Falls Prevention Guidelines

Falls are a significant cause of harm to older people. The rate, intensity and cost of falls identify them as a national safety and quality issue. Following are some of the most important guidelines summarised as produced by The Australian Commission on Safety and Quality in Health Care (ACSQHC) which relate to the hospitals and residential aged care settings.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) is charged with leading and coordinating improvements in the safety and quality of health care nationally, and has consequently produced guidelines on preventing falls and harm from falls in older people.
Health care services are provided in a range of settings. Therefore, ACSQHC has developed three separate falls prevention guidelines that address the three main care settings: the community, hospitals and residential aged care facilities. Although there are common elements across the three guidelines, some information and recommendations are specific to each setting. Collectively, the guidelines are referred to as the Falls Guidelines. These guidelines aim to reduce the number of falls and the harm from falls experienced by older people in residential aged care.
The guidelines and support materials are suitable for residential aged care facilities (RACFs) that:

•  do not have a falls prevention program or plan in place


•  have recently initiated a falls prevention program or plan


•  have a successful falls prevention program or plan in place

Older people themselves are at the centre of the guidelines.Their participation, to the full extent of their desire and ability, encourages shared responsibility in health care, better assures care quality and focuses accountability.
The guidelines are written to promote resident-centred independence and rehabilitation. RACF care in any form involves some risk for older people. The guidelines do not promote an entirely risk-averse approach to the health care of older people. Some falls are preventable, some are not. However, an excessively custodial and risk-averse approach designed to avoid complaints or litigation from older people and their carers may infringe on a person’s autonomy and limit rehabilitation.
Whenever possible, these guidelines are based on research evidence and are written to supplement the clinical knowledge, competence and experience applied by health professionals.  However, as with all guidelines and the principles of evidence based practice, their application is intended to be in the context of professional judgment, clinical knowledge, competence and experience of health professionals.
The guidelines also acknowledge that the clinical judgment of informed professionals is best practice in the absence of goodquality published evidence. Some flexibility may therefore be required to adapt these guidelines to specific settings, to local circumstances, and to older people’s needs, circumstances and wishes.
Summary of recommendations and good practice points
Standard falls prevention strategies
Falls prevention interventions
Recommendations
Intervention  

•  A multifactorial approach using standard falls prevention interventions should be routine care for all residents of residential aged care facilities. (Level I)7


•  In addition to a multifactorial approach using standard falls prevention interventions, develop and implement a targeted and individualised falls prevention plan of care based on the findings of a falls screen or assessment. (Level II)31


•  Provide vitamin D with calcium supplementation to residents with low blood levels of vitamin D, because it works as a single intervention to prevent falls. (Level I)7


•  Residents should have their medications reviewed by a pharmacist. (Level II)32.

Key messages of the guidelines

• Many falls can be prevented.


• Fall and injury prevention need to be addressed at both point of care and from a multidisciplinary perspective.


• Managing many of the risk factors for falls (eg delirium or balance problems) will have wider benefits beyond merely falls prevention.


• Engaging older people is an integral part of preventing falls and minimising harm from falls.


• Best practice in fall and injury prevention includes implementing standard falls prevention strategies, identifying fall risk and implementing targeted individualised strategies that are resourced adequately, and monitored and reviewed regularly.


• The consequences of falls resulting in minor or no injury are often neglected, but factors such as fear of falling and reduced activity level can profoundly affect function and quality of life, and increase the risk of seriously harmful falls.


• The most effective approach to falls prevention is likely to be one that includes all staff in health care facilities engaged in a multifactorial falls prevention program.


• At a strategic level, there will be a time lag between investment in a falls prevention program and improvements in outcome measures.

Falls risk screening and assessment
Recommendations
Screening and assessment  

• If a falls risk screening process is used as a first step, rather than an assessment of all residents on admission, all residents should be screened as soon as practicable thereafter, then regularly (every six months) or when a change in functional status is evident.


• Use separate screening tools for residents who can and cannot stand unaided.


• The introduction of falls risk screens and assessments needs to be supported with education for staff and intermittent reviews to ensure appropriate and consistent use.


• Screens and assessments will only be useful when supported by appropriate interventions related to the risks identified.


• Identifying the presence of cognitive impairment should form part of the falls risk assessment process.

Good practice points
Falls risk screening  

•  Using a formal screening tool has the benefit of forming part of routine clinical management, and will inform further assessment and care for all residents.


•  If a resident is identified as being ‘at risk’ for any item on a multiple risk factor screen, interventions should be considered for that risk factor even if the person has a low falls risk score overall. Falls risk assessment


• Conduct falls risk assessments for residents who exceed the threshold of a falls risk screening tool, who suffer a fall, or who move to or reside in a setting where most people are considered to have a high risk of falls (eg high-care facilities, dementia units).


•  Interventions delivered as a result of the assessment provide benefit; therefore, it is essential that interventions systematically address the identified risk factors.

Management strategies for common falls risk factors
Balance and mobility limitations
Recommendations
Intervention  

•  Use supervised and individualised balance and gait exercises as part of a multifactorial intervention to reduce the risk of falls and fractures in residential aged care facility residents. (Level II)58


•  Consider using gait, balance and functional coordination exercises as single interventions. (Level II)59,60

Good practice points  

• Assessment tools can be used to: – quantify the extent of balance and mobility limitations and muscle weaknesses – guide exercise prescription – measure improvements in balance, mobility and strength – assess whether residents have a high risk of falling.


• Exercise should be supervised and delivered by appropriately trained personnel.

Cognitive impairment
Recommendations
Assessment  

• Residents with cognitive impairment should have other falls risk factors assessed.

Intervention  

•  Address identified falls risk factors as part of a multifactorial falls prevention program, and also consider injury minimisation strategies (such as hip protectors or vitamin D and calcium supplementation). (Level I)7

Good practice points  

•  Address all reversible causes of acute or progressive cognitive decline.


•  Residents presenting with an acute change in cognitive function should be assessed for delirium and the underlying cause of this change.


•  Residents with gradual-onset, progressive cognitive impairment should undergo detailed assessment to determine diagnosis and, where possible, reversible causes of the cognitive decline. Reversible causes of acute or progressive cognitive decline should be treated.


•  If a resident with cognitive impairment does fall, reassess their cognitive status, including presence of delirium (eg using the Confusion Assessment Method tool).


•  Interventions shown to work in cognitively intact populations should not be withheld from cognitively impaired populations; however, interventions for people with cognitive impairment may need to be modified and supervised as appropriate.

Continence
Recommendations
Assessment  

• Older residents should be offered a continence assessment to check for problems that can be modified or prevented.

Intervention  

•  All residents should have a urinalysis to screen for urinary tract infections or function. (Level II-*)112


•  Regular, individualised toileting should be in place for residents at risk of falling, as part of multifactorial intervention. (Level II)60


•  Managing problems associated with urinary tract function is effective as part of a multifactorial approach to care. (Level II-*)112 Note: although there is observational evidence of an association between incontinence and falls, there is no direct evidence that interventions to manage incontinence affect the rate of falls.113

Feet and footwear
Recommendations
Assessment  

• In addition to standard falls risk assessments, screen residents for ill-fitting or inappropriate footwear.

Intervention  

•  As part of a multifactorial intervention program, prevent falls by making sure residents have fitted footwear. (Level II)31.

Good practice points  

•  Include an assessment of foot problems and footwear as part of an individualised, multifactorial intervention for preventing falls in residents.


•  Refer residents to a podiatrist for assessment and treatment of foot conditions as needed.


•  Safe footwear characteristics include: – soles: shoes with thinner, firmer soles appear to improve foot position sense; a tread sole may further prevent slips on slippery surfaces – heels: a low, square heel improves stability – collar: shoes with a supporting collar improve stability.

Syncope
Recommendations
Assessment  

• Residents who report unexplained falls or episodes of collapse should be assessed for the underlying cause.

Intervention  

•  Assessment and management of presyncope, syncope and postural hypotension, and review of medications (including medications associated with presyncope and syncope) should form part of a multifactorial assessment and management plan for preventing falls in residents. (Level I-*)34


•  Older people with unexplained falls or episodes of collapse who are diagnosed with the cardioinhibitory form of carotid sinus hypersensitivity should be treated with the insertion of a dual-chamber cardiac pacemaker. (Level II-*)177

Note: there is no evidence derived specifically from the residential aged care setting relating to syncope and falls prevention. Recommendations have been inferred from community and hospital populations.
Dizziness and vertigo
Recommendations
Assessment  

• Vestibular dysfunction as a cause of dizziness, vertigo and imbalance needs to be identified in residents in the residential care setting. A history of vertigo or a sensation of spinning is highly characteristic of vestibular pathology.


• Use the Dix–Hallpike test to diagnose benign paroxysmal positional vertigo. This is the most common cause of vertigo in older people, and can be identified in the residential aged care setting. This is the only cause of vertigo that can be treated easily. Note: there is no evidence from randomised controlled trials that treating vestibular disorders will reduce the rate of falls.

Good practice points  

•  Use vestibular rehabilitation to treat dizziness and balance problems where indicated and available.


•  Use the Epley manoeuvre to manage benign paroxysmal positional vertigo.


•  Manoeuvres should only be done by an experienced person.

Medications
Recommendations
Assessment  

• Residents of residential aged care facilities should have their medications (prescribed and nonprescribed) reviewed at least yearly by a pharmacist after a fall, or after initiation or escalation in dosage of medication, or if there is multiple drug use.

Intervention  

•  As part of a multifactorial intervention,37 or as a single intervention,32 residents taking psychoactive medication should have their medication reviewed by a pharmacist and, where possible, discontinued gradually to minimise side effects and to reduce their risk of falling. (Level II)


•  Limit multiple drug use to reduce side effects and interactions. (Level II-*)37.

Vision
Recommendations
Assessment  

• Arrange regular eye examinations (every two years) for residents in residential aged care facilities to reduce the incidence of visual impairment, which is associated with an increased risk of falls.

Intervention  

• Residents with visual impairment related to cataract should have cataract surgery as soon as practicable.
  (Level II-*)237,238


• Environmental assessment and modification should be undertaken for residents with severe visual impairments (visual acuity worse than 6/24). (Level II-*)239


• When correcting other visual impairment (eg prescription of new glasses), explain to the resident and their carers that extra care is needed while the resident gets used to the new visual information. Falls may increase as a result of visual acuity correction. (Level II-*)240


• Advise residents with a history of falls or an increased risk of falls to avoid bifocals or multifocals and to use singlelens distance glasses when walking — especially when negotiating steps or walking in unfamiliar surroundings. (Level III-2-*)241

Note: there have not been enough studies to form strong, Evidence based recommendations about correcting visual impairment to prevent falls in any setting (community, hospital, residential aged care facility), particularly when used as single interventions. One trial, set in the community, showed an increase in falls as a result of visual acuity assessment and correction.240 However, correcting visual impairment may improve the health of the older person in other ways (eg by increasing independence). Considerable research has linked falls with visual impairment in the community setting, although no trials have reduced falls by correcting visual impairment, and these results may also apply to the residential aged care setting.
Environmental considerations
Recommendations
Assessment  

• Residents considered to be at a higher risk of falling should be assessed by an occupational therapist and physiotherapist for specific environmental or equipment needs and training to maximise safety.

Intervention  

• Environmental review and modification should be considered as part of a multifactorial approach in a falls prevention program. (Level I)7

Good practice points  

• Residential aged care facility staff should discuss with residents their preferred arrangement for personal belongings and furniture. They should also determine the resident’s preferred sleeping arrangements.


• Make sure residents’ personal belongings and equipment are easy and safe for them to access.


• Check all aspects of the environment and modify as necessary to reduce the risk of falls (eg furniture, lighting, floor surfaces, clutter and spills, and mobilisation aids).


• Conduct environmental reviews regularly, and consider combining them with occupational health and safety audits.

Individual observation and surveillance
Recommendations
Intervention  

• Include individual observation and surveillance as components of a multifactorial falls prevention program, but take care not to infringe on residents’ privacy.
  (Level III-2-*)38


• Falls risk alert cards and symbols can be used to flag highrisk residents as part of a multifactorial falls prevention program, as long as appropriate interventions are used as follow-up. (Level II-*)185


• Falls alerts used on their own are ineffective. (Level II)35


• Consider using a volunteer sitter program for people who have a high risk of falling, and define the volunteer roles clearly. (Level IV-*)281,282


•  Residents with dementia should be observed more frequently for their risk of falling, because severe cognitive impairment is predictive of lying on the floor for a long time after a fall. (Level III-2-*)38 Note: most falls in residential aged care facilities are unwitnessed.23 Therefore, as is done in the hospital setting, the key to reducing falls is to improve surveillance, particularly for residents with a high risk of falling.38

Good practice points  

• Individual observation and surveillance are likely to prevent falls. Many falls happen in the immediate bed or bedside area, or are associated with restlessness, agitation, attempts to transfer and stand, lack of awareness or wandering in people with dementia.


• Residents who have a high risk of falling should be indentified and checked regularly.


• A staff member should stay with at-risk residents while they are in the bathroom.


• Although many residents are frail, not all are at a high risk of falling; therefore, surveillance interventions can be targeted to those residents who have the highest risk.


• A range of alarm systems and alert devices are commercially available, including motion sensors, video surveillance and pressure sensors. They should be tested for suitability before purchase, and appropriate training and response mechanisms should be offered to staff. Suppliers of these devices should be located if a facility is considering this intervention. However, there is no evidence that their use in residential aged care facilities reduces falls or improves safety.