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Secondary prevention of falls

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									              Public Health Wales                       Secondary Prevention of falls for older adults




       Secondary Prevention of falls for
                older adults
                           Quality improvement toolkit
Author: Primary             Care Quality and Information Service
Date: November 2010                                     Version: 1
Status: Final
Intended audience: Public (Internet) / NHS Wales (Intranet) / Public Health Wales
(Intranet)
Purpose and summary of document:
This document is for use by general practices to ensure that the delivery of service to older
adults who fall is evidence based and in line with best practice. It will support practices to review
and improve where necessary, the appropriate recording of information regarding over 65 years
that fall and help improve identification of recurrent falls within older people and enable them to
reach their optimum potential for independence
The audit toolkit will provide the user with a summary of the current evidence directing the safe
provision of service, and a schedule of patient review criteria to compare current practice against
those evidence based criteria.
Also included is a practice review section designed to encourage a whole practice response to
the audit findings and an evaluation of the quality and usefulness of the audit itself.


Publication / distribution:
 Publication in PHW Document Database (Primary Care Quality and Information)
 Link from PHW e-Bulletin




                                                   Date
                     Author
                                                 November                     Status; Final
  Primary care quality and information service
                                                   2010
         Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
              Audit Version; 0c
                                                    1               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults

Preface

                                    Quality improvement toolkits
The Primary Care Quality and Information Service (PCQIS) produces evidence based quality
improvement toolkits to assist practices in collating and auditing information regarding the
processes and outcomes of their care to patients.

They should be seen as good practice guidance and may cover areas of data collection that
some or even all practices may not be recording at this stage. It is not expected that all the
criteria within these audits will necessarily be achieved in year one but the toolkits can guide
practices as to what data they should be recording for the future.

Toolkits are not designed for performance monitoring. LHB‟s considering using these toolkits
should first discuss with their constituent practices how the toolkits might be used for locality
audits.

You can access other quality improvement toolkits that support enhanced services and
National Service Frameworks from Public Health Wales website:

Intranet http://howis.wales.nhs.uk/sitesplus/888/page/34029
Internet http://www.wales.nhs.uk/sitesplus/888/page/45129



                                          Education Resource
This audit can be used as a base-line to provide practices with background data on recording falls
which will describe the present organisation, structure and processes around secondary
prevention of falls in older people or as a prospective audit

The key goal of this quality improvement toolkit is to achieve changes in practice which improve
patient outcomes. Embedding continuous quality improvement (CQI) presents a useful method of
evaluating links between learning and performance. It is suitable for use by general practitioners
individually, practice nurses and those concerned with care of the elderly in the community. It is
also suitable for a practice to use as a team effort in examining care. This audit can also be found
at PGMDE Cardiff University CPD resource site which was developed to support the falls
education module
http://www.cf.ac.uk/pgmde/sections/general/cpdwales/cpdresources/falls/index.html




                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c
                                                     2               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults

Contents                                                                                  Page

Preface
Education Resource

     1    Introduction and background                                                           4

     2   1000 lives plus campaign Initiative reducing falls in the Community                    5

     3   The National Service Framework for older people                                        5

     4     Detecting a fall                                                                     6

     5    Those at risk                                                                         6

     6     Interventions for preventing falls in older people                                   7

     7     Investigations following a fall                                                      7
                  Cardiovascular effect and falls
                  Excluding the presence of orthostatic hypotension

     8 Multidisciplinary assessment and intervention                                           8

     9 Clinician reflection questions                                                           9

    10 Aim                                                                                     10

    11 Objectives                                                                              10

    12 Methodology                                                                             10

    13 Patient Audit Criteria                                                                  11

    14 Patient Data collection sheet                                                           13

    15 Data Collection Sheet summary                                                           14

     Appendix A – Practice Review sheet                                                        16

     Appendix B – General resources                                                            17

     Appendix C - Read Code Template                                                           18

     Appendix D- FRAT Tool                                                                     20

     Appendix E- Recording of Postural blood Pressure                                          22

     References                                                                                24

                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c
                                                     3               (Intranet) PHW (Intranet) / PCQIS
                Public Health Wales                       Secondary Prevention of falls for older adults




1       Introduction and Background
Definition: A fall can be defined as follows:
When someone falls, it is rarely easy to be sure if it was a simple slip or trip, or whether they were
dizzy and fainted or collapsed. Falls are therefore defined as, “an event whereby an individual
comes to rest on the ground or another lower level with or without loss of consciousness.” 1

As people get older, they may fall more often for a variety of reasons including problems with
balance, poor vision, and dementia. Fear of falling can result in self-restricted activity levels. It is
not possible to prevent falls completely, but people who tend to fall frequently can be enabled to
fall less often.

Falls are a major international public health challenge because of the myriad effects on older
individuals: direct physical and psychological injury; fear of falling and activity limitation; reduced
social participation and quality of life; increased dependence2

Falls represent the most frequent and serious type of accident in the over-65s, with one older
person dying every five hours as a result of a fall. Falls destroy confidence, increase isolation and
reduce independence. About 30 per cent of older people living in the Community fall each year,
rising to approximately 50 per cent for those aged 85 and over.1 Over half of all those aged 75+
who have fallen say that their fall had a major impact on their daily activities for a month or more.
After a fall, an older person has a 50 per cent probability of having seriously impaired mobility and
a 10 per cent probability of dying within a year. Hip fracture is the most common serious injury
related to falls in older people. Falls in later life are a common symptom of unrecognised health
problems which need to be identified and managed 3 One of the Health Gain Targets for Older
                                                                                             ;4
People in Wales is to reduce hip fractures in the 75 and over age group by 10% by 2012

Studies from various countries have shown that about one third of people aged above 65 years fall
each year. In UK primary care populations, the rate rises with age to over 60% of nonagenarians,
and is generally higher in women 2 and in socio-economically deprived populations 3. Fragility
fractures are the commonest significant injury, 300,000 annually in the UK including upwards of
70,000 hip fractures.

In a typical primary care population with 30 000 people over 65, each year approximately 2000
people will fall twice or more, 2000 will seek emergency care in hospital, and more than 1000 will
sustain osteoporotic fractures. Falls and syncope are the sixth commonest cause for emergency
hospital admission in persons over 65 years 5

A report from the world‟s largest and fastest-growing national hip fracture audit, published 2nd
September 2010 revealed that NHS hip fracture patients, highlighted as some of the most elderly
and vulnerable patients in the NHS, are now getting far greater access to specialist care by
geriatricians, as well as osteoporosis screening, assessment for the likelihood of future falls and




                                                     Date
                       Author
                                                   November                     Status; Final
    Primary care quality and information service
                                                     2010
           Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
                Audit Version; 0c
                                                      4               (Intranet) PHW (Intranet) / PCQIS
                 Public Health Wales                       Secondary Prevention of falls for older adults

bone protection drugs can reduce fracture incidence by up to 50%, potentially saving £millions to
the NHS 24

2. 1000 lives plus campaign…..Reducing Falls in the Community initiative
1000 Lives Plus is a new five year programme to improve patient safety and reduce avoidable
harm across NHS Wales. The programme will build on the work of the 1000 Lives Campaign in
delivering changes that improve patient safety and the quality of all NHS services, including
hospitals, GP surgeries and pharmacies.

The Multiagency falls Collaborative for Wales aims to support practitioners and community-
based teams to improve care for patients who have fallen. The plan of the collaborative is to
reduce mortality and harm to adults who have fallen, and are at risk of further falls, by providing a
structure around which to align and develop community services.

1000 Lives Plus Fall resources

Reducing Harm from Falls 'How to' Guide

Recommended Tools

        Falls Risk in Older People Assessment
        FRAT Tool
        Timed Up and Go Tool
        Specialist Falls Assessment Form
        Quickscreen 1 page Falls Assessment

Contact
If you want to contact someone about the 1000 lives plus campaign…..Reducing Falls in the
Community programme area, please email 1000 Lives Plus


                                                                              8
3. The National Service Framework (NSF) for Older People
The aim of Standard six is:
„To reduce the number of falls which result in serious injury and ensure effective treatment and
rehabilitation for those who have fallen.‟ To meet the standards set in the NSF organisations need
to ensure the following key areas are identified:
1.     Older people who have fallen are enabled to reach their optimum potential for independence.
2.     Reduce the number of falls amongst older people
3.     Care is provided in accordance with best practice
4.     Reduce the number of osteoporotic fractures.
5.     Identification of risk of falls.
6.     Falls assessment must be multi-factorial.
7.     Evaluation of risk factors and planned interventions made by competent persons/professionals



                                                      Date
                        Author
                                                    November                      Status; Final
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                                                      2010
            Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
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                Public Health Wales                         Secondary Prevention of falls for older adults



4. Detecting a Fall History
Identifying all falls related activity is challenging but recent estimates suggest that it accounts for
between 10% and 25% of all local health and social care spending on older people 6. Care of
fragility fractures is particularly expensive, total health and social care costs in the UK being
around £2 billion, most of which relates to hip fractures 7. Current population and incidence
projections suggest that by 2020, this figure will rise by 50%.

Detecting a history of falls is crucial. Preventing falls in older people (65years and over) depends
on identifying those most at risk of falling, and co-ordinating appropriate preventive action1. Many
people who fall do not seek medical help at the time, so older people should routinely be asked
whether they have fallen in the last year, and fallers questioned about the frequency plus
mechanism of falls 1, 4

Case finding in all services, including primary and secondary care, with a simple question “Have
You fallen in the last 12 months?” triggering appropriate assessment if the answer is positive.

Osteoporosis assessment and falls assessment should be done together22

Please refer to PCQIS osteoporosis toolkit
http://nww2.nphs.wales.nhs.uk:8080/primarycareqitdocs.nsf/85c50756737f79ac80256f2700534ea3/
6e0d355e0327df0e8025764000310b71/$FILE/OsteoporosisFinal1July09.doc



                      4
5. Those at risk
The following factors were most predictive of falling and should be considered by clinicians
responsible for assessing those at risk of falling: The presence of more than one of the following
                                      8
factors increases the risk of falling

                                            4                                                            4
Community-dwelling older people                    People cared for in extended care settings
Falls history                                       Falls history
Gait deficit                                        Balance deficit
Balance deficit                                     Visual impairment
Mobility impairment                                 Cognitive impairment
Fear/Fall related anxiety                           multiple medications (sedatives / psychotrophics)
Visual impairment                                   Postural BP instability
Cognitive impairment
Urinary incontinence
Home Hazards.

                                                      Date
                       Author
                                                    November                        Status; Final
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                                                      2010
           Secondary prevention of falls                              Intended audience: Public (Internet) / NHS
                Audit Version; 0c
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Dementia patients
Dementia is associated with complex needs and, especially in the later stages, high levels of
dependency and morbidity. As the condition progresses, mobility difficulties can lead to falls and
         4
fractures .


                                                                                                    21
6. Interventions for preventing fall in older people living in the community
A 2009 Cochrane review identified the following:
Exercise programmes may target strength, balance, flexibility, or endurance. Programmes that
contain two or more of these components reduce rate of falls and number of people falling.
Exercising in supervised groups, participating in Tai Chi, and carrying out individually prescribed
exercise programmes at home are all effective.
A multifactorial assessment of an individual‟s risk of falling should be carried out and onward
referral or treatment should be arranged as appropriate in order to reduce risk.
The NICE guidance on falls prevention does not currently make any recommendations on the use
of vitamin D. It points out that there is evidence that vitamin D deficiency and insufficiency is
common among older people and that, when present, they impair muscle strength and possibly
neuromuscular function. However a recent meta-analysis shows, there is emerging evidence that
correction of vitamin D deficiency or insufficiency may reduce the propensity for falling; there
remains uncertainty about the relative contribution to fracture reduction25

Taking vitamin D supplements probably does not reduce falls, except in people who have a low
level of vitamin D. Vitamin D has a direct beneficial effect on muscle, and improved strength and
balance in several trials in older persons. Supplemental vitamin D in a dose of 700-1000 IU a day
reduced the risk of falling among older individuals by 19% and to a similar degree as active forms
             23,25
of vitamin D      . Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin
D concentrations of less than 60 nmol/l are not associated with a reduction in the risk of falling
                           23,25
among older individuals.

Some medications increase the risk of falling. Ensuring that medications are reviewed and
adjusted if appropriate may be effective in reducing falls. Gradual withdrawal from some types of
drugs for improving sleep, reducing anxiety and treating depression has been shown to reduce
falls.
                                               4.8
7.     Investigation following falls

NICE recommend that people need further investigation if they have two or more falls in one year,
have an injury after a fall, or have gait instability. Such investigation should identify modifiable risk
factors leading to tailored interventions such as medication review, individually prescribed
exercise, and the treatment of contributory Medical problems4




                                                       Date
                        Author
                                                     November                     Status; Final
     Primary care quality and information service
                                                       2010
            Secondary prevention of falls                           Intended audience: Public (Internet) / NHS
                 Audit Version; 0c
                                                        7               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults

                                       4,8, 26
Cardiovascular effect and falls
http://ageing.oxfordjournals.org/content/30/suppl_4/19.full.pdf+html

Basic medical assessment should include heart rate and rhythm and postural
blood pressure measurement. In patients with recurrent unexplained falls, carotid sinus massage
or specialist cardiovascular assessment should be considered to identify those with cardiohibitory
syncope who may benefit from pacemaker insertion.


Excluding the presence of orthostatic hypotension (postural hypotension)
Estimates of the prevalence of postural hypotension in the elderly range from 21% to 30%, and its
prevalence increases with age. 26 Orthostatic Hypotension is a condition in which a marked fall in
blood pressure is provoked by a change in posture from lying to sitting or from lying or sitting to
standing. This may cause light headedness („dizziness‟), a fall, or TLoC (Transient loss of
consciousness („blackouts‟) 27

See guidelines for the diagnosis and management of syncope (version 2009)
http://eurheartj.oxfordjournals.org/content/30/21/2631.full.pdf+html?sid=821b4370-b478-46d5-
a492-9309caae0eca

Recommendations for the Recording of Postural Blood Pressure (See appendix E)

See NICE guidance for transient loss of consciousness („blackouts‟).
http://www.nice.org.uk/nicemedia/live/13111/50432/50432.pdf


8. Multidisciplinary Assessment & Intervention (See appendix D)

The assessment may include the following:

      Detailed falls history

      Assessment of gait, posture, balance, mobility and muscle weakness
       (http://www.nice.org.uk/nicemedia/pdf/CG021fullguideline.pdf)

      Assessment of the person‟s perceived functional ability

    Up & Go test and Turn 180° test
   http://www.cks.nhs.uk/falls_risk_assessment/management/scenario_falls_risk_assessment/ass
   essment/up_go_test_and_turn_180o_test
      Fear of falling
        http://www.profane.eu.org/fesi.php
      Assessment of visual impairment
      Assessment of cognitive impairment and neurological examination
       http://www.patient.co.uk/doctor/Abbreviated-Mental-Test-(AMT).htm

                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c
                                                     8               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults

      Cardiovascular examination and postural blood pressure measurement
      Assessment of bladder and bowel function
      Assessment of home hazards
      Medication review
      Osteoporosis risk

Interventions such as strength balance training, calcium plus vitamin D and medication review can
                          22
be effective in isolation


9. Clinician Reflection:

   1. Do we routinely ask all patients over the age of 65 if they have fallen? 4
   2. Do I /we use a falls risk assessment tool to assess the risk of falls in older people? (e.g.
      FRAT Tool See Appendix D) or link above
   3. Are the person and family aware of the risks? 4
   4. What are the risks of a serious fall and subsequent injury?
   5. Can we do anything to reduce the risk of fall and/or reduce the risk of injury?
   6. Do we regularly review medicine concordance? Could any medication increase the risk of a
      fall? Could any additional medication reduce the risk of a fall? 4




                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c
                                                     9               (Intranet) PHW (Intranet) / PCQIS
                  Public Health Wales                       Secondary Prevention of falls for older adults



10.       Aim of review
To ensure that individuals who are known fallers are offered appropriate information, assessment
                                                                  4,
and interventions aimed at reducing the incidence of further falls 8

11.       Objectives
                                                                 3
     Improve identification of patients who repeatedly fall
                                                                 3
     improve the care and treatment of those who have fallen
                                                                    4
     Assess practice policies and procedures in relation to falls.
                                                      1,8, 11.17
     Reduce the number of osteoporotic fractures
     Heighten awareness and knowledge of staff, patients and carers on the prevention and causes
                   1,4, 8
      of accidents        (http://www.nice.org.uk/nicemedia/pdf/CG021publicinfoenglish.pdf)

12. Methodology

The PCQIS recognises that some of the criteria in this audit may involve data that is not currently kept
routinely by the practice. Therefore it is recommended that for this audit the practice either consider
collecting baseline data or record the information prospectively, so that these criteria could be
successfully reviewed in any future audits of this type. This may include items such as gait and
balance, „get up and go‟ assessment

       Collect prospective data in the proceeding 12 month period or delayed retrospective
        data after the 12 month period
       Set a start and end date for the audit
                                                                                       4
       Compile a list of patients over the age of 65 who are recurrent fallers
        NB. Consider patients that are known to be at high risk of falling (those who have attended A&E
        with a fall related trauma within the last 12 months, those within extended care settings and those
        with a previous fragility fracture).
       Select a patient sample, over the age of 65 with a record of falling in the last 12 months
       Collect relevant data and record using the data collection sheet provided
       Collate and analyse results of the data collection process
       Reflect on the results of the audit and decide any changes to practice that you consider
        appropriate (Using the practice review form enclosed (Appendix A)
       Decide on a date to re-audit to confirm changes (if recommended)



13. Criteria
                                                       Date
                         Author
                                                     November                      Status; Final
      Primary care quality and information service
                                                       2010
             Secondary prevention of falls                           Intended audience: Public (Internet) / NHS
                  Audit Version; 0c
                                                       10                (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults


Both core and additional criteria are based on national guidelines. The criteria presented are
considered to be the key criteria associated for all patients at risk of falling or who are known
fallers. Practices are encouraged to undertake a baseline audit to determine whether practice is in
accordance with the guidance. Where practicable, the audit should be repeated on a regular basis
to monitor implementation and to enable comparisons of practice and results over time.

NB - Please note that practices should be able to access commissioned specialist services
such as falls clinics which perform the range of risk factor assessments necessary to offer
individual targeted treatment plans to reduce falls and fractures but this service may vary
throughout Wales

Inclusion Criteria
All patients registered with the practice who are over the age of 65 and who have a history of
recurrent falls (more than 2) in a 12 month period4 (as of the audit start date).


 Criterion                                           Core criteria
                Patients over the age of 65 with a history of recurrent falls have had their
     1                                                   4,8
                Medication reviewed and documented
                Patients over the age of 65 with a history of recurrent falls have a lying to
     2                                 4,8
                standing BP recorded
                Patients over the age of 65 with a history of recurrent falls have had their vision
     3                                               4, 8.9
                assessed at the practice or hospital
                Patients over the age of 65 with a history of recurrent falls have been given
     4                                     4,8
                advice on falls prevention
                Patients over the age of 65 with a history of recurrent falls have had their alcohol
     5
                intake reviewed and documented


  Criteria                                         Additional criteria
                Patients over the age of 65 with a history of recurrent falls are offered a
     6                                             4
                Multi-disciplinary fall assessment
                Patients over the age of 65 with a history of recurrent falls have a record of being
     7                                                           23
                prescribed vitamin D in a dose of 700-1000 IU
                Patients over the age of 65 with a history of recurrent falls have had their gait and
     8                                           4, 8.9
                balance assessed and recorded
                Patients over the age of 65 with a history of recurrent falls have had a mobility
      9                                                 4, 8.9
                assessment undertaken and recorded


                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c
                                                    11               (Intranet) PHW (Intranet) / PCQIS
            Public Health Wales                       Secondary Prevention of falls for older adults

             Patients over the age of 65 with a history of recurrent falls have been assessed
 10                                               4
             using the timed ‟get up and go‟ test
             Patients over the age of 65 with a history of recurrent falls have a Abbreviated
 11                                4
             Mental Test recorded
             Patients over the age of 65 with a history of recurrent falls have been referred to a
 12                                                                  4
             falls prevention service or exercise / balance training




                                                 Date
                   Author
                                               November                     Status; Final
Primary care quality and information service
                                                 2010
       Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
            Audit Version; 0c
                                                 12               (Intranet) PHW (Intranet) / PCQIS
                                 Public Health Wales                            Secondary Prevention of falls for older adults

14. Patient specific Data Collection Sheet

              Patient      Gender        C1      C2         C3      C4      C5      C6      C7      C8       C9        C10   C11      C12
                 1
                2
                3
                4
                5
                6
                7
                8
                9
                10
                11
                12
                13
                14
                15
                16
                17
                18
                19
                20


                                                                           Date
                                        Author
                                                                         November                      Status; Final
                     Primary care quality and information service
                                                                           2010
                            Secondary prevention of falls                                Intended audience: Public (Internet) / NHS
                                 Audit Version; 0c
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               Public Health Wales                       Secondary Prevention of falls for older adults

   15. Data Collection Summary

Standards to be agreed and set in practice
Audit Start Date         ___________________         Audit Completion Date           ________________
Total Number of Patients who have had 2 or more falls in a 12 month period
Males ____________ Females                 ____________

 15.1 Medication review                             Recorded         Total      % recorded        Standard
 Male
 Female

 15.2 Lying to standing BP                          Recorded         Total      % recorded        Standard
 Male
 Female

 15.3 Vision Assessed                              Recorded          Total      % recorded        Standard
 Male
 Female

 15.4 Fall Prevention Advice                       Recorded          Total      % recorded        Standard
 Male
 Female


 15.5 Alcohol Consumption Review                   Recorded          Total      % recorded        Standard
 Male
 Female

 15.6 Multidisciplinary falls review               Recorded          Total      % recorded        Standard
 Male
 Female

 15.7 Rx Vitamin D in a dose of 700-
 1000 IU                                           Recorded          Total      % recorded        Standard

 Male
 Female


                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c                    14               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                      Secondary Prevention of falls for older adults

 15.8 Gait and balance assessed                   Recorded          Total      % recorded        Standard
 Male
 Female

 15.9 Mobility assessed                           Recorded          Total      % recorded        Standard
 Male
 Female

 15.10 “Get Up and Go” Test Performed             Recorded          Total      % recorded        Standard
 Male
 Female

15.11 Abbreviated mental test                     Recorded         Total       % recorded        Standard
Male
Female

15.12 Refer to Fall Prevention Service
/ Exercise / Balance                              Recorded         Total       % recorded        Standard

Male
Female


Comment




                                                   Date
                     Author
                                                 November                     Status; Final
  Primary care quality and information service
                                                   2010
          Secondary prevention of falls                         Intended audience: Public (Internet) / NHS
               Audit Version; 0c                   15               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults


Appendix A
                                          Practice Review Sheet
A. What lessons did the practice discover from carrying out this audit?




B. What changes, if any have the practice agreed to implement as a result of this audit?




C. What support would enable the practice to enhance the service it provides to patients?




This audit was compiled by;
Name(s)           ______________________________________________________
Signature(s)      ______________________________________________________
Practice (name and address)

___________________________________________________________________


                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c                    16               (Intranet) PHW (Intranet) / PCQIS
                  Public Health Wales                            Secondary Prevention of falls for older adults

Appendix B General resources
Welsh Assembly Government. National Service Framework for Older People in Wales. 2006.

Department of Health in England. Prevention Package for Older People.

British Orthopaedic Association. The care of patients with fragility fracture. 2007. (PDF)

National Osteoporosis Society. Protecting fragile bones: A strategy to reduce the impact of osteoporosis and fragility
fractures in Wales. 2009. (PDF)

National Institute for Health and Clinical Excellence. Falls: the assessment and prevention of falls in older people.
Clinical guideline 21. 2004.

National Institute for Health and Clinical Excellence. Bisphosphonates (alendronate, etidronate, risedronate), selective
oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of
osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 87. 2005.

National Institute for Health and Clinical Excellence. Alendronate (review), etidronate (review), risedronate (review),
raloxifene (review) strontium ranelate and teriparatide (review) for the secondary prevention of osteoporotic fragility
fractures in postmenopausal women. Technology Appraisal 161. 2008.

The Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians, London. National Audit of Falls and
Bone Health for Older People. 2009.

The Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians, London. National Clinical Audit of
Falls and Bone Health in Older People. 2007.

The Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians, London. National Audit of the
Organisation of Services for Falls and Bone Health for Older People. 2009.

Chartered Society of Physiotherapy - Falls audit.
College of Occupational Therapists – Falls Management (PDF)
Profane ProFaNE is a thematic network with 25 partners focusing on the issue of prevention of falls and improvement
of postural stability amongst elderly people

Preventing Falls in this statement from help the Aged they investigate people‟s attitudes towards falls prevention and
advice and identify ways to increase the uptake of services. They point out that once a person has fallen it may be too
late to avoid serious consequences.

Fall Guidance American Geriatric Society gives insight into the risks associated with falling. Frequently older people
are not aware of the risks involved with falling and do not report issues to their GP.

Falls, Fragility & Fractures this paper highlights the link between falls and osteoporosis. Falls is older people with
osteoporosis are likely to result in a worse outcome. Exercise is an important component in the prevention of falls, when
muscle power and flexibility decline the older person is less likely to prevent a slip, tumble or trip becoming a fall.

Blue Book investigates the current evidence for the management of osteoporosis patients and looks at the appropriate
pathways along which they should be referred

Improving your strength and balance This Age Concern leaflet has information and advice for everyone, whether their fit
and active, have mobility problems, or are worried about falling. As well as practical advice on how you can improve
strength, balance and mobility, this leaflet looks at the impact that anxiety about falling can have on people‟s lives
20 key principles for falls management and prevention This strategic health authority document summarises clinical
advice on the key principles which should be followed when commissioning or providing Falls Management and
Prevention Services for Older People.

                                                          Date
                       Author
                                                        November                             Status; Final
    Primary care quality and information service
                                                          2010
            Secondary prevention of falls                                  Intended audience: Public (Internet) / NHS
                 Audit Version; 0c                          17                 (Intranet) PHW (Intranet) / PCQIS
                   Public Health Wales                              Secondary Prevention of falls for older adults


Appendix C                   READ Codes / Falls Prevention Template

                                                  READ                                                                   READ
History / Assessment
                                                  CODE                                                                   CODE
Falls (History / Symptoms)                        16D..% At risk of osteoporotic fracture                                14OD.
[X]Falls (external causes)                        U10..% CVD risk assessment done                                        9OhA.
Falls assessment                                      38A..%    At risk accident in home                                 13VE.
Accidental falls                                      TC…%      High risk drug monitoring                                66P..
At risk of falls                                      14OC.     Falls risk assessment complete                           9Og2.
Falls caused by medication                            8BIG.     Osteoporosis risk assessment done                        9OdA.
Falls risk assessment administration                  9Og..     Medication review                                        8B3S.
Medication monitoring                                 66c..     Other medication review                                  8BI..%
Medication - risk monitoring                          66P..     Recurrent falls                                          16D1.
O/E - gait                                            299..%    Balance assessment                                       7P121
Disorder of gait and/or balance present               29LD.     Disorder of gait and/or balance not present              29LE.
Hearing symptoms                                  1C1..% Disability assessment-physical                                  39...%
Disability assessment - mental                        3A...%    Assessment of needs                                      389..%
Cognitive assessment                                  311B.     Visual testing                                           312..%
Abbreviated mental test                               388L.     Alcohol consumption                                      136..%
H/O: collapse                                         147C.     H/O: blackout                                            147D.
H/O: eye disorder                                     148..%    H/O: ear disorder                                        149..%
H/O: cardiovascular disease                           14A..%    Incontinence of urine                                    1A23.
Bowels-incontinence assessment                        393..%    Bladder-incontinence assessment                          394..%
Fear of falling                                       1Bb0.     O/E - muscle power                                       29A..%
Neurological disorder monitoring                      666..%    Exercise grading                                         138..%
Physical exercises                                    8E7..%    Get up and go test                                       3986.
Get up and go test - normal                           3984.     Get up and go test - abnormal                            3985.

                                                      READ                                                               READ
Diagnosis / Investigations
                                                      CODE                                                               CODE
12 lead ECG                                           321B      Chest X-Ray                                               535
TFT                                                    442J     U&E                                                      44JB
Fasting Blood Glucose                                 44TK      FBC                                                       424
Urinalysis                                             461      LFT                                                      44D6

                                                            Date
                          Author
                                                          November                        Status; Final
       Primary care quality and information service
                                                            2010
              Secondary prevention of falls                                 Intended audience: Public (Internet) / NHS
                   Audit Version; 0c                           18               (Intranet) PHW (Intranet) / PCQIS
                    Public Health Wales                               Secondary Prevention of falls for older adults

Fasting Blood Lipids                                  44O5

                                                      READ                                                                  READ
Referrals
                                                      CODE                                                                  CODE
Refer to district nurse                               8H72.       Refer to social worker                                    8H75.
Referral to falls service                             8Hk1.       Refer to physiotherapist                                  8H77.
Referral to Occupational therapy                      8H7J.       Referral to rheumatology clinic                           8HTd.
Refer for falls assessment                            66aF.       Referral to leg ulcer clinic                              8HTh.
Refer to A. & E. department                           8HC1.       Referral to elderly falls prevention clinic               8HTl.
Referral to incontinence clinic                       8HTX.       Referral to deep vein thrombosis clinic                   8HTm.
Referral to memory clinic                             8HTY.       Referral to fracture clinic                               8HTo.
Referral to osteoporosis clinic                       8HTS.       Falls risk assessment referral                            9Og0.
Referral to optometrist                               8HlC.       Refer to podiatry                                         8H7X.
Refer to optician                                     8H7H.       Referral to physical activity programme                   8H7s.
Referral to Social Services                       8HHB.           Referral for exercise therapy                             8H7q.
Referred for exercise programme                       8HHc.

                                                  READ                                                                      READ
Treatment / Prevention
                                                  CODE                                                                      CODE
Falls prevention plan                             8CM7.           Osteoporosis - falls prevention                           66a9.
Falls advice                                          67IC.       Fracture therapy follow-up                                8HB9.
Patient advised re exercise                           8CA5.       Osteoporosis - exercise advice                            66a8.
Vitamin D                                              ip...      Adverse reaction to Vitamin D                             U60E7
Vitamin D deficiency                                  C28..       [V]Personal history of vitamin D3 allergy                 ZV14M
Combined calcium and vitamin D3                                   Combined calcium and vitamin D3
                                                      8I3f.                                                                 8I2W.
preparation declined                                              preparation contraindicated
Combined calcium and vitamin D3                                   Combined calcium and vitamin D3
preparation not indicated                             8I6S.                                                                 8I7F.
                                                                  preparation not tolerated
Alfacalcidol                                          ip1..       Calcitriol                                                 ip2..
Cholecalciferol or ergocalciferol                     ip3..       Dihydrotachysterol                                         ip4..
Paricalcitol                                          ip5..

preparation not indicated



   Appendix D
                                                                 Date
                          Author
                                                               November                      Status; Final
       Primary care quality and information service
                                                                 2010
               Secondary prevention of falls                                   Intended audience: Public (Internet) / NHS
                    Audit Version; 0c                            19                (Intranet) PHW (Intranet) / PCQIS
                Public Health Wales                       Secondary Prevention of falls for older adults

                               Assessment of falls risk in older people
                                (Falls Risk Assessment Tool-FRAT)
Multi - professional guidance for use by the primary health care team, hospital staff, care home
staff and social care workers This guidance has been derived from longitudinal studies of factors
predicting falls in older people and randomised controlled trials that have shown a reduction in the
risk of falling.
(Originally designed by Queen Mary College, University of London)

Definition Fall- An event whereby an individual comes to rest on the ground or another lower level
with or without loss of consciousness (NICE 2004)

Notes for users:
1) Complete assessment form below.

The more positive factors the higher the risk for falling.
2) If there is a positive response to three or more of the questions on the form, then please see
suggestions on guidance for further assessment, referral options and interventions for certain risk
factors.
3) Some users of the guidance may feel able to undertake further assessment and appropriate
interventions at the time of the assessment.
4) Consider which referral would be most appropriate given the patient's needs and local
resources.

Name _______________________ Date of Birth ___________

1    Is there a history of any fall in the previous year?                 Yes         No
     How assessed? Ask the person.
2    Is the patient / client on four or more medications per day?
     How assessed? Identify number of prescribed
     medications.
3    Does the patient / client have a diagnosis of stroke or
     Parkinson's Disease?
     How assessed? Ask the person.
4    Does the patient / client report any problems with his/ her
     balance?
     How assessed? Ask the person.
5    Is the patient/client unable to rise from a chair of knee
     height?
     How assessed? Ask the person to stand up from a chair
     of knee height without using their arms.

Suggestions for further assessment, referral options and interventions
Assessment by nurse or doctor


                                                     Date
                       Author
                                                   November                     Status; Final
    Primary care quality and information service
                                                     2010
           Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
                Audit Version; 0c                    20               (Intranet) PHW (Intranet) / PCQIS
                 Public Health Wales                          Secondary Prevention of falls for older adults

Risk factor present           Further assessment              Referral Options      Interventions
1) History of falling         Review incident(s),             Occupational          Discuss fear of falling and
in the previous year          Identifying                     Therapy,Physiotherapy realistic preventative
                              precipitating                                         measures.
                              factors.
2) Four or more               Identify types of               Falls Clinic (1)             Review medications,
medications per day           Medication prescribed.                                       particularly sleeping
                              Ask about symptoms                                           tablets.Discuss changes in
                              of dizziness.                                                sleep patterns normal with
                                                                                           ageing, and sleep promoting
                                                                                           behavioural techniques.
3)Postural                    Two readings taken              District Nurse               Offer extra pillows or consider
hypotension                   1. After rest five              Practice nurse               raising head of bed if severe.
                              minutes supine                  Falls Clinic (1)             Review medications.
                              2. 1 minutes later                                           Teach to stabilise self after
                              standing                                                     changing position and before
                              Drop in systolic BP ��                                        walking.
                              20mmHg and or drop
                              in diastolic                                                 Avoid dehydration
                              ��
                              or more
4) Balance and gait           Can they talk while             Occupational                 Teach about risk. And how to
problems                      walking? (2)                    Therapy                      manoeuvre safely, effectively
                              Do they sway                                                 and efficiently.
                              significantly on                Physiotherapy                Physiotherapy evaluation for
                              standing?(3)                                                 range of movement, strength,
                                                              Falls Clinic/ICT (1          balance and/or gait exercises.
                              such as Timed Up &                                           Transfer exercises.
                              Go test                                                      Evaluate for assistive
                                                                                           devices.
                                                                                           Consider environmental
                                                                                           modifications (a) to
                                                                                           compensate for disability and
                                                                                           to maximise safety, (b) so that
                                                                                           daily activities do not require
                                                                                           stooping or reaching
                                                                                           overhead.
1 Consider Falls Clinic/ Intermediate Care Referral Form.
2. While the patient is walking ask them a question but keep walking while you do so. If the patient stops
walking either immediately or as soon as they start to answer, they are at higher risk of falling.
3. The patient stands between the assessor and the examination couch (or something they can safely hold on
to). First assess if the person sways significantly (raises arms or compensates foot placement) while standing
freely. Then ask the person to take their weight on to one leg and try to lift the other foot off the floor by about
an inch (allow a few practice attempts).



                                                       Date
                       Author
                                                     November                         Status; Final
    Primary care quality and information service
                                                       2010
           Secondary prevention of falls                                Intended audience: Public (Internet) / NHS
                Audit Version; 0c                        21                 (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults


Appendix E               Recording of Postural blood Pressure

These recommendations for the Recording of Postural Blood Pressure are based upon the
European Society of Cardiology Guidelines on the Assessment and Management of Syncope
(2009) and the British Hypertension Society Guidelines on the Measurement of Blood Pressure.

It is recognised that the guidance is based upon best practice and that in each clinical area where
they are applied consideration will need to be given to local factors and resources in there
application.

Equipment:
It is recommended that manual recording techniques are used rather than automated devices.
Rationale: Automated devices are unreliable and are prone to fail/error when recording blood
pressure readings that are either variable or unstable.

Tilt table testing is NOT indicated in the routine assessment of patients for orthostatic hypotension.

Postural Challenge:

Ideally patients should rest supine for a minimum of 5 minutes before BP readings are taken a .
Patients should then be asked to stand briskly with support if needed to ensure safety. They should
remain near bed/couch onto which they can be returned promptly if necessary.
Seated to standing measurements of blood pressure should NOT be used routinelyb.

Rationale: a Stabilisation of BP requires period of rest and although evidence suggests >10 minutes
is optimal standard practice is to allow a minimum of 5 minutes.
Rationale :b The use of seated to standing blood pressures fails to identify many cases of
orthostatic hypotension and should only be used when there is no alternative.

Measurements:
BP readings should be undertaken in line with standard guidance from the British Hypertension
Society.
Both heart rate and blood pressure should be recorded whilst supine and immediately on standing.
There should then follow a series of readings made over the next 3 minutes; this period may need
to be extended where there is evidence of borderline significant cardiovascular instability (e.g.
gradually reductions in blood pressure).

Rationale: The control of postural cardiovascular responses are complex and several patterns of
orthostatic hypotension are now recognised which will not be identified unless serial
measurements are recorded.

Recording:
Pulse and Blood pressure readings should be recorded on a suitable chart or in the case notes. In
addition any symptoms (e.g. dizzy, light-headed, chest pain) or signs (pallor, body sway) that occur
should also be recorded.
                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c                    22               (Intranet) PHW (Intranet) / PCQIS
               Public Health Wales                       Secondary Prevention of falls for older adults


Rationale: Heart rate changes or absence and the presence or absence of symptoms/signs are
beneficial to clinician interpreting the measurements.


Interpretation Guidance:
Orthostatic Hypotension is present when there is a 20mmHg drop in systolic Blood Pressure
following postural change, or a drop to <90mmHg. Lesser drops in blood pressure, particularly
from relatively low baseline measurements, may also be significant especially when symptoms or
signs are present.

Diastolic hypotension is defined as a drop of 10mmHg, however its significance in the assessment
of patients who have fallen is uncertain.




   1) Guidelines for the diagnosis and management of syncope (version 2009) European Heart
      Journal (2009) 30, 2631–2671 (on line: www.escardio.org/guidelines)

   2) Report of the Fourth Working Party of the British Hypertension Society, 2004 - BHS IV.
   Journal of Human Hypertension 2004; 18: 139-185 (on line: http://www.bhsoc.org)




                                                    Date
                      Author
                                                  November                     Status; Final
   Primary care quality and information service
                                                    2010
          Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
               Audit Version; 0c                    23               (Intranet) PHW (Intranet) / PCQIS
                 Public Health Wales                       Secondary Prevention of falls for older adults


REFERENCES:

1      Help the Aged: Preventing Falls 2007
       http://www.helptheaged.org.uk/NR/rdonlyres/1CC82E06-9223-43CD-B04E-
       F39F3F2E5E91/0/preventing_falls_statement_130807.pdf

2.     Fleming J, Matthews FE, Brayne C. Cambridge City over-75s Cohort (CC75C) study
       collaboration. Falls in advanced old age: recalled falls and prospective follow-up of over-90-
       year-olds in the Cambridge City over-75s Cohort study. BMC Geriatrics 2008; 8: 6.

3.    Todd C et al. Falls and falls prevention amongst older people: socioeconomic and ethnic
      factors. Report to the English Department of Health, 2008. London, DH

4.     NICE guideline 21; Falls The assessment and prevention of falls in older people
       November 2004 http://www.nice.org.uk/nicemedia/pdf/word/CG021NICEguideline.doc

5.     Kenny RA, O‟Shea D, Walker HF. Impact of a dedicated syncope and falls facility for older
       adults on emergency beds. Age Ageing 2002; 31: 272–5.

6.    NHS Information Centre for Health and Social Care. Integrating information on services for
      older people. Interim Project Report 2008 www.ic.nhs.uk 2008.

7.    British Orthopaedic Association. The Care of Patients with fragility fracture. London: BOA,
      2007.

8      NSF for Older People in Wales 2003 Standard 8 pg 109 Falls & Fractures
       http://www.wales.nhs.uk/sites3/documents/439/NSFforOlderPeopleInWalesEnglish.pdf

9      Cryer C; Patel S: Falls, Fragility and Fractures November 2001. Risk Assessment form
       taken from documentation of above literature.
       http://www.laterlifetraining.co.uk/documents/fallsfragility_fractures.pdf

10     British Geriatric Society (BGS) Falls Guidance
       http://www.falls-and-bone-health.org.uk/pdf/Fallguide.pdf

11     NICE Guidelines 160-Primary prevention of osteoporotic fragility fractures in
       postmenopausal women 2008
       http://www.nice.org.uk/Guidance/TA161

12     American Geriatrics Society, British Geriatrics Society, American Association of
       Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older
       persons. Journal of the American Geriatrics Society. 2001; 49: 664-672

13     Scottish Intercollegiate Guidelines Network -Prevention and Management of Hip Fracture on
       Older People http://www.sign.ac.uk/guidelines/fulltext/56/section2.html
                                                      Date
                        Author
                                                    November                     Status; Final
     Primary care quality and information service
                                                      2010
            Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
                 Audit Version; 0c                    24               (Intranet) PHW (Intranet) / PCQIS
                 Public Health Wales                       Secondary Prevention of falls for older adults


14     NICE Clinical Guideline 42 -Supporting people with dementia and their carers in health
       and social care http://www.nice.org.uk/nicemedia/pdf/word/CG042NICEGuideline.doc
15     Royal College of Physicians-CEEU national clinical audit of falls & bone health in older
       people, November 2007
       http://www.rcplondon.ac.uk/clinical-standards/ceeu/Documents/fbhop-nationalreport.pdf
16     British Orthopaedic Association-The care of fragility fracture patients, September 2003
       www.boa.ac.uk
17     National Osteoporosis Society https://www.nos.org.uk
18    Nuffield Institute for Health and NHS Centre for Reviews and Dissemination (1996);
      Preventing falls and subsequent injury in older people. Effective Health Care Bulletin, 2
      (4), 1-16

19    Mathias, S., Nayak, U. S. and Isaacs, B. (1986) Balance in elderly patients: the
      „get-up and go‟ test. Arch Phys Med Rehabil; 76 387-9

20    Podsiadlo, D. and Richardson, S. (1991) The timed „up and go‟ : a test of basic
      functional mobility for frail elderly persons. J Am Geriatr Soc; 39: 142-148

21    Interventions for preventing fall in older people living in the community; (Cochrane Review)
      http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD007146/pdf_fs.html

22    DOH 2008 Prevention package for older people

23    H A Bischoff-Ferrari et al (2009) fall prevention with supplemental and active forms of
      vitamin D: a meta-analysis of randomised controlled trials. BMJ 2009; 339:b3692

24     Health Quality Improvement Partnership Biggest ever hip fracture audit shows improvements
       in care, but significant geographical variations (2010)
       www.hquip.org.uk

25     Database of Abstracts of Reviews of Effects (DARE) Fall prevention with supplemental
       and active forms of vitamin D: a meta-analysis of randomised controlled trials
       Bischoff-Ferrari H A, Dawson-Hughes B, Staehelin H B, Orav J E, Stuck A E, Theiler R,
       Wong J B, Egli A, Kiel D P, Henschkowski J

26     Clinical knowledge Summary 2009 Falls Risk assessment

27     NICE Clinical Guidelines-Transient loss of consciousness („blackouts‟) management in
       adults and young people (August 2010)
       http://www.nice.org.uk/nicemedia/live/13111/50432/50432.pdf


                                                      Date
                        Author
                                                    November                     Status; Final
     Primary care quality and information service
                                                      2010
            Secondary prevention of falls                          Intended audience: Public (Internet) / NHS
                 Audit Version; 0c                    25               (Intranet) PHW (Intranet) / PCQIS

								
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