Transcript Training Older People to lead exercise within their

An Evaluation of the Greater
Glasgow & Clyde Osteoporosis
and Falls Strategy
Dr Dawn Skelton & Fiona Neil,
School of Health
The Process
• Jan 2008, Fiona Neil, OT within the Falls Service, was seconded to the
GCAL 0.5 FTE for one year.
• Visits to representatives of all parts of the service (Jan 2008-Aug 2008)
–
–
–
–
Record current Protocols and Processes
Discuss and gather previous audits
Discuss potential data collection
Advise on relevant up to date guidelines/evidence base
• Any previously gathered audit or outcome information (for
presentations at conferences etc) was collected as well as raw data
where possible.
• Data blinded by the relevant service, permission sought from the
Caldicott Guardian for NHSGGC.
• Some small audit projects and 2 Masters Project (GCU OT & PT
student, with full NHS ethical approval)
CFPP
• Specialist falls service which aims to prevent further
falls by providing a comprehensive falls screening,
health education, exercise, rehabilitation and onward
referral
• The service is available to individuals who are over 65,
live at home and have had a fall in the last year
• 221 referrals a month in 2008
• Telephone triage completed within 24 hours of
receiving referral
• Home screening completed within 5 working days of
triage
Pathway
Multifactoral
interventions
Fall in past
year.
Community
dweller.
Aged 65+
Open
Referral
Falls Clinic/ Medical
review and gateway to
day hospital
COPT/
IRIS/
DART
Falls
Admin
centre- Deliver
triage
(within
24
hours) Home
Falls
Prevention
Programme
HFPP Physio
assessment and falls
exercise classes
Pharmacy review
1to1 Physio at community
site for musculoskeletal
problem
Multifactorial
Falls Risk Onward
Screening referral
Home visit
within 5
working
days.
Community older peoples
team (COPT)
Dietician
Podiatry
OT
Optician
Sensory Impairment
Dexa Scan
GP/Audiology
Community Alarms
Handy Persons
Benefits Advisor
Social Work/Home Care
INTEGRATED PLANS
Fracture
Osteoporosis
Falls
> 95% hip fractures
due to a fall
> 90% of hip fractures
due to osteoporosis
Falls, Fragility & Fractures, Cryer & Patel, 2002
NICE Falls CG: specialist integrated
service model, 2004
ABS/BGS Guidelines 2001
Assessment
History of falls
Medications & Medical
Conditions
Vision
Gait and Balance
Lower Limb Joints
(assistive devices)
Neurological (sensory) &
Continence
Cardiovascular
Multifactorial intervention
(as appropriate)
Gait, balance and exercise
programmes
Medication modification
Postural Hypotension Treatment
Environmental Hazard
Modification
Cardiovascular disorder treatment
AGS/BGS Guidelines
J Am Geriatr Soc 2001; 49: 664 – 672.
Comparison of current strategy with
the NICE guidelines 21: Clinical
protocol for prevention of falls
Case/risk identification
• POSITIVE
– Large number of referrals into CFPP. Telephone Triage followed by
home visit and onward referral.
– Linkages and communication with CHCPs, DART, IRIS & COPT to
support case risk identification
• NEEDS WORK ON
– Reducing refusals and non-responses to invite letters from CFPP.
– DNAs to Falls Clinic.
– Engaging GPs and A&E Depts to identify high risk fallers (eg. those who
have presented with a fall)
– FPCs work in Hospitals and Care Homes. Have identified issues and
more work is needed to engage hospital AHPs and Care Home Staff
Comparison of current strategy with
the NICE guidelines 21: Clinical
protocol for prevention of falls
Multifactorial Falls Risk Assessment
• POSITIVE
– Excellent links with Fracture Liaison Service and Direct Access DEXA
Scan and Pharmacy to ensure bone health is also considered
• NEEDS WORK ON
– Urinary Incontinence, Fear of falling, anxiety and depression and Vision
assessment is minimal.
– Roll out of DADS into Clyde
Comparison of current strategy with
the NICE guidelines 21: Clinical
protocol for prevention of falls
Multifactorial Interventions
•
•
POSITIVE
– Evidence based exercise delivery continuum.
– Good OT input to CFPP interventions.
– Excellent links with Fracture Liaison Service & Pharmacy
NEEDS WORK ON
– dedicated support time for CFPP (& Falls Clinics) Clinical Psychology
– Hospital based OTs to ensure home visits before discharge
– Equitable access to services across GG&C (eg syncope clinic for
potential cardiac pacing).
– long-term support of home exercise programmes and primary
prevention programmes
– No “tie-up” or follow up after interventions (Falls Clinics, CFPP, Little
evidence of exercise or other multi-factorial interventions occurring in
care homes (apart from FPCs currently raising awareness)
Comparison of current strategy with
the NICE guidelines 21: Clinical
protocol for prevention of falls
Patient Engagement
• POSITIVE
– Evidence of patient satisfaction questionnaires in some parts of the
service
• NEEDS WORK ON
– Falls Clinics need to engage patients to understand reasons for DNAs
Comparison of current strategy with
the NICE guidelines 21: Clinical
protocol for prevention of falls
Case/risk identification
• POSITIVE
– Large number of referrals into CFPP. Telephone Triage followed by
home visit and onward referral.
– Linkages and communication with CHCPs, DART, IRIS & COPT to
support case risk identification
• NEEDS WORK ON
– Reducing refusals and non-responses to invite letters from CFPP.
– DNAs to Falls Clinic.
– Engaging GPs and A&E Depts to identify high risk fallers (eg. those who
have presented with a fall)
– FPCs work in Hospitals and Care Homes. Have identified issues and
more work is needed to engage hospital AHPs and Care Home Staff
Comparison of current strategy with
the AGS/BGS Guidelines
Assessment
History of falls
Medications & Medical
Conditions
Vision
Gait and Balance
Lower Limb Joints
(assistive devices)
Neurological (sensory) &
Continence
Cardiovascular
Multifactorial intervention
(as appropriate)
Gait, balance and exercise
programmes
Medication modification
Postural Hypotension Treatment
Environmental Hazard
Modification
Cardiovascular disorder treatment
Emergency admissions due to falls
in the home by age group
70
60
50
40
30
20
10
Age (years)
0
10
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
0
Number of Emergency Admissions
Emergency Admissions due to falls in the home by age
Cumulative percentage of
emergency admissions by age
range
Emergency admissions due to falls in the home, 2008, cumulative percentage
100%
Greater Glasgow & Clyde
Patients aged 65+ account for 57% of admissions
Patients aged 75+ account for 43% of admissions
Patients aged 80+ account for 31% of admissions
Patients aged 85+ account for 17% of admissions
Greater Glasgow
Patients aged 65+ account for 55% of admissions
Patients aged 75+ account for 42% of admissions
Patients aged 80+ account for 30% of admissions
Patients aged 85+ account for 17% of admissions
90%
80%
60%
50%
40%
30%
Greater Glasgow & Clyde
Greater Glasgow
20%
10%
103
97
94
91
88
85
82
79
76
73
70
67
64
61
100
Age years
58
55
52
49
46
43
40
37
34
31
28
25
22
19
16
13
10
7
4
0%
1
Percentage
70%
Percentage of emergency
admissions due to falls
70%
60%
50%
Greater Glasgow & Clyde
Greater Glasgow
40%
30%
20%
Place where fall occured
Trade and service
area
Street and
highway
Sports and
athletics area
School, other
institution and
public
administration area
0%
Residential
institution
10%
Home
Percentage of total falls by place of occurance
Percentage of emergency admissions due to falls, age 65 or over, admitted in 2008, Greater Glasgow &
Greater Glasgow & Clyde
Number of admissions due to falls
in relation the number of medical
conditions diagnosed
Number of different conditions that persons aged 65 or more, admitted as the result of a fall in 2008, have had
recorded on previous admissions, Greater Glasgow & Clyde
800
700
Number of patients
600
500
400
300
200
100
0
1
2
3
4
5
6
Number of admissions
7
8
9
10
Emergency admissions and bed
days occupied from falls
Injuries to Hip and Thigh
Injuries to the Head
Emergency
Admissions
for falls
(number)
% total
adm.
for falls
Bed
Days
(averag
e
number
)
% total
bed
days for
falls
admissi
ons
Emergency
Admissions
for falls
(number)
% total
adm.
for falls
Bed
Days
(averag
e
number
)
% total
bed
days for
falls
admissi
ons
Greater Glasgow
and Clyde
376
35.6%
33.5
51.1%
178
16.8%
10.5
7.6%
Greater Glasgow
271
36.7 %
32.8
52.6%
128
17.3%
11.7
8.8%
Relationship between emergency
admissions and deprivation
Greater Glasgow & Clyde
Rate per 100,000 persons having had an emergency admission due to a fall in the home, persons aged 65 or
more, 2006
600
Rate per 100,000 population
500
400
300
200
100
0
1 - Least Deprived
2
3
Deprivation quintile
4
5 - Most Deprived
Deaths due to falls by deprivation
index
Rate per 100,000 population of deaths in Scotland of people aged 65 or more who died as the result of a fall, 2006
90
Rate per 100,000 population
80
70
60
50
40
30
20
10
0
1 - Least
Deprived
2
3
4
5 - Most
Deprived
1 - Least
Deprived
Deprivation quintile
2
3
4
5 - Most
Deprived
Emergency Admissions due to falls
over a ten year period (1998-2008)
1998
2008
% change over 10 yrs
Total admissions due to
falls in 65+
3939
4240
+ 7.6%
Admissions due to falls
at home
1567
1059
-32.4%
Admissions due to falls
in residential
institutions
309
205
-27.2%
Admissions due to falls
in the street/highway
330
199
-39.7%
Unspecified or unknown
place
1561
2074
+32.9%
Bed days, emergency admissions and
mean stay due to falls in the home in
the 65+ age group 1998-2008
Greater Glasgow
Greater Glasgow & Clyde
Year
Bed
Days
Number of
admissions
Mean
Stay
Bed
Days
Number of
admissions
Mean
Stay
1998
34248
1173
29.2
48261
1567
30.8
2008
16909
740
22.9
24624
1059
23.3
%
Change
1998 to
2008
-50.6%
-36.9%
-21.7%
-49.0%
-32.4%
-24.5%
%
Change
2005 to
2008
-31.5%
-8.5%
-25.1%
-30.2%
-10.5%
-22.1%
Number of emergency admissions
due to falls in the home
Number of emergency admissions due to falls in the home, Greater Glasgow and Greater Glasgow & Clyde
1800
Number of emergency admissions
1600
1400
1200
1000
800
600
400
200
0
1998
1999
2000
2001
2002
2003
Year of admission
2004
2005
2006
2007
2008
Comparison with Scotland
Admission due to falls in the home (1998-2006)
9000
8000
7000
6000
5000
Scotland
4000
Greater Glasgow & Clyde
% change in Scotland = -5%
% change in GGC = -28%
3000
2000
1000
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
Falls Admissions in England related to frailty in over 60 year olds
1999-2008
Codes W00, W01, W04-8, W010, W018-19
250,000
Growth 5.6% per year
200,000
150,000
100,000
50,000
0
98-99
99-00
00-01
01-02
02-03
03-04
04-05
05-06
06-07
07-08
Bed days due to admission for
falls in the home
Emergency admissions due to falls in the home, aged 65 or over, bed days
60000
50000
Bed days
40000
30000
20000
Greater Glasgow
Greater Glasgow & Clyde
10000
0
1998
1999
2000
2001
2002
2003
Year of admission
2004
2005
2006
2007
2008
Bed-days in England for frailty related falls in over 60 year olds
1999-2007
Codes W00, W01, W04-8, W010, W018-19
3,000,000
Growth 1.7% per year
Estimated from proportion of FCEs by age group
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
98-99
99-00
00-01
01-02
02-03
03-04
04-05
05-06
06-07
07-08
Hip fracture admissions in over 65s
Emergency Admissions due to Hip Fractures Codes
S.72.0-72.2 (1998-2008) for
2,000
1,500
1,000
500
Greater Glasgow & Clyde
Greater Glasgow
No change –0.4%
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Admissions for Hip Fractures in England
(ICD S72.0, 72.1 and 72.2)
66,000
Growth 1.8% per year
64,000
62,000
60,000
58,000
56,000
54,000
52,000
50,000
1998-1999
1999-2000
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
In a bit more depth…
• CFPP referrals and interventions
– Any parts of the process that need work?
• Strength and Balance Interventions
– Do they improve balance?
– Do they reduce fear of falling, improve balance confidence and
quality of life?
– Why do people not necessarily progress from rehab-led to
instructor-led classes?
• Assessment of bone health in Falls Clinics
– Can we use a “tool” and not do DEXA scans?
Compared to Other Falls
Services
• SDO Report 2007 – services in England
– 231 services reported back - median new attendances p.a = 180
(range 10–1700) at a cost of £32 million!
– 116 Community based services
• Average cost £110k
• see on average 195 pts p.a
– 110 Acute based services
• Average cost £171k
• see on average 269 pts p.a
– 5 A&E based services
• Average cost £363k
• refer on average 1000 pts p.a to GP etc.
• CFPP GGC sees 2652 pts p.a – at unknown cost
0
152 158
Jan-07
Feb-07
133
Mar-07
144 144
Apr-07
201
May-07
Jun-07
162 156
Jul-07
Aug-07
150
144
Sep-07
150
Oct-07
204
Nov-07
100
Dec-07
173 164
Average 2007
Jan-08
Feb-08
177
Mar-08
300
Apr-08
350
May-08
Jun-08
250
Average 2008 Jan-Jun
200
Average 2007 & 2008
Number of people referred
CFPP Referrals
CFPP - Referrals per month Jan 07 - Jun 08
343
262
221 233
188
139
84
50
0
IRIS/DART
Home carers
Health Visitor
Pharmacy
70
SN
Practice Nurse
Falls Clinic - Consultant
Accident & Emergency
Family Member
Occupational Therapy (all)
District Nurse / Nurse
Social Work Departments
OTHER **
Fracture Clinic
Self Referral
Physiotherapy (all)
G.P
Pendent Alarm, Glasgow
CFPP Referrals
CFPP Source of Referrals - Average and percentage per
month (Jan 07 - Jun 08)
80
Average/month
%
60
50
40
30
20
10
709
Over 65’s
presenting to A+E
482
Audit (July-Sept 2008)
of A & E attendee’s at
the SGH
Not fall related
227 falls
32% of all A & E
attendee’s over the
age of 65 have had a
fall
6
Admitted or
already inpatient
221 outpatient
falls
(Potential referrals to
community falls team)
65 #
159 non #
3 falls with
multiple
injury
Mean age 68yrs
Median age 76yrs
65 had had a fracture
and half of these had
a history of falls
66 ♂ (74.9 yrs)
155♀ (77.6yrs)
2 were referred to the
CFPP direct from A&E!
34
History of falls
(18 with previous
#)
31
1st
fall
91
History of falls
68
1st
fall
0
Deceased
Parkinsons
IRIS/DART Involved
Already Visited < 1per month
Care Home Dweller
Out Of Area
No Fall
In Hospital
Too Young
COPT Already Involved
Referred to COPT - urgent needs
Black Out - fast track to Clinic
Exercise Class - direct access
Declined
Not home - client to return phonecall
CFPP appointments
Outcome of CFPP Telephone Triage - Reasons for non-appointment
- Average and percentage per month (Jan 08 - Jun 08)
100
90
no.people
80
% total referrals
70
60
50
40
30
20
10
CFPP workload
CFPP - Home visits - Average per month (Jan 08 June 08)
120
102
90
100
80
60
40
12
20
0
Visits - total
Visit after 1st contact by
phone
Visits where client has
returned call
0
Handyperson
Sensory Impairment
Continence
DADSGP
S/W
DADS
Dietician
Audiology
S.W.O.T.
COPT
Podiatry
Pendant Alarm
Occupational Therapy
Physiotherapy
Falls Clinic
Pharmacy
CFPP Interventions
CFPP Referrals following home visits - Average
per month (Jan 07-Jun 08)
70
60
50
40
30
20
10
Physiotherapy Intervention
•
•
•
•
•
•
12 Strength & Balance Classes
Classes locally delivered
Free transport service (70% utilise)
12-18 week attendance
Home Exercises
Partnership working with Day hospital and
Leisure services (Glasgow Culture & Sport)
Hospital Falls
Clinics
COPT/IRIS/DART
(ref made by
physiotherapist)
CFPP
Physiotherapy
assessment
Level 1 Day Hospital class Tinetti 15-18 Physio led
Level 2 CFPP community class Tinetti 19-28 Physio led.
VITALITY community classes levels 1-4 Instructor led
Osteoporosis and Ozone classes for low risk fallers
Referral Pathways for Exercise Classes– exit and entry routes
Strength & Balance
Programmes
• Evidence based exercises
– (Skelton 2005; Robertson 2001; Campbell 1999)
• Evidence based “deliverers”
– Physiotherapists and trained Postural Stability
Instructors (Skelton 2004)
• Evidence based duration
– Dose of 50 hours of balance challenging
exercise (Sherrington 2008)
Attendance at classes
CFPP Exercise Class Attendance- average
per month citywide 2007
277
300
245
250
200
Number of
150
people
100
17
50
15
es
ra
t te
la
Re
gu
la
ta
rt i
ng
C
nt
sS
Pa
tie
Ne
w
nd
e
ss
PP
CF
at
ss
es
se
d
nt
sA
Pa
tie
Ne
w
To
t
al
at
te
nd
ee
s/
m
on
th
0
Evaluation of effect
• N= 274 clients considered over a time period in 2007.
• Attended on average 11.9 (sd 3.8) weeks
• Outcome measures:
– Duration of attendance
– Functional tests
•
•
•
•
•
•
Tinetti Mobility and Balance Score
Timed Up and Go
180 degree turn
Functional Reach
Confidence in Maintaining Balance
Tinetti’s Falls Efficacy Scale (FES)
– Patient Satisfaction Questionnaires (N=91)
• Same assessor throughout - not all tests completed on
all clients
Outcome measures
Test
Mean (sd)
Tinetti Balance
Score
180 deg turn (deg)
Functional Reach
(cm)
TUAG (sec)
ConFBal
Tinetti FES
Number Before
of clients exercise
sessions
274
23.1 (3.3)
After
exercise
sessions
24.8 (3.1)
P-value
253
112
5.5 (1.9)
19.2 (5.9)
5.0 (1.6)
20.9 (6.9)
0.000
0.000
137
162
43
18.6 (6.7) 16.3 (5.9)
19.4 (3.9) 16.9 (3.4)
29.3 (16.5) 21.5 (11.6)
0.000
0.000
0.000
0.0002
Balance improvements are
duration dependent
• The Tinetti Mobility and Balance
Score showed considerable
improvement, but the change was
dependent on duration of exercise
attendance.
• Those attendees that drop out of
sessions before 12 weeks are
unlikely to see clinically significant
changes in their balance.
• This is in line with the recent
systematic review of exercise
(Sherrington et al. 2008) where a
dose of at less than 50 hours confers
little benefit to fall risk reduction.
Client Satisfaction
• Satisfaction forms at week 10 of their exercise programme (n=117
issued).
• 91 patients returned the forms (response rate 78%).
• 85% had received information about the class before the sessions
started and most (83%) found the pre-class information useful.
• Only 1% thought the class was not in a suitable location; the staffs
were not helpful; the exercises were rushed, too short or not well
explained (showing a high degree of satisfaction with facilities and
delivery).
• 98% felt the exercise classes were beneficial and 94% thought the
sessions were good or very good.
• Open response questions showed good improvements to wellbeing
(see next slide) however, many people just wrote “enjoyed” in this
section!
Open responses to feedback
Open responses to any improvements felt as
a result of exercise sessions (n=91)
Confidence /
wellbeing / mood
Number of patients
35
30
Balance
25
Walking / stamina /
fitness / mobility
20
15
Strength / muscle
tone
10
5
Social benefits
0
Improvement/Benefit
Flexibility
Summary
• The CFPP exercise service to prevent falls in Glasgow
does improve many of the known risk factors for falls
• The benefits are duration dependent
– clients should be encouraged to adhere for at least 12 weeks,
ideally to the maximum 18 weeks and then to move into normal
community exercise sessions for older people to maintain the
improvements
• High degree of client satisfaction (though questionnaire
could have been designed better)
WHAT ARE THE EFFECTS OF THE GGC FALLS EXERCISE
SESSIONS ON FEAR OF FALLING, BALANCE CONFIDENCE AND
QUALITY OF LIFE IN GLASWEGIAN FALLERS?
Gaynor McGrath
MSc Rehabilitation Science
Glasgow Caledonian University
Submitted Oct 2009
Aims and Methods
• Objectives: To examine whether a 12 week strength and balance exercise
class improved an individual’s perception of their fear of falling, balance
confidence and quality of life and whether there was an inter-relationship
between outcome measures pre and post the exercise intervention.
• Methods: Prospective cohort study.
• Participants: Female fallers (n=13) aged >=65 years
• Questionnaires specific to fear of falling (SFES-I), balance confidence
(CONFbal) and quality of life (SF-12) were completed prior to and on
completion of the 12 week exercise intervention.
Results and Conclusion
• Results: following completion of the 12 week exercise intervention there
was a significant reduction in fear of falling (p<0.05) together with a
significant improvement in balance confidence (p<0.05) and quality of life
(p<0.05). However, the only significant inter-relationship between
outcome measures was between fear of falling and balance confidence
post exercise intervention (p<0.05).
• Conclusion: An exercise intervention is effective in reducing fear of falling
whilst improving balance confidence and quality of life in community
dwelling older females 65 years and older. It also improves the interrelationship between fear of falling and balance confidence post
intervention.
WHAT ARE OLDER PEOPLE’S VIEWS ON THEIR FORTHCOMING
TRANSITION BETWEEN THE PHYSIOTHERAPY-LED FALLS
PREVENTION EXERCISE CLASS AND THE INSTRUCTOR-LED
FALLS PREVENTION EXERCISE CLASS?
Aisling O’Connor
MSc Rehabilitation Science
Glasgow Caledonian University
31st January 2009
Falls Intervention Programme
• GG & C – tiered exercise programme:
Physiotherapist-led community class (12-18 weeks)
Postural Stability Instructor (PSI)-led class

Benefits of Falls Prevention Exercise Programmes
(Hauer et al., 2003; Skelton et al., 1995; Narici et al., 2004; Mazzeo & Tanaka, 2001)
Exercise intervention greater than 6 months in duration is
necessary (Skelton, 2007).


PSI-led class: low uptake & high drop-out rates
Aims
• Explore older people’s views on falls exercise classes
• Transition from physiotherapist-led classes to PSI-led
classes
• Motivators & Barriers to the uptake and adherence
• Increase attendance rates at PSI-led classes
Methods – Qualitative Research
• Design: Principles of grounded theory.
• Sample: 5 participants from physiotherapist-led class
(saturation point reached)
• Recruitment: Visit by researcher to classes
• Data Collection: Semi-structured interviews: 7 open
questions
• Analysis of data: Transcription of interviews
-
Open coding >> axial coding >> selective coding (+ memo writing)
Findings
MOTIVATORS
Benefits of Exercise (physical
& psychological)
Desire to Improve
Social Interaction
Confidence in Class Set-Up
BARRIERS
Knowledge of PSI-led
Class
Low Self Efficacy
Low Outcome
Expectations
New themes.…Motivator
CONFIDENCE IN CLASS SET-UP
- Not previously discussed in the literature
- “...But I mean these people, whether it’s this class or
the next advanced class, presumably they are experts
in their own field.” (P4, pg.10, L358-360)
New themes….Barrier
KNOWLEDGE OF PSI-LED CLASS
Not previously discussed in the literature
“…What’s this other class?” (P1, pg.1, L5-6)
“...What time would it be?” (P2, pg.3, L109)
“...Where would I have to go in the first place?”(P5, pg.11, L419)
Clinical Implications
• Lack of knowledge of PSI-led classes
• Increase awareness of Falls Prevention Services
- booklet?
- DVD?
- reinforce information every week?
• Essential if attendance rates at PSI-led classes are to be
increased and the risk of falling reduced
Future Research…
• …on the transition between classes with larger sample sizes
& bigger geographical area
• …strategies to encourage older people with low self efficacy
But most importantly…
• Effective strategy to inform older people of their options
within Falls Prevention Programmes urgently needed!
How useful is the fracture Risk
Assessment Tool (FRAX) in a falls
clinic population?
McCarthy C, Skelton DA, Gallacher S, Mitchell LE
Abstract presented at 10th National Conference on Postural
Stability and Falls, Blackpool, 07/09/09
So what about case finding for
bone fragility?
Used to determine 10 year fracture risk in community dwelling adults –
then NOGG suggests guidance on treatment
NOGG Advice based on FRAX
Research Questions
• What are the implications of using FRAX / NOGG in a
falls clinic Setting?
• Can they identify those patients who would benefit from
BMD assessment?
• Can they be used to determine treatment without the use
of DEXA?
Methods
• 44 consecutive patients (33 F) attending a falls
clinic
– Mean age 78.0 (sd 6.0) years
• BMD measured
– Lunar Prodigy, L2-L4 and neck of femur
• FRAX and NOGG assessed
• Statistics
– Sensitivity, specificity, negative predictive values,
positive predictive value, false negative and false
positive rate for each FRAX cut off and NOGG advice
to treat or not – before and after BMD measurement
Demographic Results
Mean
St Dev
Tinetti (score)
20.2
5.4
TUG (sec)
19.7
8.1
FRAX score major OP
(%)
17.2
8.6
FRAX score hip (%)
7.8
5.9
BMD at Spine
-0.5
1.8
BMD at hip
-1.7
1.1
• After DEXA
– Total 29.5% (n=13) had Osteoporosis (T < -2.5)
– 4 at hip and spine, 1 at spine alone, 8 at hip alone
– A further 47% (n=21) had Osteopenia at spine and/or hip (T < -1)
Results pre-DEXA
• NOGG advice (DEXA or treat) followed:
– 46% (n=6) of those with OP at either spine and/or hip would not
be treated or advised a DEXA
– Of those where DEXA was advised (n=18), 72% did not have
osteoporosis (n=13)
– Treatment advised in 2 patients both of whom had osteoporosis
on subsequent DEXA
FRAX and NOGG not good in falls clinic at
predicting need for DEXA and treatment
Pre-FRAX
NOGG
Advice
Sensitivity
%
Specificity
%
NPV
%
PPV
%
FP
%
FN
%
DXA advised
and has OP
53.9
58.1
75.0
35.0
41.9
46.2
DXA advised
and has OP or
OS
42.9
55.6
20.0
79.0
44.4
57.1
The Benefits
• ‘Loss leader’ that has led to a strong relationship
– Access and willingness to work on research within
various parts of the service
• Masters students data projects x 2
• 2 large NIHR outline bids, dementia and physical activity,
visual impairment and falls
– Memorandum of Agreement to increase research
capacity within Specialist Registrars
• Footwear and balance in wards
• FRAX and BMD in Falls Clinic Attenders