Guidelines for preventive activities in general practice

Injury prevention

Falls

      1. Falls

Injury prevention | Falls 

Approximately 30% of people aged ≥65 years report having one or more falls in the past 12 months,1 and this increases with age. Approximately 10% of falls in those aged ≥65 years result in a fracture.2 Falls are more prevalent in people with dementia, especially those with Parkinson’s dementia.3 Almost half of those who experience a fall will have a repeat fall within the next year.3 Injuries are higher in older people due to the prevalence of underlying disease and reduced physiological reserve.3 It is important to ask patients whether they have experienced ‘near falls’ as well as falls.3

Most falls are caused by an interaction of multiple risk factors. Older people who fall are at risk of a ‘long lie’ because of their inability to get up from the fall without assistance, which can result in hypothermia, bronchopneumonia, dehydration, pressure injuries, rhabdomyolysis and, in some instances, death.3

Some falls are associated with a loss of confidence, functional decline, social withdrawal, anxiety and depression, increased use of medical services and a fear of falling. An older person is at greater risk of institutionalisation following a fall.3

Case finding

Recommendation Grade How often References
GPs should routinely ask about falls in interactions with community-dwelling older (≥65 years) adults, asking whether they have experienced a fall in the past year, because falls will not often be spontaneously reported. Recommended (Strong) At least once a year 1,4

Preventive activities and advice

Recommendation Grade How often References
All older adults should be advised on falls prevention and physical activity. Refer to Staying active and on your feet or the Exercises for falls prevention in the Handbook of non-drug interventions (HANDI). Recommended (Strong) Annually 1,4
Older adults who had a single, non-severe fall but also have gait and or balance problems should be considered as being at ‘intermediate risk’ (see Figure 1) and would benefit from a strength and balance exercise intervention or physiotherapist referral. Recommended (Strong) Annually 1,4,5
 
 
Older adults at high risk (see Figure 1) should be offered a multifactorial falls risk assessment to inform individualised, tailored interventions. Recommended (Strong) Annually 1,4

The World guidelines for falls prevention and management for older adults: A global initiative provides an algorithm for risk stratification, assessment and interventions for community-dwelling older adults (see Figure 1). Opportunistic case finding begins with one question: ‘Have you fallen in the past 12 months?’ This question is highly specific in predicting future falls, but it has low sensitivity because it does not consider common risk factors, resulting in a high rate of false negatives.1 Tools that assess more than one fall risk factor, such as the 3 Key Questions (3KQ), have higher sensitivity.1 The 3KQ are: 

  1. Have you fallen in the past year?
  2. Do you feel unsteady when standing or walking?
  3. Do you have worries about falling?1 


Figure 1.
Algorithm for falls prevention for older adults.

Reproduced from Montero-Odasso et al. with permission from Oxford Academic.1

Medications should be regularly reviewed, and patients should be encouraged to keep a medication review card.3,6 Reduce doses to address side effects and dose sensitivity and stop medications that are no longer needed. Certain medications, such as psychotropic drugs, those with anticholinergic or sedative effects and those with hypotensive or orthostatic hypotensive side effects, can contribute to falls.3,6
 
Although treatment of osteoporosis does not reduce the number of falls, it may reduce the number of falls that result in a fracture. Refer to the osteoporosis chapter for information on the prevention of osteoporosis.3,6

For individuals at a moderately high to high risk of falls, a home assessment should be considered. Occupational therapy interventions can help identify falls hazards, raise awareness of falls risks and implement safety strategies.6,7 When referring patients, it is essential to specify fall prevention as the goal.

The Quickscreen assessment tool, developed and validated for use in an Australian population, includes home assessment tests, as well as simple assessments of medication use, vision, sensation and balance. However, payment is required to access this tool.

Active management of other risk factors involves:6,7

  • 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)
  • investigation of the causes of dizziness
  • optimal management of other medical conditions that may increase the risk of falls (eg Parkinson disease, multiple sclerosis, dementia).

Falls can be prevented through both pharmacological and non-pharmacological means.3 Pharmacological-related prevention of falls includes:3

  • deprescribing where possible, including a pharmacist review of medications where appropriate (refer to Part A: Deprescribing in the Silver Book)
  • reducing or ceasing psychotropic medications
  • reviewing medications with a dehydrating effect/those contributing to postural hypotension (eg diuretics, laxatives)
  • ensuring the patient is replete of vitamin D by checking the baseline, and supplement if required (low levels of vitamin D may make no difference to the risk of falling in individuals, but being vitamin D replete reduces the rate of falling)
  • ensuring the patient is replete of vitamin B12. 

Non-pharmacological approaches to the prevention of falls include:3

  • managing other medical conditions (as required)
  • addressing the causes of postural hypotension: encourage adequate hydration; reduce salt in the diet where possible; review medications; consider graduated light pressure stockings (if tolerated); suggest small frequent meals rather than large meals; advise mindful, slow postural adjustments after rising in the morning, after meals and after defecation
  • addressing undernutrition
  • managing incontinence
  • managing visual impairment: optometrist/ophthalmologist input, expedite necessary cataract surgery
  • managing hearing impairment: refer for audiology assessment
  • developing an individualised exercise program to improve muscle strength, balance, endurance and flexibility; referral to a physiotherapist for individual or group classes may assist with improving muscle strength, balance, endurance and flexibility (eg commencing Tai Chi)
  • referring to a physiotherapist for mobility assistive devices
  • referring to a podiatrist for foot care and appropriate footwear
  • referring to an occupational therapist for home assessment and environmental modifications (eg flooring, furniture, lighting, handrails).

Screening for falls in Aboriginal and Torres Strait Islander people is from the age of ≥50 years. Refer to the section on falls in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people for specific recommendations and advice.

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

  1. Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: A global initiative. Age Ageing 2022;51(9):afac205. doi: 10.1093/ageing/afac205.
  2. The Royal Australian College of General Practitioners (RACGP). Exercises for falls prevention. In: Handbook of Non-Drug Interventions (HANDI). RACGP, 2014 [Accessed 31 January 2024].
  3. The Royal Australian College of General Practitioners (RACGP). Falls. In: RACGP aged care clinical guide – Silver Book: Part A. RACGP, 2019 [Accessed 31 January 2024].
  4. Lamb SE, Bruce J, Hossain A, et al. Screening and intervention to prevent falls and fractures in older people. N Engl J Med 2020;383:1848–59. doi: 10.1056/nejmoa2001500.
  5. Ganz DA, Latham NK. Prevention of falls in community-dwelling older adults. N Engl J Med 2020;382:734–43. doi: 10.1056/nejmcp1903252.
  6. 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. doi: 10.1002/14651858.cd007146.pub3.
  7. 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. doi: 10.1111/j.1532-5415.2010.03234.x.
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