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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Falls

Author Dr Emma Fitzsimons 
Expert reviewer Dr Dina LoGiudice

Background

A fall is defined as ‘an event which results in a person coming to rest inadvertently on the ground or floor or other level’.20 Studies in Australia and similar countries have demonstrated that 30–40% of people over the age of 65 years fall each year, and a proportion of these will have serious injuries and require hospitalisation.21 Half of all falls occur in the home, mostly during the day, and mostly due to ‘slipping, tripping and stumbling’.22 Ten to fifteen percent of those who fall will sustain serious injuries, with 2–6% sustaining fractures and 0.2–1.5% sustaining a hip fracture.21 In Australia, falls account for 3.8% of hospital separations and 9.3% of all hospital bed days for people aged 65 years and over.22 A fall (whether or not it results in serious injury) may also result in a fear of falling, and consequent decreased mobility and independence, which in turn may increase the chance of the person subsequently requiring residential care.

Aboriginal and Torres Strait Islander people have increased rates of hospitalisation for falls when compared with other Australians, especially in the 25–65 years age group, but the average length of stay is shorter.23 This suggests that the increased risk for falling due to age is occurring at a younger age in Aboriginal and Torres Strait Islander people, but that the average severity of injury may be less. However, the number of Aboriginal and Torres Strait Islander people in the over 55 years age group is increasing rapidly,2 and the number of falls in the elderly may increase proportionally.

Recommendations: Falls prevention
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All people aged ≥50 years at all risk levels Assess for risk factors for falls (see Table 16.2) Annually IA24,25
Residents of aged care facilities (RACFs) RACF staff should screen for risk factors for falls to allow for an individualised fall prevention plan 6 monthly IIB26
People with a past history of falls Recommend a detailed assessment including the following:
  • cardiac and neurological disease assessment
  • medication review
  • assessment of vision, gait and balance
  • home environment assessment
Opportunistic IA 25
Those with falls due to carotid sinus hypersensitivity Consider referral for pacemaker insertion As needed IIC27
Those with vision threatening cataract disease Referral for cataract surgery As needed IIC27
Behavioural All people aged ≥50 years Recommend exercise which may include the following modalities:
  • multicomponent group exercise (defined as targeting at least two of the following: strength, balance, endurance and flexibility)
  • tai chi as a group exercise
  • individually prescribed exercise to be carried out at home as per Australian physical activity guidelines (see Chapter 1: Lifestyle, section on physical activity)
As part of an annual health assessment IA25
People at high risk Recommend gait, balance and functional coordination exercises as part of a multifactorial intervention As part of an annual health assessment IIC26
Chemoprophylaxis   People aged ≥50 years with known vitamin D deficiency or inadequate exposure to sunlight Consider vitamin D supplementation (see also osteoporosis section) As part of an annual health assessment IC27,28
People at high risk taking medications   Review medications At least annually and recommend 6 monthly for people taking four or more medications IIB21
If taking psychotropic medications review the indications and consider gradual withdrawal if clinically appropriate Opportunistic and as part of an annual health assessment IIC29
Consider home medication review by a pharmacist Annually or when there is a clinical need IIB30
People in RACFs Arrange medication review by a pharmacist Annually IIA31
Consider vitamin D supplementation Ongoing IA27
Environmental All people aged >50 years not at high risk Home assessment and intervention is not recommended N/A IA 25
People at high risk Arrange for home assessment and intervention involving a multidisciplinary team One-off for those with poor vision; opportunistic for all others IIC25,27
People in RACFs who are at high risk of falls Consider use of hip protectors Opportunistic IIB5

 

Table 16.2. Risk factors for falls
  • Increasing age
  • Past history of falls
  • Neurological conditions: stroke, Parkinson disease, peripheral neuropathy
  • Multiple medications
  • Psychotropic medications
  • Impaired balance, gait and mobility
  • Reduced muscle mass
  • Visual impairment
  • Cognitive impairment
  • Depression
  • Fear of falling
  • Low levels of physical activity
Source: The RACGP 200924

References

  1. Australian Bureau of Statistics. Experimental estimates and projections, Aboriginal and Torres Strait Islander Australians, cat. no. 3238.0. Canberra: ABS, 2009. Cited October 2011. Available at www.ausstats.abs.gov.au/ Ausstats/subscriber.nsf/0/27B5997509AF75AECA25762A001D0337/ $File/32380_1991%20to%202021.pdf.
  2. The Royal Australian College of General Practitioners. Clinical guidelines for the prevention and treatment of osteoporosis in postemenopausal women and older men. Melbourne: RACGP, 2010. Cited October 2011. Available at www.racgp.org.au/your-practice/guidelines/ musculoskeletal/osteoporosis/.
  3. World Health Organization. Falls: fact sheet no. 344. Geneva: WHO, 2010. Available at www.who.int/mediacentre/factsheets/fs344/en.
  4. Australian Commission on Safety and Quality in Healthcare. Guidebook for preventing falls and harm from falls in older people: Australian community care, 2009. Cited January 2012. Available at www.health.gov.au/internet/safety/ publishing.nsf/Content/962A0110A26385E3CA25775300 1F01F2/$File/30455-COMM-Guidebook.PDF.
  5. Bradley C, Pointer S. Hospitalisations due to falls by older people, Australia 2005–06. Adelaide: AIHW, 2009.
  6. Helps YL, Harrison JE. Hospitalised injury of Australia’s Aboriginal and Torres Strait Islander people 2000–2002. Adelaide: Australian Institute of Health and Welfare, 2006.
  7. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (red book), 7th edn. Melbourne: RACGP, 2009. Cited October 2011. Available at www.racgp.org.au/your-practice/ guidelines/redbook/.
  8. Gillespie L, Robertson M, Gillespie W, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009;Apr 15;(2):CD007146.
  9. Australian Commission on Safety and Quality in Healthcare. Guidebook for preventing falls and harm from falls in older people: australian residential aged care facilities. ACSQHC, 2009. Cited January 2012. Available at www.health.gov.au/internet/ safety/publishing.nsf/content/com-pubs_FallsGuidelines/$File/30454-RACF-Guidebook.PDF.
  10. Cameron I, Murray G, Gillespie L, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010;Jan 20;(1):CD005465.
  11. Michael Y, Whitlock EP, Lin J, Fu R, O’Connor E, Gold R. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the US Preventive Services Task Force. Ann Intern Med 2010;153:815–25.
  12. Campbell A, Robertson M, Gardner M, Norton R, Buchner D. Psychotropic medication withdrawal and a home based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999;47(7):850–3.
  13. Pit SW, Byles JE, Henry DA, Holt L, Hansen V, Bowman DA. A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. Med J Aust 2007;187(1):23–30.
  14. Zermansky A, Alldred D, Petty D, et al. Clinical medication review by a pharmacist of elderley people living in care homes--randomised controlled trial. Age Ageing 2006;35:586–91.
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