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Falls

Falls are serious and common for those over 75. Risk factors have been identified and specific interventions proven to reduce falls.

Falls are serious and common for those over 75. Risk factors have been identified and specific interventions proven to reduce falls.

Risk factors

• Age over 80 • Cognitive impairment

• History of fall and fall-related injury • Arthritis

• Depression • Use of mobility aid

• Gait and balance impairment • Lower limb muscle weakness

• Visual deficit • Impaired daily functioning, or a low score on the Nottingham EADL scale

• Use of psychotropic medications

Those with multiple risk factors are at a higher risk of falls.

Diagnosis

• Ask older people (aged 75 and older) routinely once a year: 'Have you had a fall in the last year?'

• Perform simple gait assessment (see below).

• Distinguish between 'hot' and 'cold' falls.

– 'Hot' falls result from major medical conditions such as stroke, myocardial infarction or seizure. Treatment of the acute illness usually entails admission to hospital.

– 'Cold' falls occur in the absence of serious acute illness. This article deals with management of cold falls and those with high risk of falls.

• Refer anyone for falls risk assessment if they have had a recent 'cold' fall or recurrent falls in the last year, or with an abnormality of gait or balance. The NSF for older people recommends that this should take place in a specialist falls centre.

Specific evaluation

A falls risk assessment includes:

• history of fall circumstances • medication review

• review of chronic medical problems including alcohol misuse

• examination of:

– vision– gait and balance (see below)

– lower leg strength

– neurological system, especially proprioceptive and co-ordination function and including mental status– cardiovascular system, especially heart rate and rhythm, lying and standing blood pressure and the murmurs of valvular disease

• the environment in which the falls occurred, with attention to:

– hazards such as loose mats, cords and unstable furniture– lighting levels

• assessment of the person's fear of falling and the effect it has on functional ability

• investigations including FBC and ECG.

Simple gait assessment

Ask the patient to stand from a chair, without using the arms, walk 3m, turn around and return (the 'get up and go' test). Unsteadiness or difficulty doing this in less than 30 seconds shows a gait and balance deficit and further evaluation is needed.

Management

• Results of the evaluation will guide specific management. Most patients needing intervention will have multiple risk factors.

• Multifactorial intervention is more effective than single intervention in preventing future falls, with a RR of 0.73 (95 per cent CI 0.63 to 0.85) for unselected older people and 0.60 (95 per cent CI 0.50 to 0.73) for those in residential care.

• Refer all with a history of loss of consciousness to a physician. Investigations, such as a 24-hour ECG, may reveal a cause. Carotid sinus hypersensitivity can be detected by carotid sinus massage in controlled conditions including cardiac monitoring.

• Ensure that trained professionals conduct the falls prevention programme. A common- sense approach, without such training, can be counter-productive. For instance, recommending brisk walking to older people at risk of falling can raise the fracture rate.

Community-dwelling older people at high risk of recurrent falls

• Refer for a programme of muscle strengthening and balance retraining and advice on use of assistive devices. This depends on the local availability of a falls clinic or falls-related exercise groups.

• Encourage increased exercise such as walking or refer to an exercise programme with a balance component.

• Recommend vestibular rehabilitation exercises for those who have a problem with their balance (see box).

• Refer for Tai Chi. A 15-week course reduces falls by 50 per cent. The availability of classes may be limited.

• Assess vision and refer if necessary.

• Review medications and reduce psychotropics. Drugs that are especially likely to cause falls are benzodiazepines, tricyclic antidepressants, phenothiazines and butyrophenones, antihypertensive medicines, anticholinergics and hypoglycaemic agents.

• Assess home environment – whether loose carpets, poor lighting or general cluttering of furniture are increasing the risk. Refer for modification of other environmental hazards according to the availability of occupational therapy.

• Review all medical conditions. Treat cardiovascular disorders, including postural hypotension and any cardiac arrhythmia.

• Consider osteoporosis prevention –giving vitamin D3 800iu daily with calcium co-supplementation to reduce the risk of vertebral fracture. The vitamin D may, in addition, increase muscle strength and neuromuscular co-ordination.

Older people in residential care and assisted living settings at high risk of recurrent falls

• Intensive multicomponent interventions including individualised activity programmes, staff education, medical review, hip protective garments and environmental hazard reduction have been successful in in residential care.

• Refer to physiotherapy for gait and balance training and advice on use of assistive devices. This depends on the availability of physiotherapy services in long-term care.

• Consider giving vitamin D3 800iu daily with calcium to reduce risk of hip fracture.

• Offer hip protective devices. Follow-up is needed; they are only effective if worn.

This is an extract from Practical General Practice 5e, ISBN 07506 8867X, Elsevier Ltd, April 2006, price £47.99. To order your copy please go to www.elsevierhealth.com or phone Elsevier customer services on 01865 474000.Practical General Practice 5e is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

Vestibular exercises

For rehabilitation

In bed, performed slowly initially then more rapidly:

– eye movements: up and down, side to side, focusing on a finger as it moves from 1m away to 30cm away

– head movements: moving head forwards then backwards and turning from side to side

Sitting: rotating the head; bending down and standing up with eyes open and closed

Standing: throwing a small ball from hand to hand, turning through 360°

Moving about: walking across the room, up and down a slope, up and down stairs with eyes open and then closed

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