patient should receive full falls assessment

Multi-factorial causes 1. Acute medical condition that causes postural hypotension 2. Falls history, including mechanism, frequencies and consequences of the falls

incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of

falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; poly-pharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition

2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and exclude syncope

3. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium.

4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls

incidences, and exclude syncope

3. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium.

4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls

incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such

as infection & delirium.

4. Cognitive impairment. AMTs and CAM [Inouye, S., van Dyck, C., Alessi, C., et al. Clarifying confusion: The confusion assessment method.

Annals of Internal Medicine. 1990; 113(12); 941-948]. Cohort bay may benefit.

5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and

exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as

infection & delirium. 4. Cognitive impairment.

5. Visual impairment; acuity and peripheral eyesight. Full document Look_Out.pdf

6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls

incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of

falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight

6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls

incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of

falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope

7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and

exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as

infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues

8. Neurological examination; motor, sensory and coordination

9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and

exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as

infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination

9. Postural instability, unable to stand-up without support. Physiotherapist have a major role in strengthening Quadriceps and increase feet orientation.

10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Falls history, including mechanism, frequencies and consequences of the falls incidences, and exclude syncope 2. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium. 3. Cognitive impairment.4. Visual impairment; acuity and peripheral eyesight 5. Cardiac cause of syncope6. Continence issues 7. Neurological examination; motor, sensory and coordination 8. Postural instability, unable to stand-up without support

9. Footwear that is unsuitable or missing or foot defect that affect gait. [Amin, K and Watkins, D. September 2016 “Falls unit working hard to keep patients on their feet”. Romford recorder, News; page 14].

10. Mobility impairment due to neurological or skeletal diseases11. Postural hypotension 12. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.

11. Mobility impairment due to neurological or skeletal diseases. TUG test

12. Postural hypotension 13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases

12. Postural hypotension https://www.rcplondon.ac.uk/projects/outputs/measurement-lying-and-standing-blood-pressure-brief-guide-clinical-staff

13. Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic

1. Acute medical condition 2. Falls history, including mechanism, frequencies and consequences of the falls incidences, and exclude syncope 3. Acute or acute worsening health problems that may increase their risk of falling; such as infection & delirium. 4. Cognitive impairment.5. Visual impairment; acuity and peripheral eyesight 6. Cardiac cause of syncope7. Continence issues 8. Neurological examination; motor, sensory and coordination 9. Postural instability, unable to stand-up without support 10. Footwear that is unsuitable or missing or foot defect that affect gait.11. Mobility impairment due to neurological or skeletal diseases12. Postural hypotension

13.Medication; polypharmacy, anticholinergic, sedatives and anti-psychotic – ageing brain care https://www.uea.ac.uk/documents/3306616/10940915/Anticholinergics/088bb9e6-3ee2-4b75-b8ce-b2d59dc538c2

Assessment • Identification mechanisms of the falls and consequence

• Is it syncope?

• Falls assessment

• Assessment of osteoporosis risk

• Assessment of home hazards

Medical Report for patient at a risk of falls/ had a fall Self-Adhesive insert for medical notes

Medical Report High Risk of Falls Assessment: Patient Name:

Hospital No: Consider history – cause of fall (mechanism of fall and previous Hx of falls) Examination: CVS, and Neurology (motor & sensory) ECG Cognitive Assessment – AMTS, dementia or delirium

Seen by (Name): Sign: Gait Assessment (get-up and go test) Medication review: (esp. benzodiazepine, sedation, agents causes postural hypotension), consider bone protection

Lying and standing blood pressure – postural drop Consider footwear and visual problems

Date: Time: Consider infective cause, e.g UTI Consider referral to old age psychiatry or Dementia CNS

Check x-ray as appropriate and Vitamin D level Consider community falls clinic on discharge

“I just slipped”…..

• Usually an attempt to rationalise the fall, occasionally denied it

• Most inpatient falls have more than one cause. Cardiovascular and iatrogenic causes are common.

“I just slipped”…..

• Usually an attempt to rationalise the fall, occasionally denied it

• Most inpatient falls have more than one cause. Cardiovascular and iatrogenic causes are common.

•A “mechanical” fall?

“I just slipped”…..

• Usually an attempt to rationalise the fall, occasionally denied it

• Most inpatient falls have more than one cause. Cardiovascular and iatrogenic causes are common.

• A “mechanical” fall?

NODo not blame patient that s/he had a fall

• The effects may be mechanical BUT the causes are usually not

“I just slipped”…..

• There were 131 falls reported in December 2016 and over 1200 falls in a year at BHRUT

• Of the 131 falls reported in December 2016 there were five severe harm falls reported.

• There have been 1013 falls reported between April - December 2016

• Most of these falls were avoidable

Why do any of this?

CostsExtra bed days, longer rehabilitation, POC, equipment,…..

Litigation costs

• Basic history to identify mechanism of the fall and syncope • Examine the patient

• Do not forget • ECG L&S BP Medication assess for trauma

• In-patient fall incidence 12 hrs unless #NOF or spinal injury is suspected then 30 minutes review

• Refer to falls clinic

In Summary

Thank you

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