The American Geriatrics Society and British Geriatrics Society have just released their updated “Clinical Practice Guideline for Prevention of Falls in Older Person” (the previous guideline had been written in 2001). The new guideline addresses elderly patients living in the community and those residing in long-term care facilities.
The updated guidelines emphasize the importance of the multifactorial assessment and intervention strategy. Not all elderly patients who have had a fall require assessment. If it was a solitary fall and the patient has no difficulties or unsteadiness during evaluation of gait and balance, a full fall assessment is not necessary. For most others, an assessment is indicated. The guideline describes the multiple components of the assessment, including the focused history, detailed assessment of gait/balance/mobility and lower extremity joint function, full neurological examination, cardiovascular status (including orthostatic blood pressure and pulse), visual acuity, and examination of the feet and footwear. A functional assessment (ADL skills, adaptive equipment and mobility aids, etc.) should be done where appropriate. Also important is the patient’s perceived functional ability and fear of falls. An environmental assessment, including a search for home safety hazards and facilitators, should also be done.
They make a whole host of recommendations regarding interventions. One new change is that certain medications (particularly psychoactive medications) be reduced or withdrawn regardless of the total number of medications a patient is taking (the old guideline focused on reducing these only in patients on 4 or more medications). An exercise component is a mainstay of any multifactorial intervention. The evidence for visual interventions was not considered strong enough to be recommended except that cataract surgery for elderly women with cataracts is recommended. Despite the recent hubbub about the lack of good evidence for many uses of vitamin D, one that does have a good evidence base is its use in community-dwelling or LTC residents with proven or suspected vitamin D deficiency. The recommendations, therefore, are for at least 800 international units of vitamin D per day for those persons with proven or suspected vitamin D deficiency and those with an abnormal gait or balance or who are otherwise at risk for falls.
The above guideline does not address falls in the acute care hospital setting. But there is one new resource applicable to the inpatient population. We have found the one of the biggest deficiencies in hospital’s approach to falls is what is done after a fall (see our April 16, 2007 Patient Safety Tip of the Week “Falls with Injury”). Apparently the British feel that way, too. The UK NPSA (National Patient Safety Agency) has just issued a Rapid Response Report “Essential care after an inpatient fall”. They issued that report because their incident reporting database had shown numerous instances of inadequate post-fall evaluation and management. Specifically, they often found delays in recognition of fractures, inadequate neurological assessments and monitoring in those ultimately shown to have intracranial injury, inappropriate movement of patients with fractures or spine injuries, and delays in access to urgent investigations or surgery. They also note failure to consider anticoagulated patients as being more vulnerable (see our July 17, 2007 Patient Safety Tip of the Week “ “).
The report recommends that all hospitals have protocols readily available for nurses to assess patients for possible fractures and spine injuries and manage those with such injuries. Appropriate equipment to handle such patients needs to be readily available. The protocol should also specify the frequency and duration of neurological observations to be done (including appropriate use of the Glasgow Coma Scale) and timescales for when the medical examination should be done after a fall. Access to diagnostic tests and specialist evaluations should be as rapid as would be expected if the patient was in the emergency room. They recommend the protocol should be kept in a laminated card readily available to all nursing staff.
While that rapid response report does have some good recommendations, it overlooks the need to do a mini-root cause analysis on the spot after every such fall. Often that is the only way to identify factors that led to the fall, which might be modified to prevent future falls.
Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons.
Journal of the American Geriatrics Society 2011; 59(1): 148-157
Article first published online: 13 JAN 2011
on the American Geriatrics Society website:
2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (Summary of Recommendations).
Patient education materials on preventing falls
NPSA. Rapid Response Report. Essential care after an inpatient fall. January 13, 2011