Bone Health

Introduction: Falls are a leading cause of mortality and morbidity in older people and the risk of falling is exacerbated by underlying mental health conditions and associated treatments. NICE recommends that people who fall should undergo multifactorial assessment including a post-fall protocol with assessment for injury before being safely moved, a timely medical examination (within a maximum of 12 hours or 30 minutes if fast-tracked), neurological observations (if there is suspicion of head injury or unwitnessed fall) and a medication review. Aim: We aimed to assess the quality of post-falls assessment and documentation in order to identify areas for improvement to reduce potential harm from injuries and implement strategies to reduce further falls. Methods: We identified ten falls over a 3-month period on two old age psychiatric inpatient wards. Data collected from e-notes was analysed for assessment for injuries, medical review, neurological observations and medication review. We also looked whether patients had OT/Physio input post-falls and MDT discussion to determine the likely cause for fall. Results: Only 40% of patients had a medical assessment completed within 12 hours. There was suspicion of head injury in 40% of patients but none of them had neurological observations completed. In 20% of falls, an MDT discussion took place to determine likely cause of fall and patients had their medications reviewed post-falls. Almost 90% had OT/physio input post-falls. Conclusion: We have since conducted a survey among healthcare professionals to identify common knowledge gaps that can be targeted to improve quality of care post-falls and conducted teaching sessions on relevant themes. Feedback has showed participants confidence has significantly improved in post-falls assessment. We have also created a weekly falls review meeting and designed and displayed a post-falls board with all necessary information. We aim to re-audit our practice now that changes have been implemented.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to community based service and has access to rapid diagnostic and intervention services. Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers. Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls. Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services. Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

Introduction

Fracture prevention is a key component in the care of frail patients who fall. Patients that have already fallen and suffered a fractured neck of femur are highly likely to fall again, and have proven themselves high risk for fracture. Bone protection is a priority, and recent guidelines recommend IV Bisphosphonates as an appropriate 1st line drug. Vitamin D level should be 50 or above before this is given.

Method: I audited the notes of 41 patients age 60 years or over who were admitted in 2022 with a fractured neck of femur. I reviewed their admission Vitamin D level, and whether they required loading with Vitamin D before IV Bisphosphonates could be given. I reviewed the loading regime used, and how many of the patients had received bone protection medication, either as an inpatient or post-discharge. I liaised with 3 other neighbouring trusts to find out their current Vitamin D loading regimens to compare to our own.

Results: The audit identified that 54% of those patients required Vitamin D loading before they could be given IV Bisphosphonates. 36% of those never had their loading regime prescribed, and of those that did all were prescribed a 7 week long regime. 1 patient was already receiving IV Bisphosphonates prior to admission, and continued on those. 4 Patients were prescribed PO Bisphosphonates. 4 patients were Fast-Track or EOL. 7 patients had low CrCl preventing use of bisphosphonates. Of those that remained, none got inpatient treatment.  I identified that the long loading regime was proving a barrier, and so drafted a new rapid loading guideline, similar to the practice of nearby trusts. Re-audit to assess the impact of this will be performed in July & August 2023 with results presented at conference

Introduction:Aging has been defined as a progressive, generalized impairment of function resulting in a loss of adaptive responses.Balance impairment is a major contributor to falling in elderly as efficiency of postural control system decreases with aging.Several different exercise programs have been suggested to address balance and falls in elderly.Virtual reality gaming and dual task training on balance may be an effective tool for addressing these problems because it includes different elements of balance which may improve functional mobility and is at the same time enjoyable and engaging.

Method:A total of 30 participants with the mean age of 67.63 ±4.32 years were included in the study, they were randomly divided in two groups. Group 1(Virtual reality Gaming) and Group 2(Dual task training).Both the groups received conventional therapy along with the specific interventions mentioned.The total duration of the intervention was 2 weeks and 5 sessions were given per week, each lasting for about 40 minutes.Pre and post-assessment for balance was assessed by scales including One-legged standing(OLS) test and Performance Oriented Mobility Assessment(POMA).The within-group comparison was made using Wilcoxon Signed rank test and between-group using the Mann Whitney U test to see the effect of treatment intervention.

Results:Within-group comparison for OLS and POMA showed statistically significant differences for the Pre and Post-intervention values (p<0.05).Between-group comparison demonstrated that Dual task training was more effective in improving the OLS balance as compared to virtual reality gaming (p=0.038).For POMA both the interventions were equally effective (p=1.00)

Conclusion:The study concluded that both Virtual reality Gaming and Dual task training were equally effective in improving balance when measured on POMA scale but Dual task training proved to be more effective in improving the OLS balance of the elderly when compared with Virtual reality.Therefore, we conclude that both the interventions can be used in improving balance of the elderly.

Introduction:Aging has been defined as a progressive, generalized impairment of function resulting in a loss of adaptive responses.Balance impairment is a major contributor to falling in elderly as efficiency of postural control system decreases with aging.Several different exercise programs have been suggested to address balance and falls in elderly.Virtual reality gaming and dual task training on balance may be an effective tool for addressing these problems because it includes different elements of balance which may improve functional mobility and is at the same time enjoyable and engaging.

Method:A total of 30 participants with the mean age of 67.63 ±4.32 years were included in the study, they were randomly divided in two groups. Group 1(Virtual reality Gaming) and Group 2(Dual task training).Both the groups received conventional therapy along with the specific interventions mentioned.The total duration of the intervention was 2 weeks and 5 sessions were given per week, each lasting for about 40 minutes.Pre and post-assessment for balance was assessed by scales including One-legged standing(OLS) test and Performance Oriented Mobility Assessment(POMA).The within-group comparison was made using Wilcoxon Signed rank test and between-group using the Mann Whitney U test to see the effect of treatment intervention.

Results:Within-group comparison for OLS and POMA showed statistically significant differences for the Pre and Post-intervention values (p<0.05).Between-group comparison demonstrated that Dual task training was more effective in improving the OLS balance as compared to virtual reality gaming (p=0.038).For POMA both the interventions were equally effective (p=1.00)

Conclusion:The study concluded that both Virtual reality Gaming and Dual task training were equally effective in improving balance when measured on POMA scale but Dual task training proved to be more effective in improving the OLS balance of the elderly when compared with Virtual reality.Therefore, we conclude that both the interventions can be used in improving balance of the elderly.

Introduction  

People with Parkinson’s (PWP) are twice as likely to fracture and over twice as likely to develop osteoporosis (1. Henderson et al, Parkinsonism & Related Disorders, 2019, Vol.64, pp.181-187). This is associated with significant morbidity (1). Assessment of bone health is often overlooked in clinic (2. UK Parkinson’s Excellence Network, 2019, pp.4-56), deeming it a priority area for improvement. Our project focuses on implementing routine bone health assessment for PWP in clinic, to achieve better standards of care.  

Methods  

This was a 12-week medical student led project, supported by the specialist multi-disciplinary Parkinson’s team (MDT) in Cardiff and Vale. To establish baseline current practice, a retrospective fracture risk assessment was completed for 141 patients using the Bone-Park algorithm (1). To screen bone health, we developed a bone health proforma, incorporating the FRAX tool. We trialled proforma integration in clinic, by gaining patient feedback and analysing logistics. Administration was done in a patient, healthcare assistant (HCA) and clinician led format.  

Results  

The retrospective analysis showed that 61.7% (n=87/141) of patients required bone health intervention. Of these patients, 41.4% required vitamin D supplementation. 40.2% required bone density measurement. 18.4% required bone strengthening treatment. This was subsequently initiated. Issues identified with self-administered forms (n=8/30) were physical difficulty in completing forms and confusion around medical terminologies, which clinician led administration (n=14/30) could support. HCA’s (n= 8/30) required MDT support to complete forms. 

Conclusion  

As PWP have an increased fracture risk (1), our results provide compelling evidence that routine bone health assessment should be better integrated into Parkinson’s management. Clinician led administration of our proforma was the best model of integration. This was based on patient preference, a reduction in duplication and improved accuracy. Further bone health education is needed within our MDT, which we aim to incorporate through our Parkinson’s web application.   

Introduction

Old age psychiatry wards facilitate patients who have physical health needs alongside mental health needs, deeming them high risk for falls. Following a fall, best practice suggests a doctor should perform a medical review. An audit of this was performed within the Harplands Hospital in-patient elderly care psychiatric ward, which revealed incomplete documentation or the absence of a review. Subsequently, a post-falls proforma was implemented and a re-audit was performed.

Method

Audit cycle one gathered data on post-falls documentation between August and September 2020. A falls proforma was then introduced and cascaded to ward staff. Audit cycle two then gathered data on post-falls documentation between November and December 2021. Information collected included if falls occurred within normal working hours (Monday-Friday, 09:00-17:00), whether witnessed or unwitnessed, if an assessment was documented, whether a head injury occurred, whether anticoagulation status was documented, and whether neurological observations were completed.

Results

The first cycle showed a total of 31 falls. Insufficient documentation was recorded in 5 falls (16.1%), including 2 falls (6.5%) with no documentation of a physical assessment. A head injury was recorded following 25% of falls, with anticoagulation status documented in 100% of cases. The re-audit showed a total of 10 falls. All falls (100%) were reviewed by a doctor with documentation recorded, including a brief history and assessment. A head injury was recorded in 4 cases (40%), with anticoagulant status only being documented in one case (25%).

Conclusion

This audit demonstrated the implementation of a falls proforma improved post fall documentation. It was noted that the falls proforma was not always utilised, which was thought to be due to junior doctor rotational changes alongside lack of communication regarding this tool. Moving forward, this second cycle identified the need for proforma digitalisation and junior doctor education at induction. 

Fractures occurring after “low energy trauma” are described as fragility fractures. They most commonly happen in the spine, hip and wrist due to osteoporosis and its associated risk factors, including gender, age, medications (e.g. steroids), etc (1). Menopause in women also has a drastic impact on the risk of osteoporosis. In 2019, 3,775,000 UK citizens had a diagnosis of osteoporosis - 820,000 men and 2,955,000 women. In the same year, there were 527,000 new fragility fractures in the UK (2). Nevertheless, osteoporosis and fragility fractures do not only pose a problem within the UK. It is estimated that the number of hip fractures worldwide will increase by 4,600,000 between 1990 and 2050 as a result of an ageing population (3). The percentage of the world's population over the age of 60 is projected to rise from 12% to 22% between 2015 and 2050 (6). This age shift in particular will bring on challenges as the risk of hip fractures doubles every 10 years after the age of 50 (3). Fragility fractures can have a drastic effect on patient well-being. Surgery for hip fractures for instance has a 4% mortality rate and approximately 20% of patients die within a year (3). Patient mobility, housing conditions and quality of life all deteriorate after hip fractures (4). The impact on health economics is also significant. Direct medical costs resulting from fragility fractures in the UK were approximated at £1.8 billion in 2000 and were projected to rise to £2.2 billion by 2025 (1). However, newer reports have shown that we underestimated this burden with the total annual cost of fragility fractures in the UK reaching £4.4 billion in 2022 (5).

Introduction:

Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². Previous work highlights drivers, but not experiences that explain why they occur.

Aim: to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey of frontline ambulance staff from one English ambulance service in May 2023. Including open questions that generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Results:

81 participants completed the survey. Analysis identified three themes:

Care Pathways: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.

“Only issue does arise when it’s between 1700 and 0900, as there’s very very limited alternative pathways” P6

Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice. 

Communication: Decision-making confidence was impacted by the participants experiences; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.

"Many services are helpful and willing to assist with education for hospital avoidance.” P18

Conclusion:

Prominent themes arose from the challenge of a regional and 24/7 ambulance service, not having consistent pathways available. This variation led to concerns when responding to patients outside of the clinician’s usual area and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2006) Qualitative Research in Psychology, 3; 77-101.

Introduction

Postural BP readings are important in assessing older people, but are infrequently measured (1) The National Audit of Inpatient Falls (NAIF) 2022 has shown measurement of lying standing blood pressure (LSBP) remains below 50% (2)  

NICE guidelines suggest checking LSBP in patients with:  

1) Hypertension and postural hypotension symptoms  

2) Hypertension and Type 2 diabetes  

3) Hypertension and age ≥ 80 years (3)  

4) Patients presenting with falls (4).  

We aimed to update local data for LSBP recording and investigate LSBP measurements in hypertensive patients.

Method   

Data was collected across 4 wards in University Hospital of Wales between 22^nd May and 9^th June. Patient notes and NEWS charts were reviewed to establish whether an LSBP was necessary and carried out according to NICE guidelines (2) and whether appropriate reasons were documented.   

Results   

The table below shows the number of patients required and completed LSBPs.  

Total Number of Patients  98  

Number of Patients requiring a LSBP  76 

Total number of postural measurements completed 18 (16 LSBP, 2 sit/stand) 

Number of acceptable reasons for not completing postural BP reading  12 

All categories of patient requiring a LSBP have <40% completion; no LSBP’s were completed in patients that were hypertensive and diabetic.

 Conclusion  

Results indicate that local LSBP measurement requires improvement, with only 24% of requiring patients having a postural reading completed. Significant variations in guidelines (NAIF (2), MFRA (4), Cardiff and Vale Falls Policy (5)) have been highlighted as a potential factor, hence clearer guidance is needed on when LSBP is required, to improve detection of postural hypotension and therefore improve falls prevention and hypertension management.  

 References  

1. Detecting Risk of Postural hypotension. BMJ. 2020  
2. National Audit of Inpatient Falls report 2022.  
3. NICE. Hypertension in adults 2022  
4. NICE. Falls in older people 2013. 
5. CAVUHB. Falls Policy 2021  

INTRODUCTION:

Constipation is common in older individuals and becomes prevalent in elderly inpatients. Those recovering from a hip fracture experience worsening constipation due to poor mobility, changes in diet and hydration, general anaesthesia and opioid use. This study explores the feasibility of the pelvic radiographs (PXR) already available in this population in assessing the severity of constipation in order to guide post-operative bowel management. AIM: To evaluate the effectiveness of diagnosis and management of constipation based on PXR findings of elderly patients presenting with hip fracture.

METHODS:

Retrospective analysis of consecutive patients aged 65 and above admitted with hip fracture to our hospital over a 5-week period. Patients without a PXR or experiencing severe complications were excluded. PXRs, medical records, drug charts and bowel charts were reviewed. Constipation was graded from 1+ to 3+ based on faeces in the sections of large bowel and rectum seen on PXR. A specific combination of oral and rectal laxatives was used based on such grading. The average time taken for the bowels to function was compared between patients with protocol-compliant management, minimally deviated management and non-compliant management.

RESULTS:

46 patients were included. Those with bowel management in line with our protocol (23) achieved bowel movement 1.7 days after surgery on average. By contrast, patients with minimal (9) and major deviations (14) from our protocol had a bowel movement respectively 3.6 and 4.2 days after surgery.

CONCLUSION:

These findings highlight the benefits of utilising admission PXRs in elderly patients with hip fracture to grade and manage constipation and, hence, reduce hospital stay and complications. Patients managed in line with our protocol experienced bowels functioning in less than 2 days, compared to over 4 days for patients with major deviations.