Pathways for Health 2009: Editor

$1.10 Case finding for falls & fractures$

1.60: Escalation thresholds & decision aids

1.70: Red Flags

Head Injury -

treat first esp if on Warfarin then focus on fall

3.40: Definitive Treatments (Tx)

4.40: Definitive Treatments (Tx)

4.42: Second line therapies

For complex / non responding disease. Exercise programme

4.43: Symp -tomatic treatments

Eg analgesia, physio -therapy

4.44: Medication

Bisphos -phonates,

+/- Vitamin D & Calcium

4.50: Rehabilitation, Review & QoL measurement

Follow up patients after intervention eg vertebroplasty / kyphoplasty. Consider the need for oesteoporosis treatment.

Early mobilisation, strength & balance programme to stop future falls and improve bone density & promote patient activity & confidence.

1.00: Fall +/-

fragility #

5.00

4.41: Cancer treatment

For eg myeloma. Treatments include

radiotherapy/ oncology

4.45: Pre interventional assessment

4.46: Surgical intervention

Eg vertebroplasty, kyphoplasty

3.00: Specialist Falls Assessment & Treatment

History and clinical assessment as per NICE guideline

Visual Assessment

Gait & Balance Assessment

Medication review

2.70: Red Flags

CA ,Wt loss , acute illness or rapid deteriortaion

2.60: Escalation Thresholds & Remote advice

Locally agreed referral criteria

+/- Dx doubt

4.24: CA investigations

For myeloma or metastases

4.23: DXA scan

Inc repeat scans for pt monitoring

4.22: Imaging

Isotope bone scans, CT / MRI

3.24: Bone Health Assessment

Imaging

DXA scan

Bone scan if ?CA

Falls risk tool eg PARR

4.20: Diagnostics (Dx)

3.22: Blood Tests & ECG

CVS - for fainting eg 24hr ECG

Baseline bloods & ECG for most pts

3.20: Diagnostics (Dx) & Assessments (Ax)

2.30: Decision aids

Gait & Balance screening criteria

3.21: No diagnostic required

Most patients will not require complex if any diagnostics

4.21: Investigations

For meta -bolic bone disease, renal disease, malab -sorption

2.10: Decision aids

DXA scan protocol
Fracture risk scores eg FRAX

3.10: Decision aids

DXA scan protocol & Syncope protocol

2.21: No diagnostic required

2.22: Imaging

Plain X-rays

2.23: DXA scan

Direct referral according to protocol

2.24: Basic Blood Tests & ECG

Also screen for UTI

3.23: Brain Imaging

Eg for gait / balance / movement problems or cognitive impairment

2.20: Diagnostics (Dx)

3.46: Vestibular services

Eg Epleys manouevere & Hallpike, vestibular rehab

3.44: Strength & balance training

Individually prescribed evidence based programme according to pt need. Sufficient frequency / duration

3.43: Physical or / & occupational therapy

Assesment / treatment / home hazard modification

Non specific exercise programme

3.42: Syncope service

Interventions for cardiac syncope eg pacing or drug therapy

3.41: Info, reassurance, self help

Give info such as

- Local falls contact

e.g NOS leaflets

Advice on driving

2.46: Bone strengthening drugs

Bisphosphonates, +/- Calcium & Vit D as per NICE / NOGG Guidelines

2.41: Info, reassurance, self help

Info eg

- Local falls contact

- Local information leaflets

e.g - Help the Aged information

2.42: Active monitoring

For pts at risk of further falls - to mainatain indepen -dence & monitor further deterioration

inc case managment

2.43: Physical or / & occupational therapy

Assesment / treatment / home hazard modification

Routine physio Tx

2.44: Strength & balance training

Individually prescribed evidence based programme according to pt need. Sufficient frequency / duration

2.40: Treatments (Tx)

2.50: Pro-active PCT & patient led ongoing prevention strategies

Ongoing self led exercise - eg New Zealand programme. Cochrane review

3.50: Compliance support

Refer back to 2.50 plus compliance support with medication & specialist follow up for selected patients eg post pacemaker. Follow up closer to the patients home is preferable in most cases

3.60: Escalation thresholds & decision aids

4.00: Specialist Bone Health Assessment & Treatment Service

Complex bone health assessments & diagnostics requiring specialist bone health advice, treatments and interventions

4.10: Decision aids

Agreed local protocols plus NICE / NOGG

2.00: Initial Assessment

Components of assessment set out as per NICE guidance eg medication, gait & balance assessment

Awareness of co-morbidities. Visual Assessment

Initial assessment includes screening for bone health as per

NICE guideline

3.30: Treatment thresholds

Specialist signposting

4.30: Treatment thresholds & decision aids

NICE / NOGG

2.45: Mx Review

Adjust drugs that increase falls risk. Full Mx review

Falls and fragility fracture secondary prevention pathway

V3 May 2009

3.45: Drug therapy

For specific conditions

1.40: Local Falls Service

To review & adjust medicines with care homes - can result in cost savings to prescribing budgets & increase compliance in patients

1.30: Primary Prevention & Self Care

Participating in exercise - keeping active. Regular eye checks, safer footwear & walking aids, home hazards, regular health checks & meds review & visual assessment

Refer to local falls contact & Help the Aged website

1.20: Incidence & Prevalence

80,000 hip # per yr

200,000 non hip # ie wrist, arm, shoulder, ankle. Nursing homes 50% of care home residents fall once per yr, 40% fall twice

1.10: Case finding for falls & fractures

Ask older people if they have fallen in the last year. If gait & balance problems or 2 + falls or long lie, injury or hospital attendance then need initial Ax (NICE)

The Pathway Commissioning Workforce Technology Service Improvement Activity Flows Financial Flows Patient Pathway Information and Decision Aids References and Resources

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