Falls Prevention Guidelines, Falls Risk Assessment and Vision Interventions in Older People

Professor Stephen Lord

Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals, Residential Aged Care Facilities and Community Care 2009

Additions: • Cost effectiveness evidence • Discharge . Community.Guideline contents Guidelines • Consisting of three documents: Hospital. Residential Aged Care.

nurses. health service managers. smaller versions for frontline health professionals • Fact sheets for residents/patients.Guideline resources Guidebook and other support materials • Guidebook from each guideline. allied health professionals. doctors. support staff • Implementation guide for hospitals and residential care facilities .

What is the result? .

What’s in the Guidelines Each part contains Evidence based recommendations Good practice tips Points of interest Case studies .

gov.Availability of Guidelines Guidelines available at ACSQHC website : www.au/ Go to Our Work Section and choose Falls Prevention Guidelines .safetyandquality.

au e.fallsnetwork.vance@neura.Contact details NSW Falls Prevention Network www.edu.au .edu.neura.

Falls Risk Assessment in Older People .

identification of risk factors amenable to treatments / correction  Tailoring intervention strategies .Screening or assessment? Screening – identification of people at risk  Increased surveillance  Referral for further assessment and intervention Assessment .

Simplest screen  Have you fallen in the past 12 months?  Degree of difficulty – easy  Sensitivity and specificity – reasonable  Information gained about prevention strategies – nil .

Community Falls Risk Assessment .

QuickScreen© Clinical Falls Risk Assessment  Falls  Has the patient had any falls in the past 12 months?  Medications  Does the patient take 4 or more medications? (excluding vitamins and minerals)  Does the patient take any psychoactive medications? .

QuickScreen© Clinical Falls Risk Assessment Low contrast visual acuity test Read all of the letters on the 5th line Tactile sensitivity test Must feel at least 2 of the 3 trials .

must complete within 12 secs Alternate step test 8 foot taps.5cm Near tandem stand test Stand for 10 secs with eyes closed .5cm 2. must complete within 10 secs 2.QuickScreen© Clinical Falls Risk Assessment Sit to stand test 5 repetitions with arms folded.

QuickScreen© assessment form .

Hospital Assessments .

Most important falls risk factors in hospital       Previous falls Agitation. frequent toileting Gait instability Lower limb weakness Prescription of psychoactive medications  Low body mass index  Low bone mineral density  Fragile skin Oliver. Age and Ageing 2004 . confusion or impaired judgement Urinary incontinence.

Ontario refinement  Items  falls as a presenting complaint  agitation  frequent toileting  visual impairment  transfer and mobility score  Sensitivity 93% and specificity of 88% in  development hospital Sensitivity 92% and specificity 68% in different hospital .Hospitals: STRATIFY (Oliver 1997) .

History of falls.g. Mobility score (MS)  Walks with help of one person (verbal or physical)  Wheelchair independent including corners etc  Immobile If value total between 0-3 then score = 0 2 3 If values total between 4-6 then score = 7 . Please fill in if no patient label is available Date: / / Item Falls Risk Screening Assessment Did the patient present to hospital with a fall or have they fallen since admission? No  Yes  Value Score 1. frequency urgency. lacking awareness. unable to make purposeful decisions. disorganised thinking and memory impairment) No  Yes  Yes to any = 14 2. incontinence. frequent movements and anxious) No  Yes  Does the patient require eyeglasses continually? No  Yes  3. nocturia) ? No  Yes   Independent use of aids to be independent is allowed  Minor help.Modified Stratify SS Falls Risk Screening Please read instructions for use MR Number…………………… Surname ………………………. Mental Status Is the patient disorientated (i. being mistaken about time. Transfer score (TS) [means from bed to chair and back] 1 2 Add transfer score (TS) and mobility score (MS) 3 0 1 6.e. cane) Yes = 2 0 5.e. Vision Does the patient report blurred vision ? No  Yes  Does the patient have glaucoma. one person easily or needs supervision for safety  Major help – one strong skilled helper or two normal people. mechanical lift  Independent (but may use any aid e. cataracts or macular degeneration? No  Yes  Yes to any = 1 4. Date of Birth …………………. has the patient fallen within the last 2 months? No  Yes  Yes to any = 6 Ontario Stratify SS Is the patient confused (i. Toileting Are there any alterations in urination (i. If not. fearful affect.e.e.. physically can sit  Unable no sitting balance. place or person) No  Yes  Is the patient agitated (i.

Residential Aged Care Assessments .

 medication use. 2008 . urinary incontinence. MJA. falls history. cognitive status. use of assistive devices Standing balance and sit-to-stand ability  Falls follow-up for 6 months from incident reports Delbaere K et al.FREE Screening Tool  2005 residents (aged 65 to 104)  898 from intermediate care RACFs  1107 from high care RACFs  Baseline risk factor assessments:  Medical conditions.

Can the resident stand unaided? Yes Can the resident stand on a foam mat? No No Yes Do any of the 2 following apply: •Falls history •High care RACF •Incontinent Does any of the following apply: •Falls history •Low care RACF •Polypharmacy (9+) Yes High falls risk No Low falls risk Yes High falls risk No Low falls risk .

VISION & FALLS Impaired vision – a risk factor for falls & hip fracture  visual acuity  contrast sensitivity  visual field size  depth perception .

activity levels. falls efficacy (balance confidence).Cataract surgery on the first eye  306 women aged 70 years and over  Expedited (4 weeks) or routine (12 months wait) surgery  Visual acuity. depth perception. handicap and Euroquol quality of life improved significantly in the operated group  Falls in the operated group were reduced by 34% (IRR=0. .89:53-59. Br J Ophthalmol 2005. 95% CI=0. anxiety. depression.45-0. visual disability. contrast sensitivity.04) Harwood et al.96)  Four subjects in the operated group (3%) suffered fractures compared with 12 (8%) in the control group (p = 0.66.

irrespective of vision improvement.57.Updating glasses can increase fall risk  Intervention primarily comprised updating glasses  A small percentage also received cataract surgery  Intervention significantly increased the risk of falls – by more than 50% (IRR=1.20-2. may have increased falls Cumming et al. J Am Geriatr Soc.05)  Falls increased across 12 month follow-up. but particularly soon after glasses change  Authors speculate that the change. 2007 . 95%CI=1.

Multifocal glasses  Impair ability to see contrast and judge depth  Increase the risk of falls  Due to trips  On stairs  Outside the home .

95%CI=0.92.VISIBLE Trial – for multifocal glasses wearers  Intervention comprised an optometry assessment. BMJ. provision of additional single lens glasses and counseling  Intervention reduced the risk of falls – by 8% (IRR=0.73-1.60.15) –not significant  Intervention reduced the risk of falls in those who regularly went outside – by 40% (IRR=0. 95%CI=0.87) – significant  Increase in outside falls in those who less regularly went outside Haran et al.42-0. 2010 .

Conclusions .interventions Cataract surgery prevent falls Simply updating current glasses does not appear to prevent falls. and may be harmful in the absence of advice about vision changes and/or other interventions The provision of single lens glasses for older people who take part in regular outdoor activities is a simple and effective falls prevention strategy The intervention may be harmful for frail older people who take part in little outdoor activity .

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