Falls prevention health assessment | Management | Falls & Fracture Nurse action | Referral |
---|---|---|---|
Circumstances of previous fall | Changes in environment and activity to reduce risk of further falls | Directs further assessment and management. Address any immediate safety issues | Referral according to categories below |
Medication review: High risk medications: benzodiazepines, other sleeping medications, neuroleptics, antidepressants, anti-convulsants [15] | Review and reduction of medications [6, 15] | Request family physician review of medications according to protocol | Family physician or geriatrician |
Vision: Acuity < 20/60; decreased depth perception, contrast sensitivity (Melbourne edge test) [21, 50] | Ample lighting without glare; avoidance of multifocal glasses while walking | Arrange correction of lighting, highlight potential hazard edges | Optometrist, ophthalmologist (e.g. cataracts), family physician, geriatrician; if visual acuity 6/24 or worse, offer referral to Royal NZ Foundation of the Blind |
Postural blood pressure (after > 5 mins in a supine position, immediately after standing, and 2 minutes after standing): Standing systolic blood pressure < 100 mmHg or = 20 mmHg postural drop if systolic blood pressure < 130 mmHg or with symptoms (immediate or > 2 mins) | Diagnosis and treatment of underlying cause | Adequate hydration, compensatory strategies (e.g. elevation of head of bed, rising slowly, dorsiflexion exercises), pressure stockings | Family physician or geriatrician: diagnosis and treatment of underlying cause, review and reduction of medications, or pharmacological therapy for postural hypotension |
Balance and gait: Patient's report or observation of unsteadiness. Impairment on brief assessment (timed up and go test [48, 51, 52], 4-test balance scale [38]) | Diagnosis and treatment of underlying cause | Coordinate Otago Exercise Programme (see below) or referral as appropriate | Family physician or geriatrician review Physiotherapist: assistance devices, supervised gait and progressive balance training if specific neurological problem or unable to do Otago Exercise Programme |
Targeted neurologic examination: Impaired proprioception [53]; decreased muscle strength (chair stand test [37]) | Diagnosis and treatment of underlying cause | Increase proprioceptive input (assistance device, appropriate footwear), caretaker's awareness of cognitive deficits | Family physician or geriatrician: review medications that impede cognition Physiotherapist: supervised gait, balance and strength training |
Targeted musculoskeletal examination: Legs (joints and range of motion) and examination of feet to identify problems interfering with function | Diagnosis and treatment of underlying cause | Offer Otago Exercise Programme (see below) or referral as appropriate | Physiotherapist: supervised strength, range-of-motion, gait and balance training, assistance devices, appropriate footwear; Podiatrist or chiropodist: assist with feet Family physician address impairments (e.g. osteoarthritis) |
Targeted cardiovascular examination: Syncope or arrhythmia [54, 55] |  |  | Family physician or geriatrician for ECG ± cardiologist referral, carotid-sinus massage (in case of syncope) [56] |
Continence/overactive bladder: Particularly if related to circumstances of previous fall [57] | Â | Nightlights, bladder retraining | Continence service/nurse for assessment, bladder retraining; family physician or geriatrician for medical management, exclusion of other pathology |
Home hazards assessment | Â | Â | |
Hazard identified according to protocol [14] | Changes in environment to reduce risk of further falls | Identify and modify minor home hazards (e.g. remove loose rugs, use nightlights) | Occupational therapist assessment for major hazards (e.g. bath/toilet grab rails) [17] |
Bone health assessment | Â | Â | |
Osteoporosis risk from osteoporosis screen questionnaire | Consider calcium and vitamin D supplementation if not receiving | Â | Refer to family physician for appropriate management with suggestion of vitamin D and calcium supplementation with guidelines [18, 46] |
Previous fragility fracture [58] | Consideration for appropriate management (including bisphosphonates) [58] | Organise vouchers and referral | Referral for voucher for DEXA scan and review by family physician for application for bisphosphonates [47] |
Otago Exercise Programme [10, 45] | Â | Â | |
All participants | Increase muscle strength and balance | Offer delivery of Otago Exercise Programme | Otago Exercise Programme delivered by accredited physiotherapist or nurse [45] |
Unable to commence the Otago Exercise Programme or chronic neurological problem (e.g. existing CVA, Parkinson's disease), timed up and go test > 30 seconds, or cognitive impairment | Increase muscle strength and balance | Referral | Referral to physiotherapist for individualised rehabilitation programme |