Falls prevention and management

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This tool is designed as a reference to support family physicians, primary care nurse practitioners and other interprofessional team members prevent and manage falls among people aged 65 and older living in the community.

The impact of falls on older adults in Canada3

Falls are the leading cause of injury-related morbidity and mortality among people aged 65 and older living in the community, and th

Falls are the leading cause of injury-related morbidity and mortality among people aged 65 and older living in the community, and those who have experienced recurrent falls (>1 per year) are at an increased risk for mortality and morbidity.1–4 The good news is that most falls are preventable. As a crutial component of older adult care, healthcare providers should work in partnership with older adults to implement a variety of interventions to address and reduce their risk for falling.2

20-30% of ≥65 years of age experience a fall each year
85% of injury-related hospitalizations among older adults are caused by falls
50% of all falls causing hospitalization happen at home
95% of all hip fractures are caused by falls

20-30% of ≥65 years of age experience a fall each year

85% of injury-related hospitalizations among older adults are caused by falls

50% of all falls causing hospitalization happen at home

95% of all hip fractures are caused by falls

Initiate universal screening

Timing of universal screening6,7

  • Annually screen all patients 65 years of age and older for falls risk6
  • Other opportunities for screening include:
    • After a hospitalization, ER visit or medical event (e.g., stroke, fracture, delirium, etc.)
    • After a bone mineral density test, decrease in bone density or diagnosis of osteoporosis
    • After a significant change in health status (e.g., weight gain or loss, increased frailty, dementia, etc.)6
    • After a relevant medication change or addition (e.g., CNS medications or hypotensives)
  • Use clinical judgement to determine when these opportunities for screening may also apply to patients <65 years
Talking points
Click to view

Identify contributing risk factors

Work in partnership with patients to assess their fall risk factors over a series of appointments. Engage caregiver(s), family members and other members of the patient’s care team to provide input on the patient’s risk factors.

General approach

  • Use patient-centred interviewing techniques to better understand what matters to the patient and to get a picture of their knowledge, perceptions, motivation and individual risk factors
    • FIFE (Feelings, Ideas, Functioning, Expectations)11,12
    • Ask-Tell-Ask approach13
    • Motivational interviewing14
    • Avoid labels like “at risk” which can be associated with stigma , frailty, and a loss of independence
Talking points
Click to view

Fall risk assessment8,16–18

Quick assessment: Focus on the 3Ps (Pills, Pain/mobility issues and Postural hypotension).19

Full assessment:

Check all the risk factors in the table below. Some aspects of the assessment may not be needed if you know the patient well or have recently assessed these items. A longer appointment may be required or risk factors can be assessed over a series of appointments. See Integrate falls prevention into your practice for tips on how to integrate the full assessment into your practice in a time-efficient way.

History
Fall history

  • If the patient has previously experienced a fall, ask about (can be collected while patient is in the waiting room):20
    • Circumstances of the fall(s) (e.g., what the patient was doing and when at the time of the fall, beliefs as to the cause, duration on the ground, how they got up)
    • Symptoms preceding and after the fall (e.g., palpitations, syncope, nausea)
    • Frequency of falls
    • Details of any fall-related physical and/or psychological injuries
    • Post-fall interventions implemented
    • Any recent ER visits or hospitalizations
    • Any changes in ADLs, mobility status or confidence in mobility status
    • Any witnesses to the fall who could provide more detail
    • Consider referral to rehabilitation for support for patients recovering from physical, cognitive or communication problems caused by a fall-related injury

Click on risk factor to view how to assess

  • If the patient has previously experienced a fall, ask about (can be collected while patient is in the waiting room):20
    • Circumstances of the fall(s) (e.g., what the patient was doing and when at the time of the fall, beliefs as to the cause, duration on the ground, how they got up)
    • Symptoms preceding and after the fall (e.g., palpitations, syncope, nausea)
    • Frequency of falls
    • Details of any fall-related physical and/or psychological injuries
    • Post-fall interventions implemented
    • Any recent ER visits or hospitalizations
    • Any changes in ADLs, mobility status or confidence in mobility status
    • Any witnesses to the fall who could provide more detail
    • Consider referral to rehabilitation for support for patients recovering from physical, cognitive or communication problems caused by a fall-related injury
  • Ask patient about their current level of activity, including:2,6,21–26
    • Aerobic physical activities
    • Muscle strengthening activities
    • Balance activities
    • Posture awareness
  • Check for adequate nutrition
    • Ask about food intake
    • Ask about changes in weight or check current weight against what is in the patient’s record and if weight change has occurred, inquire into cause (e.g. changes in appetite, digestion, chewing/swallowing, interest in food, ability to shop or prepare food, food security)
  • Check for adequate hydration
    • Ask about fluid intake (e.g. water, other fluids, caffeine, alcohol)
  • Have patients bring in all medications (over the counter and pr escription)
  • Check for medications that have potential to cause falls (see Reducing fall risk from medications)2,6,8,27
  • Ask patients to explain how/when they are taking their medications
  • Engage the patient’s pharmacist if feasible
  • Provide patients with the home safety checklist (could be done in the waiting room or at home and brought to the next appointment)
  • Consider doing a home visit or referring to a home and community care coordinator (public) or occupational therapist(private) to evaluate home safety and accessibility (if hazards suspected OR fall not attributable to physical/mental health OR if patient has severe gait, mobility or balance issues)
  • If a home visit is not possible, have the patient do a mental walk-through of their home environment and identify potential safety and accessibility issues (e.g., where they sleep and use the bathroom, how they get in/out of the house, what the rooms look like, how they walk through rooms, etc)
  • Check for history of osteoporosis and assess fracture risk using the FRAX tool28
  • Ask about vitamin D and calcium intake from diet and supplements7,28
  • Check medical history and/or screen for conditions that increase fall risk (these comorbidities may also increase risk in patients <65 years old):
    • Dementia
    • Parkinson’s disease
    • Chronic kidney disease
    • Dizziness, vertigo and syncope
    • Sleep disorders (e.g., obstructive sleep apnea) or poor sleep
    • Depression
    • Chronic obstructive pulmonary disease
    • Stroke
    • Arthritis
    • Urinary incontinence and benign prostatic hyperplasia
    • Chronic pain
    • Cognitive impairment
    • Hypotension
    • Diabetes
    • Cardic system issues
  • Ask about use of alcohol and recreational substances
    • “How often do you have more than X drink(s) in a day?” (X=1 for women, 1-2 for men)36
    • “How many times in the past year have you used recreational substances or used a prescription medication for non-medical reasons?” (≥1 = positive)37,38
  • Ask the patient about:
    • Whether they live alone
    • Recent losses (e.g., spouse, family member)
    • Roles or responsibilities (e.g., being a caregiver)
    • Recent changes in living arrangements
    • Access to food and housing
  • Look for red flags for elder abuse (See Forms of Abuse for potential signs to look for)
  • Listen for suicide risk
Physical exam

Click on risk factor to view how to assess

  • Assess for gait, strength and balance issues using the Timed Up and Go (TUG) test
    • Time patient while they:
      1. Stand up from a chair
      2. Walk to the line on the floor at your normal pace
      3. Turn
      4. Walk back to the chair at your normal pace
      5. Sit down again
    • Patients who take ≥12 seconds to complete the TUG test are at r isk for falling
  • Check/ask if the patient uses a mobility aid
  • Conduct a musculoskeletal examination of back and lower extremities including back flexibility (e.g. how far can the patient bend while sitting or standing)
  • Conduct a neurological examination (sensory, pyramidal, cerebellar, extrapyramidal, peripheral neuropathy, spinal stenosis, radiculopathy)
  • Consider referring to a home and community care coordinator (public) or physiotherapist (private) for gait, strength and balance assessment or musculoskeletal examination
  • Measure standing/sitting blood pressure (BP) to identify presence of postural hypotension
    • A drop in systolic BP of ≥20 mmHg or in diastolic BP of ≥10 mmHg within 1-5 minutes of standing is considered abnormal (see Measuring Orthostatic Blood Pressurev)8,20
  • Ask about dizziness or light-headedness after standing up (patients may also be asymptomatic)20
  • Evaluate arrhythmia, murmurs and bruits20
  • Use Snellen eye test to quickly assess visual acuity8
  • Ask if patient has had an eye exam in the past year
  • Ask if patient wears multifocal lenses (increases the risk of falls)18
  • Check for history or presence of cataracts20
  • Screen for medications that may affect vision (e.g., anticholinergics)18
  • Take note of any comorbidities that may impact vision (e.g., macular degeneration, glaucoma)
  • Evaluate feet for peripheral neuropathy and peripheral vascular disease20
  • Use the Stay On Your Feet checklist to screen for footwear that increases falls risk
  • Pay attention to the patient’s footwear when they come in to the office.
  • Assess the footwear they wear at home.

Provide patients and caregivers with this handout on how they can take an active role in reducing falls risk: You CAN prevent falls!

Act on results

Implement individualized multi-factorial interventions, tailored to each patient’s individual risk factors. Multi-factorial interventions can prevent and reduce a patient’s risk of falls by about 24% and are more effective than single interventions.1,20–22,41 Collaborate with the patient, their caregiver(s), family members and other members of the patient’s care team to implement these interventions.6 Reassess fall risk annually.8

Tips to support intervention implementation7
  • Emphasize the benefits of interventions such as maintaining independence, improving mobility and allowing them to participate more actively in life. For patients who are concerned about the ir falls risk, emphasize the benefits of reducing anxiety and fe ars, and improving their safety.
  • Support the patient to be an active participant in deciding which interventions would be most suitable for them, tailoring them to
    match what is important to the patient and to their roles and activities in life (e.g., their interests, abilities and lifestyle).
  • Patients are more likely to act if they perceive a risk factor is modifiable. Ensure the interventions are realistic and actionable for the patient. Emphasize that many interventions do not need to be ti me consuming, expensive or difficult and can be done at home.
  • Empower patients to take an active role in documenting and implementing their interventions as well as monitoring their own risk factors (e.g., taking their blood pressure at home, monitoring home hazards.)
  • Engage the patient’s family and caregivers.

Interventions for all older adults

Click on risk factor (as identified in Fall risk assessment to view intervention

  • Support the patient to choose activities appropriate for their abilities, level of fitness/frailty, mobility and interests, including:2,6,21–26
    • Aerobic physical activities (at least 150 minutes per week, in chunks as short as 10 minutes; this may include everyday activities such as housekeeping, gardening, shopping and walking)
    • Muscle strengthening activities (at least twice a week)
    • Balance activities (every day)
    • Posture awareness (tuck chin in, draw chest up; every day)
  • Provide the patient with the Too Fit to Fall or Fracture or connect them with a local Seniors Active Living Centre (minimal membership fees) or home and community care coordinator (to arrange connection with local Exercise and Falls Prevention Program; no membership fees)
  • Provide education on the importance of healthy eating and adequate hydration (e.g. eat a variety of healthy foods, make water your preferred beverage, ensure adequate fluid, caloric and protein intake)
  • Consider referral to a home and community care coordinator (public; to arrange local support with healthy eating or to connect with meal delivery or dining programs) or dietitian (private) if inadequate nutrition and hydration are suspected

Patient-specific interventions

Click on risk factor (as identified in Fall risk assessment to view intervention

  • If possible, reduce, taper or discontinue medications identified that may contribute to falls risk (see Reducing fall risk from medications)2,6,8,27
  • Consider asking a pharmacists to do a medication check that can be faxed back to the provider to inform deprescribing
  • Consider a consult from GeriMedRisk (via telephone, eConsult or fax) for support optimizing medications
  • Encourage patients in partnership with any family members and caregivers to make the patient’s home safer by addressing hazards and accessibility issues23,24
  • If the patient lives alone, support them to set up fall alarms/medical alert devices
  • Consider referral to a home and community care coordinator (public) or occupational therapist (private) to support the addressing of identified home hazards and accessibility issues
  • Support patients to increase vitamin D intake through supplementation and calcium intake through diet to optimize bone health if current intake low (calcium supplementation may be explored if patient is deficient)1,6,21–24
    • Vitamin D intake should be 800-2,000 IU/day7,28
    • Elemental calcium intake should be 500-1,200 mg/day7,28
  • Refer patient for a bone mineral density test or review existing results if ≤5 years old (≤3 years if previous results demonstrated moderate fracture risk)28
  • Optimize the management of ostoporosis if present28
  • Optimize the management of medical conditions (while being mindful of medications that may contribute to falls risk)8
  • Connect isolated patients with a local Seniors Active Living Centre (minimal membership fees)
  • Connect patients who are acting as a caregiver for another individual with caregiver support
  • Connect patients facing barriers related to food and housing security with a home and community care coordinator (to arrange local supportive housing, meal delivery or dining programs) or explore 211Ontario for local resources
  • Connect patients who report or show signs of elder abuse to Elder Abuse Prevention Ontario for resources and information, and provide the Senior Support Line (1-866-299-1011)
  • Connect patients who report or show signs of suicide risk to Crisis Services Canada for a list of local resources and support
  • Support the patient to engage in physical activities appropriate for their abilities, level of fitness/frailty, mobility and interests (see Physical activity)
  • For patients with mobility issues, support them to acquire appropriate mobility aids (see Mobility aids for information on coverage for mobility aids through the Ontario Assistive Devices Program)
  • Ensure patients with existing mobility aids have the appropriate aid and that it is fitted properly for them:53
    • The height of a cane or a walker should be level with the patient’s wrist crease
    • A cane should be held contralateral to the patient’s weak or painful lower extremity and moved forward at the same time as the weak or painful leg. When using a walker, the patient’s feet should stay between the walker’s back legs or wheels
    • With both devices, the patient’s posture should be upright without leaning forward or to the side
    • For more information on choosing and fitting a mobility aid see Ambulatory Devices for Chronic Gait Disorders in the Elderly

Reserve hip protectors for those at risk of hip fracture (low evidence)8,21,24,42 (OHIP coverage for optometry services is currently on hold)

  • Review blood pressure target and adjust blood pressure medications as needed8
  • Provide education on how to identify and manage postural hypotension (see Postural hypotension)
  • Consider a referral to an optometrist for patients with possible/worsening visual acuity issues for a vision assessment, provision or adjustment of prescription or cataract surgery assessment8,21,24,42
  • If patient wears multifocal lenses, provide education on depth perception and single vs. multifocal lenses8
  • Consider reducing, tapering or discontinuing medications that might affect vision (e.g., anticholinergics)8
  • Encourage patients to purchase appropriate footwear using the Stay On Your Feet checklist
  • After conducting a foot exam, consider a referral to a podiatrist/chiropodist or further assessment and treatment if peripheral neuropathy or peripheral vascular disease identified21 (OHIP covers a portion of each visit to a registered podiatrist/chiropodist to a designated limit plus contributions to x-rays)42

When to refer a patient to your local Specialized Geriatric Services (SGS):xxiv if a patient has experienced recurrent falls (>1 per year) and has complex care needs (e.g., cognitive decline, neurological comorbidities such as Parkinson’s disease).6
SGSs offers coordinated access to geriatric medicine, geriatric mental health, consultation and group programming services.

Reducing fall risk from medications

Medication review
  • Confirm all medications patient is currently prescribed and taking (have patients bring in all over the counter and prescription medications), medical history and allergies
  • Check for medications or the concurrent use of medication (e.g. three or more central nervous system agents) that have potential to cause falls (see Medications that increase fall risk below)
Medication that increase fall risk

Click on medication class to view resources

Provider resources:

Patient resources:

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Integrate falls prevention into your practice

Integrating falls prevention into your practiced
  • Use previous falls as a starting point for discussion. Ask patients if they have done anything to reduce risk since their fall and emphasize that they can prevent future falls.
  • Display falls prevention related materials in the office to help start a conversation with patients.
  • Display muscle, balance and posture exercises on waiting room televisions/screens for patients to follow while waiting for their
    appointment.
  • Use annual reminders in the EMR tools when available.
  • If you know you will be doing a falls assessment, consider scheduling more time with the patient and asking them to bring a caregiver or family member. Alternatively, you can do the assessment over a series of appointments.
  • When possible, observe balance, gait and home environment first hand by rooming your own patients and conducting home visits.
Leveraging interprofessional teams and community supports
  • Where possible, ask team members such as nurses, physician assistants, clinic assistants or front of office staff to complete tas ks such as observing the patient’s gait, taking postural blood pressure, collecting any pre-screening documents or information, checking the patient’s medical record before the appointment or helping the patient remove their shoes.
  • Refer to other interprofessional team members, such as geriatric specialists, physiotherapists, occupational therapists and dietitians to provide specialized care to patients. Consider referring to interdisciplinary programs where available (e.g., fall prevention programs, geriatric day hospitals)
  • Connect patients to home and community care coordinator, via a local care coordinator, to assist with coordinated access to services for older adults such as home safety and accessibility assessments, food and housing services, specalized care and interdisclipinary programs.
  • Engage a pharmacist to do a medication review with the patient.
Engaging patients and caregivers
  • Emphasize the partnership between yourself and the patient.
  • Engage family members or caregivers before the visit to get information for the falls risk assessment. This can include having them assist with screening questionnaires at home or in the waiting room.
  • Encourage a family member or caregiver to attend falls risk assessment and follow-up appointments to discuss risk factors and interventions. If they cannot be present, reach out my phone or email.
  • Share resources that patients and caregivers can review and follow at home.
  • Encourage patients to come in-person for the falls risk assessment so you can do a physical exam. Follow-up visits could be done over video or phone if preferred and appropriate.

Supporting resources

References

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