Falls: assessment and prevention

Definition

Fall: unintentional loss of balance resulting in coming to rest on the floor

Simple fall: result of a chronic impairment of cognition, vision, balance, or mobility.

Medical collapse signifies an acute medical problem (e.g. arrhythmia, transient ischaemic attack, syncope, or vertigo) precipitated the fall.

Environmental hazard (e.g. loose carpet) may precipitate a fall.

Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s.

Epidemiology

Falls are common in older people; prevalence increases with age.

30% of >65y experience at least one fall each year,
50% of> 80y experience at least one fall each year

Prognosis

About 40–60% of falls result in major lacerations, traumatic brain injuries, or fractures.

Consequences

Falls are the main cause of injury, injury-related disability, and death in older people

A fall can cause a fragility fracture, intracranial injury and mortality.

The risk of a fragility fracture amalgamates:

  1. Risk of fall

  2. Pre-existing bone health: bone mineral density [BMD]

  3. Age

  4. Various co-morbidities, smoking and corticosteroid usage

MULTIFACTORIAL ASSESSMENT (based upon identifying established risk factors)

IDENTIFYING PEOPLE AT RISK OF FALLING

All inpatients aged 65 years or older
Do not use fall risk prediction tools to predict inpatients' risk of falling in hospital

CURRENT FALL AND PREVIOUS FALLS

History of current fall
Previous falls
Frequency and causation of falls
Fear of falling
Person’s perceived functional ability

HEALTH ISSUES PREDISPOSING TO FALL

  1. CNS impairment
    Cognitive (acute: delirium; long-standing: dementia, depression)
    Visual assessment and referral
    Neurological examination and screen for neurological disorders (Parkinson’s disease, stroke, TIA)
    Balance and gait
    Use Timed Up & Go test and/or the Turn 180° test and/or functional reach

  2. CVS impairment
    Cardiovascular examination, checking for postural hypotension, arrhythmias and syncope syndrome
    Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls

  3. Musculoskeletal disease
    Mobility
    Arthritis
    Muscle weakness
    Consider strength and balance training

  4. Urological disease
    Urinary and bowel incontinence

  5. Drug and alcohol
    Polypharmacy and medication review with modification/withdrawal
    Alcohol misuse

  6. Frailty

FOCUS ON BONE HEALTH

Bone health and fracture risk
Low bone mineral density and risk of osteoporosis
Age
Glucocorticoids
Rheumatoid arthritis
Smoking
High alcohol consumption
Low BMI
Female sex

FOCUS ON HOME HAZARDS

Loose rugs or mats, poor lighting, wet surfaces (especially in the bathroom), loose fittings (such as handrails)
Poor footwear
Cold home
Home hazard assessment and intervention

Interventions

The National Falls Prevention Coordination Group’s Falls and fracture consensus statement (2017) advocates a whole system approach to prevention.

This assessment should be part of an individualised multifactorial intervention.

Key elements included in the statement

  • identify individuals at high risk of falls or fractures through case finding (e.g. inpatients >65y)

  • multifactorial risk assessment in order to prevent the fall (primary/secondary prevention) and fragility fracture

  • balance and gait testing

  • vision assessment and referral

  • evidence based strength and balance programmes (for those low-to-moderate risk of falls)

  • medication review with modification/withdrawal of medicines

  • home hazard assessment and improvement programme (undertaken by occupational therapist)

  • bone strengthening medicines
    Estimate major osteoporotic fracture risk over 10 years, using FRAX or QFracture
    FRAX can be used for people aged between 40 and 90 years, either with or without BMD values, as specified.
    QFracture can be used for people aged between 30 and 84 years. BMD values cannot be incorporated into the risk algorithm.
    Consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold
    Consider measuring BMD with DXA before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
    Above the upper age limits defined by the tools, consider people to be at high risk.

    Consider assessment of fracture risk:

  • In all women aged 65 years and over and all men aged 75 years and over

  • In women aged under 65 years and men aged under 75 years in the presence of risk factors, for example:
    previous fragility fracture
    current use or frequent recent use of oral or systemic glucocorticoids
    history of falls
    family history of hip fracture
    other causes of secondary osteoporosis
    low body mass index (BMI) (less than 18.5 kg/m2)
    smoking
    alcohol intake of more than 14 units per week for men and women.

A Cochrane review showed risk assessment followed by individualised multifactorial intervention reduced the rate of falls by 24%

The Chief Medical Officers recommend >65y undertake:
>150 minutes of moderate (or 75 minutes of vigorous activity) per week
>2 days/week on activities that improve muscle strength, balance and coordination
Avoidance of high alcohol usage (falls and bone health) and smoking (bone health)

Follow up

ANNUAL ENQUIRY: older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s.

Dr Rajesh Varmafalls, frailty