Australian Commission On Safety and Quality in Healthcare Guidelines For Community

Guidebook for Preventing Falls and Harm From Falls inOlderPeople: Australian Community Care
A Short Version ofPreventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care 2009
Commonwealth ofAustralia2009 This work iscopyright. Itmay bereproduced inwhole orpart for study ortraining purposes subject tothe inclusion ofan acknowledgment ofthesource. Reproduction for purposes other than those indicated above requires the written permission ofthe Australian Commission onSafetyand Quality inHealth Care(ACSQHC). ACSQHC was established inJanuary 2006 bythe Australian health ministers tolead and coordinate improvements insafety and quality inAustralian healthcare. Copies ofthis document and further information onthe work ofACSQHC can befound athttp://www.safetyandquality.gov. au orobtained fromthe Office ofthe Australian Commission onSafety and Quality inHealth Care ontelephone +61292633633 oremailtomail@safetyandquality.gov.au.
Acknowledgments
ACSQHC acknowledges the authors, reviewers and editors who undertook the work ofreviewing, restructuring and writing the Falls Guidelines andguidebooks. ACSQHC acknowledges the significant contribution ofthe Falls Guidelines Review Expert Advisory Group for their time andexpertise inthe development ofthe Falls Guidelines2009. ACSQHC also acknowledges the contributions ofmany health professionals who participated infocus groups, and provided comment and other support tothe project. Inparticular, the National Injury Prevention Working Group, anetwork ofjurisdictional policy staff, played asignificant roleincommunicating the review totheir networks and providingadvice. The guidelines build onearlier work bythe former Australian Council for Safety and Quality inHealth Care and byQueenslandHealth. The contributions ofthe national and international external quality reviewers and the Office ofthe Australian Commission onSafety and QualityinHealth Care are alsoacknowledged. ACSQHC gratefully acknowledges the kind permission of St Vincents and Mater Health Sydney to reproduce many of the images in the guidebook.
Guidebook for Preventing Falls andHarm From Falls inOlder People: Australian CommunityCare
A Short Version ofPreventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Community Care2009
The Australian Commission onSafety and Quality inHealth Care (ACSQHC) has developed three separate falls prevention guidelines, with the help ofolder Australians, for olderAustralians: Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care2009 Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals2009 Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities2009. Collectively, the guidelines are referred toasthe FallsGuidelines. The Falls Guidelines are based oncurrent and relevant literature. They identify principles ofcare and special considerations for culturally and linguistically diverse, Indigenous, and rural and remote groups.
The Falls Guidelines use evidence based recommendations, good practice points, casestudies and points ofinterest tofacilitate understanding and promoteimplementation. There isaneed for further research toestablish the effects ofinterventions onfalls rates. Therefore, the Falls Guidelines recognise that the sound clinical judgment ofinformed professionals isbest practice insituations where strong recommendations have not beenmade. This abridged version ofPreventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care 2009 isdesigned asaquick reference tool, targeted specifically for use incommunity settings that is, private homes inwhich older people are receiving care, but also including low-acuity community health centres. The guidelines are intended toguide clinical practice and tohelp health professionals todevelop and implement practices toprevent falls and injuries fromfalls. The full guidelines for Australian community care areamore comprehensive resource and should bereferred towhen implementing afalls preventionprogram.
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Supportresources
Other resources available fromhttp://www.safetyandquality.gov.au: Preventing Falls and Harm From Falls inOlder People: BestPractice Guidelines for Australian CommunityCare Preventing Falls and Harm From Falls inOlder People: BestPracticeGuidelines for Australian Hospitals2009 Guidebook for Preventing Falls and Harm From Falls inOlder People: BestPractice Guidelines for AustralianHospitals Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Residential Aged Care Facilities2009 Guidebook for Preventing Falls and Harm From Falls inOlder People: BestPractice Guidelines for Australian Residential Aged CareFacilities Implementation Guide for Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities2009 Factsheets: Falls facts for patients andcarers Falls facts fordoctors Falls facts fornurses Falls facts for allied healthprofessionals Falls facts for support staff (cleaners, food services and transportstaff) Falls facts for healthmanagers.
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Guidebook for Preventing Falls and Harm From Falls inOlderPeople
Contents
Page
Acronyms 1 Background 1.1 Whatisafall? 1.2 What isanintervention? 1.3 Development ofthe FallsGuidelines 1.4 How touse theguidelines 2 Involving the older person and theircarers 3 Standard falls preventionstrategies 3.1 Falls preventioninterventions 4 Management strategies for common falls riskfactors 4.1 Falls risk screening andassessment 4.2 Balance and mobilitylimitations 4.3 Cognitiveimpairment 4.4 Continence 4.5 Feet andfootwear 4.6 Syncope 4.7 Dizziness andvertigo 4.8 Medications 4.9 Vision 4.10 Environmentalconsiderations 4.11 Individual surveillance andobservation 5 Minimising injuries fromfalls 5.1 Hipprotectors 5.2 Vitamin Dand calciumsupplementation 5.3 Osteoporosismanagement
vi 1 1 2 2 5 9 11 11 19 19 26 34 38 41 46 48 52 57 63 67 71 71 74 76
Contents
Page
6 Respondingtofalls 6.1 Immediate responsetofalls 6.2 Post-fallfollow-up 6.3 Analysing thefall 6.4 Reporting and recordingfalls 6.5 Comprehensive assessment afterafall 6.6 Loss ofconfidence afterafall 6.7 Fallsclinics References Notes
79 79 82 82 83 84 84 85 87 101
Acronyms
ACSQHC BPPV DMMR GP IU(OH)D VR
Australian Commission onSafety and Quality inHealthCare benign paroxysmal positionalvertigo domiciliary medication managementreview generalpractitioner international unit hydroxyvitamin D vestibularrehabilitation
vi
1 Background
Key messages oftheguidelines

Many falls canbeprevented. Fall and injury prevention needs tobe addressed atthe point ofcare andfrom amultidisciplinaryperspective. Managing many ofthe risk factors for falls (eg delirium orbalance problems) will have wider benefits beyond fallsprevention. Engaging older people themselves isan integral part ofpreventing fallsand minimising harm fromfalls. Best practice infall and injury prevention includes implementing falls prevention strategies, identifying falls risk, and implementing targeted individualised strategies that are resourced adequately, and monitored and reviewedregularly. Multifactorial interventions (ie acombination ofinterventions tailored tothe individual) are effective for reducing the rate offalls inthe communitysetting. In the community setting, some single interventions (eg certain exercise programs and home safety programs inhigh-risk subgroups, and vitaminD with calcium supplementation for older people with lowbloodlevels) can reduce falls and the numberoffallers. The consequences offalls that result inminor orno injury are often neglected. Factors such asfear offalling and reduced activity level can profoundly affect function and quality oflife, and increase the riskofseriously harmfulfalls. At astrategic level, there will beatime lag between investment inafallsprevention program and improvements inoutcomemeasures.
1 Background
1.1 Whatisafall?
The World Health Organization defines afall asan event which results ina person coming torest inadvertently onthe ground orfloor orother lowerlevel. An injurious fall isafall that causes afracture tothe limbs, hip orshoulders, orone that causes atraumatic braininjury.
http://www.who.int/violence_injury_prevention/other_injury/falls/links/en/ index.html
1.2 What isanintervention?

An intervention isatherapeutic procedure ortreatment strategy designed tocure, alleviate orimprove acertain condition. Interventions can bein the form ofmedication, surgery, early detection (screening), dietary supplements, education orminimisation ofriskfactors. In falls prevention, interventions canbe: targeted atsingle risk factors singleinterventions targeted atmultiple riskfactors multiple interventions where everyone receives the same, fixedcombinationofinterventions multifactorial interventions where people receive multiple interventions, but the combination ofthese interventions istailored tothe individual, based onan individualassessment.
1 Background
1.3 Development ofthe FallsGuidelines

The Falls Guidelines were developed byamultidisciplinary expert panel (the Falls Guidelines Review Expert Advisory Group). Whenever necessary, the expert panel accessed resources outside its membership. Anadditional external quality reviewer was appointed toreview the guidelines from anAustralianperspective. The Falls Guidelines also drew onthe following sourcesofinformation: the previous version oftheguidelines a search ofthe most recent literature for each risk factor orintervention (seeSection1.3.1) the most recent Cochrane review offalls prevention interventions inthecommunitysetting feedback from health professionals and policy staff implementing thepreviousguidelines clinical advice from the expert advisorygroup guidance from external expertreviewers guidance from international external expertreviewers guidance from specialist groups (such asthe Royal Australian College ofGeneral Practitioners, Australian Association ofGerontology and Continence Foundation ofAustralia).
1.3.1 Levelsofevidence
Papers that were retrieved from the literature review were classified using the National Health and Medical Research Councils six-point rating system. This system identifies the strength ofevidence based onthe specific methods used inthepaper.
Table1.1 National Health and Medical Research Council levelsofevidence
Level
I II III-1 III-2
Description
Evidence obtained from asystematic review ofall relevant randomised controlledtrials Evidence obtained from atleast one properly designed randomised controlledtrial Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation orsome othermethod) Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), casecontrol studies, orinterrupted time series with acontrolgroup Evidence obtained from comparative studies with historical control, two ormore single-arm studies, orinterrupted time series without aparallel controlgroup Evidence obtained from case series, either post-test, orpretest andpost-test
1 Background
III-3
IV
Source:NHMRC1
1 Background
Evidence basedrecommendations
Evidence based recommendations are presented inboxes atthe start ofeach section, accompanied byreferences. They were selected based onthe best evidence and accepted bythe projects expert advisory groupand external qualityreviewers. Where possible, separate recommendations for assessment and interventions are given. Assessment recommendations have been developed bythe expert group based oncurrent practice and areview ofthe literature discussed inthe text ofeachsection. Intervention recommendations are based onareview ofthe research onthe use ofthe intervention. Each recommendation isaccompanied byareference tothe highest quality study upon which itis based, aswellasalevelofevidence.
Recommendations based onevidence nearer the Iend ofthe scale should beimplemented, whereas recommendations based onevidence nearer the IVend ofthe scale should beconsidered for implementation onacasebycase basis, taking into account the individual circumstances ofthe olderperson. The highest level ofevidence for anintervention isreported regardless ofthe setting; however, when the research setting isnot the community, an* isadded tothe level (eg LevelI-*). This shows that caution isneeded when applying economic implications for that recommendation tothe communitysetting.
1 Background
Good practicepoints
Good practice points have been developed for practice where there have not been any studies; for example, where there are nostudies assessing aparticular intervention, orwhere there are nostudies specific toaparticular setting. Inthese cases, good practice isbased onclinical experience orexpertconsensus.
Pointofinterest
These boxes indicate points ofinterest. Most points ofinterest were revealed bythe Australia-wide consultation process orfrom grey literature (unpublished conference proceedings,etc).
Casestudy
These boxes indicate case studies. The case studies provide information onlikely scenarios, which are used asillustrativeexamples.
1.4 How touse theguidelines

This quick reference guide isintended for use asa supplementary resource tothe Falls Guidelines. Figure 1.1 illustrates how touse the guidelines toprevent falls and falls injuries. Involvement ofthe older person and their carers isnecessary atallstages.
At astrategic level, afalls prevention program needs planning, implementation and evaluation asrepresented bythe outer circle inFigure1.1. Theinnercircle represents standard falls prevention strategies that are implemented atthe individual orpoint-of-care level (see Parts B-D ofthe Falls Guidelines). Individualised assessment, targeted and individualised interventions, and continuous review and monitoring arerecommended (seeChapters 4 and 5 ofthe FallsGuidelines).
1 Background
1 Background
In
ve vol
der person a the ol nd the ir ca

Plan
re
rs
fa
lls
p r e v en t i o n s t r at
eg
ie
da
n p la c e re i sa
Ensure s tan
Conduct individualised assessment
Review and monitor
Evaluate
Implement targeted, individualised falls and falls injury prevention interventions
Implement
1 Background
Plan
Plan for implementation Step 1: Identify teams Step 2: Identify, consult, analyse andengage key stakeholders Step 3: Assess organisational readiness Step 4: Analyse falls Plan for evaluation Step 5: Establish a baseline Plan for quality improvement Step 6: Review current clinical practice
Implement
Step 7: Decide on implementation approaches Step 8: Determine process forimplementation Step 9: Conduct trial Step 10: Learn from trial Step 11: Proceed to widespread implementation for improvement Step 12: Sustain implementation
Evaluate
Step 13: Measure process Step 14: Measure outcomes Step 15: Report and respond to results
Figure 1.1 Using the guidelines toprevent fallsinAustralia
1 Background
1 Background
2 Involving the older person and theircarers

2 Involving the older person and theircarers
8 Guidebook for Preventing Falls and Harm From Falls inOlderPeople
2 Involving the older person andtheircarers

2 Involving the older person andtheircarers
Good practicepoint
The participation ofthe older person intheir own health care iscentral tohigh-quality and accountable health services. Italso encourages shared responsibility inhealth care. The older person can help facilitate change inhealth carepractices.
Health care professionals should consider the following things toencourage older people toparticipate infallsprevention: Make sure the falls prevention message ispresented within the context ofpeople staying independent forlonger.2 Be aware that the term falls prevention could beunfamiliar and the concept difficult tounderstand for many people inthis agegroup.2 Provide relevant and user-friendly information toallow older people and their carers totake part indiscussions and decisions about preventing falls 3 (see the fact sheets onpreventingfalls). Find out what changes anolder person iswilling tomake toprevent falls, sothat appropriate and acceptable recommendations canbemade.3 Offer information inlanguages other than English, where appropriate; 3 however, donot assume literacy inthe older persons ownlanguage. Explore the potential barriers that prevent older people from taking action toreduce falls (such aslow self-efficacy and fear offalling) and support older people toovercome thesebarriers.3 Develop falls prevention programs that are flexible enough toaccommodate the older persons needs, circumstances andinterests.3 Ask the older persons family tohelp infalls preventionstrategies. Trial arange ofinterventions with the olderperson.4
3 Standard falls preventionstrategies


3.1 Falls preventioninterventions
3 Standard falls prevention strategies
Recommendations
Intervention
Use effective interventions toreduce falls inthe community, for example certain exercise programs, assessment followed bymultifactorial treatment, home safety interventions inhigh-risk groups, and academic detailing for general practitioners byapharmacist.(LevelI) 5
Singleinterventions
Older people should beencouraged toexercise toprevent falls. Certainprograms have been shown tobe effective and largely focus onbalance training.(LevelI) 5,6 Older people with visual impairment primarily related tocataracts shouldundergo cataract surgery assoon aspracticable.(LevelII) 7,8 When conducted asasingle intervention, home environment interventions are effective for reducing falls inhigh-risk older people.(LevelI) 9 For individual older people, gradual and supervised withdrawal ofpsychoactive medications should beconsidered toprevent falls.(LevelII) 10 People with severe visual impairment should receive ahome safety assessment and modification program specifically designed toprevent falls.(LevelII) 11,12 Use cardiac pacing inolder people who live inthe community, and who have carotid sinus hypersensitivity and ahistory ofsyncope orfalls, toreduce the rate offalls.(LevelII) 13 Collaborative review and modification ofmedication bygeneral practitioners and pharmacists, inconjunction with individual patients, isrecommended toprevent falls.(LevelII) 14 VitaminD and calcium supplementation should berecommended asan intervention strategy toprevent falls inolder people who live inthe community, particularly ifthey are not exposed tothe minimum recommended levels ofsunlight. Benefits from supplementation are most likely tobe seen inpeople who have vitaminD insufficiency (25(OH)D <50nmol/L) ordeficiency (25(OH)D<25nmol/L). (LevelI) 5(LevelI-*) 15
11
Multipleinterventions
The combination ofexercise targeting strength and balance, education and home safety intervention (the Stepping OnProgram) isrecommended toreduce the rate offalls inolder people who live inthecommunity.(LevelI) 9
Multifactorialinterventions
In older people atrisk offalls, individualised assessment leading directly totailored interventions isrecommended.(LevelI) 5
Good practicepoints
The general practitioner can prescribe verbal orwritten instructions forfalls prevention interventions (eg exercise programs) for the older person toimprove ormaintain independence, and encourageadherence. Managing many ofthe risk factors for falls (eg balance problems, medication) will have wider benefits beyond fallsprevention.
3.1.1 Singleinterventions
The following sections describe interventions that reduce the rate orriskoffalling, when used assingleinterventions.
Exerciseinterventions
Several different types ofexercise programs can reduce both the rate offalls and the risk offalling inolder people living inthe community; 5 forexample: 5 home-based balance and strength training (eg the Otago Exercise Programme) 16,17 this program isan individually prescribed home exercise program comprising balance retraining, lower limb muscle strengthening and walkingcomponents group-based tai chi18-21 this has reduced falls insome trials involving ageneral population ofolder people,20 but not inother trials involving transitionally frail older people, indicating that group tai chi classes maybemore beneficial inthe less frail olderpopulation22 other group exercise programs23-28 exercise programs that challenge balance and include frequent exercise reduce falls rates more than programs without thesefeatures.6
12
Both group and individual exercise programs can prevent falls. Itis likely that some people will bemore willing and able toexercise with others atacentre and other people would prefer ahome setting. Astrategy toachieve ongoing exercise may combine supervised group exercise withinitial, interspersed orfollow-on home exerciseprograms. To beeffective, exercise programs need tohave acomponent that challenges balance and ahigher total dose ofexercise.6 There isalso evidence that detraining occurs and benefits are lost when exercise programs finish, soamaintenance component isimportant when planninganexerciseprogram.29 See Section4.2 for more information onexerciseinterventions. Targeting falls prevention exerciseprograms Exercise programs can prevent falls when they are aimed atthe general community, aswell aswhen they are targeted atpeople who have anincreased risk offalls. Greater relative reductions infall rates have occurred intrials with broader inclusion criteria than instudies that only included people athigh risk offalls.5 This provides support for apopulationbased approach tofalls prevention with appropriate exerciseprograms. However, the consequences offalls (such asinjuries and reduced activity levels) may have agreater impact inhigher risk populations. Appropriate exercise programs for falls prevention should becarefully targeted atsubgroups athigh risk and also offered tothe general, oldercommunity.
VitaminDsupplementation
The effect ofvitaminD onfalls inolder people isunclear.5,30,31 VitaminD analogues (eg calcitriol) may beuseful for preventing falls, but are also associated with adverse effects, suchashypercalcaemia. VitaminD does help toprevent fractures,32 and there isalso astrong association between vitaminD deficiency and neuromuscular function.33 Therefore, the use ofvitaminD has been well supported inthe older population due tothe high rate ofvitaminD deficiency, particularly inthoseinlong-term care (see Section5.2 for moreinformation).
13
Medication review andwithdrawal

Gradual withdrawal ofpsychoactive medications can reduce falls inolder people living inthe community who take these medications regularly.10 However, itcan bedifficult tomaintain older people without psychoactive medications once these medications have been prescribed. The preferred approach isto avoid prescribing psychoactive drugs ifpossible and appropriate for the older person, their medical condition and their social situation. See Section4.8 for more information onmedicationinterventions.
Cardiac pacemakerinsertion
Treating cardioinhibitory carotid sinus sensitivity with apacemaker inpeople aged 50years orolder can reduce the rate offalls.13 However,cardioinhibitory carotid sinus sensitivity isnot acommon cause offalls. Carotid sinus syndrome should beconsidered inthe presence ofsyncope associated with afall, orwhen the cause ofthe fallisunexplained (see Section4.6 for moreinformation).29
Home safetyprograms
Trials ofhome safety programs have had mixed results inpreventing falls.5,9 Offering home safety asasingle intervention has the greatest effect when provided toolder people athigh risk. Strategies toimprove adherence toenvironmental recommendations should beconsidered, anditis important tohelp the older person understand the relevance ofanymodifications (see Section4.10 for moreinformation). Some older people will have impaired vision that cannot becorrected. Ahome safety assessment and modification program designed for older people with low vision can significantly reduce the rate offalls inpeople with severe visualimpairment.11
Improvingvision
Cataractsurgery Expedited cataract surgery reduces the rate offalls compared with remaining onastandard 12-month waitinglist.8 Vision assessment and eyeexamination Vision interventions (eg referral toeye care practitioners when impaired vision isdetected) can reduce the risk offalling; however, the risk offalling isreduced further when vision interventions are combined withexercise
14
and home hazard management interventions, supporting the use ofvision assessment and referral aspart ofamultifactorial approach tofallsprevention.34 Large changes invisual correction (ie >0.75diopter) may increase the risk offalls, because frail, older people may need aconsiderable period oftime toadapt totheir updated prescriptions, orbecause they may adopt more risk-taking activities (thus increasing their exposure tofalls) after vision improvements.35 Therefore, when updating anolder persons spectacle prescription, eye care professionals should prescribe conservatively and help the older person tounderstand they need tobe careful while adapting tochanges intheir spectacles. See Section4.9 for more information on visioninterventions.
3.1.2 Multipleinterventions
Multiple interventions can beused both asan individual and apublic health approach tofallsprevention.5,36 Falls prevention programs, which often take the form ofgroup learning sessions run bycommunity organisations, can reduce the rate offalls inthe community setting. Anad hoc approach may not beeffective, and therefore not cost effective inpreventing falls, sothese community organisations should consider following well-developed programs, such asthe SteppingOnprogram.
The SteppingOnprogram
The Stepping Onprogram emphasises behaviour change toavoid falls. Theprogram includes sessions onfalls risk appraisal, exercise, home hazards, strategies tomove around the local community, safe footwear, vision asarisk factor for falls, vitaminD, hip protectors, medication management, mastering safe mobility, and ahome visit tofollow through the falls prevention strategies and activities, and toassist with home adaptations and modifications ifrequired. Abooster session isheld after threemonths.
The Stay OnYour Feetprogram

A concerted population approach tofalls prevention will reduce health care use and costs.37,38 The Stay OnYour Feet program inQueensland includes community-based activities aimed atolder people ( 55years).37 The program addresses falls risk factors, such asbalance and gait problems, insufficient exercise, inappropriate footwear, poor vision, medication use, underlying medical conditions and environmentalhazards.
3 Standard falls prevention strategies 15
3.1.3 Multifactorialinterventions
Multifactorial interventions involve assessing anindividuals risk offalling, and then arranging referral orproviding direct treatment toreduce these risks. Multifactorial interventions are effective inreducing the rate of falls but donot have asignificant effect onthe risk offalling inolder people living inthecommunity.5 The effectiveness ofmultifactorial interventions may besensitive to differences between health care systems and networks atboth local and national levels. Multifactorial interventions form the basis ofmany falls prevention services, but the interventions examined inrandomised controlled trials are complex, and their effectiveness may depend onfactorsyet tobedetermined.
3.1.4 Multifactorial versus singleinterventions

Since most falls occur asaresult ofacombination offactors, the benefits ofmultifactorial interventions should begreater, intheory, than single interventions. However, single intervention approaches are just aseffective inreducing falls asmultifactorial preventionprograms.39 There isarisk that older people may become confused orbe offered conflicting advice when several interventions are attempted.11,40 Therefore,when multicomponent interventions are delivered, they shouldbedone soin astaged and integratedmanner. The multifactorial approach also makes itdifficult toevaluate the relative effects ofdifferent programs and their components inclinical trials. Factorial designs and single intervention studies are vital inthis regard, because they help toestablish which components ofthe multicomponent packages are effective. Multifactorial interventions should comprise two ormore single intervention strategies that have been demonstrated tobe effective intrials, oran actual combination ofinterventions shown tobeeffective.
16
17
4 Management strategies for common falls riskfactors

18

4.1 Falls risk screening andassessment
Recommendations
Screening andassessment
Older people should beasked about falls atleast once each year bytheir general practitioner orother health careprovider. Older people with ahistory ofone ormore falls inthe past year should beassessed using asimple, validated balance test orfalls riskscreening. Older people who perform poorly onasimple test ofbalance orgait, oron afalls risk screening tool, should undergo adetailed assessment toidentify contributory riskfactors. Falls risk screening and assessment tools used should beevidenced based (meaning that they have demonstrated good predictive accuracy, and have been evaluated inthe relevant setting inmore than onesite). Falls prevention interventions may need tobe modified tomake sure they are suitable for the individual, and often the carer orfamily members willalso play animportant role inimplementing falls preventionactions.
Good practicepoints
Falls riskscreening
Falls risk screening should beused toguide more detailed assessment and intervention, and the outcomes ofthe screening should be documented and discussed with the older person and theircarer(s). When the threshold score ofascreening tool isexceeded, afalls risk assessment should beconducted assoon aspracticable. Ifthe score isnot exceeded, standard falls prevention strategiesapply.
Falls riskassessment
To develop anindividualised plan for preventing falls, health care professionals need toidentify systematically and comprehensively thefactors contributing tothe older persons increased riskoffalling. Interventions delivered asaresult ofthe assessment provide benefit rather than the assessment itself; therefore, itis essential that interventions address the risk factors identifiedsystematically. Identifying the presence ofcognitive impairment should form part ofthefalls risk assessmentprocess.
19
4.1.1 Falls riskscreening

Falls risk screening isabrief process ofestimating apersons risk offalling, which then classifies them asbeing ateither low orincreased risk. Falls risk screening usually involves reviewing upto five items. Although not designed asacomprehensive assessment, positive screening oncertain screen items can also provide information about intervention strategies. When afalls risk screening isconducted, itneeds tobe supported with education and intermittent reviews toensure appropriate and consistent useofrelevantinterventions. The simplest falls risk screening tool that can easily beincorporated into routine care should record the older persons history offalls inthe past 12months, and their balance and mobility status. Alternatively, amultipleitem screening tool can beused.41 These tests and screens are summarised inthe followingsections.
History offalls inpast 12months

At least once ayear, the general practitioner (GP) should ask all older people (or their carers) about any falls they have experienced.41 The GPshould also take adetailed history ofthe events surrounding the fall(s). This role could also beundertaken byother health professionals who provide care toolder people livingathome.
Balance and mobilityperformance

The American and British geriatrics societies recommend that all older people who report one ormore falls inthe preceding year should beassessed onthe Timed Upand GoTest asasimple screening test toidentify whether more detailed assessment ofgait and balance iswarranted (seeTable4.1).41 The Sit-to-Stand and Alternate Step tests also have demonstrated validity, reliability and feasibility asfalls risk screens inthe community stetting.42 The Sit-to-Stand Test isameasure oflower limb strength, speed and coordination (see Table4.1). The Alternate Step Test provides ameasure oflateral stability and involves the time taken tocomplete eight steps onto astep, alternating between left and right feet, asfast aspossible (seeTable4.1).
20
Multiple-item screeningtools
Other validated falls risk screening tools contain multiple items. For example, the Elderly Fall Screening Test and the Falls Risk for Older People (community version) (FROP-Com Screen) 43,44 contain three tofive common risk factors that, incombination, can identify with reasonable accuracy those older people who have anincreased risk offalling (seeTable4.1). If any item onamultiple risk factor screening isidentified asbeing at risk, interventions should beconsidered for that risk factor even ifthe person has alow falls risk score overall. For example, ifaperson scores anoverall score oftwo onthe FROP-Com screen (consisting ofascore ofzero for aprevious fall, two for balance and mobility, and zero for achange inactivities ofdaily living), they would have alow risk offalling overall. However, apreventive approach would use anintervention toaddress their mild balance impairment atthistime. Table4.1 lists validated tests and tools that are available for falls riskscreening.
Table4.1 Screeningtools
Timed Upand GoTest(TUG) 45-47

Description TUG measures the time taken for aperson torise from achair, walk three metres atnormal pace with their usual assistive device, turn, return tothe chair and sitdown. 12minutes A time of12 seconds indicates increased riskoffalling
Time needed Criterion
Sit-to-Stand Test(STS) 42
Description STS provides ameasure oflower limb strength, speed and coordination. Itinvolves the time taken tocomplete five STSs asfast aspossible from astandard height (43cm)chair. 12minutes A time of12seconds indicates increased riskoffalling
21
Alternate Step Test(AST) 42

Description AST provides ameasure oflateral stability and involves the time taken tocomplete eight steps, alternating between left and right foot, asfast aspossible onto astepthat is19cm high and 40cmdeep. 12minutes A time of10 seconds indicates increased riskoffalling
FROP-ComScreen44
Description FROP-Com Screen is athree-item falls risk screening tool, developed from the FROP-Com assessment tool. Thethree items are ahistory offalls inthe past 12months; observations ofsteadiness while standing up, walking three metres, turning returning tothe chair and sitting down; and self reporting ofthe need for assistance inperforming domestic activities ofdailyliving. 12minutes A score of>3 indicates increased riskoffalling
4.1.2 Falls riskassessment

Assessing falls risk typically involves either the use ofmultifactorial assessment tools that cover awide range offalls risk factors; orfunctional mobility assessments that focus onthe physiological and functional domains ofpostural stability, including vision, strength, coordination, balance and gait. When identifying the cause ofafall, itis also important toremember that most falls occur asaresult ofan interaction between intrinsic and extrinsic factors, and that multiple factors increase the risk offalls.48 Many disease processes that are more common inolder people increase the risk offalls, mainly through impairing postural stability. Assessment tools provide detailed information onthe underlying deficits contributing tooverall risk and should belinked tointervention and management. Most falls risk assessments also classify people into low andhigh falls riskgroups.
22
Several falls risk assessment tools are now available for use incommunity settings. However, when selecting atool, itis important tocheck whether ithas been validated prospectively and preferably inmore than one site.49,50 Table4.2 lists some recommended falls risk assessment tools that have demonstrated applicability toAustralian communitycare.
Table4.2 Falls risk assessmenttools
QuickScreen42
Description QuickScreen isarisk assessment tool designed for use bypractice and rural nurses, allied health workers and general practitioners. Itis based onthe sensorimotor functional model for falls prediction. Itallows the clinician not only toestimate the level ofincreased falls risk, but also todetermine which sensorimotor systems are impaired. This provides anopportunity tolink assessment with evidence based, tailored interventions. The QuickScreen consists ofthe following measures: previous falls, medication use, vision, peripheral sensation, lower limb strength, balance and coordination. The falls assessment requires minimal equipment: alow-contrast eye chart, afilament for measuring touch sensation, and asmall step. There isacost associated with the purchase ofQuickScreen. Details about QuickScreen can befoundat http://www.powmri.edu.au/FBRG/quickscreen.htm Time needed Criterion 10minutes A score of4 ormore indicates anincreased riskoffalling
23
FallScreen Physiological Profile Assessment 51

Description FallScreen isavalidated risk assessment tool that can belinked toevidence based approaches tointerventions. Itprovides detailed quantitative information onthe physiological domains contributing topostural stability. FallScreen contains five items: anassessment ofvision, peripheral sensation, lower limb strength, reaction time and body sway (short version), and more detailed assessment onthese items (long version). There isacost associated with the purchase ofFallScreen. Details about FallScreen can befoundat http://www.powmri.edu.au/fbrg/calculator.htm 1520 minutes (abbreviatedversion) A score of1 ormore indicates anincreased riskoffalling
FROP-Com (Falls Risk for Older People communityversion) 44

Description FROP-Com isadetailed falls risk assessment tool. Itincludes 13risk factors in26questions with either dichotomous (01) orordinal (03) scoring. Atotal ofthese individual scores provides anoverall score offalls risk (range 060), with higher scores indicative ofgreater risk. The tool includes guidelines onscoring each risk factor, and evidence based referral orinterventions. Nospecial equipment isrequired. The full FROP-Com and its guidelines are availableathttp://www.mednwh. unimelb.edu.au/research/research_falls_service.htm 1015minutes A score >18 indicates ahigh riskoffalls
24
Falls risk assessments can beperformed byaGP orother health professional. Based onthe assessment outcome, these assessors might refer toother health professionals for more detailed assessment and management ofidentified risk factors; for example, areferral toan ophthalmologist for adetailed vision assessment for people with impaired vision, orareferral toaphysiotherapist orexercise physiologist for amore detailed assessment ofbalance and mobility ifthe older person scores poorly inthese areas. Most risk assessment tools focus onintrinsic falls risk factors only, soaseparate environmental assessment may beindicated toidentify extrinsic falls riskfactors. The outcomes ofthe falls risk assessment, together with the recommended strategies toaddress identified risk factors, need tobe documented and reported toother health care staff, and discussed with the older person andwhere applicable with theircarer(s).
Casestudy
Mrs Dwent toher general practitioner (GP) after afall. She had bruised her hip and was concerned itwas broken. The GPasked whether she had fallen onother occasions inthe past year, which MrsD confirmed. TheGP discussed the circumstances ofher falls, which she reported included several trips both inside and outside the home, and asense that her balance had progressively worsened. The GPassessed Mrs D using the Timed Up and Go Test, which she completed in16seconds. The practice nurse administered the QuickScreen assessment, which identified MrsD was taking abenzodiazepine, and performed poorly intheSittoStand and Alternate Step tests. The GPreviewed and modified Mrs Ds medications (including weaning her off the use ofthe benzodiazepine medication), and referred Mrs Dfor aphysiotherapy assessment toprescribe anexercise program. Anoccupational therapy assessment was also organised to review home safety and consider functional needs athome. Six months later, MrsDwas taking part inacommunity strength and balance exercise program and had resumed her previous activities. She had regained confidence inher outdoor mobility, and had experienced nofurtherfalls.
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4.2 Balance and mobilitylimitations

Recommendations
Assessment
Use assessment toolsto: quantify the extent ofbalance and mobility limitations, andmuscleweaknesses guide exerciseprescription measure improvements inbalance, mobility andstrength assess whether the older person has ahigh riskoffalling.

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Intervention
Deliver exercise programs toprevent falls inolder people who live inthecommunity (eg group exercise classes, home-delivered strength and balance retraining, tai chi classes).(LevelI) 5 Improve the effectiveness ofexercise programs for preventing falls byincluding challenging balance training and frequent, ongoing exercise.(LevelI) 5,6 Encourage exercise for falls prevention inall older people inthe community, not only those who have anincreased risk.(LevelI) 5,6
4.2.1 Assessing balance, mobility andstrength

Many different approaches can beused toassess balance, mobility and muscle strength inolder people. Some ofthe clinical assessments that may beof use are outlined inTable4.3. The choice oftool depends onthe time and equipment available and the level ofability ofthe people beingassessed.
Table4.3 Tools for assessing balance, mobility, strength and gait
Test
Description
Time to complete (minutes)
Level that ispredictive offalls
Tools for assessingbalance
Postural sway and leaning balance tests51
As part ofthe Physiological Profile Assessment (PPA), sway ismeasured using aswaymeter that measures displacements ofthe body atwaist level. During standing balance tests, the person has tostand asstill aspossible for 30seconds, with eyes open and closed, once onthe floor and once onapiece ofmediumdensity foam rubber (15cmthick). During leaning balance tests, the person has tolean forward and backwards asfar aspossible, orfollow atrack.
510
Part of thePPA 51
27
Test
Description
Tools for assessingbalance
Functional reach 52
Functional reach is a measure of balance and is the difference between a persons arm length and maximal forward reach, using a fixed base of support. Functional reach is a simple and easytouse clinical measure that has predictive validity in identifying recurrent falls. AST is a measure of lateral stability. It involves the time taken to complete eight steps, alternating between left and right foot, on to a step of 19cm high and 40cm deep, as fast aspossible.
12
10inches
Alternate Step Test (AST) 42
12
10seconds
Tools for assessingmobility
Six-Metre Walk Test (SMW) 42
SMW measures apersons gait speed inseconds along acorridor (over adistance of6metres) attheir normal walking speed. TUG measures the time taken for a person to rise from a chair, walk 3 metres at normal pace and with their usual assistive device, turn, return tothe chair and sit down.
12
6seconds
Timed Upand GoTest (TUG) 53
12
15seconds
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Test
Description
Tools for assessingstrength
Sit-to-Stand Test (STS) 54
STS isameasure of lower limb strength and isthe time needed toperform five consecutive chair stands from aseated position.54 As part ofthe PPA, the strength ofthree leg muscle groups (knee flexors and extensors and ankle dorsiflexors) ismeasured while participants are seated. Ineach test, there are three trials and the greatest force isrecorded.
12
12seconds
Spring balance51
Part of thePPA 51
Scales for assessing balance andgait
Berg Balance Scale55
The Berg Balance Scale isa14-item scale designed tomeasure balance ofthe older adult inaclinical setting with amaximum total score of56points(http://www. chcr.brown.edu/geriatric_ assessment_tool_kit.pdf). The Tinetti PerformanceOriented Mobility Assessment tool measures apersons gait and balance. Itis scored onthe persons ability toperform specific tasks with amaximum total scoreof28points.
1520
40
Tinetti PerformanceOriented Mobility Assessment tool56
1015
24
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Test
Description
Scale for assessing confidence and fallsefficacy57
Falls Efficacy Scale International
The Falls Efficacy Scale International provides information onlevel ofconcern onafourpoint scale (1=not atall concerned, to4=very concerned) across 16 activities ofdaily living (eg cleaning the house, simple shopping, walking onuneven surfaces).
Score 23 indicates high level ofconcern
4.2.2 Providing exerciseinterventions

Effective exercise programs for preventing falls mainly comprise challenging and progressive balance exercises. The exercise program should betailored tothe existing levels offitness and targeted tothe older persons particular deficits and lifestyle. Ifpossible, exercises should beconducted inweightbearing positions toobtain optimalbenefits.
Challenging balancesafely
To improve balance, anexercise program needs tobe challenging yet safe. Toensure asufficient challenge tobalance, the program should aimtoinclude: exercise inastandingposition minimal upper limb support (minimise the use ofrails orchairs for support while exercising; however, itis useful for older people toexercise near supportive objects sothey can steady themselves whennecessary) a minimal base ofsupport (ie exercise that involves standing orwalking with the feet closer together orstanding ononeleg) controlled movements ofthe bodys centre ofmass, such asstepping, reachingordancing. Exercises that challenge balance could lead tofalls themselves; therefore,they need tobe carefully prescribed, set upin asafe way
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(egnext toawallorcounter for hand support asrequired) and supervised ifnecessary. This isparticularly important for frailer olderpeople.
Doseofexercise
The optimum duration and frequency ofexercise programs toprevent falls isnot yet known. Asystematic review found that exercise programs prevented more falls ifthey included atleast two hours ofexercise each week over a25-week period.5 However, itis likely that effects ofexercise arelost once exercise stops; 58 therefore, ongoing exercise isprobably required for ongoing effects onfall rates. Research into other benefits ofexercise has often found that there isadoseresponse relationship that is, greater effects are seen with more exercise.58,59 This may also bethecase for fallsprevention.
Walking programs and fallsprevention

Walking isapopular form ofexercise and can provide the many health benefits associated with increased physical activity levels.58 However, the role ofwalking programs infalls prevention isunclear, because thereissome evidence that including walking isassociated with reduced effectsonfalls prevention5 and possibly anincrease infallsrates.60,61 Table4.4 lists the features that anexercise program should include tobe effective for reducingfalls.
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Table4.4 Features that should beincluded inexerciseprograms
Feature
Description
The core ofthe exercise program should bebalance training (preferably inweight-bearing positions) that aims toreduce the amount ofsupport. Additionally, the exercise program can include components of: moderate-intensity resistance training endurance exercise toincrease general fitness (notawalking program onitsown).
Program
Modalities
Exercise programs should bedesigned ordelivered byatrained professional (ie physiotherapist) toensure the exercises are challenging yetsafe. Individually prescribed and progressive (the instructor must besensitive tofatigue levels ofindividual participants and tailor the intensity ofthe programaccordingly). Individualorgroup Ongoingexercise
Intensity
Setting Duration ofprogram
4.2.3 Including all olderpeople

Exercise isgenerally safe and beneficial for older people, even those with chronic health problems. However, exercise may beunsafe for aminority ofpeople with particular medical conditions. Therefore, before starting anexercise program, older people should bescreened toassess whether they need medical clearance before exercising.62 Older people with health problems that affect their ability toexercise safely might bemore likely torequire guidance from ahealth professional orother qualified exercise leader when starting anew exerciseprogram.
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Casestudy
Mrs Tis 83 years old and presented toher general practitioner (GP) with bruises after she tripped while walking down some steps. Onfurther questioning, her GPdiscovered this was her third fall inthe past year. Thetwo earlier falls also happened when she tripped while outside. Asaresult, Mrs Tgoes outside far less frequently. The GPobserved some unsteadiness inher walking and turning, and referred Mrs Tto aphysiotherapist for abalance assessment. The physiotherapist assessed Mrs Ts performance using the Timed Upand GoTest and the functional reach test and saw she had ahigh risk offuture falls. The physiotherapist explained how she would benefit from awell-designed exercise program toimprove her balance and general wellbeing, but also toprevent future falls. The physiotherapist initially referred Mrs Tto asupervised group balance and strength program. Atalater stage, Mrs Tcould progress toself-directed exercise, although she may prefer tocontinue toexercise with other people tomaintainmotivation.
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4.3 Cognitiveimpairment
Recommendations
Assessment
Older people with cognitive impairment have anincreased risk offalls and should have their falls risk factorsassessed.

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Intervention
Identified falls risk factors should beaddressed aspart ofamultifactorial falls prevention program, and injury-minimisation strategies (such asusing hip protectors orvitaminD and calcium supplementation) should beconsidered.(LevelI-*) 15
Note: there isno evidence that falls can bereduced inolder people with cognitive impairment living inthe community.5 See the residential aged care facilities guidelines for further information onproviding treatment toolder people with cognitiveimpairment.
Good practicepoints
Older people presenting with anacute change incognitive function should beassessed for delirium and the underlying cause ofthischange. Older people with gradual onset, progressive cognitive impairment should undergo detailed assessment todetermine diagnosis, and where possible, reversible causes ofthe cognitive decline. Reversible causes ofacute orprogressive cognitive decline should beaddressed andtreated. If anolder person with cognitive impairment does fall, reassess their cognitive status, including presence ofdelirium (eg using the Confusion Assessment Methodtool). Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations; however, interventions for older people with cognitive impairment may need tobemodified and supervised,asappropriate.
4.3.1 Assessing cognitiveimpairment

Older people with cognitive impairment have anincreased risk offalls, and risk factors for falls are more prevalent inolder people with cognitive impairment than in people without cognitive impairment. Therefore,one ofthe most important initial steps inpreventing falls inolder people isto assess for cognitive impairment. Inthe absence ofspecific trial data toshow that itis possible toprevent falls inpeople with cognitive impairment, the following suggestions for care reflect good clinicalpractice.
GPs can use the following steps toassess for the presence ofcognitiveimpairment: Assess for the presence ofdementia ordelirium and treat possible medical conditions that may contribute toan alteration incognitive status. Rapiddiagnosis and treatment ofadelirium and its underlying precipitant (eg infection, dehydration, constipation, pain)iscrucial.63 Older people with aprogressive decline incognition should undergo detailed assessment todiagnose and, where possible, treat reversible causes ofthe cognitive decline.63 Referring the older person toaspecialist memory service can behelpful for diagnosing their cognitive impairment accurately, and linking with appropriate communityservices. General practitioners should assess the falls risk factors for older people with cognitive impairment (as discussed inother chapters), and offer interventions tomodify risk.64 Some interventions need the person tobe able tofollow instructions orcomply with aprogram (eg exercise). Where there isdoubt about anolder persons ability tofollow instructions safely, the general practitioner (or other member ofthe health care team) should conduct anindividualised assessment and develop afalls prevention plan using the information from the assessment ontheirbehalf. Table4.5 summarises some ofthe many tools that can beused toassess cognitivestatus.
Table4.5 Tools for assessing cognitivestatus
Dementiascreening
Folstein Mini-Mental State Examination65
Description
The Folstein Mini-Mental State Examination isawidely used method for assessing cognitive mental status. It isan 11-question measure that tests five areas ofcognitive function: orientation, registration, attention and calculation, recall and language. The maximum scoreis30.
510minutes A score 23 indicates mild cognitive impairment A score 18 indicates severe cognitiveimpairment
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Dementiascreening
Rowland Universal Dementia Scale66,67 4 Management strategies for common falls riskfactors
Description
The Rowland Universal Dementia Scale isasimple method for detecting cognitive impairment. The scale isvalid across cultures, portable and administered easily byprimary health care professionals. Ituses six items toassess multiple cognitive domains, including memory, praxis, language, judgment, drawing and bodyorientation.
Time needed Criterion Rating
10minutes A score of >23 (out ofamaximum scoreof30) 89% sensitivity 98%specificity
Deliriumscreening
Confusion Assessment Method68
Description
The Confusion Assessment Method isacomprehensive assessment instrument that screens for clinical features ofdelirium. The method comprises four features, which are determined bythe older person, nurse and family interview. These are: an onset ofmental status changes or a fluctuatingcourse inattention disorganised thinking an altered level ofconsciousness (ie other thanalert).
5minutes The older person isdiagnosed asdelirious ifthey have both the first two features, and either the third orfourthfeature 94% sensitivity 90%specificity69
Rating
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Point ofinterest: strategies for maintaining hydration inolderpeople

Older people with cognitive impairment may become dehydrated easily, which can lead todelirium. AnAustralian study used strategies developed bythe Joanna Briggs Institute Practical Application ofClinical Evidence System70 tomaintain oral hydration inresidents ofresidential aged care facilities.71 Although adherance was problematic, the following strategies recommended bythe Joanna Briggs Institute maybebeneficial: Drinks (cordial, juice and water, but not caffeinated drinks) were offered bystaff every 1.5hours (as well asmorning tea, afternoon tea and supperrounds). Residents with cognitive impairment were either helped orprompted todrink. An accessible water fountain was set upwith asupplyofcups. Filled jugs ofwater were placed onall tables, withcups. Drinks were always given withmedication. Icy poles, jellies and ice-cream were offered throughout the day assnacks and enjoyabletreats. Fruit with ahigh water content (eg grapes, peeled mandarins) was placed onkitchen tables for easy access andpicking. Light soups were given withmeals. Happy hour was introduced twice aweek with nonalcoholic wines, mocktails, soft drinks andnibbles. Warm milk drinks were given tohelp people settleatnight. These strategies may also beapplicable toolder people with cognitive impairment livingathome.
Casestudy
Mr Fis a72-year-old man living with his wife inthe community. Hewas recently diagnosed with Alzheimers disease. Inthe afternoon, MrFoften wanders off towalk around inthe garden. Togo from the house into the garden, hehas towalk upand down two steps. Onmore than one occasion, hehas fallen down the steps. Since his wife cannot help him upagain, she has toask their neighbour for help. The community nurse suggested that anoccupational therapist run ahome environment assessment. Asaresult, the occupational therapist recommended that they install anantislip ramp with arail. Now MrFcan get inand out ofthe house without having tonegotiate thesteps.
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4.4 Continence
Recommendations
Assessment
Older people should beoffered acontinence assessment tocheck forproblems that can bemodifiedorprevented.
Intervention
Manage problems associated with urinary tract function aspart ofamultifactorial approach tocare.(LevelI-*) 15
Note: there isno evidence that assessing ortreating incontinence will prevent fallsinolder people living inthecommunity.5
Good practicepoint
Check the height ofthe toilet and the need for rails toassist the older person sitting and standing from thetoilet.
4.4.1 Screeningcontinence
People will make extraordinary efforts toavoid anincontinent episode, including placing themselves atincreased risk offalling. Incontinence, assisted toileting72,73 and symptoms ofoveractive bladder74,75 have been identified asrisk factors for falls inolder people who live inthecommunity.76,77 The cause ofincontinence should beestablished through athorough assessment; for example, using ward urinalysis. Older people may have more than one type ofurinary incontinence, which can make assessment findings difficult tointerpret.78 The following strategies should beused toassess the older persons continencestatus: Obtain acontinence history from the person. This might include such things asabladder chart (a frequency/volume chart oracontinence diary). Continence history should berecorded for aminimum oftwo days79 tohelp provide avalid assessment. Simple, validated questions tothe older person can help differentiate the type ofurinary incontinence they have.80 Sometimes, abowel assessment isrequired. The older persons normal bowel habits and any significant change must bedetermined, because constipation can considerably affect bladderfunction. The suitability ofdiagnostic physical investigations should beaddressed onan individual basis. Consent from the older person must beobtained
before the physical examination, which should bedone byasuitably qualified healthprofessional. Post-void residuals should always bechecked inincontinent olderpeople.81 Functional considerations, such asreduced dexterity ormobility, can affect toileting, and should beassessed andaddressed. The toilet should beassessed for accessibility (especially ifthe older person uses awalking aid), proximity, height and the number of household members using the sametoilet. Risk factors for falling related toincontinence need tobe considered along with the symptoms and signs ofbladderdysfunction.
4.4.2 Strategies for promotingcontinence

Appropriate management ofincontinence may improve overall care, but itis difficult tomake strong recommendations because specific incontinence strategies have not been part ofsuccessful falls prevention programs inacommunity setting.82 However, studies from the hospital setting have shown that toileting protocols and practices for older people atrisk offalling should beincluded inmultifactorial falls prevention interventions.83,84 Also, multifactorial falls prevention interventions inhospitals should include management ofurinary tractfunction.85 The suggested strategies below are adapted from those recommended bythe Third International Consultation onIncontinence 200581 and should beused topromote continence inthe communitysetting: Make sure the older person has access toacomprehensive and individualised continence assessment that identifies and treats reversible causes, including constipation and medication sideeffects. Use anadequate trial ofconservative therapy asthe first lineofmanagement. Establish treatment strategies assoon asincontinence has been diagnosed. The aim ofmanaging urinary incontinence isto alter those factors causing incontinence and toimprove the continence status oftheperson. Management ofincontinence isamultidisciplinary task that ideally involves doctors, nurse continence advisors, physiotherapists, occupational therapists and other suitably qualified healthprofessionals. Address all comorbidities that canbemodified. Encourage programs tohelp improve the older persons control over their toileting regime, and reduce the likelihood ofincontinence episodes. Theseprogramsinclude
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habit retraining based onidentifying apattern ofvoiding and tailoring the toileting schedule tothe olderperson prompted voiding to increase continence byincreasing the older persons ability todiscriminate their continence status and to respondappropriately timed voiding characterised byafixed scheduleoftoileting. Trial reducing anolder persons caffeine and carbonated drinks intake tohelp decrease symptoms ofurgency andfrequency. Minimise environmental risk factors by keeping the pathway tothe toilet obstacle free and leaving alight onin the toiletatnight ensuring the older person iswearing suitable clothes that can beeasily removedorundone recommending appropriate footwear toreduce slippinginurine placing a nonslip mat onthe floor beside the bed, which may beuseful for older people who experience incontinence onrising from the bed, particularly ifon anoncarpeted floor inthe bedroom (care must betaken when using mats toensure the older person does not trip onthemat) checking the height ofthe toilet and the need for rails toassist the older person sitting and standing from the toilet (reduced range ofmotion inhip joints iscommon after total hip replacement orsurgery for fractured neck offemur, and might mean the height oftoilet seat shouldberaised). Where possible, consult with acontinence adviser ifusual continence management methods asdescribed above are not working orthe older person iskeen tolearn simple exercises toimprove their bladder orbowel control. Some men are resistant tothe idea ofdoing pelvic floor exercises. This should berecognised and the benefitsexplained. Consider the use ofcontinence aids asatrial managementstrategy.
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Casestudy
Mrs Uis an85-year-old woman who presented toher general practitioner (GP) with abruised face after falling. When the general practitioner asked why she fell, she said she was rushing tothe toilet. The continence assessment revealed that she had reduced bladder capacity and detrusor instability from chronic constipation. The constipation was treated and Mrs Uno longer needed torush tothe toilet. The GPwas also careful toconsider many ofthe other risk factors for falling that were identified from the falls risk assessment and ensure that targeted interventions were implementedaccordingly.
4.5 Feet andfootwear

Recommendations
Assessment
Assessment should include screening for ill-fitting orinappropriate footwear and for foot pain and other foot problems, because these arerisk factors forfalls.
Interventions
Include anassessment offootwear and foot problems aspart ofan individualised, multifactorial intervention for preventing falls inthe community. (LevelIV) 86,87 Health care providers should provide education and information aboutfootwear features that may reduce falls risk. (LevelIII-2) 88
Note: there isno evidence that assessing oraddressing footwear and foot problems asasingle intervention will prevent falls inolder people living inthecommunity.
Good practicepoints
Health care providers should educate older people and provide information onfoot problems and foot care, and refer them to a podiatrist, whennecessary. Safe footwear characteristicsinclude: soles: shoes with thinner, firmer soles appear toimprove foot position sense; atread sole may prevent slips onslipperysurfaces heels: alow, square heel improvesstability collar: shoes with asupporting collar improvestability.
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4.5.1 Screening feet andfootwear

Inappropriate footwear isacontributing factor tofalls 89 and fractures inolderpeople.90 An assessment offootwear and foot problems should beincluded aspart ofan individualised, multifactorial and multiple intervention for preventing falls inthe community.86,87 The following components offeet and footwear assessment are most relevant tothis group ofolderpeople: Footwear use the safe shoe checklist, which isareliable tool for evaluating specific shoe features that could improve postural stability inolderpeople.91 Foot problems assess foot pain and other foot problems regularly. Anolder person with anundiagnosed peripheral neuropathy should bereferred toamedical practitioner tolook for potentially reversible ormodifiable causes ofthe neuropathy. Some ofthe more common causes ofaperipheral neuropathy include diabetes, vitaminB12 deficiency, peripheral vascular disease, alcohol misuse and adverse effects ofsomedrugs.92 Refer the older person toahealth professional who isskilled inassessing feet and footwear (eg apodiatrist) for additional investigations and managementasrequired.93 A detailed assessment byapodiatrist for fall risk factors may also beneeded. This examination shouldinclude: 94 falls history including foot pain andfootwear dermatological assessment skin and nail problems,infection vascular assessment peripheral vascularstatus neurological assessment proprioception, balance and stability, sensory, motor and autonomicfunction biomechanical assessment posture, foot and lower limb joint range ofmotion testing, evaluation offoot deformity (eg hallux valgus) andgaitanalysis footwear assessment stability and balance features, prescription offootwear orfootwear modifications, orfoot orthoses based onassessment ofgaitinshoes education foot care and footwear, toendorse the link between footwearorfoot problems and fallsrisk.
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What makes a shoe safe?

Laces or strong fastening to hold the foot firmly Supporting collar, preferably high
Low, square heel to improve stability Thin, firm midsole for the feet to read the underlying surface
Slip-resistant sole
What makes a shoe unsafe?

Soft or stretched uppers make the foot slide around in the shoe High heels should be avoided as they impair stability when walking Narrow heels make the foot unstable when walking
Source: Lord82
Lack of laces means the foot can slide out of the shoe
Slippery or worn soles are a balance hazard, particulary in wet weather
Figure 4.1 The theoretical optimal safe shoe, and unsafeshoe
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4.5.2 Strategies for improving foot condition andfootwear

As foot pain and footwear are amenable totreatment, podiatric intervention has the potential toimprove mobility and postural stability. Todate, norandomised controlled trials have assessed foot orfootwear intervention toprevent falls. However, the following strategies, which are based onother, lower quality studies, may help toprevent falls inolder people living inthe community: Footproblems debride calluses toimprove functionalability95 use toe-strengthening exercises toreducesway96 investigate and treat the cause ofaperipheral neuropathy wherepossible.97 Footwear use textured insoles toimprove stepping responses toplatform perturbation inolderpeople98 use foot orthoses toimprove posture andbalance.97,99 Older people might bereluctant tochange their footwear. Areport published in1993 mentioned several factors that discouraged people from using safe shoes, such asfoot problems, difficulty putting them on, expense, style and lack ofknowledge about their importance.100 All health care professionals can play animportant role inadvising older people aboutsafe footwearby: identifying ill-fitting orinappropriatefootwear screening older people for foot pain orfootproblems educating older people and carers about basic foot care and providing information aboutfootwear encouraging older people toensure shoes are repaired when indicated andcleanedregularly recognising that older people who have ashuffling gait may beat higher risk offalling ifthey wear nonslip shoes oncertain carpetedfloors ensuring that people with urinary incontinence have dry, cleanfootwear ensuring older people have more than one pair ofshoes incase ofshoe soilingordamage discouraging walking while wearing slippery socks andstockings discouraging the use oftalcum powders, which may contribute toslipperyfloors
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referring anolder person toapodiatrist for further assessment and management ifany ofthe following conditions orclinical signs areevident footpain foot problems such asswelling, arthritis, bunions, toe deformities, skin and nail problems (especially corns and calluses) orother foot abnormalities (eg collapsed arches orahigh-archedfoot) conditions affecting balance, posture orproprioception inthe lower limbs, such asdiabetes, peripheral neuropathy orperipheral vasculardisease unsteady orabnormalgait inappropriate orill-fitting footwear orarequirement forfootorthoses referring the older person toapodiatrist for orthotics incases ofsignificantly deformedfeet. However, itis important torecognise that lack ofadherence toany ofthese interventions will limit the effectiveness ofgood footwear forpreventingfalls.
Casestudy
Mr Rvisited his general practitioner (GP) for management ofhis diabetes. Healso has arecent history offalls. After abasic foot screening, the GPfound that MrRhad poor sensation and some calluses and lesions onhis feet, sothe GPreferred him toacommunity podiatry service. Thepodiatrist diagnosed mild peripheral neuropathy, and also found that MrRwas unsteady because hewore over-sized sports shoes with athick, cushioned sole tohelp his calluses. The podiatrist treated MrRs lesions and taught him how tobuy better fitting footwear that improved his stability, but was still safe for his neuropathic feet. MrRs balance improvedafter hepurchased more appropriatefootwear.
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4.6 Syncope
Recommendations
Assessment
Older people who report unexplained falls orepisodes ofcollapse should beassessed for the underlyingcause.
Intervention
Assessment and management ofpotential causes ofpresyncope and syncope should form part ofamultifactorial intervention toreduce the rate offalls inolder people.(LevelI) 5 Use cardiac pacing inolder people who live inthe community, and who have carotid sinus hypersensitivity and ahistory ofsyncope orfalls, toreduce the rate offalls.(LevelII) 13
4.6.1 Assessingsyncope
Syncope isatransient and self-limiting loss ofconsciousness. Itis commonly described asblacking out or fainting. Presyncope describes the sensation offeeling faint ordizzy and can precede anepisode ofloss ofconsciousness. While anumber ofconditions can present with syncope, all share the final common pathway ofcerebral hypoperfusion leading toan alteration inconsciousness. Older people are more predisposed tosyncopal events due toage-related physiological changes that affect their ability toadapt tochanges incerebralperfusion. It isimportant toensure that older people reporting presyncope orsyncope undergo appropriate assessment and intervention, particularly ifthe cause isnot obvious. The symptoms should bereported totheir GP and, depending onthe history and results ofthe clinical examination, anumber oftests and further investigations may bewarranted. This may include anelectrocardiogram, echocardiography, Holter monitoring, tilt-table testing and carotid sinus massage orinsertion ofan implantable looprecorder.
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4.6.2 Treatingsyncope
Permanent cardiac pacing issuccessful for treating certain types ofsyncope. Pacemakers reduce falls by70% inpeople with accurately diagnosed cardioinhibitory carotid sinus hypersensitivity.13 Anumber ofsuccessful multifactorial falls prevention strategies have included assessments ofblood pressure and orthostatic hypotension, and medicationreview andmodification.73,101-103 The symptoms oforthostatic hypotension can bereduced using the followingstrategies: Ensure good hydration ismaintained, particularly inhotweather.104-106 Encourage the older person tosit upslowly from lying, stand upslowly from sitting, and wait ashort time beforewalking.104,105 Minimise exposure tohigh temperatures orother conditions that cause peripheral vasodilation, including hotbaths.105 Minimise periods ofprolonged bed rest andimmobilisation. Encourage older people torest with the head ofthe bedraised. Increase salt intake inthe diet, ifnotcontraindicated. Where possible, avoid prescribing medications that may causehypotension. Identify any need touse appropriate peripheral compression devices, suchasantiembolicstockings.105 Monitor and record postural bloodpressure.106
Case study postprandialhypotension

Mr Lis an82-year-old man who was taken toan emergency department byambulance after falling atashopping centre. Atthe emergency department, staff learnt that MrLhad suffered three other recent falls, all ofwhich hedescribed asoccurring asaresult ofblackouts. MrLwas referred toacardiology unit where, after initial assessment, heunderwent carotid sinus massage with head-up tilt. During massage ofthe right carotid sinus with 70 head-up tilt, MrLhad adocumented period ofthree seconds ofasystole from which hewas symptomatic. Hewas subsequently fitted with adual chamber pacemaker. Inthe six months after this procedure MrLsuffered nofurtherfalls.
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4.7 Dizziness andvertigo

Recommendations
Assessment
Vestibular disorders asacause ofdizziness, vertigo and imbalance need tobe identified inthe community setting. Ahistory ofvertigo orasensation ofspinning ishighly characteristic ofvestibularpathology. Use the DixHallpike test todiagnose benign paroxysmal positional vertigo, which isthe most common cause ofvertigo among older people, and can beidentified inthe community setting. This isthe only cause ofvertigo that can betreatedeasily.
Note: there isno evidence from randomised controlled trials that treating vestibular disorders will preventfalls.

48
Good practicepoints
Use vestibular rehabilitation totreat dizziness and balance problems whereindicated. Use the Epley manoeuvre tomanage benign paroxysmal positionalvertigo. All manoeuvres should only bedone byan experiencedperson.
4.7.1 Assessing vestibularfunction

Dizziness inolder people often represents adifficult diagnostic problem, because itis asubjective sensation that may result from impairment ordisease inmultiple systems. When residents describe being dizzy, giddy orfaint, this may mean anything from ananxiety orfear offalling, topostural dysequilibrium, vertigo orpresyncope. Therefore, adetailed historyiscrucial. An important step inminimising the risk of falls associated with dizziness isto assess vestibular function. This can bedone using the following steps and tests (these tests should only bedone byan experiencedperson): Ask the older person about their symptoms. Dizziness isageneral term that isused todescribe arange ofsymptoms that imply asense ofdisorientation.107 Dizziness may beused asaterm byan older person todescribe poor balance. Vertigo, asubtype ofdizziness, ishighly characteristic ofvestibular dysfunction and isgenerally described asasensationofspinning.108
Assess peripheral vestibular function using the Halmagyi head-thrust test.109 Ithas good sensitivity only ifthe vestibular dysfunction is severe or complete.110 Use audiology testing toquantify hearing loss. The auditory and vestibular systems are closely connected; therefore, auditory symptoms (hearing loss, tinnitus) commonly occur inconjunction with symptoms ofdizziness andvertigo.111 If needed, request computed tomography ormagnetic resonance imaging toidentify anacoustic neuroma orcentralpathology.108 Use the DixHallpike test todiagnose benign paroxysmal positional vertigo (BPPV). This test isincluded inadiagnostic protocol for evaluating dizziness inolder people ingeneral practice111 and isconsidered mandatory inall older people with dizziness and vertigo following head trauma.112 BPPV should bestrongly considered aspart ofthe differential diagnosis inolder people who report symptoms ofdizziness orvertigo after afall that involved some degree ofheadtrauma. Use vestibular function tests toevaluate the integrity ofthe peripheral (inner ear) and central vestibular structures. These tests are available atsome specialised audiology clinics and may berecommended ifsymptomspersist.113 Refer the older person toaspecialist, such asan ear, nose and throat specialist oraneurologist,ifrequired.108
4.7.2 Choosing interventions toreduce symptomsofdizziness

The following strategies can beused inthe community setting totreat dizziness and balance problems caused byvestibular dysfunction. They canbeused aspart ofamultifactorial falls prevention program toreducethe risk offalls relatedtodizziness.
Medicalmanagement
A randomised controlled trial showed that treatment with methylprednisolone within three days ofacute onset ofvestibular neuritis (viral infection ofinner ear structures) improves vestibular function at12-month follow-up, with complete oralmost complete recovery ofvestibular function in76% ofthe studypopulation.114
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Based onclinical experience, treatment with antiemetics and vestibular suppression medication may berequired totreat the unpleasant associated symptoms ofnausea and vomiting.115 These medications should only beused for ashort duration (one totwo weeks) because they adversely affect the process ofcentral compensation after acute vestibulardisease.108,115
Treating benign paroxysmal positionalvertigo

A range oftreatments for BPPV have been described inthe literature. Theseinclude: Brandt and Daroff exercises these can bedone regularlyathome116 the Epley manouevre this isused commonly byclinicians and involves taking the older person slowly through arange ofpositions that aim tomove the freely mobile otoconia (in the inner ear) back into the vestibule;117 ameta-analysis showed that this manouevre ishighly successful for treatingBPPV.118 Older people with diagnosed BPPV respond aswell totreatment asthe general population; therefore, nospecial approaches are needed inthis older group.119 However, itis important todiagnose and treat BPPV assoon aspossible, because treatment improves dizziness and generalwellbeing.119
Vestibularrehabilitation
Vestibular rehabilitation (VR) isamultidisciplinary approach totreating stable vestibular dysfunction. The physiotherapy intervention component focuses onminimising the older persons complaints ofdizziness and balance problems through aseries ofexercises, which are modified tosuit each person.120 The occupational therapy intervention component involves incorporating the movements required for these exercises into daily activities,121 and psychology input addresses the emotional impact ofvestibulardysfunction.122 The literature emphasises the following characteristicsofVR: VR ishighly successful intreating stable vestibular problems inpeople ofallages.123 Starting VRearly isrecommended inthe community setting, because delayed initiation ofVR isasignificant factor inpredicting unsuccessful outcomes overtime.124 The success ofVR inolder people inthe community isnot influencedbyage.125
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VR can improve measures ofbalance performance inpeople inthe community who are older than 65years;126,127 however, astudy ofpeoplewith multisensory dizziness found that the prevalence offalls over a12-month period did not differ between those receiving VRand acontrolgroup.128 Regular training courses investibular rehabilitation are held across Australia, and anincreasing number ofphysiotherapists working inthe community setting are now trained toassess and manage dizziness. These physiotherapists can befound bycontacting the Australian Physiotherapy Association orthe Australian VestibularAssociation.
Casestudy
Mr Sis an81-year-old man who presented tohis general practitioner (GP) with vague symptoms ofgiddiness. Hereported feeling giddy when getting out ofbed inthe morning sothat hehad tosit for five minutes onthe edge ofthe bed before standing up. Hewalks with astick, but has had several falls athome without serious injury. Hereported that heno longer lies flat inbed (he uses three pillows atnight) and was unable toroll tothe left without feelinggiddy. Mr Ss GPtested him for benign paroxysmal positional vertigo (BPPV) using the DixHallpike test, which identified BPPV inMr Ss left inner ear. Hewas subsequently treated with anEpley manoeuvre and taught Brandt-Daroff exercises todo dailyathome. Mr Swas nolonger giddy, could lie flat inbed and was able toroll easily onto his left side. Hereported that his balance was also better and hehad norecent falls. Some milder symptoms returned about four months later, but these were helped with arepeat ofthe Epleymanoeuvre.
http://members.physiotherapy.asn.au http://www.dizzyday.com/avesta.html
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4.8 Medications
Recommendations
Assessment
Older people living inthe community should have their medications (prescribed and nonprescribed) reviewed atleast yearly, and for those onfour ormore medications, atleast sixmonthly.

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Intervention
Medication review and modification should beundertaken aspart ofamultifactorial approach tofalls prevention.(LevelI) 5 For individual older people, gradual and supervised withdrawal of psychoactive medications should beconsidered toprevent falls.(LevelII) 10 Pharmacist-led education onmedication and aprogram offacilitated medication review bygeneral practitioners should beencouraged inthe community setting.(LevelII) 14
Good practicepoint
Consider likely pharmacological changes when prescribing any new medication toan older person and avoid prescribing psychoactive drugs ifclinicallypossible.
4.8.1 Reviewingmedications
Medication use isassociated with falls inolder people. Therefore, GPs should review medications yearly for all older people and every six months for older people who take four ormoremedications.129 Older people who live inthe community are eligible for adomiciliary medication management review (DMMR), which isaservice that encourages collaboration between the older person, their GP, pharmacist and other health professional toreview medication use. DMMR results inareport from anaccredited pharmacist tothe referring GP, and amedication management plan agreed between the GPand the older person ortheir carer. ADMMR isavailable following areferral from aGP. Formore information, see the Australian Government Department ofHealthand Ageingwebsite.
http://www.health.gov.au/internet/main/publishing.nsf/Content/ health-epc-dmmr-answers.htm
Older people who may benefit from a DMMR includethose: on multiplemedications who have recently been discharged fromhospital with recent and significant changes totheirmedications who are seeing anumber ofdifferent GPs andspecialists. Also, any member ofthe older persons health care team may use the checklist inthe following box tohelp decide whether aperson requires aDMMR from apharmacistordoctor.14
Checklist for medicationreview130

A medication review isneeded ifthe olderperson: is taking four ormore different typesofmedications is taking more than 12doses ofmedicationaday had significant changes made tothe medication regime inthe past threemonths is attending anumber ofdifferentdoctors is taking one ormore psychoactivemedications was recently discharged from ahospital (in the past fourweeks) has multiple medicalconditions is suspected ofnot adhering with their medicationregime shows symptoms that suggest anadverse medication reaction (egconfusion, dizziness, reducedbalance) is using medications with anarrow therapeutic index ormedication requiring therapeutic monitoring (suchaswarfarin) is responding subtherapeuticallytotreatment.
Figure4.1 isan example ofamedication risk-assessmentform.
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1. How old are you?
Are you (please ):

Yes
Male
Female
No
Dont know
2. Do you have 3 or more health conditions? (please ): 3. In general, would you say your health is poor? 4. Have you changed your general practitioner in the past 3 months? 5. D o you have more than one doctor involved in your care, including other general practitioners or specialist? 6. Have you been in hospital, hostel or nursing home in the past month? 7. Do you live alone? 8. Have you had a fall in the past 12 months? 9. In the last month have you: Had trouble sleeping Felt drowsy or dizzy Felt nauseous Had stomach problems Had a skin rash or itch Leaked urine Been constipated
10. How many medicines do you use? (Write in box) Medicines includes all medicines prescribed by your doctor or any other doctor, including specialists medicines bought from chemist, supermarket or health food store, medicines you take only occasionally, herbal medicines, vitamins, minerals, puffers, creams, patches, eye drops and laxatives. If you do NOT take any medicines, then there is no need to fill in the rest of this page 11. Have you started a new medicine in the last 4 weeks? 12. Do you use: Any medicine that helps you sleep Any medicines for your nerves, stress, anxiety or depression Any medicines your doctor does not know about 13. Have you been taking any medicines for more than 6 months? 14. For any medicine, you currently use, do you have any: Trouble with side effects Trouble remembering to take the medicine Trouble knowing what medicine is for Trouble using many medicines at once Trouble reading the label Trouble affording the medicine Trouble understanding the label Trouble opening bottles or packets/applying the medicines 15. Have you had more than 4 changes to your medicines in the past 12 months? 16. Do you share medicines among family and friends? 17. Has your doctor asked you to bring ALL your medicines to an appointment so he can have a look at them, in the past 12 months? Yes No Dont know
Please give all forms to your doctor

Doctors USE Only: Medication Review beneficial: Yes / No Patient agress: Yes / No
Figure 4.1 Medication risk-assessmentform14

4.8.2 Quality useofmedicines

The following strategies help toensure quality use ofmedicines, and are good practice for minimising falls inolder people inthecommunity: Multiple drug use should belimited toreduce side effects and interactions and a tendency towards proliferation ofmedicationuse. Drugs that act onthe central nervous system, especially psychoactive drugs, are associated with anincreased risk offalls; therefore, they should beused with caution and only after weighing uptheir risks andbenefits. Prescribe the lowest effective dosage ofamedication specific tothesymptoms. Provide support and reassurance topeople who are gradually stopping theuse of psychoactivemedication(s). If the older person needs totake medications known tobe implicated inincreasing the risk offalls, try tominimise the troublesome effects (iedrowsiness, dizziness, confusion and gaitdisturbance). Provide the older person (and their carer) with anexplanation ofnewly prescribed medications orchangestoprescriptions. Educate the whole multidisciplinary team, older people and their carers toimprove their awareness ofthe medications associated withanincreased riskoffalls. Document information when implementing, evaluating, intervening, reviewing, educating and making recommendations about the older persons medicationuse.
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Casestudy
Mr Pis an80-year-old man who istaking nine different medications. Hefelt unsteady and had several falls, mainly during the night. During aroutine check-up, his general practitioner (GP) assessed MrPs need foradomiciliary medication management review (DMMR). The GPreferred MrPto his community pharmacist. The community pharmacist coordinated the review and began bymaking anappointment for MrPto meet with with anaccredited pharmacist. The interview took place inMr Ps home, and the accredited pharmacist asked him about all the medications hehas, those heis taking currently, and other information. Much ofthe information required for MrPs review was inthe referral and obtained atthe meeting, but the pharmacist may also have referred tofamily members, carers, community nurses, MrPs preferred community pharmacist orother members ofthe health care team, with MrPs consent. The accredited pharmacist clinically assessed the information gathered about MrPand his medications, and prepared areport for theGP. Mr Ps DMMR report recommended that hecould slowly reduce and then stop taking asleeping tablet and anantidepressant, which hehad started taking two years earlier, after the death ofhis wife. This was agreed after adiscussion between MrPand his GPabout the DMMR, and formed part ofan agreed medication management plan. MrPslowly reduced using both medications without ill effect. Hefelt much more alert and confident while upand about, and steadier when getting upatnight.

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4.9 Vision
Recommendations
Assessment
Include atest ofvision aspart ofafalls riskassessment. Encourage older people tohave regular eye examinations (every two years) toreduce the incidence ofvisual impairment, which isassociated with anincreased riskoffalls.
Interventions
Older people with visual impairment primarily related tocataracts shouldundergo cataract surgery assoon aspracticable. (LevelII) 7,8 When correcting other visual impairment (eg prescription ofnew spectacles), explain tothe older person and totheir family and carers (where appropriate) that extra care isneeded while the older person getsused tothe new visual information.(LevelII) 35 Advise older people who take part inregular outdoor activities toavoidbifocals ormultifocals and touse single-vision distance spectacles whenwalking especially when negotiating steps orwalkinginunfamiliar surroundings.(LevelIII-2) 131 People with severe visual impairment should receive ahome safety assessment and modification program specifically designed toprevent falls.(LevelII) 11,12
Good practicepoint
Detailed assessment byan optometrist ororthoptist for afall-specific eye examinationshould: identify the presence ofeyediseases calculate subjective refraction and determine optimum spectaclecorrection check for high-contrast visual acuity using the Snellen eye chart and contrast sensitivity using the PelliRobson test charts, the Melbourne Edge Testorsimilar assess visual fields using the Humphrey Field Analyserorsimilar assess depthperception.
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4.9.1 Screeningvision
Vision screening should beincluded inmultifactorial falls preventioninterventions.34 The following strategies can beused tomeasure vision problems inolder people inthecommunity: Ask the older person about their vision and record any visual complaints and history ofeye problems and eyedisease. Check for signs ofvisual deterioration. These can include aninability tosee detail inobjects, oran inability toread (including avoiding reading) orwatch television; and apropensity tospill drinks orbump intoobjects. Measure visual acuity orcontrast sensitivity using astandard eye chart (eg Snellen eye chart) orthe Melbourne Edge Test, respectively (seeTable4.6). Check for signs ofvisual field loss using aconfrontation test (see Table4.6) and refer for afull automated perimetry test byan optometrist orophthalmologist ifany defects are found. Large, prospective studies have found that falls are mostly associated with loss offield sensitivity, rather than loss ofvisual acuity and contrastsensitivity.132,133 Arrange regular eye examinations toreduce the incidence ofvisual impairment,134 which isassociated with anincreased riskoffalls.132 Table4.6 outlines the characteristics ofeye-screeningtests.
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Table4.6 Characteristics ofeye-screeningtests
Snellen eye chart (for testing visualacuity)

Description
Standardised eye test ofvisual acuity. Comprises aseries ofsymbols (usually letters) inlines ofgradually decreasing size. Participant isasked toread the chart from adistance of6metres for standard charts (charts designed for shorter test distances are available; the examiner should check that they are using the correct working distance for the chart). Charts should also bewell lit and not obscured byglare orshadows. Visual acuity isstated asafraction, with 6 being thenumerator and the last line read the denominator (thelarger the denominator, the worse the visual acuity). Pocket versions ofSnellen charts are available for aclinical screen ofvisual acuity (these smaller charts can beused atashorter distance than the standard 6metres totest visualacuity).
5minutes A score of6/12 indicates visual impairment; however this depends onthe age ofthe person (the cut-off score will decrease with increasingage).
Melbourne Edge Test (for testing contrastsensitivity) 135

Description The test presents 20 circular patches containing edges with reducing contrast. Correct identification ofthe orientation ofthe edges onthe patches provides ameasure ofcontrast sensitivity indecibel units, where dB=10log10contrast, where contrast defines the ratio ofluminance levels ofthe two halves ofthe circularpatch. Time needed Criterion 5minutes Score ofless than 18/24 indicates visual impairment; however this depends onthe age ofthe person.135
4 Management strategies for common falls riskfactors 59
Confrontation Visual FieldTest136

Description Crude test ofvisual fields. Participant and examiner sit between 66cm and 1m apart atthe same height, with the examiners back towards ablank wall. Totest the right eye, the participant covers the left eye with the palm oftheir hand and stares atthe examiners nose. The examiner holds upboth hands inthe upper half ofthe field, one either side ofthe vertical, and each with either 1 or2 fingers extended, and asks the participant, What isthe total number offingers Iam holding up? The procedure isrepeated for the lower half ofthe field but changing the number offingers extended ineach hand. The procedure isrepeated for the left eye. Ifthe participant incorrectly counts the number offingers in the upper orlower field, the test should berepeated again and then recorded. Ifthe participant moves fixation toview the peripheral targets, repeat the presentation. Results are recorded asfinger counting fields R and L ifthe participant correctly reports the number offingers presented. For those who fail this screening, adiagram should bedrawn toindicate inwhich part ofthe field the participant madeanerror. Time needed Criterion 4minutes If the participant incorrectly reports the number offingers held upin either eye, they should bereferred for afull visual fieldtest.
If more detailed visual assessment isneeded once the older person has been assessed using the crude visual screening methods described above, orif the older person scores poorly onthese tests, the general practitioner should refer them toan optometrist, orthoptist orophthalmologist for afullvisionassessment.
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4.9.2 Choosing visioninterventions

When avisual deficit isidentified, the older persons GPshould seek adiagnosis toprovide interventions including referral toan ophthalmologist oroptometrist,asnecessary.
Cataractsurgery
Expedited cataract surgery isthe only evidence based vision intervention that has shown tobe effective inreducing both falls and fractures inolderpeople.7,8 Compared with expedited cataract surgery, prolonged waits onlists for cataract surgery are associated with anincreased risk offalls and fractures.7,8 Therefore, anoccupational therapist should assess environmental safety toidentify potential hazards, lack ofequipment and risky behaviours that might cause falls inpeople with severe visual impairment, including those waiting for cataract surgery (see Home safety assessment and modification,below).
Referral toanophthalmologist
As part ofinpatient hospital care, one randomised controlled trial showed that falls could bereduced byamultifactorial approach that included referring the older person toan ophthalmologist when anew visual problem isdetected, orif there isno known reason for poor vision.85 This could beapplied inthe community settingaswell. Also, recommend that the older person sees anoptometrist ifthey have impaired visual acuity, wear spectacles that are scratched ordo not fit comfortably, orhave not had aneye examination inthe pastyear.
Optimalprescription
If the older person wears spectacles, their GPor other member ofthe health care team may check their visual acuity with their current spectacles and refer them for optometric assessment ifit isless than 6/7.5. However, caution isrequired infrail older people, because comprehensive vision assessment with appropriate treatment may increase the risk offalls (see Section3.1.1).35 Large changes inrefractive correction should beprescribed only with great care and warnings about adaptation problems, orapartial change inrefractive correction should bemade insuchcases.
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Choiceofspectacles
Older people may benefit from anassessment byan optometrist orophthalmologist, who can provide advice onthe most appropriate type ofspectacle correction. Older people who live inthe community andwho wear bifocal ormultifocal spectacle lenses when walking outside the home and onstairs have adecreased ability tonegotiate steps safely137 and adoubled risk offalls from tripping.131 Older people with ahistory offalls oran increased risk offalls should beadvised toavoid bifocals ormultifocals and touse single-vision distance spectacles when walking especially when negotiating steps orwalking inunfamiliar surroundings. Astudy also suggested telling older people who wear multifocals and distance single-vision spectacles tobend their heads rather than just lowering their eyes tolook downwards toavoid posturalinstability.138
Home safety assessment andmodification

Interventions that improve visual cues and minimise environmental hazards should beused, including provision ofadequate lighting and contrast (egbyapplying adhesive strips for steps, orpainting the edges ofpathways white).11,12 Occupational therapists can also provide home visits tohelp older people modify their behaviours, allowing them tolive more safely inboth the home and the externalenvironments.139
Point ofinterest: mobilitytraining

Vision Australia specialises insafe mobility training for visually impairedpeople: http://www.visionaustralia.org.au/
Casestudy
Mrs Jis 75 years old and badly bruised her left arm after falling over astep. Her general practitioner (GP) tested her vision using astandard Snellen eye chart and found that her visual acuity was reduced. The GParranged for her tosee anophthalmologist, who diagnosed acataract inMrsJs right eye. Within the next month, she was scheduled for cataract extraction. After the operation, MrsJ was pleased tonotice analmost immediate improvement inher vision. She now feels much safer while walking inunfamiliar places and has not fallen since theoperation.
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4.10 Environmentalconsiderations
Recommendations
Assessment
Older people considered tobe athigher risk offalling should beassessed byan occupational therapist for specific environmental orequipment needs and training tomaximisesafety.
Intervention
Environmental review and home hazard modification should beconsidered aspart ofamultifactorial approach inafalls prevention program for older people inthe community.(LevelI) 5 When conducted asasingle intervention, home environment interventions are effective for reducing falls inhigh-risk older people.(LevelI) 9
Good practicepoint
It isimportant tohelp the older person understand the relevance ofany environmental modifications, toimprove uptake ofsuchinterventions.
4.10.1 Assessing the older person intheirenvironment

Environmental review and modification refers tochecking the older persons environment for hazards that might cause them tofall, and then modifying orrearranging the environment toremove orminimise thesehazards. An environmental assessment should bedone byahealth professional (eganoccupational therapist) with experience and training inevaluating people and their environment.5 Anoccupational therapist can evaluate older people todetermine their capacity toplan and perform activities ofdaily living and tomeet the functional demands oftheenvironment.140 Within the community setting, anoccupational therapy-based falls prevention interventionshould:141,142 focus onolder people who have ahistoryoffalls help tomake the necessary environmental modifications (eg using followup telephone calls orextra home visits,asneeded) make sure the older person understands their risk factors for falling, andthe consequences offalling (to improvecompliance) recognise the preferences ofthe older persons family orcarer and incorporate these into theintervention.
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Where anoccupational therapist receives areferral from another member ofthe health care team and isasked toreview anolder person because ofafall orrisk offalls, the occupational therapist should dothefollowing:141,143 Conduct aninitial evaluation and identify the range ofenvironments inwhich the older person lives orworks, chart their daily schedule orroutine, and identify relevant activities ofdaily living forassessment. Understand the older persons fall experiences and their beliefs about what causesfalls. Evaluate the older persons functional status within the context oftheir home environment bycheckingtheir physical resources (strength, range ofmotion, coordination, sensation, balance) infunctional situations, such asreaching andbending perceptual orcognitivefunction functionalvision generalmobility. Taking into account the personenvironment fit, conduct areview ofthe home and outdoors environment using avalidated and comprehensive tool, such asthe Westmead Home Safety Assessment (see the point ofinterest box, below). Use the tool with the older person and together identify hazards, possible solutions, and develop anaction plan. Theprocess should enable the older person toincrease their awareness and observation skills for identifying fall hazards inother environments. Consider risk-taking behaviours and encourage protective adaptations. Forexample, this may bestrategies toreduce rushing toanswer the phone orcues toremember toturn the light onat entrancewaysatnight. At the end ofthe evaluation, the occupational therapist should provide asummary that identifies requirementsfor: additional safetyequipment assistive devices and recommendations for their use any rearrangementoffurniture other environmentalmodifications mobility training and safety when walking around inpublicplaces.
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Point ofinterest: assessmenttools

The Westmead Home Safety Assessment determines how falls history, risky situations, habits, behaviours and personal characteristics affect anindividuals safety level. Itidentifies 72possible physical and environmental home hazards ofolder people atrisk offalling.144 Each item onthe assessment form israted asahazard ornot ahazard, andinformation onall categorised hazards are identified and summarised soan action plan can bedeveloped. Itshould beused inconjunction with the manual, Home Fall Hazards ,143 which outlines the evaluation approach toan environmental intervention inthehome. The Falls Behavioural Scale for Older People145 isa29-item self-reporting assessment tool that can beused toassess the kinds ofeveryday behaviours that can offer anolder person protection from falling. Itcan also begiven tothe older person before ahome visit toraise their awareness ofabroader range ofpotential risks, and therefore contribute todiscussion and problemsolving. The Home Falls and Accidents Screening Tool (Home Fast), which was developed byNewcastle University, can beused byhealth care professionals toidentify older people who have anincreased risk offalling, refer them for amore detailed falls risk assessment, and recommend falls prevention interventions. See the Department ofHealth (State Government ofVictoria) website for more information(http://www.health.vic.gov.au/ agedcare/maintaining/falls/providers/home/env_check.htm).
4.10.2 Designing multifactorial interventions that include environmentalmodifications

Effective environmental interventions should incorporate modifications, suchas: 9,84,146 ensuring adequate lighting and reducingglare enhancing contrast atchange offlooringlevels modifying slippery floorsorsteps reducingclutter using walkingaids removing loosecarpets fixing uneven and brokenpathways. Falls can befurther minimised byusing luminous toilet signs and night sensor lights, aspart ofamultifactorial falls prevention intervention.84 Other common-sense interventions include installing grab rails inthe bathroom, removing leaf litter onoutdoor paths, replacing orfixing
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worn mats, and ensuring that furniture and electrical cords are not placedinwalkways. Health care professionals orcarers should discuss with older people iftheirpersonal belongings and furniture are tobe moved. They should alsodetermine the older persons preferred sleepingarrangements.
Casestudy
Mrs H, who lives alone, was recently discharged from hospital following afall. Before she returned home, anoccupational therapist visited MrsHs home with her and made alist ofthings that needed tobe changed, toreduce Mrs Hs risk offalling again. Mrs Hs daughter worked with the occupational therapist tomake these changes, which included replacing floor mats inthe hallway with nonslip coverings, installing arailing tohelpMrs Hget inand out ofthe shower, and asking the local newsagent (who delivered the paper inthe mornings) tothrow the paper onto the driveway, instead ofon the lawn (where the grass was slippery andspringy). After Mrs Hreturned home, the occupational therapist discussed with her the importance ofmaking these changes. She also watched MrsHgoing about her normal activities ofdaily living for half aday athome, and together they wrote alist ofrisky behaviours that might increase MrsHs risk offalling (eg using anunstable chair instead ofaladder toreach the top cupboard). One week later, the occupational therapist rang MrsHto make sure that she was avoiding these risky behaviours. MrsHnow has agreatly reduced risk offalling, because she understands her own particular risk factors for falling, and the benefits ofbeing involved inmakingchanges.
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4.11 Individual surveillance andobservation

Good practicepoints
Sitter programs (eg using staff orvolunteers tosit with at-risk older people) may beuseful for individualpeople. Bed, chair orfoot alarms can alert acarer that the person isattemptingtomobilise. A personal alarm, when worn, can trigger analert that aperson has fallen, and minimise alie onthefloor. Electronic sensor monitoring systems are being developed and tested, but they are not likely tobe available widely for sometime.
4.11.1 Education andassessment

Little research onsurveillance orobservation has been done inthe community setting. The following general principles ofobservation and surveillance are based ongood practice inthe hospital setting, and may beuseful inthe communitysetting. Older people who have ahigh risk offalling should beinformed oftheir risk. Adapting aninformation brochure for the community may behelpful for families and informal carers todiscuss falls with the older person. This type ofinformation should betargeted tothose older people who have the highest riskoffalling. A home visit byan occupational therapist with the older person should beconsidered, aspart ofdischarge planning. Referral toafalls clinic may beuseful. Ifthe older person wants toremain intheir own home, the health care team (eg GP, allied health staff, carers and family) should make the home environment assafe aspossible, including setting upamonitoring system tominimise the time spent onthe floor inthe event ofafall (seebelow).
4.11.2 Sitterprograms
Some hospitals and residential aged care facilities have introduced sitter programs.147-149 These programs use volunteers, families orpaid staff tosit with older people who have ahigh risk offalling. The role ofthe sitter isto provide company for the person and tonotify the appropriate personnel when the person wishes toundertake anactivity where they may beat risk offalling. Sitter programs may beaviable strategy insome community settings, toreduce falls for selected people. However, sitter programs
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require planning, resources, education, investment (particularly for paid individuals) and ongoing coordination. Sitter programs have not been specifically researched inthe community setting, soit isnot clear whether they would behelpful for older people living athome. Also, they may betoo expensive for many older people and their carers orfamily. However, the older persons GPor other member ofthe health care team could encourage the older persons carers, family orfriends tospend time sitting with the older person, particularly inwakinghours.
4.11.3 Responsesystems
Response systems are usually aform ofmonitor, incorporating analarm that sounds when aperson moves orpresses abutton. Anumber ofresponse systems are commercially available. Aprospective cohort study investigated the use ofalarms bypeople older than 90years living either intheir own home orwithin acare home. Many participants who lived alone owned acall alarm (70%; 57 out of81participants).150 Despite this, use ofthe alarm was low among older people inthe community who fell while alone (78%; 28 out of36participants). Reasons for not using the alarm included not wearing it, wearing itbut not wanting touse it(wantingtostay independent, fearful ofbeing taken tohospital) and difficulty inactivatingit. In some systems, analarm isactivated byapressure sensor when aperson starts tomove from abed orchair. Inother systems, analarm sounds when any part ofapersons body moves within aspace monitored bythe alarm. Another style ofsystem activates when aperson falls, but does not get up. For example, abedside foot alarm towake asleeping carer may help toreduce the time the older person spends onthe floor after afall, although this has not been investigated inthe community setting. Alternatively, alight sensor under the bed can betriggered when the older person steps out ofbed during the night and alerts the sleepingcarer. Response systems require capital investment and rely onathird party151 (eg the persons carer, family, neighbour orgeneral community) torespond when the alarm sounds. Alarm systems that are triggered when aperson has fallen are not preventive. Instead, they simply report the fall after theevent, and minimise the time spent onthefloor.
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Surveillance and observation approaches are particularly useful for older people who forget ordo not realise their limitations. Good practiceinvolves: identifying those people who are atrisk inthecommunity assessing them intheir own homes, and modifying the home environment and behaviour sothe older person isas safeaspossible involving their carer, family and neighbours, where possible, toprovide additionalsurveillance encouraging them toenrol inan exercise program specifically for falls prevention, and undertake regular exercises either athome orinaclass providing them with apersonal alarm touse ifthey dofall, and ensuring they wear the alarm atall times (including inthe shower orin bed bothofwhich are high-risktimes).
Casestudy
Mrs Zis 79 years old and lives byherself. Her family worry about her, but also know that itis important toMrs Zthat she maintains her independence aslong aspossible. Mrs Zhas had three falls previously, allrelated tomeal preparation. Her family have discussed with her strategies toreduce her risk offalling, including using afourwheel walker with aseat that would allow her tocarry her food and drinks. Her family also help bybringing her meals five times aweek. Mrs Zs neighbour visits her twice aweek tohelp her inthekitchen. Mrs Zs family has also bought Mrs Za pendant alarm that she wears around her neck toactivate ifshe has afall and cannot get up. She was admitted tothe emergency department ofthe local hospital after a fall. The hospital has put agreen sticker inher case notes toindicate that she has anincreased riskoffalls.
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5 Minimising injuries fromfalls

5.1 Hipprotectors
Recommendations
Assessment
When assessing anolder persons need for hip protectors, the general practitioner orother health professional should consider the older persons recent falls history, age, mobility, disability status, and whether they have osteoporosis oralow body massindex. Assess the older persons cognition and independence indaily living skills (eg dexterity indressing) tohelp determine whether they will beable touse hipprotectors.
Intervention
Physiotherapists orother members ofthe health care team should teach older people and their carers how toput hip protectors onproperly, because their effectiveness isreduced when they are not worn correctly. (LevelII) 152 When using hip protectors aspart ofafalls prevention strategy, thehealth care team orcarer should check regularly that the older person iswearing their protector, that the hip-protectors are inthe correct position, and that they have not stopped wearing them because ofdiscomfort, inconvenience orother reasons.(LevelI) 153
Note: hip protectors have not been shown toprevent hip fractures inthe communitysetting.
Good practicepoints
Hip protectors should not berelied onto reduce falls-related injuries inthe community setting, due toproblems with adherence tothe correct use ofhip protectors. However, because they offer some protection toolder people inresidential aged care, hip protectors can beconsidered incommunity settings aspart ofastrategy tominimise harm from falls, aslong asthey are worn properly and their useismonitored.
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5.1.1 Assessing the use ofhipprotectors

Hip protectors are one approach toreducing the risk ofhip fracture. Theycome invarious styles, and are designed toabsorb ordisperse forces onthe hip ifaperson falls onto their hip area. Hip protectors consist ofundergarments with protective material inserted over the hip regions. There are three types ofhipprotectors: Soft hip protectors are made from asoftmaterial. Hard hip protectors consist ofafirm, curved shell, sewn orslipped into apocket inalycra undergarment, similar tounderpants orbikepants. Adhesive hip protectors are stuck directly tothe skin ofthewearer. When assessing anolder persons need for hip protectors, their general practitioner (GP) (or other member ofthe health care team) should consider the older persons recent history offalls, age, level ofdisability, mobility, whether they are unsteady ontheir feet, and whether they have osteoporosis. Assessing the persons cognition and independence indaily living skills (eg dexterity indressing) may also help determine whether they will beable touse hip protectors. The general practitioner can use afalls risk-assessment tool tohelp decide whether someone has ahigh risk ofhip fractures and therefore beconsidered for the use ofhipprotectors.
5.1.2 Wearing hipprotectors

Soft hip protectors must beheld inplace over the greater trochanter ofthefemur ifthe hip protectors are tobe ofany benefit. Continence pads can becomfortably worn with soft hip protectors, but should befitted first, next tothe persons skin, before the hip protectors are puton.154 Hard hip protectors are held inplace over the hip bylycra undergarments similar tounderpants orbike pants. Different sizes (small toextra large) and designs for men and women are available. Continence pads can beworn inseparate pants, underneath the garments holding the hipprotectors.155
5.1.3 Using hip protectorsatnight

There isarisk offalling and breaking the hip during the evening and night. Iftherisk is high enough tojustify the use ofhip protectors, and the person gets out ofbed togo tothe toilet atnight, the use ofhip protectors atnight should beconsidered. The soft hip protectors are relatively comfortable when positioned correctly and can beworn more easily inbed, because theyare less obtrusive than the hard shellprotectors.155
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5.1.4 Training inhip protectoruse

Fitting and managing hip protectors isoften the responsibility ofaparticular member ofthe health team usually the community nurse orallied health professional. Nurses and home care workers are inakey position toencourage adherence with hip protectors, because they often help frail, older people with dressing, bathing and toileting. Nurses and home care workers should begiven education and support for developing strategies toencourage adherence tothe correct use ofhipprotectors. Training the individual wearer may encourage older people towear hip protectors correctly, byaddressing any barriers that the person sees towearing hip protectors, and providing precise instructions and demonstrations onhow towear them.156 Before the older person starts wearing hip protectors, the health care team and carers should discuss arrangements for cleaning hip protectors. Washing indomestic washing machines and dryers isfeasible, but some hip protectors will not withstand commercial laundering. While self-adhesive hip protectors may beappealing insome instances (ie they can beworn under the older persons own undergarments), itis unclear whether they can beused safely inthe longterm.
5.1.5 Cost ofhipprotectors

Cost ofhip protectors appears tobe afactor influencing uptake. Reimbursement byprivate health funds orby appliance supply schemes mayimprove this problem. Itis unclear towhat degree cost affects adherence with the longer term use ofhipprotectors.
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Casestudy
Mr Tis an84-year-old man who lives with his 79-year-old wife intheir own home. Recently, MrT fell and broke his hip. Hospital tests atthe time ofthe fracture also revealed that MrThad reduced bone mineral density, and sowas atincreased risk offurther fractures. Although physiotherapy and rehabilitation were successful and hehas nophysical side effects from his broken hip, heis scared about falling again. This means heis reluctant totake part inhis normal activities ofdaily living, and has become more dependent onMrsT. The occupational therapist, who makes regular home visits toMr T,talked tohim about using ahip protector, togive him more confidence when moving about athome. She showed him how toput iton correctly, and also explained that, although some studies ofolder people inresidential care have shown effect inreducing hip fractures, noone really knows whether hip protectors are effective inthe home. However, MrTfeels safer when wearing it, and moves around with greater confidence and steadiness. Inturn, this reduces his risk offalling again and helps him tobe moreactive.
5.2 Vitamin Dand calciumsupplementation

Recommendations
Assessment
Consider adequacy ofcalcium and vitamin Das part ofroutine assessment offalls risk inolder people living inthecommunity.
Intervention
Vitamin Dand calcium supplementation should berecommended asan intervention strategy toprevent falls inolder people who live inthe community, particularly ifthey are not exposed tothe minimum recommended levels ofsunlight. Benefits from supplementation are most likely tobe seen inpeople who have vitaminD insufficiency (25(OH)D <50nmol/L) ordeficiency (25(OH)D <25nmol/L).(LevelI-*) 15
Good practicepoints
Encourage older people toinclude high calcium foods intheir diet, andexclude foods that limit calciumabsorption. For older people with cognitive impairment who have problems with medication compliance, consider using anintermittent but highdose preparation ofvitaminD (that is, less frequent administration, but the same total dose asrecommended for older people without cognitiveimpairment).
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5.2.1 Reviewing adequacy ofvitamin Dandcalcium

Low vitamin Dlevels have been associated with reduced bone mineral density, high bone turnover and increased risk ofhip fracture.157 Furthermore, vitaminD may prevent falls byimproving muscle strength andpsychomotor performance, independent ofany other role inmaintaining bone mineraldensity.30,158 One intervention that has been studied insome detail isthe use ofvitaminD for preventing falls. Several meta-analyses with different inclusion criteria examining the effect ofvitaminD onfalls inolder people have reported conflictingresults.5,30,31 The basic principles ofvitaminD interventions for preventing falls areto: assess adequacy ofvitaminD and calcium (eg using food preference records; food and fluid intake records; 25(OH)D blood levels; ahistory ofthe older persons dailyroutine) ensure minimum sun exposure toprevent vitaminD deficiency (ie515minutes exposure, four tosix times per week, being careful nottohave overexposure tothe sun; avitaminD supplement ofat least 800IU per day isrecommended ifsun exposure isnotpossible) consider vitaminD and calcium supplementation (for confirmed cases ofvitaminD deficiency, supplement with 30005000IU per day for atleast onemonth) encourage older people toinclude foods high incalcium intheir diets159 discourage older people from consuming foods that prevent calcium absorption (analysis offood intake records ordiet history should show adaily intake ofcalcium of800mg for men and 1000mg forwomen).159
Casestudy
Mrs Spresented toher general practitioner (GP) after falling recently athome. She lives alone and rarely goes out. Aspart ofher falls risk assessment, the GPestablished that Mrs Shas limited exposure tosunlight and that her diet isneither rich invitaminD nor calcium. The GPdiscussed the importance ofboth calcium and vitaminD with Mrs S. They realised that Mrs Sis unlikely tobe able tomaintain adequate vitaminD levels with sun exposure ordiet. However, she ishappy toincrease the calcium content ofher diet bydrinking two glasses ofmilk, inaddition toher other dietary sources ofcalcium. Mrs Sand the GPagreed that she needs oral vitaminD supplementation and that her calcium needs will bemet byaltering herdiet.
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5.3 Osteoporosismanagement
Recommendations
Assessment
Older people with ahistory ofrecurrent falls should beconsidered for abone health check. Also, older people who sustain aminimal-trauma fracture should beassessed for their riskoffalls.
Intervention
Older people with diagnosed osteoporosis orahistory oflow-trauma fractures should beoffered treatment for which there isevidence ofbenefit.(LevelI) 160
Good practicepoint
When using osteoporosis treatments, older people should be coprescribed vitaminD withcalcium.
5.3.1 Checking bonehealth

Screening for osteoporosis isimportant for minimising falls-related injuries. Itis important torecognise that people sustaining low-trauma fractures after the age of60years probably have osteoporosis and anincreased risk ofsubsequent fracture.161 Bone densitometry and specific anti-osteoporosis therapy should beconsidered inthese people. Older people with ahistory ofrecurrent falls should beconsidered for abone health check. Also, people who sustain aminimal-trauma fracture should beassessed for their riskoffalls.162
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5.3.2 Providinginterventions
As discussed above, several drug treatments are available for treating osteoporosis inpostmenopausal women, which may, inturn, reduce falls and associated injury. These drugs, which are considered tobe the first-line treatment,include: oral orintravenous bisphosphonates inpostmenopausal women who havelow bonedensity160,163 selective oestrogen receptor modulators inpostmenopausal women withosteoporosis164 strontium ranelate for preventing osteoporosis in postmenopausal women.165 However, there isalack ofdata ondrug treatment ofosteoporosis inolder men. Bisphosphonates can beused toreduce the risk ofvertebral fractures and increase bone density inolder men atrisk ofosteoporosis.166 Bisphosphonates work best when co-prescribed with vitaminD andcalcium. For people with ahistory ofrecurrent falls, orthose who have sustained aminimal-trauma fracture, the GPand health care team can consider strategies for optimising function, minimising the time spent onthe floor after afall, protecting bones, improving environmental safety and prescribing vitaminD.
Casestudy
Mrs Eis a75-year-old woman who fell, fracturing her humerus (upper arm) while walking inher home. Specific questioning revealed she had anearly menopause and that she rarely goes outside because she worries about developing skin cancer. Anorthopaedic surgeon treated her fracture inthe local hospital. The surgeon suggested that Mrs Estart taking calcium and vitaminD, and referred her tothe osteoporosisclinic.
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6 Respondingtofalls
Good practicepoints
After the immediate follow-up ofafall, determine how and why afall may have occurred and implement actions toreduce the risk ofanotherfall. It isbetter toask anolder person whether they remember the sensation offalling orwhether they think that they blacked out, because many older people who have syncope are amnestic ofthefact. An in-depth analysis ofthe fall may berequired ifthere has been aserious injury following afall, orif adeath from afall has occurred inthe presence ofamember ofthe health careteam.
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6.1 Immediate responsetofalls

The circumstances surrounding afall are acritical part ofcare, because afall may bethe first and main indication ofanother underlying and treatable problem.167 Older people who fall are more likely tofall again,168 and aprevious fall isastrong risk factor for future falls and falls injuries.169 Allmembers ofthe health care team and older people and their families should beaware ofwhat constitutes afall (see Section1.1 foradefinition). It isalso vital that community service staff know what todo when anolder person falls, orif aclient reports arecent fall tothem. Local community service guidelines should also include actions tofollow for moving someone who has fallen, including when toseek assistance, and reporting requirements (see the checklist,below). However, many older people who fall may not report the fall totheir general practitioner (GP) orother health professional,170 oreven totheir own family. Ifacommunity services staff member notices signs that afall may have occurred (eg unexplained bruising), they should discuss this with the older person, and emphasise the importance ofbeing assessed byahealth care professional tosee whether they needtreatment.
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Reporting and recording the fall isan important part ofcare. The following checklist isaguide towhat should beincluded inafalls incident policy orprotocol for acommunity service (based ongood practice from the hospital and residential aged care settings). Depending onthe background, training and experience ofthe staff member from acommunity service, the policy may primarily involve seeking assistance (eg anambulance) ormedical review inthe firstinstance.
Checklist 1: managing the older person immediately afterafall

Offer basic life support and providereassurance
Check for ongoingdanger. Check whether the older person isresponsive (eg responds toverbal orphysicalstimulus). Check the older persons airways, breathing andcirculation. Reassure and comfort the olderperson.155,167
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Check forinjuries
Conduct apreliminary assessment, including checking for level ofconsciousness and vitalsigns.167 Check for signs ofinjury, including abrasion, contusion, laceration, fracture and headinjury.155,167,171 Within the capacity ofbackground, training and experience ofthe staff member from acommunity service, assess and treat any injury, and initiate diagnostic and treatment interventions for contributing causes, orensure medical assistanceissought.167
Move the olderperson

Assess whether itis safe tomove the older person from their position, and note any special considerations inmoving them. Use alifting device orseek help instead oftrying tolift the older person alone. Itmay beappropriate tocall the ambulance service. Follow appropriate service occupational health and safety guidelinesonlifting.167
Monitor the olderperson

Ensure ongoing monitoring ofthe older person, because some injuries may not beapparent atthe time ofthefall.106,155 Observe older people who have fallen and who are taking anticoagulants orantiplatelets (blood-thinning agents), because they have anincreased risk ofbleeding and intracranial haemorrhage. Older people who have ahistory ofalcohol abuse may bemore prone tobleeding. The older persons general practitioner (GP) should becontacted and relevant details provided onany transfer information ifan ambulance has beencalled.
Report thefall
Report all falls tothe older persons GP, even ifinjuries are notapparent.106,171 At the earliest opportunity, notify the person nominated tobe contacted incase ofanemergency.167,171 Note any details ofthe fall for reference inreporting the incident, including the older persons description, ifpossible.167,171 Ataminimum, this should include the location and time ofthe fall, what the older person was doing immediately before they fell, the mechanisms ofthe fall (eg slip, trip, overbalance, dizziness), and whether they lost consciousness orhad aconsciouscollapse. Complete anincident-reporting form for all falls,106,167,171,172 regardless ofwhere the fall occurred, orwhether the older person isinjured, asper serviceguidelines. Document all details inthe older persons case file (or report this information tothe older persons case manager atthe community agency), including their appearance orresponse, evidence ofinjury, location ofthe fall, notification ofGP and actionstaken.155,171
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Discuss the fall and future riskmanagement

Communicate toall relevant staff, family and carers that the older person has fallen and has anincreased risk offallingagain.171 Discuss the circumstances oftheir fall, its consequences, and actions planned toreduce future falling risk with the older person who fell, andtheirfamily. Assume that once anolder person has fallen, they automatically become at high risk offalling again until they have beenassessed.155
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6.2 Post-fallfollow-up
After the fall, determine how and why afall may have occurred and implement actions toreduce the risk ofanother fall. The checklist inthe following box isaguide towhat steps should beincluded inapost-fall follow-up (or refer tothe GPor other health professional forthis).
Checklist 2: post-fallfollow-up
Investigate the cause ofthe fall, including assessing fordelirium. Review the implementation ofexisting falls prevention strategies, including standard falls preventionstrategies.106,155,171 Undertake afalls risk assessment, because new risk factors maybepresent.106,155,171 Implement atargeted, individualised plan for daily care, based onthefindings ofthe falls risk assessment tool. Multifactorial interventions should becarried out asappropriate and may include, but are not limited to: gait, balance and exercise programs, footwear review, medication review, hypotension management, environmental modification and cardiovascular disorder treatment.173 This will often involve referral toother members ofthe health careteam. Encourage the older person toresume their normal level ofactivity, because many older people are apprehensive after afall and the fear offalling isastrong predictor offuturefalls.174 Consider the use ofinjury-prevention interventions.106,155,171 For example, discuss with the GPthe use ofhip protectors, and vitaminD and calciumsupplementation. Consider investigations for osteoporosis inthe presence oflowtraumafractures. Ensure effective communication ofassessment and management recommendations toeveryoneinvolved.106,155,171
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6.3 Analysing thefall

An in-depth analysis ofafall issometimes known asaroot-cause analysis. Inahospital orresidential aged care setting, where aduty ofcare exists, aroot-cause analysis isalways required ifafall causes death. Also, reporting falls ismandatory inthese settings. However, ifan older person living inthe community dies because ofafall, service providers are not necessarily expected toconduct aroot-cause analysis. The death certification process bythe attending medical practitioner will address thenecessary reporting requirements (eg the report tothecoroner). Each community service should have areview processinplace.
6.4 Reporting and recordingfalls

After afall, itis important that all members ofthe older persons health care team, the older person themselves, and their carer, know about the fall and the factors that might have causedit. It isuseful for service providers tohave guidelines for reporting falls. Theseguidelines should identify the person towhom falls should befirst reported (eg service coordinator, GP, person responsible incase ofan emergency). The guidelines should also state clearly what level ofinformation should becollected and reported, and this should berelevant tothe type ofservice being provided. For example, apersonal care attendant may simply report afall totheir service coordinator, while acommunity nurse may collect and report detailed information about afalltothe older personsGP. The following checklist isaguide towhat items couldbeincluded.175
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Checklist 3: data that may form part offallsrecording

Demographic details ofthe older person (including dateofbirth). Current and relevant diagnosesorproblems. Date, time and place ofthefall. Type ofincident (eg slip, trip, bumping into orfalling onanobject). Activity attime ofthe incident (eg attempting tostand,walking). Whether the older person isindependent ordependent ona careroraids. Steps taken previously toreduce falls risk and injuryrisk. Any recent change inmedications that might beassociated with fallsrisk. Relevant information about clothing, footwear, eyewear and mobility aids, used atthe time ofthefall. Factors contributing tothe incident, such asenvironmental conditions (eg floor, lighting,clutter). Status after the fall (eg baseline observations,injuries). Interventions tobe used after the fall, and medical treatmentrequired. The older persons perception ofthe fall, including description ofany preceding sensations orsymptoms and what they think could have prevented thefall. Any witnesses tothefall. Any othercomments.
To achieve the most accurate information about the fall, the description ofthe fall should also allow for free text. There should beroom onthe reporting orincident form for additional comments tobemade.
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6.5 Comprehensive assessment afterafall

Older people who fall repeatedly and people prone toinjurious falls require acomprehensive and detailed assessment.173 For amore detailed assessment, the older person should bereferred toaspecialist (eggeriatrician) wherepossible. Older people who present for medical attention because ofafall, report recurrent falls inthe past year, ordemonstrate abnormalities ofgait orbalance should beassessed for their risk offalls.173 This assessment should bedone byaclinician with appropriate skills and experience, whichmay require areferral toaspecialist (eggeriatrician). The falls assessment shouldinclude:173 taking ahistory offall circumstances, medications, acute orchronic medical problems, and mobilitylevels examining vision, gait and balance, and lower extremity jointfunction examining basic neurological function, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, andtesting cortical, extrapyramidal and cerebellarfunction assessing basic cardiovascular status including heart rate and rhythm, postural pulse and blood pressure and, ifappropriate, heart rate and bloodpressure responses tocarotid sinusstimulation.
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6.6 Loss ofconfidence afterafall

A common but often overlooked consequence ofafall isaloss ofconfidence inwalking, orfear offalling,176 which can occur even inthe absence ofany injury. Inthe period after afall, the health care team should observe the older person who has fallen tonote any change inusual activity that might indicate the presence of, orincrease in, fear offalling. Discussion with the older person about any concerns about falling might also bean opportunity toidentify the presenceoffear. In community settings, common approaches toimproving loss of confidence orfear offalling include participation inabalance and mobility training exercise program, and other falls prevention activities, including useofhipprotectors.176,177
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6.7 Fallsclinics
Falls clinics are conducted byamultidisciplinary team with skills infalls assessment and management for people who have fallen.178 There are limited numbers offalls clinics available and areferral isusually required. Usually the falls clinic isconducted asapart ofan outpatient service. Theteam usually develops anintervention strategy for the older person, aswell asadvice, education and training for the older person, their carer and other members ofthe health care team. Falls clinics can also refer the older person tomainstream services for ongoingmanagement. Falls clinics should not bethe first intervention for anolder person who hasfallen, oris atriskoffalling.
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Guidebook for Preventing Falls and Harm From Falls inOlderPeople: Australian Community Care

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

Key messages oftheguidelines

1.2 What isanintervention?

1.3 Development ofthe FallsGuidelines

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

Table1.1 National Health and Medical Research Council levelsofevidence

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

1.4 How touse theguidelines

der person a the ol nd the ir ca

Conduct individualised assessment

Review and monitor

Implement targeted, individualised falls and falls injury prevention interventions

Figure 1.1 Using the guidelines toprevent fallsinAustralia

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

2 Involving the older person and theircarers

2 Involving the older person andtheircarers

3 Standard falls preventionstrategies

3 Standard falls preventionstrategies

3 Standard falls prevention strategies

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

3 Standard falls prevention strategies

3 Standard falls prevention strategies

Medication review andwithdrawal

3 Standard falls prevention strategies

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

3 Standard falls prevention strategies

The Stay OnYour Feetprogram

3.1.4 Multifactorial versus singleinterventions

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

3 Standard falls prevention strategies

3 Standard falls prevention strategies

4 Management strategies for common falls riskfactors

4 Management strategies for common falls riskfactors

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

4 Management strategies for common falls riskfactors

4 Management strategies for common falls riskfactors

4.1.1 Falls riskscreening

History offalls inpast 12months

Balance and mobilityperformance

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

Timed Upand GoTest(TUG) 45-47

Time needed Criterion

Time needed Criterion

4 Management strategies for common falls riskfactors

Alternate Step Test(AST) 42

Time needed Criterion

Time needed Criterion

4.1.2 Falls riskassessment

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

4 Management strategies for common falls riskfactors

Table4.2 Falls risk assessmenttools

4 Management strategies for common falls riskfactors

FallScreen Physiological Profile Assessment 51

Time needed Criterion

FROP-Com (Falls Risk for Older People communityversion) 44

Time needed Criterion

Guidebook for Preventing Falls and Harm From Falls inOlderPeople

4 Management strategies for common falls riskfactors

4 Management strategies for common falls riskfactors

4.2 Balance and mobilitylimitations

1.2 What isanintervention?

1.3 Development ofthe FallsGuidelines

Table1.1 National Health and Medical Research Council levelsofevidence

1.4 How touse theguidelines

2 Involving the older person and theircarers

2 Involving the older person andtheircarers

3 Standard falls preventionstrategies

3 Standard falls preventionstrategies

3.1.4 Multifactorial versus singleinterventions

4 Management strategies for common falls riskfactors

4 Management strategies for common falls riskfactors

4.1.1 Falls riskscreening

4.1.2 Falls riskassessment

4.2 Balance and mobilitylimitations

4.2.1 Assessing balance, mobility andstrength

4.2.2 Providing exerciseinterventions

4.2.3 Including all olderpeople

4.3.1 Assessing cognitiveimpairment

4.4.2 Strategies for promotingcontinence

4.5 Feet andfootwear

4.5.1 Screening feet andfootwear