Falls - risk assessment

Source:
Clinical Knowledge Summaries
Publication date:
01 January 2014

Abstract

Falls - risk assessment Last revised in January 2014 Next planned review by December 2019 Summary Back to topFalls - risk assessment: Summary A fall is defined as an unintentional/unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level. For the purpose of this CKS topic: A simple fall is defined as one occurring as a result of a chronic impairment of cognition, vision, balance, or mobility. A simple fall is distinguished from a collapse which occurs as a result of an acute medical problem such as an acute arrhythmia, transient ischaemic attack, or vertigo. Falls are common in older people and can result in considerable morbidity. The risk of falling is multifactorial, and prevention is usually based on assessing multiple risk factors. Fractures are a common complication of falls. About 5% of falls in older people who live in the community result in a fracture or hospitalization. Between 10% and 25% of falls in nursing homes and hospitals result in a fracture. The incidence of hip fractures in the UK is 86,000 per year, and 95% of these are the result of a fall. The cost to the NHS is £1.7 billion a year. One of the strongest risk factors for a fall is a previous fall, and all older people in regular contact with healthcare professionals should be asked about this at least once a year. Other risk factors for falling include a condition that affects mobility or balance (e.g. arthritis, stroke, or Parkinson's disease), visual or cognitive impairment, urinary incontinence, frailty, and polypharmacy or the use of certain drugs. Assessment of the risk of falling should include an assessment of gait and balance (for example by using the Timed Up & Go test and/or the Turn 180° test). 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 risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. A multifactorial assessment may include assessing for home hazards, visual impairment, and drug treatments. A multifactorial risk assessment should be followed by an individualized, multifactorial intervention. Interventions offered by specialist falls services may include: Strength and balance training. Home hazard assessment and intervention. Vision assessment and referral. Medication review with modification or withdrawal. Have I got the right topic? Back to topHave I got the right topic? From age 65 years onwards.This CKS topic is based on the National Institute for Health and Care Excellence guideline: Falls. Assessment and prevention of falls in older people [National Institute for Health and Care Excellence, 2013]. This CKS topic covers the identification and management of the risk of falling in older people in the community. This CKS topic does not cover the identification and management of the risk of falling in older people in hospital. This CKS topic does not cover the management of a collapse caused by an acute medical problem, for example arrhythmias, stroke, transient ischaemic attack, or vertigo. There are separate CKS topics on Osteoporosis - prevention of fragility fractures, Stroke and TIA, Benign paroxysmal positional vertigo, Vertigo, and Palpitations. The target audience for this CKS topic is healthcare professionals working within the NHS in the UK and providing first contact or primary health care. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes January 2014 — reviewed. A literature search was conducted in January 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. The following changes were made: A 'definition node' has been added in background information to clarify that this topic covers 'simple falls' as opposed to a collapse due to an acute medical problem. The scope of this CKS topic has been revised to clarify the above, and additional links to relevant CKS topics have been included. The section on assessing the risk of falls has been rewritten for clarity. Back to top Previous changes Previous changes September 2008 to June 2009 — this is a new CKS topic, based on the National Collaborating Centre for Nursing and Supportive Care guideline, Clinical practice guideline for the assessment and prevention of falls in older people [National Collaborating Centre for Nursing and Supportive Care, 2004], commissioned by the National Institute for Health and Clinical Excellence. Back to top Update Update Back to top New evidence New evidence Evidence-based guidelines NHS England (2017) Supporting routine frailty identification and frailty care through the GP Contract 2017/2018. NHS England. www.england.nhs.uk [Free Full-text] HTAs (Health Technology Assessments)No new HTAs since 1 January 2014.Economic appraisalsNo new economic appraisals relevant to England since 1 January 2014.Systematic reviews and meta-analysesNo new systematic reviews since 1 January 2014.Primary evidenceNo new randomized controlled trials since 1 January 2014. Back to top New policies New policies No new national policies or guidelines since 1 January 2014. Back to top New safety alerts New safety alerts No new safety alerts since 1 January 2014. Back to top Changes in product availability Changes in product availability No changes in product availability since 1 January 2014. Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To make an accurate assessment of a person at risk of fallingTo refer people at risk of falling for a multidisciplinary falls assessmentTo provide appropriate advice to people at risk of falling Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria No audit criteria were found during the review of this topic. Back to top QOF indicators QOF indicators No QOF indicators were found during the review of this topic. Back to top QIPP - Options for local implementation QIPP — Options for local implementation No QIPP indicators were found during the review of this topic. Back to top NICE quality standards NICE quality standards No NICE quality standards were found during the review of this topic. Background information Back to topBackground information Back to top Definition What is it? A fall is defined as an unintentional/unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level [Lach et al, 1991; Wolf et al, 1996]. For the purpose of this CKS topic: A simple fall is defined as one occurring as a result of a chronic impairment of cognition, vision, balance, or mobility. A simple fall is distinguished from a collapse which occurs as a result of an acute medical problem such as an acute arrhythmia, transient ischaemic attack, or vertigo. Back to top Prevalence How common is it? Falls are common in older people and can result in considerable morbidity. About 30% of people 65 years of age or older have a fall each year, increasing to 50% in people 80 years of age or older [National Institute for Health and Care Excellence, 2013]. Back to top Risk factors What are the risk factors? The risk of falling is multifactorial, and prevention is usually based on assessing multiple risk factors [National Institute for Health and Care Excellence, 2013]. The more risk factors a person has, the greater their risk of falling. See Assessing risk of falling for further details. Back to top Complications What are the complications? Fractures are a common complication of falls [National Institute for Health and Care Excellence, 2013]: About 5% of falls in older people who live in the community result in a fracture or hospitalization. Between 10% and 25% of falls in nursing homes and hospitals result in a fracture. The incidence of hip fractures in the UK is 86,000 per year, and 95% of these are the result of a fall. The cost to the NHS is £1.7 billion a year. Management Back to topManagement Scenario: Falls - risk assessment: covers the identification and management of the risk of falling in older people (65 years of age and older). Back to top Scenario: Falls - risk assessment Scenario: Falls - risk assessment From age 65 years onwards. Back to top Assessing risk of falling How should I assess people for risk of falling? Identify people aged 65 years and over who: Have had one or more falls in the last 12 months. Distinguish a simple fall (caused by a chronic impairment of cognition, vision, mobility, or balance) from a collapse (caused by an acute medical problem, for example arrhythmias, transient ischaemic attack, or vertigo). To do this, ask about the circumstances in which the fall occurred, how often the person has fallen, and whether any symptoms were associated with the fall (for example light headedness or loss of consciousness). If possible, obtain an eye-witness account. Are at risk of falling because they: Have cognitive impairment. Have a visual impairment. Are physically frail or have a condition that affects mobility or balance such as arthritis, diabetes, incontinence, stroke, or Parkinson's disease. Are taking multiple drugs, psychoactive drugs (such as benzodiazepines), or drugs that can cause postural hypotension (such as anti-hypertensive drugs). Have a fear of falling. For people who have had one or more falls or are considered to be at risk of a fall, assess their gait and balance, for example by using the Timed Up & Go test and/or the Turn 180° test. Offer a multifactorial falls risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service) to all people aged 65 years and over who: Have had two or more falls in the last 12 months, or Present for medical attention following a fall, or Cannot perform, or perform poorly on, the Timed Up & Go test and/or the Turn 180o test. For people who do not have an indication to be referred for a multifactorial risk assessment, reassess at least annually. Back to top Timed Up & Go test and Turn 180° test Timed Up & Go test and Turn 180° test Timed Up & Go test Time the person getting up from a chair without using their arms, walking 3 metres, turning around, returning to the chair, and sitting down. If the person usually uses a walking aid, this can be used during the test. During the test, observe the person's postural stability, gait, stride length, and sway [CDC, 2013]. Standardized cut-off scores to predict risk of falling have not yet been established [American College of Rheumatology, 2013]. A score of 12 to 14 seconds or more (depending on the study) has been shown to indicate high risk of falls in older people. See Evidence on the Timed Up & Go test and Turn 180° test for more information. Use clinical judgement to interpret the test, and consider the time taken to complete the test as well as other factors such as age of the person, the type of footwear, the use of a walking aid, and the general health of the person [American College of Rheumatology, 2013]. For a summary of the Timed Up & Go test and an assessment checklist, see The Timed Up and Go (TUG) Test (pdf) produced by the Centers for Disease Control and Prevention. Turn 180° test [Nevitt, 1989; Simpson et al, 2002]  Ask the person to stand up and step around until they are facing the opposite direction. If the person takes more than four steps, further assessment should be considered. Back to top Basis for recommendation Basis for recommendation These recommendations are based largely on the National Institute for Health and Care Excellence (NICE) guideline: Falls. Assessment and prevention of falls in older people [National Institute for Health and Care Excellence, 2013]. Distinguishing a simple fall from a collapse CKS recommends distinguishing between a simple fall and a collapse due to an acute medical problem (for example arrhythmias, transient ischaemic attack, or vertigo) as the management will differ. Identifying people who have had one or more falls or are considered to be at risk of falling NICE found evidence suggesting that a previous fall and/or gait and balance disorders are the strongest risk factors for falls. The other risk factors were reported as statistically significant [National Institute for Health and Care Excellence, 2013]. Evidence from a systematic review of 28 observational studies and one randomized controlled trial was unable to conclusively show an association between any specific class of drug and falls. However, there was weak evidence of an association between falls and benzodiazepines, antidepressants, and antipsychotics [Hartikainen et al, 2007]. Assessing gait and balance There is a lack of evidence regarding which assessment tool is most predictive of falls and therefore most useful. NICE reviewed the evidence and assessed the utility, feasibility, and acceptability of a range of key assessment tools and concluded that the Timed Up & Go test and the Turn 180° test are pragmatic, can be used in any setting, and require no special equipment [National Institute for Health and Care Excellence, 2013]. Evidence from studies of older people living in the community or attending a day hospital indicates that the Timed Up & Go test and the Turn 180° test are useful for predicting the risk of falling. Offering a multifactorial risk assessment Based on evidence from two systematic reviews, one of which was published by the Cochrane Collaboration, NICE recommends a multifactorial falls risk assessment for older people at risk of falling, to identify and address future risks [National Institute for Health and Care Excellence, 2013]. However, NICE points out that the benefit of a multifactorial assessment (that is, reduced risk of falls) only appears to be achieved if it is followed by referral for an individualized, multifactorial intervention [National Institute for Health and Care Excellence, 2013]. Reassessing falls risk annually Experts from the American and British Geriatrics Societies advise that if a fall has not occurred, the person should be reassessed periodically [American Geriatrics Society and British Geriatrics Society, 2011]. Although this is not specifically stated in the NICE guideline, it is implied by the recommendation that older people in regular contact with healthcare professionals should be asked routinely whether they have fallen in the past year [National Institute for Health and Care Excellence, 2013]. Back to top Managing people at high risk of falls How should I manage older people assessed to be at high risk of falling? For older people assessed to be at high risk of falling, offer a multifactorial risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service). This assessment should be part of an individualized, multifactorial intervention. A multifactorial assessment may include assessment for: Chronic conditions that affect mobility or balance (including arthritis, diabetes mellitus, stroke, Parkinson's disease, and dementia). Gait, balance, and mobility problems. Osteoporosis risk. Perceived impaired functional ability and fear relating to falling. Visual impairment. Cognitive, neurological, and cardiovascular problems. Urinary incontinence. Home hazards. Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants). Interventions commonly offered by specialist falls services include: Strength and balance training — most likely to benefit older community-dwelling people with a history of recurrent falls or balance and gait deficit. Home hazard assessment and intervention — should be offered to older people who have received treatment in hospital following a fall. Vision assessment and referral. Medication review — psychotropic drugs are reviewed, with specialist input if appropriate, and discontinued if possible. Back to top Basis for recommendation Basis for recommendation These recommendations are based largely on the National Institute for Health and Care Excellence (NICE) guideline: Falls. Assessment and prevention of falls in older people [National Institute for Health and Care Excellence, 2013]. Multifactorial risk assessment NICE recommends a multifactorial falls risk assessment for older people at risk of falling, to identify and address future risks [National Institute for Health and Care Excellence, 2013]. An evidence based report on falls prevention, identified by NICE, concluded that although not proven, it makes clinical sense that a comprehensive risk assessment should be targeted to people who have had a fall or are at high risk of a fall as they have most to gain [Shekelle et al, 2002]. However, NICE points out that the benefit of a multifactorial assessment (that is, reduced risk of falls) only appears to be achieved if it is followed by referral for an individualized, multifactorial intervention [National Institute for Health and Care Excellence, 2013]. Individualized, multifactorial intervention The NICE guideline does not give specific information on what a falls service should offer a person identified to be at risk of falling. However, the guideline does state that a personalized intervention aimed at promoting independence and improving physical and psychological function should be offered. Strength and balance training, home hazard and vision assessment and intervention, and medication review are common components in successful multifactorial intervention programmes [National Institute for Health and Care Excellence, 2013]. A Cochrane systematic review (search date: March 2012) that assessed interventions for preventing falls in older people living in the community [Gillespie et al, 2012] found good evidence that these and other interventions reduce the rate and/or risk of falls. Interventions not recommended NICE does not currently recommend the following interventions [National Institute for Health and Care Excellence, 2013]: Low intensity exercise combined with incontinence programmes. Group exercise (untargeted). Cognitive/behavioural interventions. Referral for correction of visual impairment. Vitamin D. Hip protectors. Brisk walking. NICE states that the decision not to recommend these interventions is because there is insufficient or conflicting evidence (no evidence in the case of brisk walking) to support their use [National Institute for Health and Care Excellence, 2013]. Supporting evidence Back to topSupporting evidence Back to top Timed Up & Go test and Turn 180° test Evidence on the Timed Up & Go test and the Turn 180° test There is a lack of evidence regarding which assessment tool is most predictive of falls and therefore most useful. The National Institute for Health and Care Excellence suggests that the Timed Up & Go test and the Turn 180° test are useful in the primary care setting as no special equipment is required [National Institute for Health and Care Excellence, 2013]. Timed Up & Go test A prospective cohort study to determine the accuracy of the Timed Up & Go test in community-dwelling elderly people (n = 63) found that [Alexandre et al, 2012]: Those who performed the test in 12 seconds or more were at higher risk of falling. Participants who suffered at least one fall throughout the follow up period of the study (11 women and 10 men) had a slower performance on the Timed Up & Go test (p = 0.02) and greater difficulties in the performance of daily living activities (p