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How to minimise cost of expensive locums

Dr Opinder Sahota and Dr Ramin Yazdani explain the strategies GPs can use to prevent falls in older people

The need to reduce falls and fractures has risen steadily up the agenda of health care politics over recent years. The White Paper 'Saving Lives: Our Healthier Nation' of 1999 identifies 'ageing' and the 'prevention of accidents' as two of the five national health priorities. More recently, the publication of key documents and development of certain collaborative programmes recognise service provision deficiencies and recommend dedicated strategies to reduce falls and fractures.

This agenda has culminated in the decision to produce:

lA NICE guideline on falls due out next month

lThe referral of the newer treatments for osteoporosis for health technology appraisal by NICE (confirmation of publication dates awaited). 'Faller's clinics' are also to be the subject of a NICE technology appraisal.

lThe production of a NICE guideline for osteoporosis (expected June 2005).

Epidemiology and risk factors

Thirty per cent of those aged 65 and over who live in the community fall each year, increasing to 45 per cent in those aged 80 or above. Between 10 and 25 per cent of fallers sustain a serious injury and up to

6 per cent of falls culminate in a fracture. Recurrent falls are associated with increased mortality, increased rates of hospitalisation, curtailment of daily activities and higher rates of institutionalisation.

This is compounded by psychological sequelae with loss of confidence, increased fear of falling, lower quality of life1 and post-fall anxiety syndrome2. Fifty per cent of fallers will have a further fall within the next 12 months3.

In institutions the rate of falls is almost three times that of community-dwelling elderly, with injury rates also considerably higher; 10-20 per cent of institutional falls result in an osteoporotic hip fracture.

Risk factors for falls are commonly classified into intrinsic, extrinsic and environmental. Intrinsic factors relate to factors within the body (eg cognitive/ functional impairment, visual problems, balance disorders, muscle weakness).

Extrinsic factors relate to external risk (eg polypharmacy) and environmental risks include factors like poor lighting, loose carpets and rugs. The risk of falling rises as the number of risk factors increase and many factors are often involved in individual patients.

Who should we assess?

Screening the community-dwelling elderly for falls risk factors is a sensible but impractical option and so targeted assessment has to be focused on the high-risk patient.

These are patients who have had two or more falls over the last 12 months or one fall and a major injury and/or loss of consciousness over the last year. Primary preventive strategies may be cost-effective in dedicated high-risk groups and one group may be ambulatory subjects residing in residential and nursing homes.

Assessment and interventions

Multifactorial interventions

A recent systematic review4 and meta-analysis of randomised clinical trials of interventions for the prevention of falls in older people showed multifactorial falls risk assessment and management programmes to be the most effective component in reducing falls risk

(risk reduction 0.82 [95%CI 0.72, 0.94], NNT 11).

Individualised, supervised exercise (focusing on strength and balance strategies) was also shown to be

beneficial in reducing falls risk (0.86 [95%CI 0.75, 0.99], NNT 16), either as a component of individualised multifactorial intervention for those at high risk or as a primary prevention measure for otherwise healthy community-dwelling people over 80.

As the vast majority of osteoporotic fractures are the direct consequence of a fall, it is crucial a falls assessment is accompanied by a bone health

assessment.

Single intrinsic interventions

Cardiovascular

Cardiovascular disorders are responsible for as many as 77 per cent of patients presenting to the A&E with unexplained or recurrent falls and falls associated with unexplained loss of consciousness. These patients should be referred to a specialist falls/cardiology clinic.

Vision

A significant relationship exists between falls, fractures and visual acuity. Falls-related hip fractures have been reported to be higher in patients with visual impairment. Visual factors associated with two or more falls include poor visual acuity, reduced contrast sensitivity, decreased visual field, posterior sub-capsular cataract and nonmiotic glaucoma medication. Vision should be formally assessed and any remediable abnormalities treated.

Medication review

A number of types of medications have been associated with increased risk of falls, including: •psychotropics •anti-epileptics •antihypertensives •diuretics •opiod analgesics. There are no randomised controlled trials that have evaluated the manipulation of risk medication as a sole intervention in reducing falls, but medication review has been shown

to be a prominent component of

effective falls reduction in multifactorial studies3, 5-7.

Calcium and vitamin D

More specific to pharmacological intervention in the prevention of falls is the prescribing of calcium and vitamin D. Impairment in neuromuscular function is a major contributory factor for falls and there is now increasing evidence that vitamin D plays an important role in helping to maintain this. In a recent systematic review, three trials showed a positive effect of vitamin D in combination with calcium in reducing falls and/or improving physical function8.

So it is becoming increasingly common in everyday clinical practice to supplement high-risk patients with combination calcium and vitamin D (for example Calcichew D3 Forte, one tablet twice daily).

Single extrinsic interventions

Footwear

General advice recommends sensible footwear in the elderly to reduce falls, although there are no randomised controlled trials that have evaluated studies of footwear and falls reduction outcomes. But published studies have reported immediate falls-related outcomes and footwear intervention such as sway and balance. Shoes compared with bare feet, low-heeled compared with high-heeled and high mid-sole hardness compared with low mid-sole thickness shoes have all been associated with better outcomes.

Hip protectors

Hip protector pads are an effective way of reducing hip fractures within a selected

high-risk population9. Reduction in hip fracture rates of around 40-60 per cent

have been reported in institutionalised residents.

Opinder Sahota is the Department of

Health's clinical champion for

older people and consultant physician

at Queen's Medical Centre,

Nottingham

Ramin Yazdani is specialist registrar at

Queen's Medical Centre, Nottingham

Why the Government

wants to reduce the

number of falls

•The DoH has stated that the number of

falls could be reduced by 30 per cent; the national service framework aims to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen

•Up to £30 million a

year could be saved by preventing falls and fractures in care home residents

•The rate of falls in care homes is almost three times the number in the community

•Despite the weight of evidence in support

of high-strength calcium and vitamin D in reducing falls, it

remains greatly under-used

Essential elements of a

falls risk assessment

•vCircumstances relating to the fall (incorporating a witness account if possible)

•Medication

•Acute and chronic medical problems

•Vision assessment

•Gait/balance assessment

(3m 'get up & go test')*

•Lower extremity joint functional assessment

•Cardiovascular examination, including heart rate and rhythm, postural pulse and blood pressure (if appropriate heart rate and blood pressure responses to carotid stimulation)

•Neurological examination, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical function/ pyramidal/extra pyramidal/ cerebellar function)

•Environmental risks

*Subjects are asked to rise from a chair,

walk 1.5m, turn around, walk back

to the chair and then sit down

(>15 seconds equates to increased

risk of falls)

Key guidelines and policies

National service framework for older people (DoH 2001)

National Primary Care Development Team, DoH: Healthy Communities Collaborative – Falls (2003) and National Falls Collaborative (2002)

Primary Care Strategy for Osteoporosis and Falls (National Osteoporosis Society, 2002)

Guideline for the Prevention of Falls in Older People. American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedics Surgeons Panel on Falls Prevention (2001)

Scottish Intercollegiate Guideline Network (SIGN) guidelines (56; 71) on hip fracture

Useful websites

www.nice.org.uk/page.aspx?o=113089

www.boa.ac.uk/PDF%20files/care%20of%20fragility%20fractures.pdf

www.rcplondon.ac.uk/files/osteosummary.pdf

References

1 Cumming RG et al. Prospective study of the impact of fear of falling in activities of daily living, SF-36 scores and nursing home admission. J Gerontology 2000; 55: 299-305

2 Tinetti ME et al. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders.

J Geron 1994; 49: 140-7

3 Close J et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93-7

4 Chang JT et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004;328:680-9

5 Tinetti ME et al. A mutifactorial intervention to reduce the risk of falling among elderly people living in the community. NEJM 1994; 331:821-7

6 Campbell AJ et al. Psychotropic medication withdrawal

and a home-based exercise programme to reduce falls.

JAGS 1999; 47:850-3

7 Wagner EH et al. Preventing disability and falls in older adults. Am J Public Health 1994; 84: 1800-06

8 Latham NK et al. Effects of Vitamin D Supplementation on Strength, Physical Performance and Falls in Older Persons:

a systematic review 2003:51 1219-26

9 Parker MJ et al. Hip protectors for preventing hip fractures in the elderly. (Cochrane Review) 2001;2:CD001255

Preventing falls with calcium and vitamin D

Dr Lester Russell makes the case for wider

use from a GP's perspective

There are 120,000 falls annually among the UK's nursing home population of 180,000. These result in some 12,000 fractures, of which 4,500 are hip fractures. The financial cost of managing these fractures is £66 million a year, representing a significant health economic burden from a potentially preventable cause.

What should we do about it?

There is evidence that improving calcium and vitamin D intake can slow down the process of bone loss in elderly people and the literature does seem to demonstrate that this leads to fewer fractures. The crucial dosage in most of the studies that provide the supporting evidence seems to be a total daily intake of 1g (1,000mg) calcium and 800 international units of vitamin D.

Combining calcium with vitamin D also improves postural sway – reducing falls and improving musculoskeletal function significantly. Chapuy et al1 studied 1,728 women randomised to receive calcium and vitamin D supplements or placebo, looking at the incidence of fractures at 18 and 36 months. There was a significantly reduced number of fractures at 18 and 36 months. Other studies2-4 have shown similar results.

Supplementation with calcium and vitamin D for the elderly in residential care homes is now widely recommended by the Royal College of Physicians, the NHS Modernisation Agency orthopaedic service collaborative and in the national service framework for older people.

Common experience and evidence from studies suggests few of our elderly patients are receiving osteoporosis prevention. A pharmacy study in 2002 collected data on the medications of 484 residents (82 per cent ambulatory) in 15 residential care homes5. Within this high-risk population it was found 2 per cent of patients were receiving effective doses of calcium and vitamin D.

What cost and what gain?

Prescribing high-strength combined calcium/vitamin D supplementation for all residential and nursing home residents would cost around £12.5 million, based on a cost of £70 per patient per year. This would be expected to prevent around 4,500 fractures and save £29 million in costs as well as freeing up 55,000 hospital bed days with bed costs of £13.5 million.

Hence net saving on calcium/vitamin D supplementation in residential and nursing homes would be approximately £30 million.

Looking further back in the chain of prevention at the younger post-menopausal population, there is evidence that we could reduce their loss of bone mass by improving our use of bisphosphonates. The majority of pivotal clinical trials with bisphosphonates were conducted with adjunctive calcium and/or vitamin D and this is reflected in the licensed indications for alendronate and risedronate which advise that calcium and vitamin D levels must be maintained.

If we could aim to raise calcium and vitamin D to optimal levels in patients receiving bisphosphonates we might reduce the burden of preventive effort required later in life.

Lester Russell is a GP in Gosport, Hampshire, and medical adviser for NHS Direct Hampshire and Isle of Wight

References

1 Chapuy et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. New England Journal of Medicine, 1992 327: 1637-42

2 Deroisy R et al. Effects of two one-year calcium and vitamin D3 treatments on bone remodelling markers and femoral bone density in elderly women. Curr Ther Res 1998; 59 (12): 850-62

3 Larsen et al. Vitamin D and calcium supplementation prevents osteoporotic fracture in elderly community-dwelling residents:

A pragmatic three-year intervention study, Journal of Bone and Mineral Research, Vol 19, No 4, 2004

4 Dawson-Hughes B et al. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997; 337: 670-6

5 Wilcock M et al. Residential home patients and their

medicines – are we heading for a fall? Pharmacy in Practice 2002: May: 158-62

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