Medical care of older persons in residential facilities

Falls and hip fracture prevention

Risk assessment
Fall prevention interventions
Injury prevention interventions

Falls are a marker of increased frailty in older people and occur frequently among residents of RACFs, with 13-60% of residents falling at least once per year. The risk of hip fracture for older people living in residential aged care has been estimated to be 7% per annum, rising to 14-41% for recurrent fallers. Other major risk factors for hip fracture are reduced bone mineral density (osteoporosis) and previous low trauma fracture.¹⁶⁶ When an older person falls, the cause is frequently multifactorial and requires a multidisciplinary approach to intervention. The risk of an older person falling increases with the number of risk factors. Risk factors for falling include:¹⁶⁷

age 65 years or over
fallen in the past 12 months
gait or balance disorder
dementia, delirium or confusion
incontinence
syncope or dizziness
low vitamin D levels
takes more than three medications, particularly psychotropic medications
visual deficit, or wears bi- or multi-focal spectacles when walking
inappropriate footwear (eg. slippers) or presence of foot pain
requires supervision for ambulation
is restrained (physically or chemically)
functions in a cluttered, poorly lit environment.

Multifaceted interventions, based on assessment of the resident and their environment, are more likely to be effective than single interventions for reducing falls and related injuries.

Evidence based Australian guidelines¹⁶⁸ for hospitals and RACFs recommend that all facilities implement 12 standard fall prevention strategies, fall risk assessment, fall and injury prevention interventions, and postfall management processes.

General practitioners can play an important role in RACF falls prevention programs and falls data monitoring, as well preventing harm from falls in residents by:¹⁶⁹

promoting independence for older people
examining falls prevention in the context of an older person's medical circumstances, goals and interests
ensuring the prevention of falls is standard practice when caring for older people
taking an active role in assessing a person's risk of falling by reviewing past and current history, physical examination, medications and investigations then acting on the results
using evidence based falls prevention interventions and outcome measures as part of a multidisciplinary, multifactorial approach
continually reviewing the standard strategies, assessments, interventions and outcomes to identify areas for improvement
analysing the circumstances around a fall and ensuring that additional injury prevention interventions are implemented for people who have fallen
recognising that they play an important role in the team approach to planning, implementing and evaluating the effect of a falls prevention program.

Risk assessment

Assessment of a resident's fall risk may be undertaken by the GP and facility staff on admission, and after a fall. Assessing the risk of a fall and hip fracture includes collecting and interpreting information on:¹⁷⁰

history of falls
medication (polypharmacy, laxatives, some psychotropics, antihypertensives and corticosteroids)
confusion or altered mental state
anxiety, mood disturbance or sleep disturbance
sensory or visual impairment
bowel or urinary continence
gait and/or balance impairment
history of hip fracture or pattern of injury
bone mineral density
feet and footwear
cardiovascular status including heart rate and rhythm, postural hypotension
vitamin D and calcium levels
acute conditions including infection, changes in blood glucose level
use of restraints
their environment.

Postfall assessment includes the following:¹⁷¹

a history of fall circumstances, medications, acute or chronic medical problems, and mobility levels
an examination of vision, gait and balance and lower extremity joint function
an examination of basic neurological function, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function
assessment of basic cardiovascular status including heart rate and rhythm, postural pulse and blood pressure and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation.

Some residents at high risk may benefit from referral to a local ACAT or falls and balance clinic.

Fall prevention interventions

The following interventions may be considered:¹⁷²

reduction in the number of medications where possible
reduction or cessation of psychotropic medications where possible
review of medications that have a dehydrating effect, including laxatives and diuretics
management of cognitive impairment, confusion and delirium
nutritional assessment and development of an appropriate meal plan
continence assessment and management plan
management of visual impairment
individualised exercise program to increase muscle strength, balance and cardiovascular fitness
management of foot pain and footwear (eg. firm soled, low heeled shoes)
mobility assisting devices (eg. walking stick, frames)
eliminating or minimising the use of restraints
implementing surveillance and observation strategies (eg. bed alarms and call bells)
environmental modification (eg. flooring, proximity of furniture, adequate lighting, handrails in toilets and bathrooms).

Injury prevention interventions

Many falls can be prevented. Some falls will still occur. To minimise the risk of injury if an older person falls, injury prevention interventions can be implemented such as:^173,174

hip protector pads in compliant wearers
vitamin D supplements (ergocalciferol 1000 IU daily)
5-15 minutes exposure of the face and upper limbs to sunlight 4-6 times per week (avoiding exposure between 10 am-3 pm)
calcium (1000-1500 mg in postmenopausal women,800-1000mg in premenopausal women, and men)
osteoporosis management.