An Evaluation of the Greater Glasgow Clyde Osteoporosis .ppt

1、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-Au

2、g 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 whe

3、re 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 comprehe

4、nsive falls screening, health education, exercise, rehabilitation and onward referralThe service is available to individuals who are over 65, live at home and have had a fall in the last year221 referrals a month in 2008Telephone triage completed within 24 hours of receiving referralHome screening c

5、ompleted within 5 working days of triage,Onward referral,Fall in past year.Community dweller.Aged 65+,Falls Admin centre-triage (within 24 hours),Open Referral,Multi-factorial Falls Risk ScreeningHome visit within 5 working days.,HFPP Physio assessment and falls exercise classes,Pharmacy review,1to1

6、 Physio at community site for musculoskeletal problem,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,Falls Clinic/ Medical review and gateway to day hospital,Multifacto

7、ral interventions,COPT/ IRIS/ DART,Pathway,Home Falls Prevention Programme,Deliver,INTEGRATED PLANS,FractureOsteoporosis Falls 95% hip fractures due to a fall 90% of hip fracturesdue to osteoporosis,Falls, Fragility & Fractures, Cryer & Patel, 2002,NICE Falls CG: specialist integrated service model,

8、 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 mo

9、dification 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

10、 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. Engagin

11、g 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

12、 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

13、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 Serv

14、ice & 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 pr

15、imary 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

16、 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

17、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 t

18、o 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 curren

19、t 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 Medi

20、cation modification Postural Hypotension Treatment Environmental Hazard Modification Cardiovascular disorder treatment,Emergency admissions due to falls in the home by age group,Cumulative percentage of emergency admissions by age range,Percentage of emergency admissions due to falls,Number of admis

21、sions due to falls in relation the number of medical conditions diagnosed,Emergency admissions and bed days occupied from falls,Relationship between emergency admissions and deprivation,Deaths due to falls by deprivation index,Emergency Admissions due to falls over a ten year period (1998-2008),Bed

22、days, emergency admissions and mean stay due to falls in the home in the 65+ age group 1998-2008,Number of emergency admissions due to falls in the home,Comparison with Scotland,Growth 5.6% per year,Bed days due to admission for falls in the home,Growth 1.7% per year,Hip fracture admissions in over

23、65s,No change 0.4%,Growth 1.8% per year,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 necessar

24、ily 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 101700) at a cost of

25、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,CFPP Referrals,CFPP R

26、eferrals,Audit (July-Sept 2008) of A & E attendees at the SGH 32% of all A & E attendees over the age of 65 have had a fall 65 had had a fracture and half of these had a history of falls 2 were referred to the CFPP direct from A&E!,CFPP appointments,CFPP workload,CFPP Interventions,Physiotherapy Int

27、ervention,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 Ph

28、ysiotherapy assessment,Level 1 Day Hospital class Tinetti 15-18 Physio led,VITALITY community classes levels 1-4 Instructor led,Level 2 CFPP community class Tinetti 19-28 Physio led.,Osteoporosis and Ozone classes for low risk fallers,Referral Pathways for Exercise Classes exit and entry routes,Stre

29、ngth & 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),Attendan

30、ce at classes,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 Bal

31、ance Tinettis Falls Efficacy Scale (FES) Patient Satisfaction Questionnaires (N=91) Same assessor throughout - not all tests completed on all clients,Outcome measures,Balance improvements are duration dependent,The Tinetti Mobility and Balance Score showed considerable improvement, but the change wa

32、s 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

33、 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-clas

34、s 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

35、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,Summary,The CFPP exercise service to prevent falls in Glasgow does improve many of the known risk

36、factors for fallsThe 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 improvementsHigh degree of client satisfaction (though question

37、naire 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

38、examine whether a 12 week strength and balance exercise class improved an individuals 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 st

39、udy. Participants: Female fallers (n=13) aged =65 yearsQuestionnaires 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

40、 the 12 week exercise intervention there was a significant reduction in fear of falling (p0.05) together with a significant improvement in balance confidence (p0.05) and quality of life (p0.05). However, the only significant inter-relationship between outcome measures was between fear of falling and

41、 balance confidence post exercise intervention (p0.05).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 inter-relationship between fear of

42、 falling and balance confidence post intervention.,WHAT ARE OLDER PEOPLES VIEWS ON THEIR FORTHCOMING TRANSITION BETWEEN THE PHYSIOTHERAPY-LED FALLS PREVENTION EXERCISE CLASS AND THE INSTRUCTOR-LED FALLS PREVENTION EXERCISE CLASS?,Aisling OConnor MSc Rehabilitation Science Glasgow Caledonian Universi

43、ty 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 &

44、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 peoples views on falls exercise classesTransition from physiotherapist-led classes to PSI-led classesMotivators & Barriers to the upta

45、ke and adherenceIncrease 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 classesData Collection: Semi-structured interviews: 7 o

46、pen questionsAnalysis of data: Transcription of interviews Open coding axial coding selective coding (+ memo writing),Findings,MOTIVATORSBenefits of Exercise (physical & psychological)Desire to ImproveSocial InteractionConfidence in Class Set-Up,BARRIERSKnowledge of PSI-led ClassLow Self EfficacyLow

47、 Outcome Expectations,New themes.Motivator,CONFIDENCE IN CLASS SET-UPNot previously discussed in the literature“.But I mean these people, whether its 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

48、CLASSNot previously discussed in the literature“Whats 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 classesIncrease awareness of Falls Prevention Servic

49、es- 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 areastrategies 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?,