BGS Falls and Postural Stability Meeting - 2018 Conference Report
Is the falls service better in Liverpool or Manchester? How would we know? How should we be testing vision in falls clinics? How do we pick those who would most benefit from the falls clinic? Is frailty a useful construct in falls assessment and management?
These were some of the hot topics discussed at an excellent BGS Falls and Postural Stability Conference in Leeds in September. About 200 of us met for a day packed with discussion and presentations.
Dr Daniel Mackintyre from Public Health England started the day presenting the Consensus Statement on Falls and Fractures published in January 2017 (plus the resource pack in July 2017). This report aimed to use the latest evidence base to guide commissioners when they are considering provision of falls and fragility fracture services. It is a rapidly changing field, with new evidence coming to light, and local issues and drivers also come into play as commissioners decide whether to give priority to fracture liaison or falls in the present cash strapped economy. Many local programmes e.g. active balance classes are not run on the scale of those in the trials – are they still effective? The electronic Frailty Index is an increasingly used tool and is currently not included. The report is an excellent place to start, with a toolkit to come at the end of 2019, to help commissioners set up effective programmes.
The EUGMS Task and Finish group looked at a meta-analysis of falls-risk-increasing medications. The first period after starting a new medication appears to be the most risky, and the increased falls risk settles with time. Of note, the newer antipsychotics were not better than traditional ones in this analysis. Digoxin and loop diuretics were offenders, whilst statins appeared to be mildly protective. Other risks were with PPI use for more than a year.
A fairly aerated debate followed on whether frailty was a useful construct in considering falls. On the one hand, the Rockwood score on which the electronic Frailty Index is based contains many of the risk factors for falls. Recognition of frailty should trigger a comprehensive Geriatric Assessment including a falls review and medication assessment, although sadly does not always do so. On the other hand, concentrating on the frail would miss about 18 per cent of fallers who are not frail (2 million people), and may distract from upstream prevention such as encouragement of exercise in the over 60s, osteoporosis detection, and other prevention measures. The attendees of the conference were divided 50:50 – Frailty is an important predictor of falls, but it must not stop us thinking wider as well.
The RESPOND trial in Australia sought to follow up all attendees at ED with falls who were discharged home, looking at vision, bone strength, and balance. The intervention included one home visit and follow up phone calls. This led to significantly fewer further falls and fractures compared with a control group. A similar project in North Tyneside was mentioned by another speaker, which had a team to home visit callers to the ambulance service with falls which did not need medical services – this again was cost effective in preventing further falls and fractures.
Delegates had enormous fun leading one another around the coffee area, with the blind leading the blind – wearing glasses to simulate cataracts, leading those with glasses to simulate field defects (and vice versa..) It gave a real insight into feelings of fear of falling and vulnerability.
Visual assessment is often badly done in the falls clinic. Twenty-three per cent of the over 85s have visual acuity less than 6/18. As well as visual acuity, contrast sensitivity, visual fields, visual attention and depth perception are also important factors.
The Eyes Right tool kit and a quick field test might go a little way in improving the quality of initial screening. The charity sector and OTs can be a great help in aiding those who are of poor vision in adapting to their loss of vision.
These are just a few highlights of a packed day with much food for thought. Watch this space as our evidence base grows as to how best help this vulnerable group of people.
Gloucester Hospitals NHS Foundation Trust