Annotation A: Older Person Encounters Health Care Provider
This guideline algorithm is to be used in the clinical setting for assessment and intervention to reduce falls among community-residing older persons (>65 years). The guideline algorithm is not intended to address fall injuries per se or falls that occur in hospital.
Annotation B: Screen for Falls or Risk for Falling
BACKGROUND
The screening for falls and risk for falling is aimed at preventing or reducing fall risk. Structuring and standardizing the screening process may improve adherence of providers to the guideline recommendations. The use of a finite number of simple questions, requiring a yes/no answer, may also simplify documentation. Any positive answer to the screening questions puts the person screened in a high-risk group that warrants further evaluation.
All older persons who are under the care of a health professional (or their caregivers) should be asked at least once a year about falls, frequency of falling, and difficulties in gait or balance.
RECOMMENDATIONS
- All older individuals should be asked whether they have fallen (in the past year).
- An older person who reports a fall should be asked about the frequency and circumstances of the fall(s).
- Older individuals should be asked if they experience difficulties with walking or balance.
Annotation C: Screen Positive for Falls or Risk for Falling?
Background
Falls among older persons can be caused by several factors. Persons at higher risk of falling, identified by screening, should be assessed for known risk factors, which include a history of falls; taking multiple medications (particularly psychotropic medications); problems with gait, balance, or mobility; impaired vision; other neurological impairments; reduced muscle strength; problems with heart rate or rhythm; postural hypotension; foot problems. The assessment by itself will not reduce falls. However, the assessment is essential to allow tailoring the intervention and follow-up to the individual risk.
A multifactorial fall risk assessment should be performed for community-dwelling older persons who
- report recurrent (two or more) falls
- report difficulties with gait or balance
- seek medical attention or present to the Emergency Department because of a fall.
Recommendations
- Older persons who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance (with or without activity curtailment) should have a multifactorial fall risk assessment.
- Older persons who cannot perform or perform poorly on a standardized gait and balance test (see Annotation E: Gait and Balance) should be given a multifactorial fall risk assessment.
Rationale
The recommendations for assessment are based on epidemiological studies demonstrating an association between risk factors and falls (see Background for risk factors) and from experimental studies in which assessment followed by intervention demonstrated benefit (see Interventions to Prevent Falls, below). Thus, the suggested assessment describes what steps need to be taken to understand an individual’s risk factors and apply effective intervention(s).
The risk factors identified in the assessment may be modifiable (e.g., muscle weakness, medication adverse effect, or hypotension) or non-modifiable (e.g., hemiplegia or blindness). However, knowledge of all risk factors is important for treatment planning. Essential components of the fall-related patient assessment were identified whenever possible from successful controlled trials of fall prevention interventions. The justification for assessment to identify a specific risk factor was strongest when successful treatment or other risk-reduction strategies were explicitly based on this specific risk factor. In some cases, the link between identified risk factors and the content of interventions was not clear. When conclusive data on the importance of specific aspects of the assessment were not available, decisions were based on panel consensus.
Evidence Statements
Multifactorial falls risk assessment and management programs may be the most effective intervention for reducing both the risk for falling and the monthly rate of falling, assuming that the interventions are carried out (Chang, 2004). Recent trials of multifactorial risk assessment followed by referral without assurance of completion of the intervention have not proven effective.
Multidisciplinary, multifactorial, health/environmental risk factor screening and/or intervention programs that are likely to be beneficial in the community are those aimed at: a) an unselected population of older people; b) older people with a history of falling; c) older people selected with known risk factors; and d) older people in long-term care facilities. (Gillespie, 2003)
Annotation D: Does the Person Report a Single Fall in the Past 12 Months?
Background
A (first) single fall may indicate difficulties or unsteadiness in walking or standing. In older individuals, a fall may be a sign of problems in gait or balance that were not present in the past. For the purposes of early detection and risk modification, the person should be observed for gait and balance deficits.
Many older persons are not aware of deterioration in their normal gait or balance. A simple test can identify deficits in gait and balance and whether there is a need for further evaluation and intervention.
Recommendations
- Older persons who report a single fall in the past 12 months should be evaluated for gait and balance.
Rationale
Persons with two or more falls in the past 12 months or with gait or balance abnormalities have a strong likelihood of subsequent falls and therefore would benefit from a multifactorial falls risk assessment. While persons reporting a single fall within the prior 12 months but with no problems with gait or balance may similarly derive benefit from multifactorial assessment and intervention, the evidence for this is lacking.
Annotation E: Evaluate Gait and Balance
Background
The purpose of the gait and balance evaluation is to identify older individuals who need a multifactorial assessment of risk factors for falling. Because deficits in balance and gait are the most predictive risk factors for falls, a quick test is recommended.
Gait and balance deficits should be evaluated in older individuals reporting a single fall as a screen for identifying individuals who may benefit from a multifactorial fall risk assessment. For persons who screen positive for falls or fall risk, evaluation of balance and gait should be part of the multifactorial fall risk assessment.
Recommendations
- Older persons who have fallen should have an assessment of gait and balance using one of the available evaluations.[B] (See list below.)
- Older persons who have difficulty or demonstrate unsteadiness during the evaluation require a multifactorial fall risk assessment.
- Older persons reporting only a single fall in the past year and reporting or demonstrating no difficulty or unsteadiness during the evaluation do not require a fall risk assessment.
Rationale
Frequently used tests of gait or balance include the Get up and Go test (Mathias, (1986); Timed Up and Go test (Podsiadlo et al,1991), the Berg Balance Scale (Berg et al, 1989), the Performance-Oriented Mobility Assessment (Tinetti 1986; Tinetti et al 1988), and others.
Evidence Statements
No adequate prospective study has been published that permits selection of a specific test of balance and gait nor is there adequate validation of a cut-off score for any of the tests for identification of future fallers from a population of single fallers or from a mixed community of individuals not selected for fall status.
Timed Up and Go test
The systematic review undertaken to evaluate the Timed Up and Go test by the ProFANE research group, as yet unpublished, did not find any studies that addressed adequately defined populations prospectively tested against falls outcomes. In a retrospective study (Whitney 2004), and two case-control studies (Shumway-Cook 2000, Dite 2002), different definitions of fall status were utilized. Two studies (Shumway-Cook, Rose 1997) compared people with recurrent falls to people without falls (excluding persons who had fallen once).
In each of the above studies, cut-off scores were selected based on their sample (ranging from 10 to 14 seconds). Two studies (Rose and Whitney) also evaluated a cut-off suggested by Shumway-Cook (13.5 seconds). Sensitivity ranged from 30% to 89% and specificity from 56% to 100%. The sensitivity, in particular, was much lower when the cut-off score was pre-suggested and not dependent on data from the sample. In summary, the methodological quality and variability made meta-analyses unsuitable.
The Berg Balance Scale
Although the Berg Balance Scale is widely used and can distinguish fallers from non-fallers in case-control studies, it lacks a gait assessment component. A recent small case-control study comparing the Berg Balance Scale against other functional tests of mobility and balance demonstrated that it had better discriminating ability than the Performance-Oriented Mobility Assessment Score or the Timed Up and Go test, with high sensitivity and specificity. The most effective screening item for identifying risk was ”retrieve an object from the floor” from the Berg Balance Scale (Chiu, 2003)
Performance-Oriented Mobility Assessment
The Performance-Oriented Mobility Assessment has not demonstrated a reliable cut-off score for predicting falls. However, a recent review (in French) of postural stability assessments concluded that older assessments, including the Berg Balance Scale and the Functional Reach Test, do not have the necessary validity, and that the Performance-Oriented Mobility Assessment and the Timed Up and Gotest are preferable in terms of feasibility and validity as postural assessments for older people. This review reiterated, however, that the predictive ability of these tests for future falls was modest. (Perennou, 2005)
Evidence Table
|
Evidence |
Source |
LE |
QE |
SR |
|---|---|---|---|---|---|
1 |
Performance tests of gait and balance are adequate for the detection of people at risk of falling. The tests we suggest are the Get Up and Go test, Timed Up and Go test, Berg Balance Scale or the Performance-Oriented Mobility Assessment. |
Mathias, 1986 |
I |
Fair |
B |
LE = level of evidence; QE = quality of evidence; SR = strength of recommendation.
Annotation F Determine Multifactorial Fall Risks
Background
A multifactorial fall risk assessment can reveal the factors that put an older adult at risk of falling and can help identify the most appropriate interventions.
The assessment may be carried out by a single clinician or, alternatively, more than one clinician may complete the components most relevant to their expertise. Assessments should be performed by clinicians with appropriate skills and training (e.g., a physician, nurse practitioner, physical therapist, occupational therapist, or pharmacist).
A multifactorial fall risk assessment followed by intervention to modify any identified risks is a highly effective strategy to reduce both falls and the risk of falling in older persons.
Recommendations
- The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training.
- The multifactorial fall risk assessment should include the following:
- Focused History
- History of falls: Detailed description of the circumstances of the fall(s), frequency, symptoms at time of fall, injuries, other consequences
- Medication review: All prescribed and over-the-counter medications with dosages
- History of relevant risk factors: Acute or chronic medical problems, (e.g., osteoporosis, urinary incontinence, cardiovascular disease)
- Physical Examination
- Detailed assessment of gait, balance, and mobility levels and lower extremity joint function
- Neurological function: Cognitive evaluation, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function
- Muscle strength (lower extremities)
- Cardiovascular status: Heart rate and rhythm, postural pulse and postural blood pressure; and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation
- Assessment of visual acuity
- Examination of the feet and footwear
- Functional Assessment
- Assessment of activities of daily living (ADL) skills including use of adaptive equipment and mobility aids, as appropriate
- Assessment of the individual’s perceived functional ability and fear related to falling
- Environmental Assessment
(Assessment of current activity levels with attention to the extent to which concerns about falling are protective [i.e., appropriate given abilities] or contributing to deconditioning and/or compromised quality of life [i.e., individual is curtailing involvement in activities he or she is safely able to perform due to fear of falling])
- The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program.[A]
Rationale
The results of several individual studies have shown that a multifactorial risk assessment that was not tied to intervention was not effective in reducing falls. Multifactorial falls risk assessment and management programs may be the most effective intervention for reducing both the risk for falling and the monthly rate of falling, assuming that the interventions are carried out (Chang, 2004). Recent trials of multifactorial risk assessment followed by referral without assurance of completion of the intervention have not proven effective.
Evidence Statements
Risk Factors for Falling
Many published studies have documented important identifiable risk factors for falling. In the initial version of this Guideline, this literature was reviewed extensively and summarized. While not systematically updated here, the literature on fall risk factors has had no major changes. These risk factors can be classified as either intrinsic or extrinsic. Major intrinsic risk factors include lower extremity weakness, previous falls, gait and balance disorders, visual impairment, depression, functional and cognitive impairment, dizziness, low body mass index, urinary incontinence, orthostatic hypotension, female sex and being over age 80. Extrinsic risk factors include polypharmacy (i.e., taking over four prescription medications), psychotropic medications, and environmental hazards such as poor lighting, loose carpets, and lack of bathroom safety equipment.
Perhaps as important as identifying risk factors is appreciating the interaction and probable synergism between multiple risk factors. Several studies have shown that the risk of falling increases dramatically as the number of risk factors increases. Tinetti et al. surveyed community-dwelling older adults and reported that the percentage of persons falling increased from 27% for those with no or one risk factor to 78% for those with four or more risk factors. (Tinneti et al, 1988)
Similar results were found among an institutionalized population. (Tinetti, 1986) In another study, Nevitt et al. reported that the percentage of community-living persons with recurrent falls increased from 10% to 69% as the number of risk factors increased from one to four or more. (Nevitt et al, 1989)
Robbins et al. used multivariate analysis to simplify risk factors so that maximum predictive accuracy could be obtained. They employed only three risk factors – hip weakness, unstable balance, taking more than four medications – in an algorithm format. With this model, they predicted 1-year risk of falling ranged from 12% for persons with none of the three risk factors to 100% for persons with all three. (Robbins et al, 1997)