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


Chapter 5. The health of older people

Falls

☰ Table of contents


Recommendations: Falls

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

All people aged ≥50 years at all risk levels Assess for risk factors for falls (Box 1). If at high risk, refer for multifactorial falls assessment – refer to below Annually IA 5, 40
Residents of aged care facilities (RACFs) RACF staff should screen for risk factors for falls to allow for an individualised fall prevention plan On admission, then sixmonthly IIB 34, 41
People with a past history of falls or at high risk Recommend a detailed assessment, including the following:
  • cardiac and neurological disease assessment
  • medication review
  • assessment of vision, gait and balance
  • home environment assessment, possibly most effective if conducted by an occupational therapist
Opportunistic IA 5, 40
Those with falls due to carotid sinus hypersensitivity Consider referral for pacemaker insertion As needed IIC 40
Those with vision threatening cataract disease Referral for cataract surgery (first eye) As needed IIC 40

Behavioural

All people aged ≥50 years
 
Recommend regular exercise, which may include the following modalities:
  • multicomponent group exercise (defined as targeting at least two of the following: strength, balance, endurance and flexibility)
  • individually prescribed multicomponent exercise to be carried out at home as per Australian physical activity guidelines (refer to Chapter 1: Lifestyle, ‘Physical activity’: Box 1)
  • tai chi as a group exercise
As part of an annual health assessment


 
IA 38, 40
People at high risk Recommend gait, balance and functional coordination exercises as part of a multifactorial intervention As part of an annual health assessment IC 40

Chemo-prophylaxis

People aged ≥50 years with known vitamin D deficiency or inadequate exposure to sunlight Consider vitamin D supplementation (refer also to ‘Osteoporosis’ section) As part of an annual health assessment IC 8
People at high risk taking medications Review the number and type of medications and assess whether they may increase falls risk At least annually and recommend six-monthly for people taking four or more medications IIB 34
If taking psychotropic medications, review the indications and consider gradual withdrawal if clinically appropriate Opportunistic and as part of an annual health assessment IIC 34, 42
Consider a home medication review by a pharmacist Annually or when there is a clinical need IIB 43, 44
People in RACFs

 

Arrange medication review by a pharmacist Annually IIA 34
Consider vitamin D supplementation (refer to ‘Recommendations: Osteoporosis’) Ongoing IA 41

Environmental

All people aged >50 years at moderate to high risk of falls Arrange for home assessment and modification, preferably by an occupational therapist Once off for those with poor vision

Opportunistic for all others
IA 40
People in RACFs who are at high risk of falls Consider use of hip protectors to lower the risk of harm related to a fall (refer to ‘Recommendations: Osteoporosis’) Opportunistic IIB 28

 

Box 1. Risk factors for falls

Risk factors for falls in older people include:45

  • increasing age
  • past history of falls
  • neurological conditions: stroke, Parkinson’s 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


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’.33 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.34 Half of all falls occur in the home, mostly during the day, and mostly due to ‘slipping, tripping and stumbling’.35 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.34 Hip fractures cause significant mortality, with about 13% dying during hospitalisation36 and about 27% dying over the following year.37 They are associated with significant morbidity (eg permanently decreased mobility), and in some people a fall will precipitate residential placement in an aged care facility. 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.35 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 peoples 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.35 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 age group is increasing rapidly,2 and the number of falls in older people may increase proportionally. Emerging evidence suggests that the rate of hip fracture in Aboriginal and Torres Strait Islander peoples may be higher than that of the general population (refer to ‘Osteoporosis’ section).


Interventions


Exercise has been shown to reduce both the risk of falls and rate of falling. The relative risk reduction is higher for fractures and injurious falls compared with all falls.38 Studies have shown benefits for populations at average and above-average risk of falling, and all older people should be encouraged to engage in exercise for falls prevention.39 People at higher risk of falls have a higher rate of falling and injuries and are likely to benefit most, but will need to have additional input into the design of their exercise program so as to prevent falls occurring during the exercises. A physiotherapist or similar professional is able to assess the person’s current abilities and design an appropriate exercise program.

The most effective strategy for reducing the risk of falls is balance training. Depending on the abilities of the person, this may involve challenging balance by standing with feet together, or on one foot, and using less to no support from upper limbs. Controlled movement of the body’s centre of mass, such as in tai chi, improves balance. However, most of the exercise programs that have demonstrated benefit in trials have combined balance training with another exercise component addressing gait, flexibility, strength training or endurance.38 Also, programs with the most benefit have had higher ‘doses’ of exercise, at least two hours per week for about six months.
In addition to improving balance, exercise may reduce the risk of falls and injuries from falls by benefiting cognition and reaction times, such as righting reflexes or the ability to grab onto objects to break a fall. Additionally, exercise may increase muscle mass and thereby protect bones and other tissues from the impact of a fall.38

Effective exercise programs should be at least two hours per week and can be home or group based, or a combination of the two (eg a group session complemented by exercises practiced at home). Exercise should be continued long term for ongoing benefits.

Brisk walking alone has not been shown to prevent falls: though it may have other benefits, it should be prescribed with caution as it can increase the risk of fractures in some older people. It may be included after with other types of exercise after assessing safety for the individual.
Balance and strength decline with age and it is likely that exercise in mid-life prevents falls and injuries from falls later in life.39 This is difficult to prove using randomised controlled trials (RCTs) because of the long time required for follow-up but is suggested by observational studies.39

For people with a history of falls, or who are deemed high risk (Box 1), a thorough evaluation is required. This should involve a detailed history of recent falls and known medical conditions and a thorough examination. These people will require an assessment of balance, of medication use, and of issues such as vision, incontinence and cognition. Interventions to prevent falls can then be tailored to the needs of the individual. Home-based safety assessment and modification interventions (particularly when delivered by an occupational therapist or similar professional) and review of medication by a pharmacist are effective in reducing the rate of falls and the risk of falling, particularly for those at high risk of falling.40

For people in aged care homes, regular assessment of falls risk should be conducted by staff from the facility, and interventions tailored to the person’s needs. Regular review of medications (especially psychotropic medications) is essential and annual review of medications by a pharmacist is recommended. Evidence regarding exercise programs for people living in aged care facilities is mixed, and strength and balance exercises should be undertaken with supervision by an appropriate professional.41

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

 





 
 
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