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Identification and management of falls-related risk factors
CONTINUING PROFESSIONAL DEVELOPMENT ANF iFOLIO CLINICAL UPDATE: Identification and management of ANFClinical Updates falls-related risk factors Identification and management Read this article and complete the quiz to earn 1 iFolio hourof falls-related risk factors
Effective falls prevention strategies rely on the clinician’s ability to assess an individual, identify risk factors, and implement solutions to reduce the chance of falling.1,2 It is essential that all clinicians are aware of falls-related risk factors and prepared with solutions to help manage them. A wide range of solutions are required as not every option will be appropriate or realistic for all patients. Person-centred plans should be multifactorial, fully resourced, and achievable in order to promote ongoing patient safety and reduce the risk of a fall.1-3
WHAT ARE FALLS-RELATED RISK FACTORS?
Falls-related risk factors are potential reasons or causes for a fall.4 Modifiable risk factors are those that are amenable to intervention. Even if a risk factor cannot be completely eliminated, strategies can be used to minimise the risk of a fall and prevent injury associated with a fall. There are three types of falls-related risk factors and each has its own set of risk factors matched with interventions that may be useful to help prevent a fall:4
• Environmental
• Physical function and health
• Psychological function
ENVIRONMENTAL RISK FACTORS
Environmental hazards are responsible for up to one third of falls in older adults.5 They include:1,2,4 • Absence of bed and hand rails
• Chairs, lounges, showers, and bathtubs that are difficult to get in to and out of
• High bed heights
• Inaccessible light switches
• Inadequate lighting • Pets
• Poorly maintained floor covering
• Presence of trip hazards, such as loose rugs, cords, floor clutter, or obstacles
• Slippery surfaces
• Unfamiliar environments
At home, the bathroom and stairs are most likely to be associated with injuries from falls.5 This is often because these areas require older adults to turn and transfer frequently. They also are more likely to have structural features that increase the risk of falls, such as uneven stairs, slippery floors, and lack of transfer assist aids.5
Environmental hazards can be assessed using a home safety screening tool, such as the Home Falls and Accidents Screening Tool (Home FAST).1,2,5 Once environmental hazards have been identified, they can be removed or managed. Unfortunately, research to understand the impact of managing or removing environmental hazards on the rates of falls has had conflicting results. This may be because there is no standard definition of environmental hazards for falls and no consistent approach to assessing these hazards in the community. Falls prevention experts are calling for a more consistent approach to the assessment and management of environmental hazards in the future.5
PHYSICAL FUNCTION AND HEALTH RISK FACTORS
Balance and mobility limitations (including limited physical activity and history of falls) • Continence issues
• Dizziness and vertigo
• Feet and footwear
• Impaired vision Of all falls in older people, 50 to 70% occur when the individual is mobile.2 There are a variety of screening tools that can be used to assess balance, mobility, gait, and strength. Exercise may be beneficial for patients with low levels of physical activity, impaired mobility, and gait.6,7 While independent, general exercise may not make a significant difference, strength and mobility training programs, including Tai Chi, are likely beneficial and costeffective for individuals at risk.6,7
The identification of physical function and health related risk factors often suggests the need for referral to other health professionals.1,2 For example, any patient with ongoing concerns about their physical function should be reviewed by a medical practitioner.1,2 The underlying causes of conditions, such as loss of consciousness, syncope, black outs, or seizures need to be investigated and treated.1 Other health professionals that may be involved include a physiotherapist, occupational therapist, podiatrist, or continence nurse.1,2 However, there is limited evidence to support some of these referrals. For example, visual assessments are not beneficial as a single intervention for preventing falls, but may be useful as part of a multifactorial falls prevention plan. A referral to a continence nurse, in isolation of other interventions, may not be effective.8
There are two ways that medication use may increase the risk of a fall. The first is through polypharmacy, or the use of multiple medications that increase the risk of a fall.1,2 The second is from the use of individual medications that increase the risk of a fall.1,2 Psychotropic drugs, including benzodiazepines, antidepressants, and antipsychotics are most commonly associated with falls.1,2 However, medications that affect heart rate or blood pressure may also increase the risk of a fall.5
The most common intervention for risk factors related to medications is a medication review.1,2 To date, medication
reviews have not been conclusively linked to an improvement in the risk of a fall or rates of falls in hospital or aged care settings.9 Many sites recommend that a nurse, pharmacist or doctor undertake the review.1,2 This is only beneficial if the multidisciplinary team environment is conducive to medical practitioners implementing changes suggested by other professionals.1,2 As such, a general medication review may not be helpful. However, a targeted medication review with modifications, such as reduced use of psychoactive medications, titrated dosing of medications that affect heart rate and blood pressure, and prescription of vitamin D, calcium, and osteoporosis medication (as indicated) may be effective.9
PSYCHOLOGICAL FUNCTION RISK FACTORS
One of the most significant falls related risk factors is impaired cognition.5 Other psychological risk factors include fear of falling, low mood or affect, and an overall poor quality of life.5 Individuals who experience a new onset cognitive impairment or deterioration of their condition require a review by a medical practitioner to assess for underlying causes, such as medications, delirium, or dementia.1,2 Interventions to increase surveillance of people with cognitive impairment, such as frequent monitoring, high observation rooms, sitters/carers/ family members at the bedside or electronic bed, or chair alarms may be useful for some patients.1,2 However, at present there is insufficient evidence to suggest these interventions have a significant impact on the rates or risk of falls in any setting.9 Overall, while screening and assessment are the first steps of falls prevention, they must be followed by the selection and implementation of multifactorial personcentred interventions in order to prevent falls in healthcare settings.
REFERENCES
1. Australian Commission on Safety and Quality in Healthcare. Preventing falls and harm from falls in older people. Best practice guidelines for Australian residential aged facilities 2009.
Canberra: Commonwealth of Australia; 2009. 220p. 2. Australian Commission on Safety and Quality in Healthcare. Preventing falls and harm from falls in older people. Best practice guidelines for Australian community care 2009. Canberra: Commonwealth of Australia; 2009. 202p. 3. Hopewell S, Adedire O, Copsey BJ, Boniface GJ, Sherrington C, Clemson L,
Close JCT, Lamb SE. Multifactorial and multiple component interventions for preventing falls in older people living in the community.
Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD012221. DOI: 10.1002/14651858.CD012221.pub2. 4. Prevention of Falls Network Earth. Falls & fracture prevention [Internet]. West Yorkshire: ProFaNE.co; 2012 [cited 2019 Jul].
Available from: http://profane.co/wp-content/uploads/2012/12/Map_of_Falls_Fracture_Prevention_December_2012.pdf. 5. Blanchet R, Edwards N. A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: results of a scoping review. BMC Geriatrics. 2018:18(27);1-16. Available from: https:// doi.org/10.1186/s12877-018-0958-1 6. Sherrington C, Fairhall NJ, Wallbank GK,
Tiedemann A, Michaleff ZA, Howard K,
Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2019, Issue 1. Art.
No.: CD012424. DOI: 10.1002/14651858.
CD012424.pub2. 7. Winser SJ, Chan HTF, Ho L, Chung LS,
Ching LT, Felix TKL, Kannan P. Dosage for cost-effective exercise-based falls prevention programs for older people: A systematic review of economic evaluations. Ann Phys
Rehabil Med. 2019 Jul 12. doi: 10.1016/j. rehab.2019.06.012. [Epub ahead of print] 8. National Institute for Health and Care Excellence (NICE). Falls in older people: assessing risk and prevention [Internet]. CG161. NICE; 2013 June [cited 2019 Aug]. Available from https://www.nice.org.uk/guidance/cg161/ chapter/About-this-guideline. 9. Cameron ID, Dyer SM, Panagoda CE, Murray GR, Hill KD, Cumming RG, Kerse N.
Interventions for preventing falls in older people in care facilities and hospitals.
Cochrane Database of Systematic Reviews 2018, Issue 9. Art. No.: CD005465. DOI: 10.1002/14651858.CD005465.pub4.
