lord falls network rural conf 2010 1
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Falls Prevention Guidelines,
Falls Risk Assessmentand Vision Interventions
in Older People
Professor Stephen Lord
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Preventing Falls and Harm from Falls in OlderPeople: Best Practice Guidelines for
Australian Hospitals, Residential Aged CareFacilities and Community Care 2009
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Guideline contents
Guidelines Consisting of three documents:
Hospital;
Residential Aged Care;Community.
Additions:
Cost effectiveness evidence
Discharge
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Guideline resources
Guidebook and other support materials Guidebook from each guideline; smaller
versions for frontline health professionals
Fact sheets for residents/patients, healthservice managers, nurses, doctors, alliedhealth professionals, support staff
Implementation guide for hospitals andresidential care facilities
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What is the result?
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Whats in the Guidelines
Each part contains
Evidence based recommendations
Good practice tips
Points of interest
Case studies
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Availability of Guidelines
Guidelines available at ACSQHC website :
www.safetyandquality.gov.au/
Go to Our Work Section and choose Falls
Prevention Guidelines
http://www.safetyandquality.gov.au/http://www.safetyandquality.gov.au/ -
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Contact details
NSW Falls Prevention Network
www.fallsnetwork.neura.edu.au
e.vance@neura.edu.au
http://www.fallsnetwork.neura.edu.au/http://www.fallsnetwork.neura.edu.au/http://www.fallsnetwork.neura.edu.au/ -
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Falls Risk Assessment
in Older People
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Screening or assessment?
Screening identification of people at risk
Increased surveillance
Referral for further assessment andintervention
Assessment - identification of risk factorsamenable to treatments / correction
Tailoring intervention strategies
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Simplest screen
Have you fallen in the past 12 months?
Degree of difficulty easy
Sensitivity and specificity reasonable
Information gained about preventionstrategies nil
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Community Falls Risk Assessment
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QuickScreen Clinical Falls RiskAssessment
Falls
Has the patient had any falls in thepast 12 months?
Medications
Does the patient take 4 or more
medications?(excluding vitamins and minerals)
Does the patient take any
psychoactive medications?
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QuickScreen Clinical Falls RiskAssessment
Low contrast visualacuity test
Read all of the
letters on the 5thline
Tactile sensitivity test
Must feel at least 2 of
the 3 trials
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QuickScreen Clinical Falls RiskAssessment
2.5cm
2.5cm
Near tandem stand test
Stand for 10 secs with
eyes closed
Alternate step test
8 foot taps, must
complete within 10
secs
Sit to stand test
5 repetitions with arms
folded, must complete
within 12 secs
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QuickScreenassessmentform
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Hospital Assessments
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Most important falls risk factors inhospital
Previous falls Agitation, confusion or impaired judgement Urinary incontinence, 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
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Hospitals: STRATIFY (Oliver 1997)- Ontario refinement
Items falls as a presenting complaint agitation
frequent toileting visual impairment transfer and mobility score
Sensitivity 93% and specificity of 88% indevelopment hospital
Sensitivity 92% and specificity 68% indifferent hospital
M difi d St tif SS MR N b
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Modified Stratify SS
Falls Risk Screening
Please read instructions for use
MR NumberSurname .Date of Birth ..
Please fill in if no patient label is available
Date: / /
Item Falls Risk Screening Assessment Value Score
1. History of falls.
Did the patient present to hospital with a fall orhave they fallen since admission? No Yes
If not, has the patient fallen within the last 2
months? No Yes
Yes to any = 6
2. Mental Status
Is the patient confused (i.e. unable to makepurposeful decisions, disorganised thinking andmemory impairment) No Yes
Is the patient disorientated (i.e. lacking awareness,being mistaken about time, place or person)
No Yes
Is the patient agitated (i.e. fearful affect, frequentmovements and anxious) No Yes
Yes to any = 14
3. Vision
Does the patient require eyeglasses continually?No Yes
Does the patient report blurred vision ?No Yes
Does the patient have glaucoma, cataracts ormacular degeneration? No Yes
Yes to any = 1
4. Toileting Are there any alterations in urination (i.e.frequency urgency, incontinence, nocturia) ?
No Yes
Yes = 2
5. Transfer score (TS)[means from bed to chair
and back]
Independent use of aids to be independent isallowed
Minor help, one person easily or needssupervision for safety
Major help one strong skilled helper or twonormal people; physically can sit
Unable no sitting balance; mechanical lift
0
1
2
3
6. Mobility score (MS) Independent (but may use any aid e.g. cane)
Walks with help of one person (verbal orphysical)
Wheelchair independent including corners etc
Immobile
0
1
2
3
Addtransferscore
(TS) andmobilityscore(MS)
If valuetotalbetween0-3 thenscore =0
If valuestotalbetween
4-6 thenscore =7
Ontario Stratify -
SS
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Residential Aged Care
Assessments
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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, cognitive status,
medication use, urinary incontinence, fallshistory, use of assistive devices
Standing balance and sit-to-stand ability
Falls follow-up for 6 months from incidentreports
Delbaere K et al. MJA, 2008
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Can the resident standunaided?
Yes
Can the resident stand ona foam mat?
No Yes
Do any of the 2 following apply:Falls historyHigh care RACF
Incontinent
Yes No
Low falls riskHigh falls risk
Does any of the following apply:Falls historyLow care RACF
Polypharmacy (9+)
No
Yes No
Low falls riskHigh falls risk
Can the resident standunaided?
Do any of the 2 following apply:Falls historyHigh care RACF
Incontinent
Does any of the following apply:Falls historyLow care RACF
Polypharmacy (9+)
Can the resident stand ona foam mat?
Can the resident standunaided?
Do any of the 2 following apply:Falls historyHigh care RACF
Incontinent
Does any of the following apply:Falls historyLow care RACF
Polypharmacy (9+)
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VISION & FALLS
Impaired vision a risk factor for falls & hip
fracture
visual acuity
contrast sensitivity
visual field size
depth perception
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Cataract surgery on the first eye
306 women aged 70 years and over
Expedited (4 weeks) or routine (12 months wait) surgery
Visual acuity, contrast sensitivity, depth perception, visual
disability, activity levels, anxiety, depression, falls efficacy(balance confidence), handicap and Euroquol quality of life
improved significantly in the operated group
Falls in the operated group were reduced by 34%
(IRR=0.66, 95% CI=0.45-0.96)
Four subjects in the operated group (3%) suffered fractures
compared with 12 (8%) in the control group (p = 0.04)
Harwood et al. Br J Ophthalmol 2005;89:53-59.
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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=1.57, 95%CI=1.20-2.05)Falls increased across 12 month follow-up, but particularly
soon after glasses change
Authors speculate that the change, irrespective of vision
improvement, may have increased falls
Cumming et al, J Am Geriatr Soc, 2007
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Impair ability to see
contrast and judge
depth
Increase the risk of
falls
Due to trips
On stairs
Outside the home
Multifocal
glasses
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VISIBLE Trial for multifocal glasses
wearers
Intervention comprised an optometry assessment, provision
of additional single lens glasses and counseling
Intervention reduced the risk of falls by 8% (IRR=0.92,
95%CI=0.73-1.15)
not significantIntervention reduced the risk of falls in those who regularly
went outside by 40% (IRR=0.60, 95%CI=0.42-0.87)
significant
Increase in outside falls in those who less regularly wentoutside
Haran et al, BMJ, 2010
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Conclusions - interventions
Cataract surgery prevent fallsSimply 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 strategyThe intervention may be harmful for frail older
people who take part in little outdoor activity
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