Medical care of older persons in residential aged care facilities


The Silver Book
Falls and hip fracture prevention
☰ Table of contents


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.

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  238. Guy RJ et al., op. cit.
  239. Australian Medicines Handbook, op. cit.
  240. Ibid.
  241. National Health and Medical Research Council, op. cit.
  242. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  243. Ibid.
  244. Australian Medicines Handbook, op. cit.
  245. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary Tract Infections, op. cit.
  246. Australian Medicines Handbook, op. cit, 5-8.
  247. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  248. Ibid.
  249. Australian Medicines Handbook, op. cit, 5-8.
  250. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  251. Australian Medicines Handbook, op. cit, 5-8.
  252. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  253. Australian Medicines Handbook, op. cit, 5-8.
  254. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  255. Ibid.
  256. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  257. Australian Medicines Handbook, op. cit, 5-8.
  258. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care, op. cit.
  259. Australian Government Department of Health and Ageing. Medicare Benefits Schedule, 2005. Available atwww7.health.gov.au/pubs/mbs/index.htm [Accessed 10 May 2005].
  260. Aged Care Standards Agency. Continuous improvement for residential aged care: an education package, 2001.  [Accessed 10 May 2005].
  261. NSW Health Department. Easy guide to clinical practice improvement. A guide for health care professionals, 2002. [Accessed 10 May 2005].
  262. Dorevitch M, Davis S, Andrews G, op. cit.
  263. Flicker l, Loguidice D, Carlin JB, Ames D. The predictive value of dementia screening in clinical populations. Int J Geriatric Psychiatry 1997;12:203-9.
  264. Dorevitch M, Davis S, Andrews G, op. cit.