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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

5.3 Falls

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Approximately 30% of people aged ≥65 years report one or more falls in the past 12 months.32 Most falls are caused by an interaction of multiple risk factors. Having one fall puts you at risk of another fall, and the more risk factors, the greater the chance of falling. You can help your patients manage their risk and prevent further falls by regularly asking them about falls.

Table 5.3.1. Falls: Identifying risks
Who is at risk of falls?What should be done?How often?References
Average risk
  • All people aged ≥65 years
Screen for falls (I, A) Every 12 months 29,33
Moderately high risk
  • Older people presenting with one or more falls, who report recurrent falls or with multiple risk factors (refer to Table 5.3.2)
Case find for risk factors and involve in preventive activities (I, A) Every six months 32,33
Table 5.3.2. Falls: Preventive interventions
InterventionTechnique
Screening for falls risk

Case finding questions about risk factors to be used in those at moderately high risk
Ask the following three screening questions 32,34–36:
  1. Have you had two or more falls in the past 12 months?
  2. Are you presenting following a fall?
  3. Are you having difficulty with walking or balance?
If the answers to any of these are positive, complete a multifactorial risk assessment including obtaining relevant medical history, completing a physical examination, and performing cognitive and functional assessments

History should include 29,32,33,37:
  • detailed history of falls (eg how many falls?, at home or outdoors?, patient perception of causes, any fear of falling)
  • multiple medications, and specific medications (eg psychotropic medications)
  • impaired gait, balance and mobility
  • foot pain and deformities, and unsafe footwear
  • home hazards
  • bifocal or multifocal spectacle use
  • incontinence
  • recent discharge from hospital
  • chronic illness such as stroke, multiple sclerosis (MS), Parkinson’s disease, cognitive impairment/dementia
  • vitamin D deficiency/poor sun exposure if housebound or in a care facility
Physical examination should include:
  • impaired visual acuity, including cataracts
  • reduced visual fields
  • muscle weakness
  • neurological impairment
  • cardiac dysrhythmias
  • postural hypotension
  • six-metre walk, balance, sit-to-stand*
Cognitive and functional impairments should include:
  • dementia/cognitive impairment assessment (eg General Practitioner Assessment of Cognition [GPCOG])
  • activities of daily living and home assessment as appropriate (eg by occupational therapist)
  • falls risk–assessment tools
  • if unsteady, gait and mobility assessment by physiotherapist29
There are many fall risk–assessment tools. However, reports from researchers are variable, so no single tool can be recommended for implementation in all settings or for all subpopulations within each setting38,39

Also refer to Chapter 13. Urinary incontinence
Falls risk reduction Prescribe or refer for a home-based exercise program and/or encourage participation in a community-based exercise program, particularly targeting balance and which may include strength and endurance (I)40–47,29,33

Specific exercises to reduce the risk of falls are available here

Patients who report unsteadiness or are at higher risk of falls should be referred to a health professional for individual exercise prescription. Referral should specify fall prevention

Exercise programs targeting non–English-speaking patients may need to address cultural norms about appropriate levels of physical activity.41

Exercise guidelines for fall prevention recommend the following:
  • Exercise that specifically challenges balance is the most effective physical activity intervention to prevent falls48,49
  • Exercise needs to be done for at least two hours per week and continue as a lifetime activity
  • Fall prevention exercises can be home-based or a group program.
  • Walking or strength training as a single intervention does not appear to prevent falls
Regularly review medication. Encourage patients to keep a medication review card. Reduce dose to address side effects and dose sensitivity, and stop medications that are no longer needed 33

Medications that can promote falls include psychotropic medications, and medications with anticholinergic activity, sedation effects and hypotensive effects or orthostatic hypotensive side effects

Also refer to Chapter 14. Osteoporosis

A home assessment should be considered for those at moderately high to high risk of falls. Occupational therapy interventions can reduce fall hazards, raise awareness of fall risk and implement safety strategies. Referral should specify fall prevention29,33

Other risk factors should be managed actively including29,33:
  • using a multidisciplinary team (eg podiatrist regarding foot problems, optometrist regarding avoidance of multifocal lenses, physiotherapist or nurse regarding urge incontinence)
  • referring to relevant medical specialists (eg ophthalmologist for cataract surgery, cardiologist for consideration of pacemaker)
  • investigating the causes of dizziness
*Two simple tests are the repeated chair standing test and alternate step test. The repeated chair standing test measures how quickly an older person can rise from a chair five times without using the arms.

A time of >12 seconds indicates an increased fall risk. The alternate step test measures how quickly an older person can alternate steps (left, right, left, etc) onto an 18 cm high step a total of eight times. A time >10 seconds indicates an increased fall risk.

The Quickscreen assessment tool, developed and validated for use in an Australian population, includes these tests as well as simple assessments of medication use, vision, sensation and balance.

GPCOG, General Practitioner Assessment of Cognition; MS, multiple sclerosis

References

  1. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59(1):148–57.
  2. Nelson M, Rejeski W, Blair S, et al. Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39(8):1435–45.
  3. Department of Health. Australia’s physical activity and sedentary behaviour guidelines. Canberra: DoH, 2014. Available at www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines [Accessed 21 March 2016].
  4. National Falls Prevention for Older People Initiative. An analysis of research on preventing falls and falls injury in older people: Community, residential care and hospital settings. Canberra: Department of Health and Ageing, 2004.
  5. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.
  6. Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology 2004;111(5):857–62.
  7. Hodge W, Horsley T, Albiani D, et al. The consequences of waiting for cataract surgery: A systematic review. Can Med Assoc J 2007;176(9):1285–90.
  8. National Institute for Health and Care Excellence. Falls – Assessment and prevention of falls in older people. London: NICE, 2013.
  9. Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age Ageing 2007;36(2):130–39.
  10. Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010;65(8):896–903.
  11. Tiedemann A, Shimada H, Sherrington C, Murray S, Lord S. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing 2008;37(4):430–35.
  12. Australian Commission on Safety and Quality in Health Care. Preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals, residential aged care facilities and community care. Sydney: ACSQHC, 2009.
  13. Borschmann K, Moore K, Russell M, et al. Overcoming barriers to physical activity among culturally and linguistically diverse older adults: A randomised controlled trial. Australas J Ageing 2010;29(2):77–80.
  14. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010;1:CD005465.
  15. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009;2:CD007146.
  16. Sherrington C, Whitney J, Lord S, Herbert R, Cumming R, Close J. Effective exercise for the prevention of falls: A systematic review and meta-analysis. J Am Geriatr Soc 2008;56(12):2234–43.
  17. US Preventive Services Task Force. Prevention of falls in community-dwelling older adults. Rockville, MD: USPSTF, 2012. Available at www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm [Accessed 15 December 2015].
  18. Wyman JF, Croghan CF, Nachreiner NM, et al. Effectiveness of education and individualized counseling in reducing environmental hazards in the homes of community-dwelling older women. J Am Geriatr Soc 2007;55(10):1548–56.
  19. Zijlstra GA, van Haastregt JC, van Rossum E, van Eijk JT, Yardley L, Kempen GI. Interventions to reduce fear of falling in community-living older people: A systematic review. J Am Geriatr Soc 2007;55(4):603–15.
  20. Sherrington C, Lord S, JCT C. Best-practice recommendations for physical activity to prevent falls in older adults: An evidence check rapid review brokered by the Sax Institute for the Centre for Health Advancement. Sydney: Department of Health, 2008. Available at www.saxinstitute.org.au [Accessed 15 May 2016].
  21. Tiedemann A, Sherrington C, Close JC, Lord SR. Exercise and Sports Science Australia position statement on exercise and falls prevention in older people. J Sci Med Sport 2011; 14(6):489–95.
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