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AN APPROACH TO THE PREVENTION OF FALLS IN OLDER ADULTS
For Primary Care Physicians
• Done annually on patients aged 75+, and • When assessing patients for osteoporosis ASK: About falls and whether injurious. All seniors 65+ with injurious
falls should lead to an assessment for modifiable fall risk factors. OBSERVE: Balance & gait (mobility) problems
injurious fall and no

GENERAL ADVICE
ASS ESSMENT:
• Address bone health • Advise to find and MANAGEMENT:
• Medication reduction for those on 4+ drugs • Environmental evaluation/modification ALL PATIENTS SHOULD BE ENCOURAGED TO ENGAGE IN EXERCISES THAT
IMPROVE/ MAINTAIN ENDURANCE, BALANCE, STRENGTH AND FLEXIBILITY
Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 SCREEN:

There is no agreement on the best time to start screening older patients about falls. In line with
other recommendations1,2, we suggest that annual screening start at 75. However, all seniors
(65+) who have had an injurious fall should be assessed for modifiable risk factors.
• Falls and their resultant injuries are a common reason for an older patient to visit a physician, go to an Emergency Department, and be hospitalized. The identification of risk factors makes it feasible to identify seniors at high risk for falls. • The most important risk factors are having a fall in the last year and impaired
balance/ gait. Once a high risk group is identified there are interventions that can
decrease the likelihood of further falls.
• Falls in older adults are common and have serious consequences. • Approximately a third of older adults living in the community will fall per year, and the likelihood of falling is even higher among those who reside in long-term care facilities. • The presence of fall risk factors and the likelihood of falling both increase sharply after • About half of seniors who fall will have multiple falls, and they tend to be frailer, more
ASK:
Falls / Injurious Falls

• Patients 75 years of age and older (75+) should be asked once a year about falls as should patients being assessed for osteoporosis. • Persons who have had recurrent falls (i.e., 2+ falls) in the last year or have had an injurious fall (e.g., requiring medical attention such as a fracture, joint dislocation,
wound needing suturing, or other serious soft tissue injury) require further
assessment.

OBSERVE:
Balance & Gait Abnormalities

• Every year patients 75+ and those being assessed for osteoporosis should have their basic mobility skills (i.e., ability to transfer and walk) observed. Two simple ways of doing this are: Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 Get-up and Go Test
• This takes 1-2 minutes to perform. No specialized equipment is required. • Subjects are asked to sit in straight-backed office chair with arm rests that is placed 3 m from a line of brightly coloured tape (or cone) on the floor. The walking space must be free of any obstructions. They are then asked to rise, stand still momentarily, then walk at a comfortable pace to the line of tape (or cone), turn, walk back to the chair, and sit down. • A trial run for familiarization is done first. For safety, the tester should stand in close proximity to the patient while observing their gait. • Individuals who have difficulty or demonstrate unsteadiness while performing
this manoeuvre require further assessment.
1. Normal (n = 1; normal movements, no sign of any fall risk) 2. Very slight abnormality (2; basically safe performance but cautious with adjusted movements such as being slow and/ or having a wider base of support than normal) 3. Mildly abnormal (3; clearly abnormal – might be hesitant, walk excessively rapid/ at an unsafe speed, and/ or show uncoordinated, irregular movements such as staggering/ weaving) 4. Moderately abnormal (4; supervision required with clear abnormalities such as having trouble getting up from sitting or with sitting down) 5. Severely abnormal (5; clear risk of falling; stand-by assistance or physical • The grading is based on observing the patient for their risk for falling, gait speed, hesitancy, staggering, and stumbling. If grading, a score of 3 or more is
considered abnormal.

• Neither this test nor the following one is appropriate for patients with severe cognitive impairment that prevents them from understanding the task or those who cannot transfer independently from sitting to standing.3,4 Timed Up & Go Test
• To address concerns about the poor inter-rater reliability observed with the intermediate grades of the “Get-up and Go” test, the timed “Up and Go” (TUG) test was developed. • It also takes 1-2 minutes to perform and requires no specialized equipment. • This test measures (in seconds) the time taken by an individual to stand from a standard chair (approximate seat height 46 cm), walk a distance of 3 m (note: there must be no obstructions), turn, walk back to the chair, and sit down again. • The patient wears his/ her regular footwear and uses his customary walking aid (none, cane, walker). No physical assistance is given but the tester stays in close proximity to the patient for safety. • He/she starts with his/her back against the chair, his/her arms resting on the chair’s arms, and his/her walking aid at hand. He/ she is instructed that, on the word “go,” he/she is to get up and walk at a comfortable and safe pace to the line (or cone) on the floor 3 m away, turn, return to the chair, and sit down again. The subject walks Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 through the test once before being timed in order to become familiar with it. Either a wrist-watch with a second hand or a stop-watch can be used to time the performance. • Formal norms have not been established for the TUG but a healthy 80-89 year old male takes on average 10 seconds to perform the task while similarly aged women take 11 seconds5. • For identifying a high fall risk, an abnormal result is requiring 13.5 seconds or
more to perform the task6,7.

GENERAL ADVICE:

Stay Active

Encourage physical activity.
• If there are no contraindications, recommend at least 30 minutes of activity that makes you
breathe hard on most or all days of the week. • If an exercise/physical activity prescription is provided, seniors are more apt to follow through with these programs. Options include Tai Chi, strength training, walking, water fitness, and dancing. • Exercise and Physical Activity – Getting Fit for Life http://www.nia.nih.gov/NR/rdonlyres/91DBE1D1-2136-4C6E-8A01-C747E94DD605/8162/Exercise_and_Physical_ActivityGetting_Fit_For_Life.pdf • Exercise – A Guide from the National Institute on Aging http://www.nia.nih.gov/NR/rdonlyres/25C76114-D120-4960-946A-3F576B528BBD/0/ExerciseGuide_2008.pdf • Be Falls Smart in What You Do – Physical Activity
Bone Health
• Resources:
• Toward Optimized Practice (TOP) Clinical Practice Guidelines for the Diagnosis and Mananagement of Osteoporosis http://www.topalbertadoctors.org/cpgs/osteoporosis.html • Maintain Your Independence: Keep Healthy Bones for Life www.calgaryhealthregion.ca/programs/injuryprevention/olderadult_athome_fallprevention.htm
Find and Fix Hazards in the Home

Identify and modify home hazards.
• Patients and/or their families should be given (or directed to) a home safety checklist and
encouraged to examine their home for environmental risks. Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 • Check for Safety – A Home Fall Prevention Checklist for Older Adults http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/DesktopPDF/English/booklet_Eng_desktop.pdf
ASSESSMENT:
If seen immediately after a fall, examine the patient for signs of physical injury. Seniors at
high risk for falls should have a multi-factorial fall risk assessment performed to identify
predisposing and precipitating factors. Interventions would then be implemented for the
identified modifiable risk factors.
This assessment should be done by a clinician with the skills needed to do it well and in certain
circumstances may require a referral to a specialist (e.g., geriatrician) or a specialty service
(e.g., falls clinic). Please note that while the approach outlined will decrease the risk of further
falls for many patients, it will not eliminate it. A multi-factorial fall risk assessment should
include the following:
Patient History:
• History of falls and their circumstances (e.g., number, setting, what the patient was doing at the time of a fall, patient’s perception as to the cause, associated symptoms preceding and after the fall). o A comprehensive medication review should be conducted on all patients who have had multiple falls and/or an injurious fall. o Older patients on 4+ prescription medication have a higher risk of falling than those o Certain types of medications are associated with a higher risk of falling.
o High risk medications are psychotropics such as benzodiazepines (and
benzodiazepine-like sleeping pills), antidepressants (including tricyclic antidepressants and selective serotonin reuptake inhibitors), and antipsychotics. o Anticonvulsants and cardiovascular agents that lower blood pressure such as antihypertensives (in general), beta-blockers, peripheral vasoldilators, and nitrates are more weakly associated with a risk for falls8. o Consider referring the patient to a pharmacist for a complete medication review. • Acute or chronic medical problems. • Functional abilities (assessment of basic and instrumental activities of daily living). • Examination of visual acuity. • Assessment of balance (static and dynamic) and gait. Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 • Targeted musculoskeletal examination including an examination of the lower extremities (joints and range of motion) and feet. • Targeted neurological examination including mental status, lower extremity muscle strength (e.g., can the patient stand from sitting without using their arms?), lower extremity sensation & reflexes, and testing of cortical, extrapyramidal, and cerebellar function. • Cardiovascular examination including heart rate and rhythm, postural pulse and blood
MANAGEMENT:

Medical Risk Factors
The specifics of this would depend very much on what medical risk factors for falls are
discovered (or suspected). Following is some advice for a number of the more commonly
identified factors.
Impaired vision
• Ensure ample lighting without glare. • Be careful with multifocal and reading glasses while walking. Staircases and curbs • If the patient has severe visual impairment, identification and modification of environmental hazards can decrease the risk of further falls9. • Refer to ophthalmologist – if impaired vision is from cataracts, expedited surgery for the first cataract can reduce the risk for falling and enduring a fracture10. • Diagnosis and treatment of underlying cause.
• Review medications; reduce and try to stop medications suspected as causing or
contributing to the problem when appropriate. • Ensure adequate fluid intake especially when febrile, during a bout of the “stomach • Modification of salt restriction when appropriate.
• Compensatory strategies (e.g., elevate head of the bed, rise slowly, dorsiflex feet
• Pressure stockings (preferably thigh high) where appropriate. • Consider pharmacological therapy (e.g., fludrocortisone, midodrine) if above • If syncopal falls are suspected, refer to a cardiologist.
Medication Reduction
Falls are associated with the use of medications but it can be difficult to tease apart what is due
to the medication and what might be secondary to the indication for the medication (e.g., is the
association between antidepressants and falls due to the antidepressants themselves or is it
secondary to the depression that led to the prescription of the antidepressant?). In clinical
Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 practice we are continuously weighing the relative benefits and risks of the medications that we prescribe. • Older patients on 4+ prescription medication have a higher risk of falling than those • Certain types of medications are associated with a higher risk of falling.
High risk medications are psychotropics such as benzodiazepines (and
benzodiazepine-like sleeping pills), antidepressants (including tricyclic antidepressants and selective serotonin reuptake inhibitors), and antipsychotics. • Anticonvulsants and cardiovascular agents that lower blood pressure such as antihypertensives (in general), beta-blockers, peripheral vasoldilators, and nitrates are more weakly associated with a risk for falls11. • As noted in the Assessment section, a comprehensive medication review should be
conducted on all patients who have had multiple falls and/or an injurious fall. • Medication reduction should be considered for those taking 4+ prescribed medications and/ or are taking a high risk medication (especially a psychotropic). Ask yourself: o Are these medications still required? o Is there a nonpharmacological approach for this problem? o Can I switch the patient to a less hazardous medication that would have the same • Gradual withdrawal (i.e., discontinuation or reduction to the lowest effective dose if discontinuation is not possible) of psychotropics and other drugs associated with an increased risk of falling have been found to reduce the likelihood of further falls13,14. • Consider consulting with a pharmacist in your efforts to reduce medications. Their assistance can be invaluable in mapping out an approach to gradually withdrawing psychotropics and other drugs associated with an increased risk of falling. Balance & Gait Abnormalities
• Referral to a physiotherapist for assessment and treatment. Interventions would include: o Individualized program for muscle strengthening and balance/ gait training. o Advice on their daily routine to minimize, if not eliminate, high risk activities (e.g., stooping, reaching overhead, climbing up on chairs/ ladders). o Prescription of an assistive device (e.g. walking aid, environmental modifications to help with problems in transfers); for those already with an assistive device, evaluation of its appropriateness (including determination of whether it is in good repair). • Consider the prescription of an appropriate exercise/ physical activity program. Program should include balance training as well as strengthening exercises and should be monitored by a trained professional. • For local programs - InformAlberta

Supplementation with Vitamin D
There is a high prevalence of vitamin D deficiency among seniors, especially if they are
institutionalized or housebound. It has become recently appreciated that low levels of vitamin
D are associated with diminished muscle strength, worse physical performance (e.g., repeated
chair stands, TUG) and a higher rate of falling15,16. Vitamin D supplementation in older adults
can lead to a 12-22% decrease in the likelihood of falling17,18.
Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 • In high risk seniors without a contraindication (e.g., conditions associated with hypercalcemia like primary hyperparathyroidism) supplementation with vitamin D in an effort to decrease the risk of falling is recommended. The suggested dose of cholecalciferol (vitamin D3) is 800-1,000 i.u. per day. Most would also concurrently give the patient 1,000 mg. of elemental calcium per day. • Resource: Maintain Your Independence: Keep Healthy Bones for Life www.calgaryhealthregion.ca/programs/injuryprevention/olderadult_athome_fallprevention.
htm
Patient Education

• Brochures on fall prevention, bone health, diet, and other topics should be provided as • Be Falls Smart in Your Community • Be Falls Smart in What You Do – Medications • Be Falls Smart in What You Do – Physical Activity • Take Action to prevent a fall before it happens • Check for Safety – A Home Fall Prevention Checklist for Older Adults http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/DesktopPDF/English/booklet_Eng_desktop.pdf
Environmental Evaluation and Modification
• For high-risk patients being discharged from hospital, a home assessment by an occupational therapist before their return home, or shortly afterwards, might minimize the risk of falling after leaving hospital19,20. • If the patient has severe visual impairment, identification and modification of environmental hazards by an occupational therapist can decrease the risk of further falls21. • Identification and modification of home hazards that is professionally prescribed by, for example, an occupational therapist might be helpful for community-dwelling older people with a history of falls, but it must be realized that this will often not be available. In those situations, patients and/ or their families can be given (or directed to) a home safety checklist and encouraged to examine their home for environmental risks. • Be Falls Smart in Your Community • Check for Safety – A Home Fall Prevention Checklist for Older Adults http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/DesktopPDF/English/booklet_Eng_desktop.pdf
Osteoporosis and Injury Reduction/Prevention

• Refer to Toward Optimized Practice (TOP) Clinical Practice Guidelines for the Diagnosis and Mananagement of Osteoporosis (hidden link http://www.topalbertadoctors.org/cpgs/osteoporosis.html) Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 • Hip protectors (a device that absorbs and/or shunts away the energy of the impact of a fall from the greater trochanter) might have a role in preventing hip fractures within long term care facilities but at this time their use in the community cannot be recommended. Adherence, particularly in the long term, is an issue22,23. • In winter the use of footwear to minimize the risk of slipping (e.g., Ice Grippers, Yaktrax Walker ®) might reduce the likelihood of falls and their injuries during outdoor walking24. • For seniors living alone who are at high risk of falling, an emergency response system (a signaling device that summons help during an emergency) should be considered.


1 Tinetti ME: Preventing Falls in Elderly Persons. N Engl J Med 2003, 348:42-49. 2 Chang, JT & Ganz, DA, Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. J Am Geriatr Soc 2007, 55:S327-S334. 3 Mathias S, Nayak US, Isaacs B: Balance in elderly patients: the "get-up and go" test. Arch Phys Med Rehabil 1986, 67:387-9. 4 Nordin E, Lindelöf N, Rosendahl E, Jensen J, Lundin-Olsson L: Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's global judgement and fall history in evaluating fall risk in residential care facilities. Age Ageing. 2008, 37:442-8. 5 Steffen TM, Hacker TA, Mollinger L: Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther 2002, 82:128-37. 6 Podsiadlo D, Richardson S: The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991, 39:142-8. 7 Shumway-Cook A, Brauer S, Woollacott M: Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther 2000, 80:896-903. 8 Hartikainen S, Lönnroos E, Louhivuori K: Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007, 62:1172-81. 9 Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA: Randomised controlled trial of prevention of falls in people aged > or =75 with severe visual impairment: the VIP trial. BMJ 2005, 331(7520):817-24. 10 Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T: Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol 2005, 89:53-9. 11 Hartikainen S, Lönnroos E, Louhivuori K: Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007, 62:1172-81. 12 Hogan DB, Kwan M: Falls and seniors: the role of medications. DUE Quarterly January 2002, Issue 33:1-2, 4. 13 Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM: Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999, 47:850-3. 14 van der Velde N, Stricker BH, Pols HA, van der Cammen TJ: Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol. 2007, 63:232-7. 15 Dam TT, von Mühlen D, Barrett-Connor EL: Sex-specific association of serum vitamin D levels with physical function in older adults. Osteoporos Int 2008 Sep 19. 16 Ceglia L: Vitamin D and skeletal muscle tissue and function. Mol Aspects Med 2008 Aug 8. 17 Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al: Effect of Vitamin D on Falls. JAMA 2004, 291:1999-2006. 18 Jackson C, Gaugris S, Sen SS, Hosking D: The effect of cholecalciferol (vitamin D3) on the risk of fall and fracture: a meta-analysis. Q J Med 2007, 100:185-92. 19 Cumming RG, Thomas M, Szonyi G, Salkeld G, O'Neill E, Westbury C, Frampton G: Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. J Am Geriatr Soc 1999, 47:1397-402. Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008 20 Di Monaco M, Vallero F, De Toma E, De Lauso L, Tappero R, Cavanna A: A single home visit by an occupational therapist reduces the risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial. J Rehabil Med 2008, 40:446-50. 21 Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA: Randomised controlled trial of prevention of falls in people aged > or =75 with severe visual impairment: the VIP trial. BMJ 2005, 331(7520):817-24. 22 Parker MJ, Gillespie WJ, Gillespie LD: Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev 2005 Jul 20; (3):CD001255. 23 Parker MJ, Gillespie WJ, Gillespie LD: Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review. BMJ 2006, 332:571-74. 24 McKiernan FE: A Simple Gait-Stabilizing Device Reduces Outdoor Falls and Nonserious Injurious Falls in Fall-Prone Older People During the Winter. J Am Geriatr Soc 2005, 53:943-47 Created by and used with the permission of the Calgary Health Region Copyright Calgary Health Region and Alberta Centre for Injury Control & Research 2008

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