Background
Methods
Aims
Design
Study population
Recruitment
Randomisation and blinding
Outcome measures
Cost variables
Intervention group
Falls prevention health assessment | Management | Falls & Fracture Nurse action | Referral |
---|---|---|---|
Circumstances of previous fall
| Changes in environment and activity to reduce risk of further falls | Directs further assessment and management. Address any immediate safety issues | Referral according to categories below |
Medication review:
High risk medications: benzodiazepines, other sleeping medications, neuroleptics, antidepressants, anti-convulsants [15] | Review and reduction of medications [6, 15] | Request family physician review of medications according to protocol | Family physician or geriatrician |
Vision:
Acuity < 20/60; decreased depth perception, contrast sensitivity (Melbourne edge test) [21, 50] | Ample lighting without glare; avoidance of multifocal glasses while walking | Arrange correction of lighting, highlight potential hazard edges | Optometrist, ophthalmologist (e.g. cataracts), family physician, geriatrician; if visual acuity 6/24 or worse, offer referral to Royal NZ Foundation of the Blind |
Postural blood pressure (after > 5 mins in a supine position, immediately after standing, and 2 minutes after standing): Standing systolic blood pressure < 100 mmHg or = 20 mmHg postural drop if systolic blood pressure < 130 mmHg or with symptoms (immediate or > 2 mins) | Diagnosis and treatment of underlying cause | Adequate hydration, compensatory strategies (e.g. elevation of head of bed, rising slowly, dorsiflexion exercises), pressure stockings | Family physician or geriatrician: diagnosis and treatment of underlying cause, review and reduction of medications, or pharmacological therapy for postural hypotension |
Balance and gait:
Patient's report or observation of unsteadiness. Impairment on brief assessment (timed up and go test [48, 51, 52], 4-test balance scale [38]) | Diagnosis and treatment of underlying cause | Coordinate Otago Exercise Programme (see below) or referral as appropriate | Family physician or geriatrician review Physiotherapist: assistance devices, supervised gait and progressive balance training if specific neurological problem or unable to do Otago Exercise Programme |
Targeted neurologic examination:
Impaired proprioception [53]; decreased muscle strength (chair stand test [37]) | Diagnosis and treatment of underlying cause | Increase proprioceptive input (assistance device, appropriate footwear), caretaker's awareness of cognitive deficits | Family physician or geriatrician: review medications that impede cognition Physiotherapist: supervised gait, balance and strength training |
Targeted musculoskeletal examination: Legs (joints and range of motion) and examination of feet to identify problems interfering with function | Diagnosis and treatment of underlying cause | Offer Otago Exercise Programme (see below) or referral as appropriate | Physiotherapist: supervised strength, range-of-motion, gait and balance training, assistance devices, appropriate footwear; Podiatrist or chiropodist: assist with feet Family physician address impairments (e.g. osteoarthritis) |
Targeted cardiovascular examination: Syncope or arrhythmia [54, 55] | Family physician or geriatrician for ECG ± cardiologist referral, carotid-sinus massage (in case of syncope) [56] | ||
Continence/overactive bladder:
Particularly if related to circumstances of previous fall [57] | Nightlights, bladder retraining | Continence service/nurse for assessment, bladder retraining; family physician or geriatrician for medical management, exclusion of other pathology | |
Home hazards assessment
| |||
Hazard identified according to protocol [14] | Changes in environment to reduce risk of further falls | Identify and modify minor home hazards (e.g. remove loose rugs, use nightlights) | Occupational therapist assessment for major hazards (e.g. bath/toilet grab rails) [17] |
Bone health assessment
| |||
Osteoporosis risk from osteoporosis screen questionnaire | Consider calcium and vitamin D supplementation if not receiving | Refer to family physician for appropriate management with suggestion of vitamin D and calcium supplementation with guidelines [18, 46] | |
Previous fragility fracture [58] | Consideration for appropriate management (including bisphosphonates) [58] | Organise vouchers and referral | Referral for voucher for DEXA scan and review by family physician for application for bisphosphonates [47] |
Otago Exercise Programme [10, 45] | |||
All participants | Increase muscle strength and balance | Offer delivery of Otago Exercise Programme | Otago Exercise Programme delivered by accredited physiotherapist or nurse [45] |
Unable to commence the Otago Exercise Programme or chronic neurological problem (e.g. existing CVA, Parkinson's disease), timed up and go test > 30 seconds, or cognitive impairment | Increase muscle strength and balance | Referral | Referral to physiotherapist for individualised rehabilitation programme |
Control group
Sample size
Analysis
Results
Recruitment rates
Characteristics of participants using different recruitment strategies
Baseline characteristics
Characteristic | Intervention (n = 155) | Control (n = 157) | Total (n = 312) |
---|---|---|---|
Age, years | 80.4 (4.8) | 81.1 (5.3) | 80.8 (5.0) |
Female n (%) | 105 (67%) | 110 (70%) | 215 (69%) |
Number of falls in previous year Median [interquartile range] | 2 [1,3] | 2 [1,4] | 2 [1,3] |
Systolic blood pressure, mmHg | 148.4 (24.2) | 149.9 (21.7) | 149.2 (22.9) |
Diastolic blood pressure, mmHg | 71.6 (11.9) | 72.2 (11.4) | 71.9 (11.6) |
Body mass index, kg/m2
| 27.0 (6.0) | 27.4 (4.7) | 27.2 (5.4) |
FICSIT 4-test balance score | 3.5 (1.2) | 3.5 (1.2) | 3.5 (1.2) |
Step test, number of steps | 8.2 (4.5) | 8.3 (4.5) | 8.2 (4.5) |
Timed up and go, seconds Median [interquartile range] | 12 [10,16] | 12 [10,16.5] | 12 [10,16] |
30 second chair stand, number of stands | 8.5 (4.5) | 8.2 (4.6) | 8.3 (4.6) |
Nottingham extended ADL score | 18.4 (3.4) | 18.1 (3.4) | 18.3 (3.4) |
Modified falls efficacy score | 8.1 (1.8) | 8.0 (1.9) | 8.05 (1.83) |
Number of medical conditions | 6.9 (2.8) | 7.2 (2.9) | 7.0 (2.9) |
Number of medications | 5.3 (3.4) | 5.6 (3.2) | 5.5 (3.3) |
Taking psychotropic medication(s) n (%) | 48 (31%) | 41 (26%) | 89 (29%) |
Previous cerebrovascular accident n (%) | 28 (18%) | 48 (31%) | 76 (24%) |
Previous fracture† n (%) | 60 (39%) | 47 (30%) | 107 (34%) |
Previous hip fracture† n (%) | 2 (1%) | 6 (4%) | 8 (3%) |
Leisure activity/walking, minutes/week Median [interquartile range] | 120 [20, 250] | 120 [13, 218] | 120 [16, 240] |