Falls and Frail Elderly Rapid Assessment Service.

1. Falls and Frail Elderly Rapid Assessment Service. July 4th 2015 Rebecca Marshall Band 6 Physiotherapist rebecca.marshall5@nhs.net 01332 254615

2. What Constitutes Frail Elderly People • 65 years and over • Deteriorating in day to day function • Frailty Register set up in MAU triage and ED as part of Frailty Pathway • Criteria • Over 65 & in Care Home • Over 75 & history of Falls • Over 75 & history of confusion or delirium • Over 85 & 4 or more co-morbidities • Screening tool flag live on ICM

3. Falls and Rapid Assessment Service Development of service linked in with GP commissioning – Health and Social Care Bill 2012.

4. Referrals to Falls and Rapid Assessment Service • Frail Elderly Assessment Team (FEAT) - A & E and Medical Assessment Unit • GP via choose and book • Single point of access includes referrals from wards, Intermediate Care and Community • DME Consultants • All other health professionals including Community Matrons, MH, community sectors e.g. Residential or Nursing Homes

5. Aims of Falls and Rapid Service • Reduce A & E visits and admissions by seeing patients who have fallen or at risk of falling within 48 hours of referral • Full MDT assessment • Strengthen links with other services • Prevent decline in current level of function • Improve level of function where possible • Improve confidence and reduce fear of falling

6. Falls and Rapid Service • Comprehensive geriatric assessment • Bone health • Vestibular assessment, screening • Anxiety management • Dietician, SALT • MDT meetings • Continence • Cognitive screening • Action plan, report completed • 1:1 rehabilitation/groups

7. Patient Journey • Consultant led service. • Initial Assessment: whole day session • Front sheet containing overall falls history is completed • Assessments from PT, OT, nurse & consultant geriatrician • Patients are provided with information (i.e. Lifeline, cosy feet, managing medication, healthy diet) • End of day have MDT meeting, action plan completed and sent patient, GP

8. Example Action Plan

9. Action Plan

10. Action Plan

11. Falls and Rapid Current Evidence: Fit for Frailty • Assess for presence of frailty during all encounters with health professionals • Review medical, functional, psychological and social needs based on principles of comprehensive geriatric assessment • Causes decline in function and review medications • Patient centred care with proper support plans outlining treatment goals, management plans and plans for urgent care • Recognise many frail older people in crisis will manage better in own homes but only with appropriate support systems in place

12. Fit for Frailty Continued • Derby Hospitals Frail Elderly Pathway starts with Frail Elderly Assessment Team (FEAT) within A & E and MAU • MDT working extended (staff and working hours) to provide Comprehensive Geriatric Assessment (Gold Standard for management of frailty in older person) (Fit for Frailty 2014) • Falls and Rapid Assessment are part of pathway providing MDT working with shared documentation, Frailty Register and onward referrals and management plans

13. Current Evidence • NICE Guidelines Falls in Older people: assessment after a fall and preventing further falls. (March 2015) Multi-factorial falls risk assessment should take place with the aim of identifying individual risk factors for falling • Includes – Identification of falls history • Assessment of fracture risk • Assessment of visual impairment • Assessment of urinary incontinence

14. Physiotherapy within the service “Older people who present for medical input due to a fall or report current falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multi-factorial falls risk assessment” (NICE 2015) • MDT working • Outcome measures • Goal setting • Advice and education • Exercises 1:1/classes (Otago) • Signposting exercise groups • Indoor/outdoor mobility assessment

15. Physiotherapy Continued • Stairs/transfers/gait assessment • Education group • Strength/balance work • Backward chaining • Footwear/Orthotics • Improve confidence and reducing fear of falling • Reducing/help manage pain

16. Evidence for Physiotherapy • Balance impairment and muscle weakness most prevalent modifiable risk factors for falls (NICE 2015) • Strength and balance training has been identified as an effective single intervention and as a component to reduce subsequent falls (NICE 2015) • Exercises must be of the correct type, duration and intensity (Age UK 2013) • Exercises challenging, resistance training, in standing, be progressive, 2-3 times a week and continued over a duration of 50 hours. (Age UK 2013), (Sherrington et al 2011) • Goal setting is important (AGILE 2012)

17. Evidence Continued • Important to consider the UK physical Activity guidelines for Older adults (Start Active, Stay Active 2011) • Some physical activity is better than none, minimise sedentary activity • Older adults active daily. Over a week activity least 150 minutes (2 ½ hours) of moderate intensity • Active regularly at moderate intensity can get benefits through 75 minutes of vigorous intensity activity • Muscle strength, balance and co-ordination should occur twice a week

18. Future Development • The Functional Fitness MOT (Bob Laventure British Heart Foundation National Centre, Loughborough university and Prof. Dawn Skelton 2013) • Education and motivational tool • Highlights Physical Activity Guidelines for Older People • Listen and talk • Understand different components of fitness, physical activity benefits • Personalised advice very important

19. Conclusion • The impact of having a fall can be devastating and hugely impact on a persons quality of life • The falls and Rapid Assessment Service is an evidence based service that provides appropriate care and outcomes for Older Adults and the Frail Elderly Physiotherapy has a vital role in preventing frailty

20. References • AGILE: Chartered Physiotherapists working with Older People Produced by the AGILE Falls guidelines working group. (August 2012). Victoria Goodwin and Louise Briggs. • British Geriatrics Society in association with the Royal College of General Practitioners and Age UK (June 2014). Fit for Frailty Consensus best practice guidance for the care of older people living with frailty in the community and outpatient settings. • British Heart Foundation National Centre, Physical activity+health. (2012). Physical activity for older Adults (65+ years) Evidence briefing. BHF National centre for Physical Activity and health. • Charters A (2013). Age UK Improving Later Life. Expert Series, falls Prevention Exercise – following the evidence. The evidence for falls prevention exercise and how it can be applied to practice.

21. References Continued • NICE National Institute for Health and Care Excellence (March 2015). Falls in older people: assessment after a fall and preventing further falls. NICE quality standard 86 guidance.nice.org.uk/qs86 . • Sherrington C, Tiedemann A, Fairhall N, Close J C, Lord S R., (2011). Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin; 22:78-83. • The Functional Fitness MOT Bob Laventure later Life Training, British Heart Foundation National Centre, Loughborough university and Prof. Dawn Skelton (2013).