Falls

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An 83-year-old woman had had four falls at home in the last month. She had bilateral early cataracts and age-related macular degeneration; her footwear was badly worn, uneven heels of 4cm height. Her daughter stated that her mother had become more forgetful over the last year and often forgot to take her medication (aspirin 75mg daily, simvastatin 40mg daily, bendroflumethiazide 2.5mg daily, lisinopril 10mg daily, paracetamol 1g QDS).What aspect of assessment will have the greatest impact on onward management of her falls risk?

A. Assessment of cognition

B. Ensuring correct spectacles are worn

C. Measuring lying and standing BP

D. Medication review

E. Provision of suitable footwear

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30. A. In this case all of these may be important in reducing her falls risk. However, assessment of cognition is the most crucial component of a comprehensive falls risk assessment, as any intervention to minimize falls risk relies upon the individual being able to understand and cooperate with that intervention.

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36. A 75-year-old man was found by his wife having apparently fallen off his commode in the bedroom. When she found him he was more confused than usual and appeared to be in severe pain. In the ED he was found to have a fractured right clavicle, flail right chest, right haemothorax, and fractured left humerus. Neurological examination was consistent with Parkinson’s disease with no other neurological deficit.His wife was distraught that he should have sustained such severe injuries in the short time that she had left him to answer the telephone downstairs. Parkinson’s disease had been diagnosed 4 years earlier. He had been changed from monotherapy with a dopamine agonist to levodopa 8 months earlier because of developing cognitive impairment. In the last 4 months, he had started on an acetylcholinesterase inhibitor and the dose gradually titrated up. He was not on any other medication. He did not normally suffer any motor fluctuations.What is the most likely cause for his fall?

A. Convulsion

B. Elder abuse

C. Orthostatic hypotension

D. Dyskinesias

E. Transient ischaemic attack

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A. He had recently been started on an acetylcholinesterase inhibitor and the dose was being increased. These drugs lower seizure threshold.

Carer strain increases with increasing demands placed on the carer (this equates to physical severity of Parkinson’s and degree of cognitive impairment). It is important to consider elder abuse, as these injuries are excessive for just having fallen of the commode. The wife has given a reasonable explanation of events and seems appropriately concerned, making abuse less likely. Autonomic dysfunction accompanying Parkinson’s disease might explain a fall, but would not usually result in such severe injuries if he had simply fallen trying to stand up from the commode, in his wife’s absence. You are told he did not have motor fluctuations and so dyskinesias are an unlikely explanation. The only neurological abnormalities were those of the Parkinson’s, the absence of acute neurological deficit does not imply he has had a TIA.

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71. A woman with a history of a stroke and recurrent falls asked for advice regarding reducing her risk of falling. Which of the following would be the least appropriate to recommend? A. A set of perching stools for use in the kitchen and bathroom B. A walking stick sized by measuring from the wrist to the ground C. Four wheel rollator frame with handgrips at wrist height when elbows bent 45º D. Installation of grab rails in her kitchen and bathroom E. Two wheel rollator frame with handgrips at wrist height when elbows bent 15º

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71. C. Correct sizing of walking aids is important to enable them to be used safely. Walking sticks should be measured from the wrist height to the ground and frames should be sized so that the grips are at wrist height when the elbows are bent at 15º. A quad stick may be preferable to a frame in patients with weakness following a stroke as they do not rely on the weak side. Appropriate home modifications such as perching stools, shower stools, and grip rails can further reduce risk of falls.

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63. A 75-year-old woman presented following a fall. She was initially slightly vague regarding the mechanism, but reported that she was moving across the living room, when her legs gave way. She did not think she had lost consciousness. She had not experienced preceding light-headedness, chest pain, or palpitations. Past medical history included atrial fibrillation (AF), diabetes mellitus, and hypertension. Medications consisted of bisoprolol 5mg OD, aspirin 75mg OD, metformin 500mg OD. On examination, bilateral periorbital bruising was evident. The patient had an irregular heart rhythm at 60beats/min. Heart sounds were normal. BP was 140/80 with no drop on standing. Respiratory and abdominal examination were unremarkable. An ECG confirmed AF at a rate of 48–65beats/min with a right bundle branch block morphology. Bloods demonstrated normal electrolytes, inflammatory markers, and troponin. Which of the following is the next most appropriate course of action? A. Admit the patient for cardiac monitoring B. Discharge and refer to community falls clinic C. Initiate calcium and vitamin D supplementation D. Physiotherapy review E. Refer for tilt table testing

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63. A. The vague recollection and significant facial injury are highly suggested of a transient loss of consciousness. While such reflex mechanisms may be slowed in older age, conscious individuals who are falling would normally break the fall with their arms, or in the event they are unable to do that, turn their head to one-side. Failure of all these protective mechanisms may imply loss of consciousness. In the absence of a significant postural drop in BP, arrhythmia must be considered, and significant pauses and/or bradycardia excluded. A reduction in the beta-blocker dose is likely indicated.

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Nice falls

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Skip to contentAccessibility helpSearch NICE…MenuCoronavirus (COVID-19)For information on how NICE is supporting the NHS and social care, view our new rapid guidelines and evidence summaries. Learn about the government response to coronavirus on GOV.UK.CloseHome NICE Guidance Conditions and diseases Injuries, accidents and woundsFalls in older people: assessing risk and preventionClinical guideline [CG161] Published date: 12 June 2013Uptake of this guidanceGuidanceTools and resourcesInformation for the publicEvidenceHistoryOverviewIntroductionPatient-centred careKey priorities for implementation1 Recommendations2 Research recommendations3 Other information4 The Guideline Development Group, Internal Clinical Guidelines Team, and NICE project team 20135 The Guideline Development Group, National Collaborating Centre and additional assistance 2004About this guidelineShareDownloadGuidance1 RecommendationsTerms used in this guideline1.1 Preventing falls in older people1.2 Preventing falls in older people during a hospital stayThe following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.The wording used in the recommendations in this guideline (for example words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.Terms used in this guidelineExtended careA care setting such as a nursing home or supported accommodation.Multifactorial assessment or multifactorial falls risk assessmentAn assessment with multiple components that aims to identify a person's risk factors for falling.Multifactorial interventionAn intervention with multiple components that aims to address the risk factors for falling that are identified in a person's multifactorial assessment.Older peopleIn section 1.1, older people are people aged 65 years and older. In section 1.2, older people are people aged 50 years and older.Older people living in the communityOlder people living in their own home or in extended care.Risk prediction toolA tool that aims to calculate a person's risk of falling, either in terms of 'at risk/not at risk', or in terms of 'low/medium/high risk', etc.1.1 Preventing falls in older people1.1.1 Case/risk identification1.1.1.1Older 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. [2004]1.1.1.2Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed in section 3.3 of the full guideline.) [2004]1.1.2 Multifactorial falls risk assessment1.1.2.1Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. [2004]1.1.2.2Multifactorial assessment may include the following:identification of falls historyassessment of gait, balance and mobility, and muscle weaknessassessment of osteoporosis riskassessment of the older person's perceived functional ability and fear relating to fallingassessment of visual impairmentassessment of cognitive impairment and neurological examinationassessment of urinary incontinenceassessment of home hazardscardiovascular examination and medication review. [2004]1.1.3 Multifactorial interventions1.1.3.1All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention.[2004]In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):strength and balance traininghome hazard assessment and interventionvision assessment and referralmedication review with modification/withdrawal. [2004]1.1.3.2Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function. [2004]1.1.4 Strength and balance training1.1.4.1Strength and balance training is recommended. Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional. [2004]1.1.5 Exercise in extended care settings1.1.5.1Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling. [2004]1.1.6 Home hazard and safety intervention1.1.6.1Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer, and appropriate members of the health care team. [2004]1.1.6.2Home hazard assessment is shown to be effective only in conjunction with follow-up and intervention, not in isolation. [2004]1.1.7 Psychotropic medications1.1.7.1Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling. [2004]1.1.8 Cardiac pacing1.1.8.1Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls. [2004]1.1.9 Encouraging the participation of older people in falls prevention programmes1.1.9.1To promote the participation of older people in falls prevention programmes the following should be considered.Healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls.Information should be relevant and available in languages other than English.Falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant. [2004]1.1.9.2Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants' different needs and preferences and should promote the social value of such programmes. [2004]1.1.10 Education and information giving1.1.10.1All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention. [2004]1.1.10.2Individuals at risk of falling, and their carers, should be offered information orally and in writing about:what measures they can take to prevent further fallshow to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing componentsthe preventable nature of some fallsthe physical and psychological benefits of modifying falls riskwhere they can seek further advice and assistancehow to cope if they have a fall, including how to summon help and how to avoid a long lie. [2004]1.1.11 Interventions that cannot be recommended1.1.11.1Brisk walking. There is no evidence[1] that brisk walking reduces the risk of falling. One trial showed that an unsupervised brisk walking programme increased the risk of falling in postmenopausal women with an upper limb fracture in the previous year. However, there may be other health benefits of brisk walking by older people. [2004]1.1.12 Interventions that cannot be recommended because of insufficient evidenceWe do not recommend implementation of the following interventions at present. This is not because there is strong evidence against them, but because there is insufficient or conflicting evidence supporting them[1]. [2004]1.1.12.1Low intensity exercise combined with incontinence programmes. There is no evidence[1] that low intensity exercise interventions combined with continence promotion programmes reduce the incidence of falls in older people in extended care settings. [2004]1.1.12.2Group exercise (untargeted). Exercise in groups should not be discouraged as a means of health promotion, but there is little evidence[1] that exercise interventions that were not individually prescribed for older people living in the community are effective in falls prevention. [2004]1.1.12.3Cognitive/behavioural interventions. There is no evidence[1] that cognitive/behavioural interventions alone reduce the incidence of falls in older people living in the community who are of unknown risk status. Such interventions included risk assessment with feedback and counselling and individual education discussions. There is no evidence[1] that complex interventions in which group activities included education, a behaviour modification programme aimed at moderating risk, advice and exercise interventions are effective in falls prevention with older people living in the community. [2004]1.1.12.4Referral for correction of visual impairment. There is no evidence[1] that referral for correction of vision as a single intervention for older people living in the community is effective in reducing the number of people falling. However, vision assessment and referral has been a component of successful multifactorial falls prevention programmes. [2004]1.1.12.5Vitamin D. There is evidence[1] that vitamin D deficiency and insufficiency are common among older people and that, when present, they impair muscle strength and possibly neuromuscular function, via CNS-mediated pathways. In addition, the use of combined calcium and vitamin D3 supplementation has been found to reduce fracture rates in older people in residential/nursing homes and sheltered accommodation. Although there is emerging evidence[1] that correction of vitamin D deficiency or insufficiency may reduce the propensity for falling, there is uncertainty about the relative contribution to fracture reduction via this mechanism (as opposed to bone mass) and about the dose and route of administration required. No firm recommendation can therefore currently be made on its use for this indication.[2] [2004, amended 2013]1.1.12.6Hip protectors. Reported trials that have used individual patient randomisation have provided no evidence[1] for the effectiveness of hip protectors to prevent fractures when offered to older people living in extended care settings or in their own homes. Data from cluster randomised trials provide some evidence[1] that hip protectors are effective in the prevention of hip fractures in older people living in extended care settings who are considered at high risk. [2004]1.2 Preventing falls in older people during a hospital stay1.2.1 Predicting patients' risk of falling in hospital1.2.1.1Do not use fall risk prediction tools to predict inpatients' risk of falling in hospital. [new 2013]1.2.1.2Regard the following groups of inpatients as being at risk of falling in hospital and manage their care according to recommendations 1.2.2.1 to 1.2.3.2:all patients aged 65 years or olderpatients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of an underlying condition. [new 2013]1.2.2 Assessment and interventions1.2.2.1Ensure that aspects of the inpatient environment (including flooring, lighting, furniture and fittings such as hand holds) that could affect patients' risk of falling are systematically identified and addressed. [new 2013]1.2.2.2For patients at risk of falling in hospital (see recommendation 1.2.1.2), consider a multifactorial assessment and a multifactorial intervention. [new 2013]1.2.2.3Ensure that any multifactorial assessmentidentifies the patient's individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include:cognitive impairmentcontinence problemsfalls history, including causes and consequences (such as injury and fear of falling)footwear that is unsuitable or missinghealth problems that may increase their risk of fallingmedicationpostural instability, mobility problems and/or balance problemssyncope syndromevisual impairment. [new 2013]1.2.2.4Ensure that any multifactorial intervention:promptly addresses the patient's identified individual risk factors for falling in hospital andtakes into account whether the risk factors can be treated, improved or managed during the patient's expected stay. [new 2013]1.2.2.5Do not offer falls prevention interventions that are not tailored to address the patient's individual risk factors for falling. [new 2013]1.2.3 Information and support1.2.3.1Provide relevant oral and written information and support for patients, and their family members and carers if the patient agrees. Take into account the patient's ability to understand and retain information. Information should include:explaining about the patient's individual risk factors for falling in hospitalshowing the patient how to use the nurse call system and encouraging them to use it when they need helpinforming family members and carers about when and how to raise and lower bed railsproviding consistent messages about when a patient should ask for help before getting up or moving abouthelping the patient to engage in any multifactorial intervention aimed at addressing their individual risk factors. [new 2013]1.2.3.2Ensure that relevant information is shared across services. Apply the principles in Patient experience in adult NHS services(NICE guideline CG138) in relation to continuity of c