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Falls prevention guidelines for general practitioners for ...

  1. 1. Falls prevention guidelines for general practitioners for assessing and managing older people Working together to prevent falls Guidelines developed by: Barwon Health These falls prevention guidelines were developed by Barwon Health for use by general practitioners for assessing and managing falls risk in older people (aged 65 and over). The document provides: • A rationale for the guidelines • Falls risk identification and evaluation framework and checklist, and • Includes a number of functional tests to assess balance and vestibular conditions. The guidelines were based in part (algorithm) on an article by the American Geriatric Society, British Geriatric Society, American Academy of Orthopaedic Surgeons, Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society 49:664-672, 2001. (Downloadable) ---TTTTTTTTTTT--- In 2005 the Department of Human Services funded the National Ageing Research Institute to review and recommend a set of falls prevention resources for general use. The materials used as the basis for this generic resource were developed by Barwon Health under a Service Agreement with the Department of Human Services. This and other falls prevention resources are available from the department’s Aged Care website at: http://www.health.vic.gov.au/agedcare.
  2. 2. Working together to prevent falls Falls prevention guidelines for general practitioners for assessing and managing older people This document provides a framework for screening, assessment and management of older people at risk of falling by general practitioners. A fall is defined as “an event reported either by the faller or a witness, resulting in a person inadvertently coming to rest on the ground or another lower level, with or without loss of consciousness or injury” i Rationale for guidelines Both the incidence of falls and the severity of falls related complications rise steadily after the age of 60 years. Thirty-five to forty percent of the community dwelling population aged 65 years and older fall annually. Fifty percent of those 80 years and older fall per year. The incidence of rates of falls in residential aged care is approximately double the rate of people living independently in the community. Five percent of community falls result in fractures and 5% result in other significant injuries. Fear of falling is a well recognised consequence of falling. Loss of confidence in safe ambulation results in self imposed lifestyle restrictions, failing independence, and can precipitate a spiralling decline in physical condition, instability and dependence. The older community too readily accepts falls as an unavoidable part of life and ageing. Frequent falls and near falls events are overlooked and very often go unreported to medical practitioners or health workers. There is now good evidence that a range of interventions can be effective in reducing the rate of falls among older people.ii The interventions best supported by evidence includeiii: • Professionally prescribed muscle strength and balance retraining; • Professionally prescribed home hazard assessment and modification; • Multi disciplinary multifactorial health / environmental risk screening / intervention programs; • Tai Chi exercises; • Withdrawal of psychotropic medication. Success of interventions is likely to be optimised by early identification of those at risk, before a serious fall occurs, with its secondary self-perpetuating consequences.
  3. 3. Falls Evaluation Falls result from a variable combination of intrinsic health problems, extrinsic environmental and task related hazards, and the effects of medication – many of which can be ameliorated. This suggested algorithm begins from the assumption that any individual over 65 years has a 40% chance of having had a fall in the past twelve months, and that deliberate inquiry must be made to identify those at risk. At any given opportunity it is recommended that an inquiry be made about the history of recent falls and circumstances of these falls. Periodic or annual health assessment is such an opportunity. A positive response to this question should prompt further inquiry along the lines outlined in the falls prevention algorithm and recommended areas of assessment for further falls evaluation be implemented. In particular, use of psychotropic medications, multiple – that is four or more medications, acute or chronic medical conditions, visual impairment and gait and balance impairment may need to be critically evaluated. Ask your patients: 1. Have you had a fall in the last 12 months? 2. Are you frightened of having a fall? 3. Do you want to do anything to prevent falling? Take the opportunity to observe your patient getting in and out of a chair, and when walking.
  4. 4. FALLS RISK IDENTIFICATION AND EVALUATIONiv v No medical intervention Periodic case finding in Recommend primary care: participate in No exercise program Ask all patients about falls in the falls that includes past year Observe patients getting in & out strength and of chair and walking balance training Single No Recurre obviou fall nt falls sprobl em Check for balance and gait problems Patient Gait / presents balance to a problem medical s facility Falls Evaluation after a fall Assessment Multifactorial interventions (As appropriate)  History  Medications  Gait, balance & exercise programs  Vision  Medication modification  Gait and  Postural hypotension treatment balance  Environmental hazard modification  Lower limb  Cardiovascular disorder treatment joints  Vestibular Rehabilitation program  Neurological  Cardiovascular
  5. 5. Falls Evaluation Checklist Assessment Comment Intervention HISTORY • Number of falls • Circumstances of falls • Suspected environmental hazards Refer to occupational therapist • Related symptoms • Altered conscious state Altered consciousness Consider cardiology Disequilibrium Consider neurology • Medications • Critical review of medication 4 or more in total requirements Psychotropic medication • Liaise with physician or psychiatrist as required • Acute medical problems • Treat all acute medical problems • Chronic medical problems • Manage all chronic geriatric medical problems to optimise function • Mobility level • Refer to physiotherapist for Reliable use of gait aid education if in doubt about technique EXAMINATION • Cognitive assessment Impaired cognition • Investigate for cause, consider Depression specific dementia treatment, manage depression to improve activity levels • Vision • Optometry / ophthalmological Corrected acuity < 12/20 review Bifocal use • Be wary of bifocal use when ambulating • General condition • Dietetic advice Nutritional status, skin • Physical exercise / training care Physical Endurance Muscle bulk • Neurological assessment • Neurological diagnostic assessment Muscle strength, tone & • Allied health management of reflexes identified disability Proprioception Cerebellar function Extrapyramidal function • Cardiovascular Heart rate, rhythm, • Manage orthostatic hypertension postural pulse & blood (symptomatic or >20mm Hg) pressure • Assessment of valvular lesions, Heart sounds ventricular function & rhythm • Feet and footwear • Podiatry / orthotic advice Disturbed foot anatomy OFFICE-BASED FUNCTION ASSESSMENTS • Get Up & Go • Poor functional performance • Single Leg Stance Refer physiotherapy • Sternal push test 1:1 / group physiotherapy / home based exercise program • Vestibular assessment if • Vestibular dysfunction indicated by symptoms Ear, Nose & Throat specialist Vestibular stepping test Falls & Mobility Clinic Hallpike test Specialist physiotherapy
  6. 6. List of local falls prevention services and programs
  7. 7. Office-based function assessments 1. Get Up & Go Test (timed or unstructured) This is possibly the single most useful screening test for any patient with a history of falls, unsteadiness or abnormality of balance or gait. Testing normal postural changes using a variety of muscle groups and muscle mechanisms. The patient is required to get up from a firm chair with arms (the patient may use their own arms for assistance as necessary), walking three metres at normal pace with (with walking aid if normally used) turning on the spot and returning to sit in the chair. Timing this test provides some objectivity that can be measured. Under normal circumstances this can be completed in ten seconds. In an unstructured sense this test provides the opportunity to note functional difficulties with transferring and gait. It can reveal arthritic disease of hip, knee and ankle; weakness of lower limbs or back; incoordination such as cerebellar ataxia or apraxia; Parkinsonism, bradykinesia or dyskinesia; cerebrovascular disease with hemiparesis and associated spasticity; and gait features including quality of arm swing, step height, length and cadence, base of support and gait speed. 2. Romberg’s Test With advanced age, individuals commonly have some impairment of proprioception as well as impaired visual and vestibular function and all sensory input is important in maintaining balance without there necessarily being visual, neuropathic or related pathology. This test assesses the capacity to withstand balance challenges with reduced visual input. The patient is required to stand with feet as close together as is comfortably possible with eyes initially open and, with standby supervision and reassurance, close the eyes. Impaired proprioception due to neuropathy or posterior column disease will cause loss of balance. Cerebellar dysfunction causes ataxia with feet together even with eyes open. Further discriminating assessment of proprioception is then warranted. 3(a) Sternal Push Test This test evaluates the patient’s ability to withstand an external perturbation. The patient stands with their feet comfortably close together. The tester stands reassuringly close to the patient. Often a chair a half step behind the patient is prudent. After a warning the patient is pushed firmly on the sternum and observation is made of the patient’s functional falls prevention actions. A normal patient can resist the sternal push without stepping and utilise hip, trunk and upper limb strategies to assist in maintaining balance. An impaired patient may take one or even two protective steps but does save himself or herself from falling with normal balance reactions. The test is definitely abnormal if the patient tends to fall backwards without
  8. 8. taking any protective step or remedy. This test is observational and gives information as to how each individual patient does cope with external stresses. 3(b) Pastor’s Test or Shoulder Tug Test This is a useful alternative to the sternal push test. On this occasion the examiner stands behind the patient, provides a warning description, and delivers a brief tug backwards on both shoulders. Patient is standing with feet comfortably close together and eyes open and is warned prior to the perturbation being applied. Some practitioners prefer this test because of improved patient safety, as a falling patient will simply prop on the examiner behind them. 4. Tandem gait or heel toe walking The patient walks forward placing heel in front of toes thereby walking with a narrow base of support. Cerebellar disorders and disorders of the brain stem and cerebellar tracts lead to difficulty performing this task. This test can unmask fairly subtle unilateral cerebellar pathology as well as midline cerebellar abnormalities that may not be revealed by routine finger-nose or heel-shin type cerebellar assessment. 5. Functional Reaching and bending The ability of the patient to reach any direction outside their base of support is essential for independent domestic functioning and can be evaluated in the office. A standardised functional reach test has been developed. Have the patient stand with arm extended at a set point next to a wall with a tape measure stuck or drawn on, and lean forward with his arm reaching as far forward along the tape as possible. The distance between steady standing and maximal reach is recorded. There is some age related variability; in general normal subjects can reach over 30cm. Less objective but more observational assessment can be made without formal measurement. 6. Standing on heels and toes Standing on heels and toes provides rapid assessment of power in dorsi flexion and plantar flexion of the ankles respectively. An L4/5 lesion makes walking on one’s heels impossible and the patient would ordinarily have a notable foot drop. An S1 lesion makes it impossible to walk on toes. Ankle strength, ankle joint quality and ankle balance strategies are all important for balance.
  9. 9. 7. Vestibular Stepping Test This is a useful screening test to assess if a vestibular lesion is peripheral or central. The patient marches on the spot for 50 steps with eyes shut. A positive test due to a unilateral peripheral vestibular lesion causes a patient to inadvertently turn greater than 45 degrees towards the affected side. 8. Hallpike Manoeuvre This test is used to diagnose benign paroxysmal positional vertigo and is lateralising. The patient is required to sit on a firm flat examination couch with legs extended along the couch. The patient is warned that they will have their balance system challenged by this test. The patient is required to lie down supine with their head rotated to either left or right with eyes open. No pillows are allowed. Older patients rarely tolerate their head dropping below horizontal. The test is positive if the patient complains of true vertigo of delayed onset subsiding within 60 seconds and accompanied by rotatory nystagmus. There is a 2-10 second latency before onset of the dizziness. The vertigo fatigues with repetition of the provoking manoeuvre. If positive the test may induce vomiting. Resumption of sitting posture may precipitate similar symptoms. If the patient complains of vertigo without the latent period, with no fatigability or with variable nystagmus then another underlying cause is presumed. Further reading: Monagle S, Reducing falls in community dwelling elderly. The role of the GP in care planning. Australian Family Physician 31:12 Dec 2002 In 2005 the Department of Human Services funded the National Ageing Research Institute to review and recommend a set of falls prevention resources for general use. The materials used as the basis for this generic resource were developed by Barwon Health under a Service Agreement with the Department of Human Services. This and other falls prevention resources are available from the department’s Aged Care website at: http://www.health.vic.gov.au/agedcare.
  10. 10. i Rubinstein et al “The Value of Assessing Falls in an Elderly Population: at randomised clinical trial” Annals of Internal Medicine 113:3082316 1990 ii Hill K, Vrantsidis F, Haralambous B et al. An Analysis of Research on Preventing Falls and Falls Injury in Older People: Community, Residential Care and Hospital Settings (2004 update). Australian Government Department of Health and Ageing, 2004 iii Gillespie LD, Gillespie WJ’ Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people (Cochrane Review). in: The Cochrane Library, Issue 2, 2003 iv American Geriatric Society, British Geriatric Society, American Academy of Orthopaedic Surgeons Guideline for Prevention of Falls in Older Persons Jags 49:664-672, 2001 v Tinetti ME. Preventing falls in elderly Persons. N.EnglJ.Med 348:1 Jan2.2003 v