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Falls assessment

A fall is defined as an event which causes a person to, unintentionally, rest on the ground or lower level , and is not a result of a major intrinsic event ( such as stroke ) or overwhelming hazard.

How common –Falls and fall-related injuries -happen more often with advancing age Falls are not inevitable part of ageing Over 1/3rd of people over age 65 fall each year and the proportion increases to 50 % by age 80 Each year abut 30% to 40 % of people aged 65 yrs and older who live in the community fall Falls are neither purely accidental nor inevitable –> many falls are preventable About 30 % of falls result in injury that requires medical attention and with fractures occurring in approximately 10 % of falls.

Risk factors
Intrinsic –Increasing age Female gender Previous h/o falls Gait , balance and mobility issues Presence of chronic disorders e,g hypertension Visual impairment Higher levels of pain Women- urinary incontinence and frailty Men higher level of depressive symptoms ,older age and being unable to take the balance test Deficits in balance and muscle function Cognitive decline Medications used and number of medications for e.g beta-blockers

Extrinsic factors –Any environmental factor that causes
tripping ,slipping or ,loss of balance this includes
rugs electrical cords pets items on floor Stairs ( no handrail ) Irregular slippery floor Bathtub Use of assistive devices as canes Low toilets or chairs , bed height Poor lighting Uneven sidewalks Footwear Snow, ice

The single greatest risk factor for falling is a previous fall in the past 12 months 
( Davies A et al Age Ageing 1996 )

Morbidity and Mortality –Falls are the 2nd leading cause of injury mortality worldwide Falls are major independent determinants of functional decline and restricted activity days ( Tinnettin ME et al 1997 ) NHS cost approximately £ 2.3 billion / year ( NICE June 2013 ) Leading cause of death due to unintentional injury in people over 65 in the US & cost 30 Billion $s in 2010 Leads to ○ distress ○ pain ○ injury ○ loss of confidence ○ loss of independence and mortality
About 5 % of falls in older people who live in community result in a fracture or hospitilization Falling and suffering serious fall increases the risk of skilled nursing facility placement 3 and 10 fold respectively More than 20-39 % of people who fall experience fear of falling which leads to further limiting of activity , independent of injury ( Campbell et al 1981 ) also mentioned in literature as Post-fall syndrome In India in the year 2005 falls injury was the cause of 25 % of all unintentional injuries with 160,000 death .

Who to refer-Falls are often unreported Up to 30 % of older people who have fallen in the last 3 months are unable to recall a fall hence relying on patient reported falls may lead to under-recognition Older people often fear admitting a fall – they fear being labeled as frail or being moved into a residential home
 The AGS / BGS guideline suggests that all individuals above 65 and over should have annual falls risk screening assessment- by asking two questions

1 if they have fallen 2 or more times in the past year or sought medical attention for a fall
2 if they have not fallen , whether they feel unsteady when walking.
AGS / BGS guidance suggests to offer a multi-factorial assessment and intervention to those who answer positively to any of these questions ie consider a referral to the Falls clinic for an assessment of
 gait and balance test medication review vision evaluation evaluation for orthostatic hypotension home evaluation for safety optimization.

 

Falls are usually multifactorial due to interplay 
of multiple risk factors like
 muscle weakness poor balance visual impairment polypharmacy – and use of certain medications environmental hazards some specific medications.

History -before the fall pre-syncopal symptoms for e.g dizzy , light-headed , palpitations what were they doing when they fell for ?
getting up 
in the toilet
walking
turning head 

During the fall –do they remember falling ? any eye witness -if so get a detailed history LOC – if no eye witness assume that there may have been some LOC mechanism of fall- must have tripped should not be taken as an answer of definitive mechanism did they use their hands to prevent injury ?-fractured wrist is consistent with no LOC whereas a significant black eye indicates an attempt to protect themselves and LOC prior to fall.

After the fall –any suggestion of a seizure for e.g urinary/ faecal incontinence were they oriented after the fall ? could they mobilise on their own how long were they on the floor ?

Examination –Orthostatic vital signs – perform a lying and 
standing BP
Postural hypotension is described as a reduction in systolic BP of atleast 20 mm Hg or in diastolic BP of atleast 10 mm Hg within 3 minutes of standing Distance visual acuity Cardiac examination- heart rate and rhythm Gait and balance Musculoskeletal examination of back and lower extremities , knee exam Neurological examination
○ cognition ○ peripheral sensation ○ proprioception
○ muscle bulk , tone , strength , reflexes and range of motion ○ higher neurological function Weight / Height Footwear / assistive devices BMI.

Investigations –FBC U/E ,LFT ,Bl glcuose ,TFT Bone profile B12 ,Folate Urinalysis ECG DEXA if osteoporosis is suspected

Vitamin D is not advised by NICE guidelines. American guideline by CDC recommends Vit D and Calcium replacement for all three categories
( low , high and medium risk of fall ) XR/CT /MRI as clinically indicated.

NICE guideline –NICE recommends that a multi-assessment risk assessment should examine
 falls history gait , balance , mobility and muscle strength osteoporosis / fracture risk functional ability & fear of falling vision , cognition and neurological assessment urinary incontinence home hazards cardiovascular problems medication

the intervention should
 provide strength and balance training address home hazards correct visual risk factors address medication associated risks provide education address specific underlying medical conditions.

Falls risk assessment tools –National Center for Injury Prevention and Control’s STEADI – stopping elderly accidents and deaths and injuries Electronic frailty index – NHS England Falls Risk Assessment Tool – developed by the Peninsula Health Falls Prevention Service in 1999 St Thomas’s Risk Assessment Tool in Falling Elderly Patients ( STRATIFY ) Falls Risk Assessment Scale for the Elderly Morse Falls Scale Care Home Falls Screen for residential aged care home facilities

NICE does not recommend usage of tools predicting risk using numeric scales.

Gait and balance tests – Time up and go test ( TUG test ) 30 second chair stand test 4 stage balance test Tinneti Performance Oriented Mobility
Assessment ( POMA ) test Berg Balance test One – Legged Stance Test ( OLST ) Turn 180 degree test

Discussion –Falls prevention is valued in practice as complex Barriers faced by HCP in managing falls can relate to 
○ from older people ( older people normalise falls )
○ HCPs barriers ( lack of skills and knowledge )
○ Lack of caregiver support ( education & support ) 
○ healthcare system related factors There is no evidence that being careful alone prevents falls Almost half of fallers will experience a repeat fall within the nexT year Studies indicate that falling is a multifactorial health condition that results from accumulated effects of co-existing conditions and their treatment It is known that primary prevention using primary care records to identify high risk people and offering them assessment and intervention does not work and is not cost effective Multifactorial prevention strategies have been proven to be effective in RCTs – barriers as physician knowledge and time constraints mean it is often necessary to collaborate to reduce the risk of falls Exercise that focus on strength and balance is a mainstay of function preservation and fall prevention- evidence of effectiveness in falls related benefits Vitamin D supplementation interventions had mixed results with a high dose being associated with higher rates of falls related outcomes – Janelle M Guirguis-Blake et at 2018( NICE does not recommend Vit D test ) Being unable to standup from a chair height without using one’s arm indicates increased fall’s risk
( Woolcott JC et al 2009 ) As risk factors are multiplicative , risk can be reduced by modifying even a few contributing factors Falls prevention is complex and the work needs to draw on the knowledge and skills from multiple health disciplines

LINKS AND RESOURCES

PATIENT INFORMATION

Age UK information with a downloadable 40-page leaflet – Staying steady https://www.ageuk.org.uk/information-advice/health-wellbeing/exercise/falls-prevention/

East Suffolk and North Essex NHS Foundation Trust printable leaflet https://i3a5v6j6.stackpathcdn.com/wp-content/uploads/2018/06/Final-05908-18-Fall-Prevention-Support-and-Education.pdf

Falls risk assessment tool for patients https://www.nhs.uk/live-well/healthy-body/are-you-at-risk-of-falling/

SAGA Get up and Go – a guide to staying steady https://www.nhs.uk/Conditions/Falls/Documents/SAGA_Falls-Prevention.pdf

Tumbles – seven step falls prevention checklist patient information booklet from NHS & Essex County Council -a useful resource https://www.livingwellessex.org/media/571076/tumbles-7-steps-falls-prevention.pdf

A compilation of resources from NSW Government Clinical Excellence Commission- a wonderful one stop collection http://cec.health.nsw.gov.au/keep-patients-safe/Falls-prevention/for-patients-carers-and-families

INFORMATION FOR CLINICIANS

NHS Acute Frailty Network https://www.acutefrailtynetwork.org.uk/

RCP bedside vision assessment tool for fall prevention https://www.rcplondon.ac.uk/projects/outputs/bedside-vision-check-falls-prevention-assessment-tool

NIHR resources on falls http://arc-em.nihr.ac.uk/search/node/falls

NHS Inform Telecare Self-Check Online Tool https://www.nhsinform.scot/care-support-and-rights/tools-and-apps/telecare-self-check-online-tool

STEADI ( Stopping Elderly Accidents, Deaths & Injuries )  resources on fall from CDC https://www.cdc.gov/steadi/patient.html

https://www.cdc.gov/steadi/materials.html

Falls Prevention Training Resource – a guide for care staff  an excellent production from IOW NHS https://www.iow.nhs.uk/Downloads/Falls/Falls%20Prevention%20Training%20Resource.pdf

A collection of various national resource from Gov UK – Falls applying all our health https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health

Risk assessment tools

Electronic Frailty Index https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/efi/

Morse Falls Scale https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3h.html

STRATIFYY risk assessment tool https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3g.html

Falls and Bone Health Multifactorial Assessment, Actions & Interventions for All Adult Inpatients ( FBHA ) https://www.cardiffandvaleuhb.wales.nhs.uk/sitesplus/documents/1143/Final%20MFA%20MFI%20tool%20V1.pdf

TUG Test video https://www.youtube.com/watch?v=BA7Y_oLElGY

30 second chair stand test https://www.youtube.com/watch?v=Ng-UOHjTejY

4 stage Balance Test https://www.youtube.com/watch?v=3HvMLLIGY6c

 

References

  1. Phelan, Elizabeth A et al. “Assessment and management of fall risk in primary care settings.” The Medical clinics of North America vol. 99,2 (2015): 281-93. doi:10.1016/j.mcna.2014.11.004
  2. Falls prevention in primary care by Dr James Frith Oct 2017 Nursing in Practice https://www.nursinginpractice.com/falls-prevention-primary-care
  3. Liddle, J., Lovarini, M., Clemson, L. et al. Making fall prevention routine in primary care practice: perspectives of allied health professionals. BMC Health Serv Res 18, 598 (2018). https://doi.org/10.1186/s12913-018-3414-1
  4. Reducing Falls A guide to falls prevention and management in Derbyshire https://www.derbyshire.gov.uk/site-elements/documents/pdf/social-health/adult-care-and-wellbeing/help-to-live-at-home/reducing-falls-a-guide-to-falls-prevention.pdf
  5. Berry, Sarah D, and Ram R Miller. “Falls: epidemiology, pathophysiology, and relationship to fracture.” Current osteoporosis reports vol. 6,4 (2008): 149-54. doi:10.1007/s11914-008-0026-4
  6. Sharif, Suleiman I et al. “Falls in the elderly: assessment of prevalence and risk factors.” Pharmacy practice vol. 16,3 (2018): 1206. doi:10.18549/PharmPract.2018.03.1206
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207352/
  7. Catharine R. Gale, Cyrus Cooper, Avan Aihie Sayer, Prevalence and risk factors for falls in older men and women: The English Longitudinal Study of Ageing, Age and Ageing, Volume 45, Issue 6, 2 November 2016, Pages 789–794, https://doi.org/10.1093/ageing/afw129
  8. Falls Assessment and prevention of falls in older people Issued: June 2013 NICE guidance number CG161 https://www.nice.org.uk/guidance/cg161/evidence/falls-full-guidance-190033741
  9. Chou, William C et al. “Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice.” Journal of general internal medicine vol. 21,2 (2006): 117-22. doi:10.1111/j.1525-1497.2005.00298.x
  10. Loganathan A, Ng CJ, Tan MP, et al
    Barriers faced by healthcare professionals when managing falls in older people in Kuala Lumpur, Malaysia: a qualitative study
  11. The Role of Primary Care Providers in Managing Falls by Jamehl L Demons , Pamela W Duncan NCMJ vol. 75, no. 5 ncmedicaljournal.com https://www.ncmedicaljournal.com/content/ncm/75/5/331.full.pdf
  12. Narayanan, V et al. “Falls screening and assessment tools used in acute mental health settings: a review of policies in England and Wales.” Physiotherapy vol. 102,2 (2016): 178-83. doi:10.1016/j.physio.2015.04.010
  13. Borowicz, Adrianna et al. “Assessing gait and balance impairment in elderly residents of nursing homes.” Journal of physical therapy science vol. 28,9 (2016): 2486-2490. doi:10.1589/jpts.28.2486
  14. Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;319(16):1705–1716. doi:10.1001/jama.2017.21962
  15. Public Health England – GuidanceFalls: applying All Our Health Updated 31 January 2020 https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health
  16. Comprehensive Assessment of a fall Oxford Medical Education http://www.oxfordmedicaleducation.com/wp-content/uploads/2015/12/Falls-History-exam-investigation-and-management.protected.pdf
  17. CGA in Primary Care Settings: Patients at risk of falls and fractures British Geriatric Society January 2019 https://www.bgs.org.uk/resources/12-cga-in-primary-care-settings-patients-at-risk-of-falls-and-fractures

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