Print This Page

CLINICAL PRACTICE GUIDELINES

Guidelines Abstracted from the Guideline for the Prevention of Falls in Older Persons

OBJECTIVE
The aim of this guideline is to assist health care professionals in their assessment of fall risk and in management of older patients who are at increased risk of falling or who have fallen.

OPTIONS
Options for evaluation of falls include those factors identified in epidemiologic studies as risk factors for falls and from experimental studies in which assessment followed by intervention demonstrated benefit. The intervention strategies that were evaluated for their effectiveness were classified as either single or multifactor strategies and as generic or individually designed. Management options were considered in relationship to the setting of patient care (e.g., community, long-term care facility, acute hospital).

In addition the Panel considered other potential interventions such as:

  1. Bone strengthening measures
  2. Cardiovascular interventions
  3. Visual interventions
  4. Footwear interventions
  5. Restraints

OUTCOMES
The principle outcome evaluated in this guideline is elimination or reduction of falls.

EVIDENCE
The Panel performed a literature search for systematic reviews, meta-analyses, randomized trials, controlled before and after studies, and cohort studies using a combination of subject heading and free text searches as well as high-quality recent review articles and bibliographies prior to September 2000. The RAND Corporation (Santa Monica, CA) conducted a literature search for the purpose of identifying quality indicators for falls and mobility problems for two ongoing national projects. This provided the initial set of articles reviewed for the guideline. The Panel identified and synthesized relevant published evidence to allow recommendations to be evidence-based, whenever possible, using the grading criteria listed below.

The categories of evidence for the guidelines were classified as follows:
Class I: Evidence from At least one randomized controlled trial or meta-analysis of randomized controlled trials.
Class II: Evidence from at least one controlled study without randomization or evidence or evidence from at least one other type of quasi experimental study.
Class III: Evidence from non-experimental studies, such as comparative studies, correlation studies and case-controlled studies.
Class IV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities.

The strength of the recommendations is classified as follows:

  1. Directly based on Class I evidence.
  2. Directly based on Class II evidence or extrapolated recommendation from Class I evidence
  3. Directly based on Class III evidence or extrapolated recommendation from Class I or II evidence.
  4. Directly based on Class IV evidence or extrapolated recommendation from Class I, II, or III evidence.

Assessment of risk factors for falls and/or a history of falls is a prerequisite to intervention. The strength of the recommendations regarding case finding and assessment were left ungraded because of their dependence on the actual falls intervention and its effectiveness in reducing subsequent falls.

COST, BENEFITS AND HARMS
An explicit cost/benefit analysis of the falls guideline was not made. In issuing the guideline the Panel makes an implicit assumption that by identifying older patients at increased risk of falls and managing conditions that lead to fall related injury (e.g., osteoporosis), clinicians will reduce harm and benefit patients. The panel notes that fall-related injuries account for 6% of all medical expenditures for persons 65 years old and older in the United States. In addition to physical injury the Panel notes that falls result in substantial psychological and social consequences such as anxiety, loss of independence, and increased rate of nursing home placement. The committee cautions that when implementing the guideline in a local setting the benefits need to be set against the increased cost and workload from referral for specialist assessment.

VALUES
A fundamental tenet of the guideline is that detecting a history of falls and performing an assessment, when coupled with interventions will prevent future falls. This guideline was a joint project of the American Geriatrics Society, The American Academy of Orthopaedic Surgeons and the British Geriatrics Society. Funding was provided as unrestricted educational grants from Medtronic, Inc. (Minneapolis, MN, USA) and Shire Pharmaceuticals (Richwood, KY, USA)

VALIDATION
In addition to the American Geriatric Society and the American Academy of Orthopaedic Surgeons, and the British Geriatrics Society, an impressive number of other British and American Professional organizations with special interest and expertise in the management of falls provided peer review of the preliminary guidelines.

RECOMMENDATIONS
The Panel on Falls Prevention assumes that health care professionals will use their clinical knowledge and judgment in applying the general principles and specific recommendations of this document to assess and manage individual patients.

  1. Routine Care of Older Persons (not presenting after a fall)
    • Clinicians caring for older persons should ask about fall history annually
    • Those patients who report a single fall should undergo a balance and gait screening. This is done by observing the ability to stand up from a chair without using arms, walk several paces and return. ( i.e. the "get up and go test")
    • Those having difficulty require further assessment and appropriate intervention such as referral to physical and or occupational therapy.
  2. Evaluation of Older Persons Presenting with One or More Falls or Having Abnormalities Gait and or Balance or who report Recurrent Falls:
    • History of the fall circumstances, medications (prescribed and over the counter), acute or chronic medical problems, and mobility levels
    • An examination of vision, muscle strength, gait, balance, and neurological function including lower extremity peripheral nerves, proprioception, reflexes,cortical and extrapyramidal and cerebellar functions should be done. An assessment of cognitive function and a basic cardiovascular evaluation including heart rate and rhythm, orthostatic pulse and blood pressure should be done.,
  3. Multifactorial Interventions to Prevent falls:
    • For community living older persons should include:
      1. Gait training by physical therapists and prescription and teaching the use of assistive devices by occupational therapists (level B).
      2. Exercise programs including balance training (level B).
      3. Review and modification of medication especially psychotropic and sympathomimetic varieties (level B).
      4. Treatment of postural hypotension (level B).
      5. Modification of environmental hazards (level C).
      6. Treatment of cardiovascular disorders including arrhythmia (level D).
    • In long term care and assisted living settings multifactorial interventions should include all of the above and:
      1. Staff education programs to enhance sensitivity to identify risks for falls among all levels of caregivers (level B).
      2. Gait training and advice on the appropriate use of assistive device (level B).
      3. Review and modification of medications, especially psychotropic medications (level B).
    • Evidence is insufficient to make recommendations for or against multifactorial interventions in acute hospital settings
  4. Single interventions:
    • Exercise:
      1. Although exercise has many proven benefits, the optimum type, duration and intensity to prevent falls remains unclear (level B).
      2. Physical therapy, exercise and balance training should be offered to older persons who have recurrent falls (level B).
      3. Tai Chi C'uan is said to improve balance, it requires further evaluation before before it can be recommended (level C).
    • Environmental Modification:
      1. Older persons at increased risk for falls should have an environmental assessment done of their home by an OT or other qualified professional (level B).
    • Medications:
      1. Patients, who have fallen, should have their medications reviewed especially those on more than four prescribed meds or those taking psychotropic meds (level C). (There is no clear difference in risk for falls between long term and short-term bezodiazepines).
    • Assistive devices:
      1. There is no clear evidence that use of assistive devices alone such as bed alarms, canes, and walkers have demonstrated benefits in preventing falls. While assistive devices may be effective elements of a multifactorial intervention program, their isolated use without attention to other risk factors cannot be recommended (level C).
      2. Hip protectors do not appear to reduce the risk of falls (Class I), but have been shown to be effective in preventing fractures in high-risk individuals.
    • Behavioral and Educational Programs:
      1. When used as an isolated intervention, health and behavioral education does not reduce falls (level B).
  5. Other Potential Interventions:
    • Bone strengthening medications: a number of medications widely used to prevent osteoporosis have been shown to reduce fracture rates and should therefore be considered as an adjunctive approach to the older person who presents with a risk of falls.
    • Cardiovascular intervention: some falls have a cardiovascular cause. The way the individual falls may herald further investigation along this line. A fall without evidence of self rescue is indicative of such a scenario.
    • Visual/sensory loss: deficits in sight and sensation have been linked to a higher incidence of falls resulting in hip fractures. Identification of these deficits and appropriate intervention may be preventative.
    • Footwear interventions: there are no experimental studies of footwear examining falls as an outcome. There are, however trials looking at intermediate outcomes such as balance and sway from specific footwear interventions. For women, use of waling shoes was better than barefoot. For men, stability was best with high mid-sole hardness and low mid-sole thickness.
    • Restraints: There is no evidence that using restraint prevents falls. To the contrary, using restraints causes lower extremity weakness and deconditioning and may lead to falls.

The algorithm in Figure 1 (from the guideline) summarizes the recommended assessment and management of the patient with falls.

This AGS abstracted guideline was abstracted from The Journal of the American Geriatrics Society, 49:664-672, 2001. On behalf of the AGS Clinical Practice Committee, Christine Peterson, MSN, GNP, CRNP, Rebecca D. Elon, MD, MPH, and Samuel C. Durso, MD abstracted the guideline. Address correspondence to: American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, Tel: 212-308-1414; Fax: 212-832-8646;
E-mail:info.amger@americangeriatrics.org.