What is a targeted fall prevention strategy for urinary frequency or incontinence?

In the past decade, the falls prevention evidence has expanded and many guidelines now exist.7–14 Despite this, there remains a national trend of increasing fall related hospitalisations, which, if unchanged, will result in escalating healthcare costs.15,16 Improving outcomes requires addressing evidence practice gaps for individual patients in addition to a systemwide approach. General practitioners may identify patients who will benefit from fall prevention measures, develop and implement treatment plans with other health professionals and support patient uptake of recommendations. An Enhanced Primary Care plan may facilitate implementing falls prevention strategies.7,17

Why older people fall

Many falls are multifactorial in nature and linked to both patient specific and environmental risk factors.18 Key intrinsic risk factors are age, sensory decline, reduced lower limb strength and comorbidity.2,19 Cognitive impairment, even subtle deficits, increases risk.20 A single identifiable major factor accounts for up to 20% of falls.18

Assessment of falls and risk factors

The strongest predictors of risk are previous falls, with injurious falls and a walking or balance difficulty increasing risk even further.12,21 Screening balance tests can help identify those with deficits who will benefit from an exercise program (Table 1).22,23 High risk patients may require a more complex multifactorial assessment.12

Key components of a multifactorial assessment include:

• a detailed falls history, medication review, risk factor assessment including osteoporosis, urinary incontinence and cardiovascular disease
• physical examination including gait and balance, neurological and cognitive function, lower limb strength, visual acuity, feet and footwear
• functional assessment such as activities of daily living, perceived functional ability and fear of falling.

The history should identify presyncope, syncope and unexplained falls as these presentations have considerable overlap and may require specialist referral (Table 2). History from an observer is invaluable, as older people may have 'amnesia of syncope' or cognitive deficits effecting recall. Carotid sinus syndrome (CSS) is a neurally mediated cause of syncope which may account for a portion of 'unexplained falls' attending emergency departments.24 Pacemaker insertion in this group can reduce the rate of falls, however trial results have been mixed.8,25,26

Falls prevention strategies in the community

The cornerstone of effective falls prevention is identifying modifiable risk factors and intervening with effective strategies (Table 3). In general, multiple strategies should be used for high risk patients, however for selected patients a single strategy may be equally effective and more acceptable.27 Osteoporosis diagnosis and management should also be addressed.28

Community dwelling older adults
Strategy	Rating	Patients who benefit	Practice points
Exercise		Effective for both high falls risk and general older adult populations. Adaptation may be required if cognitive impairment present	May be home or group program, requires balance component. Needs to be performed for 2 hours/week on an ongoing basis
High dose vitamin D		Low vitamin D level (<60 nmol/L)	Cholecalciferol >800 IU/daily prevents fractures and falls
Psychoactive medication withdrawal		Taking benzodiazepine or other psychoactive medication	GP supported stepped withdrawal, average five visits
Occupational therapy home visit		High risk patients especially those with visual impairment or recent hospitalisation	Hazard reduction, training and education. Best as part of a multifactorial strategy
Restricted multifocal spectacle use		Active older people using multifocal lenses (caution – may harm inactive older adults)	Use an additional pair of single lens spectacles when outside
Expedited cataract surgery		First cataract appropriate for surgery	Wait time less than 4 weeks
Podiatry intervention58		Disabling foot pain attending podiatry clinic	May include orthoses, footwear advice, foot and ankle exercises
Multifactorial assessment with targeted interventions		High risk patients such as those with recurrent unexplained falls or those who have suffered a fall injury	Effective if interventions provided or arranged directly by assessment team
Older people living in residential care
Single intervention	Rating	Patients who benefit	Practice points
Vitamin D in high dose		All, unless known hypercalcaemia	Cholecalciferol >800 IU/daily Serum vitamin D monitoring not required
Medication review by pharmacist		All residents	Comprises multiple changes to regimen and increasing tests for monitoring
Hip protectors	Good practice point	Mobile residents who will be compliant	Acceptability and adherence a major challenge. Prevents fractures if worn
= Strongly recommended based on high quality evidence (NHMRC level A), relevant to most older adults, easily implementable = Strongly recommended based on high quality evidence (NHMRC level A), relevant to subpopulations of older adults, implementation dependant on service availability = Recommended based on good evidence (NHMRC level B), relevant to subpopulations of older adults, implementation requires application of practice points Good practice point = Recommendation based on expert opinion with limited evidence, relevant to sub-population, complex to implement

Older people are often not receptive to 'falls prevention' as they underestimate their falls risk and don't see themselves as 'fallers'. However, strategies that help maintain independence and emphasise that falls are not inevitable with age are better received.29 Discussing the positive aspects of falls prevention such as social and health benefits as well as engaging the family improves adherence.29

The evidence for effective falls prevention strategies for people with dementia living in the community is not well established. Guidelines recommend that falls prevention interventions should not be withheld, but may need modification and supervision.7

Multifactorial assessment and targeted interventions

This approach involves a detailed assessment, often by multiple health professionals, followed by development and implementation of a targeted intervention plan to address modifiable risk factors. Common interventions include exercise, a home safety review, optimising management of medical conditions and a medication review.12 Falls clinics apply this model and the evidence shows that it achieves a reduction in falls, and improved mobility, balance and confidence.30

Single strategies

Exercise programs

The link between exercise and decreased falls in older people living in the community is well-established. There is also good evidence that disability can be reduced by well-designed exercise in this population.31 There have been four systematic reviews and a number of more recent trials that have demonstrated that well-designed exercise can reduce falls in older people living in the community.7,8,10,11,13 Systematic reviews have also identified that tai chi can reduce falls by 37% and the New Zealand developed, Otago Exercise Programme, by 32%.8,11 The Otago Exercise Programme also significantly reduces the risk of death.11

Characteristics of effective programs from the largest and most recent review are outlined in Table 4. Exercise uptake can be hampered by concerns about increased pain or lack of efficacy, however recommendation from the GP significantly increases uptake.32,33

Vitamin D

Vitamin D supplementation for older adults with deficiency is an effective and simple strategy for fall and fracture prevention, with fracture benefits persisting with increasing age.8,10 Vitamin D supplementation can reduce falls by 17% and higher doses of cholecalciferol (800–2000 IU/daily) reduce hip fracture risk by 30%.10,34 Daily, weekly or 4 monthly regimens appear effective, but annual high dose administration should be avoided.34,35 A vitamin D level of >60 nmol/L is required for falls and fracture prevention with the benefit of additional calcium supplementation uncertain.34 Those requiring anti-osteoporosis treatment should have supplemental vitamin D and calcium when dietary intake is inadequate.28

Reduced benzodiazepine use

Psychoactive medications are taken by 22% of community dwelling older people and there is strong evidence they increase the risk of falls.36,37 There is no evidence that shorter acting benzodiazepines, selective serotonin reuptake inhibitors (SSRI) antidepressants and atypical antipsychotics are safer in terms of fall risk than earlier generation drugs.38

Psychoactive drug withdrawal can reduce falls by 66%.8 Almost 1 in 5 older adults take benzodiazepines long term (>4.5 years) despite a lack of evidence supporting efficacy beyond the short term.40 A meta-analysis which included the newer Z compounds (eg. zolpidem, zopiclone) demonstrated that the small sleep benefits were outweighed by adverse effects including fractures and motor vehicle accidents.41 Recent data associates the use of such sedatives with higher rates of falls, fractures, death and cancer.42,43 In contrast, cognitive behavioural therapy and sleep restriction are effective strategies for treating long term insomnia in older people.44 Prolonged release melatonin has been approved for adults >55 years of age with primary insomnia and poor quality sleep and does not result in next day impairment or rebound insomnia.45

Although benzodiazepine withdrawal is challenging, 18% of older adults quit by themselves after receiving written advice from their GP, and 62% of patients for whom this is insufficient but enrol in a stepped withdrawal program achieve cessation.46 The approach begins with transfer to equivalent diazepam dose, followed by a dose reduction of 25% per week with five consultations. Meta-analysis supports this stepped withdrawal method.47 In recent years, melatonin has been used by clinicians to support sedative withdrawal, which also appears effective.48

Optimised vision

Visual impairment is an independent risk factor for falls and fractures. Multifocal spectacles increase falls risk by distorting the lower visual field (Figure 1).49 Adults who undertake regular outdoor activity can reduce their falls risk by using single lens distance glasses instead of multifocals when going outside or to an unfamiliar environment.50 This advice however, increases falls risk in less active adults. Improving spectacle prescription alone has not resulted in falls prevention. Short waiting time for first eye cataract surgery is an effective falls and fracture prevention strategy.8

Figure 1. Distortion of lower vision field in a patient wearing multifocal spectacles

Home modification

Home safety modifications in association with transfer training and education are effective in high-risk populations8 such as patients with poor vision or those recently hospitalised.51 The benefits are greater when delivered as part of a multifactorial strategy.14

Falls prevention strategies in residential aged care settings

Falls rates are high in residential aged care facilities (RACFs), with 1 in 2 residents falling within a 6 month period.52 Residents have increased rates of cognitive impairment, continence problems, comorbidities and polypharmacy, which contribute to the increased falls risk. The evidence for falls prevention is outlined in Table 3.

Vitamin D deficiency is very high in Australian RACF residents, with 89% having a vitamin D level <60 nmol/L.53 Falls and fractures can be prevented with cholecalciferol supplementation (800–2000 IU/day) given to all residents, with the requirement for calcium supplementation uncertain.34,53 In Australia, there is no uniform approach to implementation of this evidence: other countries have addressed this using routine administration of oral cholecalciferol 50 000 IU monthly (not routinely available in Australia).54 The expert panel recommended that vitamin D level should not be tested or monitored and the only contraindication was known hypercalcaemia.

Changing medication prescription may reduce falls in RACFs.9 One randomised controlled trial using pharmacist review followed by written recommendations to the GP resulted in drug changes and decreased falls, with 75% of the recommendations accepted by the GP.55 Although regular pharmacist reviews occur in Australia, studies suggest 43% of RACF residents are prescribed at least one inappropriate medication.56

The evidence for exercise programs preventing falls for RACF residents is inconclusive.9 As some studies show an increase in falls rate, individuals capable of participation in exercises should be monitored if these are adopted. Multifactorial assessment and intervention can be effective when delivered by a multidisciplinary team. Hip protectors reduce hip fractures when worn, however, their effectiveness as an injury prevention strategy is not established, as programs are hampered by poor acceptance and adherence.57

Key points

• Challenging balance exercise for 2 or more hours per week on an ongoing basis reduces falls risk in older adults living in the community.
• Daily 800–2000 IU vitamin D supplementation prevents falls and fractures in those with vitamin D levels <60 nmol/L, regardless of living location.
• Benzodiazepine withdrawal, occupational therapy home modifications, expedited cataract procedure and restricted multifocal spectacle use outdoors for active older adults are effective single interventions to reduce falls risk.
• High risk patients with recurrent, unexplained or injurious falls should be considered for specialist referral and multidisciplinary intervention.

Conflict of interest: none declared.

Acknowledgement

Thanks to Professor Stephen Lord, Neuroscience Research Australia, for provision of the multifocal image and gold bar concept.

What are targeted fall prevention strategies?

What interventions can be used to keep patients from falling?

What are the 4 P's of fall prevention?

What is the most commonly used methods to prevent falls?