Today I spent some time on reviewing NICE guideline falls in older people June 2013 (https://www.nice.org.uk/guidance/cg161/evidence/falls-full-guidance-190033741). Because I work in the community I focused on evidance mostly applicable for this settings. Also, I have realised that single intervention are not as beneficial as holistic approach. The table below demonstrates above.
Interventions likely to be
beneficial:
|
Interventions unlikely to be
beneficial:
|
Interventions
of unknown effectiveness
|
· muscle
strengthening and balance retraining, individually prescribed at home
·
A 15-week Tai Chi group exercise
intervention
· Home
hazard assessment and modification that is professionally prescribed for
older people with a history of falling
·
Withdrawal of psychotropic
medication
· Cardiac
pacing for fallers with cardioinhibitory carotid sinus hypersensitivity
· Multidisciplinary,
multifactorial,health/environmental risk factor screening/intervention
programmes
·
Multidisciplinary assessment and
intervention programme in residential care facilities
·
|
·
Brisk walking in women with an
upper limb fracture in the previous two years
The Cochrane review concluded
the following:
·
Prevention programmes that target
an unselected group of older people with a health or environmental
intervention on the basis of risk factors or age, are less likely to be
effective than those that target known fallers.
·
Even amongst known fallers, the
risk reduction where significant is small, and the clinical significance
remains less clear.
· Interventions
that target multiple risk factors are marginally effective, as are targeted
exercise interventions, home hazard modification and reducing psychotropic
medications.
·
Where important individual risk
factors can be corrected, focused interventions may be more clearly
effective.
·
There is a lack of clarity about
the optimum duration and intensity of interventions.
·
Some interventions –for example,
brisk walking –may increase the risk of falling.
|
· Group-delivered
exercise interventions
· Individual
lower limb strength training
· Nutritional supplementation
·
Vitamin D supplementation, with
or without calcium
· Home
hazard modification in association with advice on optimising medication or in
association with an education package on exercise and reducing fall risk
·
Pharmacological therapy
(raubasine¬dihydroergocristine
·
Interventions using a cognitive/behavioural
approach alone
·
Home hazard modification for
older people without a history of falling
· Hormone
replacement therapy
· Correction of
visual deficiency
|
Key issues in preventing
falls in older people:
· Older people should be asked routinely whether they have fallen in the past
year and asked about the frequency, context and characteristics of the fall/s.
· Older people who present for
medical attention because of a fall, or report recurrent falls in the past
year, or demonstrate abnormalities of gait and/or balance should be offered a
multifactorial falls risk assessment. This assessment should be part of an
individualised, multifactorial intervention.
Regarding inpatient older people falls prevention, any multifactorial assessment should identify the patient’s individual risk factors
for falling that can be treated, improved or managed during their expected stay. These may include:
- assessment of gait, balance and
mobility, and muscle weakness
- cognitive impairment
- continence problems
- assessment of gait, balance and
mobility, and muscle weakness assessment of osteoporosis risk
- falls history, including causes
and consequences (such as injury and fear of falling)
- footwear that is unsuitable or
missing health problems that may increase their risk of falling
- medicationreview
- assessment of urinary
incontinence
- syncope syndrome
- visual
impairment and neurological examination
- assessment
of home hazards
All older
people with recurrent falls or assessed as being at increased risk of falling
should be considered for an individualised multifactorial intervention:
- mostly benefit are older people living in the community with a history
of recurrent falls and/or balance and gait deficit.
- a muscle strengthening
and balance programme should be offered.
- this should
be individually prescribed and monitored by an appropriately trained
professional.
2. home hazard assessment and
intervention
- older
people who have received treatment in hospital following a fall should be offered
a home hazard assessment and safety intervention/modifications
- normally
this should be part of discharge planning and be carried out within a timescale
agreed by the patient or carer, and appropriate members of the health care team
- it is shown
to be effective only in conjunction with follow up and intervention, not in
isolation.
3. vision assessment and referral
4. medication review with modification/withdrawal
- older people on psychotropic medications should have their medication
reviewed, with specialist input if appropriate, and discontinued if possible to
reduce their risk of falling.
- Cardiac pacing should be considered for older people with cardioinhibitory
carotid sinus hypersensitivity who have experienced unexplained falls.
There is high risk of fall are those who additional suffer
from :
· generalised pain
·
reduced
activity
·
high
alcohol consumption
·
parkinson’s disease
·
arthritis
·
diabetes
·
stroke
·
low
body mass.
Covinsky
et al. (2001) carried out regression analysis with significant risk factors and suggested that abnormal mobility, balance deficit and
previous falls history were predictive of further falls. Stalenhoef et al.
(2002) developed a risk model with postural sway, falls history, reduced grip
strength and depression as significant predictors. Cwikel et al. (1998)
developed a risk model (elderly falls screening test), which included: fall in
last year, injurious fall in last year, frequent falls, slow walking speed, and
unsteady gait. It is clear from the evidence that a previous fall and/or gait
and balance disorders may be predictive of those at highest risk, but the
presence of other less obvious factors should be considered in combination.
The
results described above were obtained mainly from community-dwelling
participants. The results from studies conducted with extended care
participants were similar, in that a previous fall was predictive of a further
fall. Medications also featured as important risk factors for both those in
community and extended care settings –for example, benzodiazepines,
antidepressants, neuroleptics and cardiotonic glycosides as single predictors,
but also the use of multiple medications (Leipzig et al. 1999).
Assessment of those at high risk of
falling in both community-dwelling and extended care settings
Timed up and go test
Turn 180º
Performance-oriented assessment of
mobility problems (Tinetti scale)
Functional reach
Dynamic gait index
Berg balance scale
Other
tests –such as the Berg balance test, Tinetti scale, functional reach and
dynamic gait test –may offer more detailed assessment and be of diagnostic
value, but take longer to administer and need both equipment and clinical expertise.
These tests cannot be recommended for use in all settings and may be more
useful during a comprehensive assessment by a multidisciplinary team.
The
potential for additional falls or risk of initial fall is suggested if one or
more of the following factors outlined below are present. This will lead to
further detailed assessment and the application of RAP (2000).
·
Triggers
for falls RAP
·
Fall
in the past month
·
Fall
in past one to six months
·
Wandering
·
Dizziness/vertigo
·
Use
of trunk restraint
·
Anxiolytic
drugs
·
Antidepressants.
Resources:
http://www.who.int/ageing/publications/Falls_prevention7March.pdf
https://www.nice.org.uk/guidance/cg161/evidence/falls-full-guidance-190033741
No comments:
Post a Comment