Falls

Approximately 30% of people aged 65 years or older have reported one or more falls in the previous 12 months. Inactivity in an older person makes them more likely to suffer from the effects of illness. For the older person, exercise provides the usual benefits, as well as minimizing some of the limitations of later life, e.g. reduced mobility, tendency to fall and reduced interaction with the environment. Impairment in vision has been well described as a risk factor for falls. Untreated cataracts have been shown to be associated with increased risk of multiple falls and reduced quality of life related to social isolation and depression.

Average risk - All people 65 years of age or over Every 12 months (A)

Ask about the occurrence of falls and any gait or balance problems. A quick screening tool is the ‘get up and go test’ which Look for the risk factors and involves looking for unsteadiness as the patient gets up from a chair without using his/her arms, walks a few meters and returns.

Screening for risk of fall

• Increased age
• Past history of falls
• Chronic medical conditions, e.g. Stroke or Parkinson disease
• Multiple medications and
• Specific medications, e.g. Long acting benzodiazepines and psychotropic medication
• Impaired balance and mobility
• Reduced muscle strength
• Sensory problems, e.g. Impaired visual acuity and depth perception and peripheral neuropathy
• Dizziness
• Impaired cognition
• Depression
• Low levels of physical activity, low BMI and osteoporosis
• Fear of falling
• Female gender
• Incontinence
• Environmental - poor home safety, stairs, slippery surfaces, ramps and rails, etc.

Moderately high risk

Older people presenting with one or more falls, who report recurrent falls or with multiple risk factors (see below). Screen for risk factors and involve in preventive activities every 6 months

Intervention

Fall risk reduction

A range of falls risk reduction through strategies in the community and residential care can be advised.

Following treatment for an injurious fall, older people should be offered an assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function. Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls (B)

The Canadian Task Force on Preventive Health Care (CTFPHC) concludes that there is fair evidence to recommend that a multifactorial intervention program for long-term care residents prevents falls and reduces the rate of injurious falls and hip fractures. Residents should be assessed on admission and re-assessed after a fall (B).

In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognized risk factors) (NGC A Recommendation):

• Strength and balance training (A)
• Home hazard assessment and intervention (C)
• Vision assessment and referral (B)
• Medication review with modification/withdrawal (psychotropic medication) (B)
• Exercise extended care settings (B)
• Treatment of postural hypotension (B)
• Staff education in self management programmes followed by implementation of changes (A)

Polypharmacy

Elderly patients are at risk of medication related problems which may cause unnecessary hospital admissions or death. This may be related to patient confusion and inadequate knowledge about medicines, poor compliance, and GPs and pharmacists not having full details of all the medications the patient is taking. Several risk factors to medication related problems include:

• Currently taking five or more regular medications
• Taking more than 12 doses of medication per day
• Significant changes in medication treatment regimen during the past 3 months.

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Created by: Dr Farouq Al-Zurba