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Falls prevention: a practical guide

Each year 1.57 million older people fall more than three times, and 70,000 fracture their hips. Falls can lead to disability and even death. Linda Nazarko explains how healthcare professionals can contribute to falls prevention, reduce falls risk and improve quality of life for the older person

Linda Nazarko
MSc PgDip BSc(Hons) RN OBE FRCN
Nurse Consultant Ealing Primary Care Trust
Visiting Fellow London South Bank University
Visiting Lecturer King's College
London

Community nurses and other healthcare professionals often encounter people who have sustained a fall. Falls are the commonest cause of accidental death in older people and every five hours someone dies as a result of a fall.(1) Each year 1.57 million people aged over 65 have three or more falls and 310,000 sustain fractures - 70,000 of these are hip fractures. Hip fractures increase the risk of death by 16 times in women and 12 times in men in the 30 days after fracture.
The National Service Framework for Older People identifies prevention of falls as an important health priority and requires NHS trusts to set up falls prevention services.(2) Although such services are vitally important, the contribution that healthcare professionals can make to prevent falls is equally important (see Box 1).

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Why do older people fall?
There are literally hundreds of reasons why people fall; however, some risk factors are more common and easily remedied than others.(3) Table 1 outlines the main risk categories and how these can be checked. These have been categorised into three headings: factors relating to the person; factors relating to the care the person receives; and environmental hazards.

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Illness
Falls can be an indication that the person is unwell. People who develop an acute illness such as a chest or ear infection may well present with a fall; treating identified infection reduces falls risk. It's important to be aware that many older people have asymptomatic bacteriuria. A urine dipstick reading is an unreliable indicator of urinary tract infection in older people  and treating a urinary tract infection in the absence of urinary symptoms exposes the person unnecessarily to the hazards of antibiotic therapy.(4) Erroneous diagnosis of urinary tract infection also causes delays in finding out the reasons why the person is really falling. 
Falls can indicate if the person has suffered a mild stroke or is developing Parkinson's disease. Observation of facial changes, such as a lopsided smile or a face that is devoid of expression, can alert you to such problems. Simple checks of limb function and power can confirm such suspicions and enable you to make an appropriate referral.(5)
Falls can occur if a person is dehydrated or malnourished. Observing the person, how their clothes fit and if their rings seem loose can alert you to the possibility of weight loss and enable you to address this. You can also observe the person for signs of dehydration and enquire about fluid intake. 
People with a long-term condition may fall because the condition is worsening or because they are not complying with medication and treatment. If you suspect this, check, optimise treatment if you are able, or refer for further investigations and treatment. 

Visual problems
Poor vision increases the risk of falls.(6) If a person cannot see clearly, they are at greater risk of falls. Some age-related changes such as macular degeneration and glaucoma are not yet treatable. The best we can do is prevent further deterioration. Many older people have treatable eye conditions. Researchers found that 76% of hospital inpatients admitted following a fall that they had poor vision; 40% needed glasses, 37% had cataracts and 14% suffered from senile macular degeneration. Seventy nine percent of individuals with poor vision were treatable.(7) Ask when your patient last had an eye test and recommend an eye test if they have not had one within the last year. If the patient is housebound, their optician may offer a domiciliary service. If this is not possible, recommend a specialist domiciliary optician (see Resources). If the patient is diagnosed with an eye disease, the optician will inform the patient's GP and recommend a specialist referral if necessary.

Gait balance and mobility problems
Foot problems are common in older people; 80% of older people have at least one foot problem and the nurse's role in educating patients on how to maintain healthy feet and in identifying problems is extremely important. Foot pain makes people walk more slowly. It impairs balance and stability and increases the risk of falling.(8) Observation of the patient's gait, expression on walking and choice of footwear can help you to identify foot problems. If the person is wearing oversized slippers or footwear with slits or holes to accommodate bunions, foot deformities or swelling, this will increase the risk of falls. You can encourage the older person to buy suitable shoes that are wide enough to accommodate these problems (see Resources) and refer them to a podiatrist. Podiatrists are skilled in treating common foot problems, correcting gait abnormalities and reducing foot pain. Podiatry treatment improves gait and reduces falls risk.
Osteoarthritis of the knee and hip can cause pain and lead to an arthralgic gait. This unbalances the body and increases the risk of falls; in severe cases the patient may require a joint replacement. In many cases aids such as a walking stick help to provide additional support and stability. If you observe a patient with an arthralgic gait, refer them to a physiotherapist who can provide appropriate treatment or aids.
If the patient has a walking aid, observe them using it. Sometimes people acquire walking sticks and walking frames. These can be the wrong size and the patient may have to stretch or stoop to be able to use them - this increases falls risk. It's also worth checking the ferrules (the rubber stoppers on the end of walking sticks and frames) on any aid. If the whorl pattern of the ferrule has worn off or the rim has worn through, then the aid is dangerous and can increase the risk of falls. The community physiotherapist can supply and fit new ferrules.
Aging and inactivity leads to muscle loss and increases falls risk. Only 14% of 75-year-olds are
sufficiently active to maintain health.(9) Aging and inactivity leads to poor posture; older people often walk with their head forward and bottom sticking out. This leads to the centre of balance changing and the person becoming unstable. They may also have poor proprioception and may have to look at feet and legs to work out where they are. Walking speed is reduced and the quadriceps muscles in the thighs and calf muscles can waste. This leads to the knees being poorly supported and more likely to give. Calf muscles can waste. The person tires easily, doesn't lift the feet, shuffles and is more likely to trip. Poor mobility increases the risk of falls; those who are less mobile lose muscle strength and balance deteriorates.(10)
Much of what is considered to be the aging process is really caused not by aging, but by inactivity. Older people can regain 27% of muscle strength, reversing age-related decline by 15 years, by attending one exercise class a week and doing home exercises.(11) If the patient has poor posture or poor mobility, you should recommend exercise classes. People who are very frail may benefit from the OTAGO exercise programme specially designed for frail older people. Physiotherapists working in the community usually run these programmes. 

Continence
Aging leads to a reduction in bladder capacity and kidneys becoming less efficient at concentrating urine. These changes mean that it is normal for the older person to get up once or twice in the night to pass urine. The older person may develop continence problems, such as urgency, and may have to rush to the toilet. It is worth enquiring about continence problems and carrying out a continence assessment to address any treatable problems. If you do not have the skills to carry out a continence assessment, refer the person to a continence specialist. 

Postural hypotension
When a healthy person stands up their blood pressure remains stable. Some people experience postural hypotension when standing. Check the person's blood pressure when sitting and ask the person to stand up quickly. Check the blood pressure again. If the systolic blood pressure falls by 20 mmHg of mercury or more, then the person has postural hypotension. Postural hypotension makes a person feel dizzy or woozy on standing and increases falls risk. It is important to take a series of readings to confirm this diagnosis. There are several reasons why a person can develop postural hypotension, such as inactivity and deconditioning.
Increased activity and exercise often corrects the problem. Dehydration can lead to postural hypotension; correcting dehydration and reviewing diuretic therapy if prescribed often helps. Medication given to treat hypertension can lead to postural hypotension and will require review. If postural hypotension persists, compression stockings can help. The person should have a Doppler ultrasound to check for arterial problems. If compression hosiery is required, then grade three full-length stockings are most effective. In my experience many older people struggle with grade three compression stockings. Grade two compression, although less effective, is better tolerated. If all other measures fail, then medication such as fludrocortisone may be prescribed.

Medication
Any medication that sedates, causes confusion, hypotension or dehydration may increase the risk of falls.(12) Older people consume 43% of all prescribed medicines, more than any other group;(13) more than 90% of people aged 75 or over are prescribed regular medicines (four medicines on average).(2,14) Those who receive four or more medicines are required to have those medications reviewed twice a year and the review is to be recorded.2 Medication review has been shown to significantly reduce the number of falls in people living in care homes.(15) Box 2 provides details of some medicines that can increase the risk of falls.

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Antidepressants increase the risk of falling by between 50% and 200%.(16,17) Tricyclic antidepressants can cause a fall in standing blood pressure, which can lead to dizziness and fainting.(18) When serotonin reuptake inhibitor antidepressants, such as fluoxetine, were introduced they were considered safer.(19) Unfortunately, a study of over 2,000 people living in Tennessee nursing homes proved that there was little difference in fall rates in those treated with tricyclics and newer antidepressants. Those who received antidepressants had a higher rate of falls than those who didn't. The rate of falls increased as the dose of antidepressant rose.(20) Older people receiving antidepressants are more likely to fall and fracture a hip than those who are not.(21) Antidepressants are frequently prescribed to older people and clinicians should balance the risks of untreated depression against the risk of falls. The latest research indicates that the benefits of antidepressants have been exaggerated and that depressed people can recover without the use of drugs.(22) If an older person is taking antidepressants, it may be worth suggesting that these are discontinued under medical supervision. 
Sedatives and benzodiazepines increase the risk of falling. The risk is dose-related and increases in line with the number of sedatives and antidepressants taken.(23) These are not recommended for long-term use and should be discontinued gradually.
Hypotensive drugs are commonly prescribed for hypertension and heart failure. Heart failure is difficult to diagnose, not all cases of swollen feet and ankle oedema are caused by cardiac failure. Accurate diagnosis and appropriate treatment is essential.(24-26) The standard therapy for people with heart failure is ACE inhibitors, ß-blockers and diuretic therapy. GPs should consult a specialist before prescribing them to frail older people.(27) Side-effects include dry cough, hypotension (which can cause falls), high levels of potassium (which can lead to cardiac arrest) and renal failure. It is important that drugs are only given when clinically indicated and dosage is carefully titrated to avoid side-effects. 
ß-blockers reduce pulse rate. This may help people with angina or tachycardia, but causes problems in patients who have pre-existing bradycardia or heart block. The excessive slowing of pulse may result in dizziness and fatigue. This can increase the risk of falls. ß-blockers should not be used in patients with heart block (unless they have a pacemaker) or anyone with a pulse below 60 beats a minute. Nonselective ß-blockers such as propranolol are potentially harmful in diabetics prone to hypoglycaemia. Cardioselective ß-blockers are less risky. All ß-blockers can mask the tremor, tachycardia and sweating, which warn diabetics of hypoglycaemia. ß-blockers should never be stopped suddenly - they should be tailed off.(28)
Diuretics are prescribed to treat hypertension, heart failure and sometimes oedema caused by immobility. Diuretic therapy should be prescribed with care and monitored to reduce risks of falls and other adverse effects.
Analgesics, especially codeine-based analgesics such as cocodamol and codydramol, can cause confusion in older people. This can increase the risk of falls. Some analgesics such as tramadol and morphine-based analgesia also increase falls risk. 
It is important to be aware that older people often don't take their prescribed medication; only about 60% of adults with long-term conditions take medicines regularly enough to obtain any benefit.(29) Medication review and minimising medication can increase the chances of the person taking prescribed medication and cut the risk of falls.

Environmental hazards
It's worth enquiring where the falls are taking place. Sometimes the older person's home may have hazards, such as a step into the kitchen, that increase falls risk. In Australia the government offered older people free home safety checks and subsidised the cost of modifications required. Modifications included nonslip flooring, improved lighting and fitting grab rails. The total number of falls fell by 63%.(30)

Conclusion
Aging, illness, care and treatment, and lifestyle factors can increase the risk of an older person falling. Often the older person has more than one falls risk factor. Community nurses and other healthcare professionals who work closely with older people are in an ideal position to identify and treat risk factors. These actions can make a huge difference to the person's quality of life and may spare the person the pain and complications related to falls. If you are unable to identify falls risk factors or if the person continues to fall despite interventions, then it is important to refer the person to a specialist falls clinic.

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References

  1. Roberts SE, Goldacre MJ. Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study. BMJ 2003;327:771-5.
  2. Department of Health. National service framework: older people. London: DH; 2001.
  3. Woolf AD, Akersson K. Preventing fractures in elderly people. BMJ 2003;327:89-95.
  4. Ducharme J, Neilson S, Ginn JL. Can urine cultures and reagent test strips be used to diagnose urinary tract infection in elderly emergency department patients without focal urinary symptoms? CJEM 2007;2:87-92.
  5. Stroke Association. Suspect a stroke? Act FAST. 2006 Available from: http://www.stroke.org.uk/campaigns/current_campaigns/stroke_is_a_medical...
  6. Abdelhafiz AH, Austin CA. Visual factors should be assessed in older people presenting with falls or hip fracture. Age Ageing 2003;32:26-30.
  7. Jack CI, Smith T, Neoh C, et al. Prevalence of low vision in elderly patients admitted to an acute geriatric unit in Liverpool; elderly people who fall are more likely to have low vision. Gerontology 1995;41:280-5.
  8. Menz HB, Lord SR. Foot pain impairs balance and functional ability in community dwelling older people. J Am Podiatr Med Assoc 2001;91:222-9.
  9. Skelton DA, Young A, Walker A, et al. Physical activity in later life. Further analysis of the Allied Dunbar National fitness Survey and the Health Education Authority National Survey on Activity and Health. London: Health Education Authority; 1999.
  10. Gialloreit LE, Marazzi MC. Risk for falls in the elderly. Role of activities of daily living and of the subjective assessment of health status. A case-control study. Recent Prog Med 1996;87:405-11.
  11. Skelton DA, McLaughlin AW. Training functional ability in old age. Physiotherapy 1996;82:159-67.
  12. Hayes N. Prevention of falls among older patients in the hospital environment. Br J Nurs 2004;13:896-901.
  13. Audit Commission. A prescription for improvement. Towards more rational prescribing in general practice. London: TSO; 1994.
  14. Harris CM, Darjda R. The scale of repeat prescribing. Br J Gen Pract 1996;46:649-53.
  15. Zermansky AG, Alldred DP, Petty DR, et al. Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial. Age Ageing 2006;35:586-91.
  16. Myers AH, Baker SP, Van Natta M. Risk factors associated with falls and injuries among elderly institutionalized persons. Am J Epidemiol 1991;133:1179-90.
  17. Ray WA, Griffin MR, Malcolm E. Cyclic antidepressants and the risk of hip fracture. Arch Intern Med 1991;151:754-6.
  18. Roose SP, Glassman AH, Giardina EGV, et al. Tricyclic antidepressants in depressed patients with cardiac disease. Arch Gen Psychiatry 1987;44:273-5.
  19. Li X, Hamdy R, Sandborn W, et al. Long-term effects of antidepressants on balance, equilibrium, and postural reflexes. Psychiatry Res 1996;63:191-6.
  20. Thapa PB, Gideon P, Milam AB, et al. Antidepressants and the risk of falls among nursing home residents. N Engl J Med 1998;339:857-82. 
  21. Liu B, Anderson G, Mittman N, et al. Use of selective seratonin reuptake inhibitors of tricyclic antidepressants and the risk of hip fractures in elderly people. Lancet 1998;351:1303-7.
  22. Kirsch I, Brett JD, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the food and drug administration. PLOS Medicine; 2008. Available from: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1...
  23. Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in community dwelling elderly. Gerontology 1998;44:217-21.
  24. Clarke KW, Gray D, Hampton JR. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J 1994;71:584-7.
  25. Wheeldon NM, McDonald TM, Flucker CJ, et al. Echocardiography in chronic heart failure in the community. Q J Med 1993;86:17-23.
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  28. Hal S, Cigarroa C, Marcoux L, et al. Time course of improvement in left ventricular function, mass and geometry in patients with congestive heart failure treated with beta-adrenergic blockade. J Am Coll Cardiol 1995;25:1154-61.
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Resources
Domiciliary opticians
Outside Clinic provides domiciliary eye tests to older people.
W: www.outsideclinicdirect.com

Vision Call specialises in providing domiciliary eye tests to people in care homes, but have just launched a domiciliary service. They also provide staff training on caring for older people with visual problems.
W: www.vision-call.co.uk

Foot wear
Cosy Feet provides a range of footwear for people requiring wide footwear and people with foot problems. They provide catalogues and a mail order service.
W: www.cosyfeet.com

Hotter provides a range of footwear for people requiring wide footwear and people with foot problems. They provide catalogues and a mail order service.
W: www.hottershoes.com