Hospital Guidelines

Preventing Falls and Harm From Falls in Older People
Best Practice Guidelines for Australian Hospitals 2009
Commonwealth ofAustralia2009 ISBN: 978-0-9806298-1-1 This work iscopyright. Itmay bereproduced inwhole orpart for study ortraining purposes subject tothe inclusion ofan acknowledgment ofthe source. Reproduction for purposes other than those indicated above requires the written permission ofthe Australian Commission onSafety and Quality inHealth Care(ACSQHC). ACSQHC was established inJanuary 2006 bythe Australian health ministers tolead and coordinate improvements insafety and quality inAustralian healthcare. Copies ofthis document and further information onthe work ofACSQHC can befound athttp://www.safetyandquality.gov.au orobtained from the Office ofthe Australian Commission onSafety and Quality inHealth Care: +61 2 9263 3633 mail@safetyandquality.gov.au. Other resources available fromhttp://www.safetyandquality.gov.au: Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Community Care2009 Guidebook for Preventing Falls and Harm From Falls inOlder People: Australian Community Care2009 Guidebook for Preventing Falls and Harm From Falls inOlder People: Australian Hospitals2009 Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Residential Aged Care Facilities2009 Guidebook for Preventing Falls and Harm From Falls inOlder People: Australian Residential Aged Care Facilities2009 Implementation Guide for Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities2009 Factsheets Falls facts for patients andcarers Falls facts fordoctors Falls facts fornurses Falls facts for allied healthprofessionals Falls facts for support staff (cleaners, food services and transportstaff) Falls facts for healthmanagers
Statement from the chief executive
Australians today enjoy alonger life expectancy than previous generations, but for some this isdisrupted byfalls. Aswe age, our sure-footedness declines and, atthe same time, our bones become increasingly brittle. The comment that he fell and broke his hip isheard all too often infact, almostone inthree older Australians will suffer afall each year. Such falls can have extremely serious consequences, including significant disability and evendeath. Falls are one ofthe largest causes ofharm incare. Preventing falls and minimising their harmful effects are critical. During care episodes, older people are usually going through aperiod ofintercurrent illness, with the resultant frailty and the uncertainty that brings. They are attheir most vulnerable, often inunfamiliar settings, and accordingly attention has been paid toacquiring evidence about what can bedone tominimise the occurrence offalls andtheir harmful effects, and touse these data inthe national FallsGuidelines. These new guidelines consider the evidence and recommend actions inthe three main care settings: the community, hospitals and residential aged care facilities. Each ofthree separate volumes addresses one ofthese care settings, providing guidance onmanaging the various risk factors that make older Australians incare vulnerabletofalling. The Australian Commission onSafety and Quality inHealth Care ischarged with leading and coordinating improvements inthe safety and quality ofhealth care for all Australians. These new guidelines are animportant part ofthatwork. The ongoing commitment ofstaff incommunity, hospital and residential aged care settings iscritical infalls prevention. Icommend these guidelinestoyou.
Professor Chris Baggoley Chief Executive Australian Commission on Safety and Quality in Health Care August 2009

iv Preventing Falls and Harm From Falls inOlderPeople
Contents
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Statement from the chiefexecutive Acronyms andabbreviations Preface Acknowledgments Summary ofrecommendations and good practicepoints
iii xiii xv xvii xix
PartA Introduction
1 Background 1.1 1.2 About theguidelines Scope oftheguidelines 1.2.1 Targeting olderAustralians 1.2.2 Specific toAustralianhospitals 1.2.3 Relevant toall hospitalstaff 1.3 Terminology 1.3.1 Definitionofafall 1.3.2 Definition ofan injuriousfall 1.3.3 Definition ofassessment and riskassessment 1.3.4 Definitionofinterventions 1.3.5 Definitionofevidence 1.4 Development oftheguidelines 1.4.1 Expert advisorygroup 1.4.2 Reviewmethods 1.4.3 Levelsofevidence 1.5 1.6 Consultation Governance ofthe Australian falls prevention project for hospitals and residential aged carefacilities How touse theguidelines 1.7.1 Overview 1.7.2 How the guidelines arepresented 2 Falls and falls injuriesinAustralia 2.1 Incidenceoffalls 2.2 Fall rates inolderpeople 2.4
1
3 3 4 4 4 4 4 4 4 4 5 5 6 6 6 7 8
8 8 8 10 13 13 13 13 14 14 14 15 17
1.7
2.3 Impactoffalls Costoffalls 2.5 Economic considerations infalls preventionprograms 2.6 Characteristicsoffalls 2.7 Risk factors forfalling 3 Involving older people infallsprevention
Part B Standard falls preventionstrategies

4 Falls preventioninterventions 4.1 Background andevidence 4.1.1 Evidence fromtrials 4.2 Choosing falls preventioninterventions 4.3 Dischargeplanning
19
21 22 22 23 24
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4.3.1 Discharge planning from the emergencydepartment 4.3.2 Fallsclinics 4.4 Specialconsiderations 4.4.1 Cognitiveimpairment 4.4.2 Rural and remotesettings 4.4.3 Indigenous and culturally and linguistically diversegroups 4.5 Economicevaluation 5 Falls risk screening andassessment 5.1 Background andevidence 5.1.1 Falls riskscreening 5.1.2 Falls riskassessment 5.2.1 Falls riskscreening 5.2.2 Falls riskassessment
25 26 27 27 27 27 27 29 30 30 31 32 32 33 37 37 37 37

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5.2 Principlesofcare
5.3 Specialconsiderations 5.3.1 Cognitiveimpairment 5.3.2 Rural and remote settings 5.2.3 Indigenous and culturally and linguistically diverse groups
Part C Management strategies for common falls riskfactors

6 Balance and mobilitylimitations 6.1 Background andevidence 6.1.1 Identifying the risk factors forfalls 6.1.2 Exercise aspart ofamultifactorial intervention 6.1.3 Discharge planning andexercise 6.2 Principlesofcare 6.2.1 Assessing balance, mobility andstrength 6.3 Specialconsiderations 6.3.1 Cognitiveimpairment 6.3.2 Rural and remotesettings 6.3.3 Indigenous and culturally and linguistically diversegroups 6.4 Economicevaluation 7 Cognitiveimpairment 7.1 Background andevidence 7.1.1 Cognitive impairment associated with increased fallsrisk 7.1.2 Cognitive impairment and fallsprevention 7.2 Principlesofcare 7.2.1 Assessing cognitiveimpairment 7.2.2 Providinginterventions 7.3 Specialconsiderations 7.3.1 Indigenous and culturally and linguistically diversegroups 7.4 Economicevaluation
39
41 42 42 42 43 44 44 47 47 47 47 47 49 50 50 51 51 51 52 54 54 54
Preventing Falls and Harm From Falls inOlderPeople
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8 Continence 8.1 Background andevidence 8.1.1 Incontinence associated with increased fallsrisk 8.1.2 Incontinence and fallsintervention 8.2 Principlesofcare 8.2.1 Screeningcontinence 8.2.2 Strategies for promotingcontinence 8.3 Specialconsiderations 8.3.1 Cognitiveimpairment 8.3.2 Rural and remotesettings 8.3.3 Indigenous and culturally and linguistically diversegroups 8.4 Economicevaluation 9 Feet andfootwear 9.1 Background andevidence 9.1.1 Footwear associated with increased fallsrisk 9.1.2 Foot problems and increased fallsrisk 9.2 Principlesofcare 9.2.1 Assessing feet andfootwear 9.2.2 Improving foot condition andfootwear 9.3 Specialconsiderations 9.3.1 Cognitiveimpairment 9.3.2 Rural and remotesettings 9.3.3 Indigenous and culturally and linguistically diversegroups 9.4 Economicevaluation 10 Syncope 10.1 Background andevidence 10.1.1 Vasovagalsyncope 10.1.2 Orthostatic hypotension (posturalhypotension) 10.1.3 Carotid sinushypersensitivity 10.1.4 Cardiacarrhythmias 10.2 Principlesofcare 10.3 Specialconsiderations 10.3.1 Cognitiveimpairment 10.4 Economicevaluation 11 Dizziness andvertigo 11.1 Background andevidence 11.1.1 Vestibular disorders associated with anincreased riskoffalling 11.2 Principlesofcare 11.2.1 Assessing vestibularfunction 11.2.2 Choosing interventions toreduce symptomsofdizziness 11.3 Specialconsiderations 11.4 Economicevaluation
55 56 56 57 58 58 59 60 60 60 60 60 61 61 62 64 64 64 65 66 66 66 66 66 67 68 68 68 69 69 69 70 70 70 71 72 72 73 73 73 75 75
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Page
12 Medications 12.1 Background andevidence 12.1.1 Medication use and increased fallsrisk 12.1.2 Evidence forinterventions 12.2 Principlesofcare 12.2.1 Assessingmedications 12.2.2 Providing in-hospitalinterventions
77 78 78 78 79 79 79 80 80 80 80 80 83 84 84 85 86 86 87 88 89 89 89 89 89 89 91 92 92 92 92 93 93 93 93 93 94 94 94 94 94

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12.2.3 Providing post-hospitalinterventions 12.3 Specialconsiderations 12.3.1 Cognitiveimpairment 12.3.2 Rural and remotesettings 12.4 Economicevaluation 13 Vision 13.1 Background andevidence 13.1.1 Visual functions associated with increased fallrisk 13.1.2 Eye diseases associated with anincreased riskoffalling 13.2 Principlesofcare 13.2.1 Screeningvision 13.2.2 Providinginterventions 13.2.3 Dischargeplanning 13.3 Specialconsiderations 13.3.1 Cognitiveimpairment 13.3.2 Rural and remotesettings 13.3.3 Indigenous and culturally and linguistically diversegroups 13.3.4 Patients with limitedmobility 13.4 Economicevaluation 14 Environmentalconsiderations 14.1 Background andevidence 14.2 Principlesofcare 14.2.1 Targeting environmentinterventions 14.2.2 Designing multifactorial interventions that includeenvironmentalmodifications 14.2.3 Incorporating capital works planning anddesign 14.2.4 Providing storage andequipment 14.2.5 Conducting environmentalreviews 14.2.6 Orientating newresidents 14.2.7 Review andmonitoring 14.3 Specialconsiderations 14.3.1 Cognitiveimpairment 14.3.2 Rural and remotesettings 14.3.3 Nonambulatorypatients 14.4 Economicevaluation
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15 Individual surveillance andobservation 15.1 Background andevidence 15.2 Principlesofcare 15.2.1 Flagging 15.2.2 Colours for stickers and bedsidenotices 15.2.3 Sitterprograms 15.2.4 Responsesystems 15.2.5 Review andmonitoring 15.3 Specialconsiderations 15.3.1 Cognitiveimpairment 15.3.2 Indigenous and culturally and linguistically diversegroups 15.4 Economicevaluation 16 Restraints 16.1 Background andevidence 16.2 Principlesofcare 16.2.1 Assessing the need for restraints and consideringalternatives 16.2.2 Usingrestraints 16.2.3 Review andmonitoring 16.3 Specialconsiderations 16.3.1 Cognitiveimpairment 16.4 Economicevaluation
97 98 98 98 99 99 99
100 100 100 100 101 103 104 104 104 105 105 106 106 106
PartD Minimising injuries fromfalls

17 Hipprotectors 17.1 Background andevidence 17.1.1 Studies onhip protectoruse 17.1.2 Types ofhipprotectors 17.1.3 How hip protectorswork 17.1.4 Adherence with use ofhipprotectors 17.2 Principlesofcare 17.2.1 Assessing the use ofhipprotectors 17.2.2 Using hip protectorsatnight 17.2.3 Cost ofhipprotectors 17.2.4 Training inhip protectoruse 17.2.5 Review andmonitoring 17.3 Specialconsiderations 17.3.1 Cognitiveimpairment 17.3.2 Indigenous and culturally and linguistically diversegroups 17.3.3 Climate 17.4 Economicevaluation
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111 112 112 112 113 113 114 114 114 114 114 115 115 115 115 115 115
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Page
18 VitaminD and calciumsupplementation 18.1 Background andevidence 18.1.1 VitaminD supplementation (with orwithout calcium) inthe communitysetting 18.1.2 VitaminD combined with calcium supplementation inthe RACFsetting 18.1.3 VitaminD supplementation alone inRACFsettings
117 118 118 119 119 119 120 120 120 120 120 120 121 121 121 121 121 123 124 124 124 125 126 126 127 127 127
18.1.4 Vitamin D, sunlight and winter inthe communitysetting 18.1.5 Toxicity anddose 18.2 Principlesofcare 18.2.1 Assess vitaminDadequacy 18.2.2 Ensure minimum sun exposure toprevent vitaminDdeficiency 18.2.3 Consider vitaminD and calciumsupplementation 18.2.4 Encourage patients toinclude foods high incalcium intheirdiet 18.2.5 Discourage patients from consuming foods that prevent calciumabsorption 18.3 Specialconsiderations 18.3.1 Cognitiveimpairment 18.3.2 Indigenous and culturally and linguistically diversegroups 18.4 Economicevaluation 19 Osteoporosismanagement 19.1 Background andevidence 19.1.1 Falls andfractures 19.1.2 Diagnosingosteoporosis 19.1.3 Evidence forinterventions 19.2 Principlesofcare 19.2.1 Review andmonitoring 19.3 Specialconsiderations 19.3.1 Cognitiveimpairment 19.4 Economicevaluation
Part E Respondingtofalls
20 Post-fallmanagement 20.1 Background 20.2 Respondingtofalls 20.2.1 Post-fallfollow-up 20.3 Analysing thefall 20.4 Reporting and recordingfalls 20.4.1 Minimum dataset for reporting and recordingfalls 20.5 Comprehensive assessment followingafall 20.6 Loss ofconfidence afterafall
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133 134 134 135 135 136 136 137 137
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Appendices
Appendix 1 Contributors totheguidelines Appendix 2 Falls risk screening and assessmenttools Appendix 3 Safe shoechecklist247 Appendix 4 Environmentalchecklist45 Appendix 5 Equipment safetychecklist 361 Appendix 6 Checklist ofissues toconsider before using hipprotectors 318 Appendix 7 Hip protector Appendix 8 Hip protector Appendix 9 Hip protector careplan247 observationrecord247 educationplan302
139
141 145 159 161 165
167 169 171 173 175 177 179 181 183
Appendix 10 Food and fluid intakechart Appendix 11 Food guidelines for calcium intake for preventing falls inolderpeople339 Appendix 12 Post-fall assessment and management Glossary References
Tables
Table 1.1 Table 2.1 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 6.1 Table 7.1 Table 13.1 Table 19.1 National Health and Medical Research Council levelsofevidence Risk factors for falling Screeningtools Risk screening tools for the emergency departmentsetting Risk assessmenttools Specific risk factorassessments Clinical assessments for measuring balance, mobility andstrength Tools for assessing cognitivestatus Characteristics ofeye-screeningtests Pharmaceutical Benefits Scheme details for osteoporosisdrugs hospitals2 7 15 32 33 34 35 44 51 86 127
Figures
Figure 1.1 Figure 9.1 Figure 13.1 Using the guidelines toprevent fallsinAustralia Normalvision 9 85 85 85 The theoretical optimal safe shoe, and unsafeshoe 63
Figure 13.2 Visual changes resulting fromcataracts Figure 13.3 Visual changes resulting fromglaucoma
Figure 13.4 Visual changes resulting from maculardegeneration 85
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xii Preventing Falls and Harm From Falls inOlderPeople
Acronyms andabbreviations
AMTS AST BPPV CAM DXA FESI FR FRAT FRHOP ICER JBI-PACES LYS MET MMSE NARI NHMRC OAB PBS PEDro PJC-FRAT POMA PPA ProFaNE PROFET PSA QALY RACF RCT RDI RUDAS
Abbreviated Mental TestScore Alternate StepTest benign paroxysmal positionalvertigo Confusion AssessmentMethod dual energy X-rayabsorptiometry Falls Efficacy ScaleInternational functionalreach Falls Risk AssessmentTool Falls Risk for Hospitalised OlderPeople incremental cost-effectivenessratio Joanna Briggs Institute Practical Application ofClinical EvidenceSystem life yearssaved Melbourne EdgeTest Mini Mental StateExamination National Ageing ResearchInstitute National Health and Medical ResearchCouncil overactivebladder Pharmaceutical BenefitsScheme Physiotherapy EvidenceDatabase Peter James Centre Fall Risk AssessmentTool Performance-Oriented Mobility AssessmentTool Physiological ProfileAssessment Prevention ofFalls NetworkEurope Prevention ofFalls inthe ElderlyTrial Pharmaceutical SocietyofAustralia quality-adjusted lifeyears residential aged carefacility randomised controlledtrial recommended dailyintake Rowland Universal DementiaScale
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SERM SHPA SMW STRATIFY STS TBI TUG VA VR

selective oestrogen receptormodulator Society for HospitalPharmacists Six-Metre WalkTest St Thomas Risk Assessment Tool inFalling ElderlyIn-patients Sit-to-StandTest traumatic braininjury Timed Up-and-GoTest visualacuity vestibularrehabilitation
xiv Preventing Falls and Harm From Falls inOlderPeople
Preface
Falls are asignificant cause ofharm toolder people. The rate, intensity and cost offalls identify them asanational safety and quality issue. The Australian Commission onSafety and Quality inHealth Care (ACSQHC) ischarged with leading and coordinating improvements inthe safety and quality ofhealth care nationally, and has consequently produced these guidelines onpreventing falls and harm from falls inolderpeople. Health care services are provided inarange ofsettings. 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, someinformation and recommendations are specific toeach setting. Collectively, the guidelines are referredtoasthe FallsGuidelines. This document, Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Hospitals 2009, aims toreduce the number offalls and the harm caused byfalls experienced byolder peopleinhospitalcare. The guidelines and support materials are suitable for hospitalsthat: do not have afalls prevention program orplaninplace have recently initiated afalls prevention programorplan have asuccessful falls prevention program orplaninplace. Older people themselves are atthe centre ofthe guidelines. Their participation, tothe full extent oftheirdesire and ability, encourages shared responsibility inhealth care, promotes quality care, andfocuseson accountability. The guidelines are written topromote patient-centred independence and rehabilitation. Hospital care inany form involves some risk for many older people. The guidelines donot promote anentirely riskaverse approach tothe health care ofolder people. Some falls are preventable; some are not preventable. However,anexcessively custodial and risk-averse approach designed toavoid complaints orlitigation fromolder people and their carers may infringe onapersons autonomy and limitrehabilitation. Wherever possible, these guidelines are based onresearch evidence and are written tosupplement the clinical knowledge, competence and experience applied byhealth professionals. However, aswith all guidelines and the principles ofevidence-based practice, their application isintended tobe inthe context ofthe professional judgment, clinical knowledge, competence and experience ofhealth professionals. The guidelines also acknowledge that the clinical judgment ofinformed professionals isbest practice inthe absence ofgood-quality published evidence. Some flexibility may therefore berequired toadapt these guidelines tospecific settings, tolocal circumstances, and toolder peoples needs, circumstances andwishes. The following additional materials have been prepared toaccompany theguidelines: Guidebook for Preventing Falls and Harm From Falls inOlder People: Australian Hospitals2009 Falls Guidelines factsheets Falls Guidelines poster. These guidelines are the result ofareview and rewrite ofthe first edition ofthe guidelines, Preventing Falls and Harm from Falls inOlder People Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities 2005,1 which were developed bythe former Australian Council for Safety and Quality inHealthCare.
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Key messages oftheguidelines

Many falls canbeprevented. Fall and injury prevention need tobe addressed atboth point ofcare and from amultidisciplinaryperspective. Managing many ofthe risk factors for falls (eg delirium orbalance problems) will have wider benefits beyond fallsprevention. Engaging older people isan integral part ofpreventing falls and minimising harm fromfalls. Best practice infall and injury prevention includes implementing standard falls prevention strategies, identifying fall risk and implementing targeted individualised strategies that are resourced adequately, and monitored and reviewedregularly. The consequences offalls resulting inminor orno injury are often neglected, but factors such asfear offalling and reduced activity level can profoundly affect function and quality oflife, and increase the risk ofseriously harmfulfalls. The most effective approach tofalls prevention islikely tobe one that includes all staff inhealth care facilities engaged inamultifactorial falls preventionprogram. At astrategic level, there will beatime lag between investment inafalls prevention program and improvements inoutcomemeasures.
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Acknowledgments
The Australian Commission onSafety and Quality inHealth Care (ACSQHC) acknowledges the authors, reviewers and editors who undertook the work ofreviewing, restructuring and writing theguidelines. ACSQHC acknowledges the significant contribution ofthe Falls Guidelines Review Expert Advisory Group fortheir time and expertise inthe development ofthe FallsGuidelines. ACSQHC also acknowledges the contribution ofmany health professionals who participated infocus groups, and provided comment and other support tothe project. Inparticular, the National Injury Prevention Working Group, anetwork ofjurisdictional policy staff, played asignificant role incommunicating the review totheir networks and providingadvice. The guidelines build onearlier work bythe former Australian Council for Safety and Quality inHealth Care and byQueenslandHealth. The contributions ofthe national and international external quality reviewers and the Office ofthe Australian Commission onSafety and Quality inHealth Care are alsoacknowledged. ACSQHC funded the preparation ofthese guidelines. Members ofthe Falls Guidelines Review Expert Advisory Group have nofinancial conflict ofinterest inthe recommendations oftheguidelines. A full list ofauthors, reviewers and contributors isprovided inAppendix1. ACSQHC gratefully acknowledges the kind permission of St Vincents and Mater Health Sydney to reproduce many of the images in the guidelines.
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Falls Guidelines Review Expert AdvisoryGroup

Chair
Associate Professor StephenLordPrincipal Research Fellow, Prince ofWales Medical Research Institute, The University ofNew SouthWales
Members
Associate Professor JacquelineCloseSenior Staff Specialist, Prince ofWales Hospital and Clinical School, The University ofNew SouthWales. Senior Research Fellow, Prince ofWales Medical Research Institute, The University ofNew SouthWales Ms MandyHardenCNC Aged Care Education/Community Aged Care Services, Hunter New England Area Health Services, NSWHealth Professor KeithHillProfessor ofAllied Health, LaTrobe University/Northern Health, Senior Researcher, Preventive and Public Health Division, National Ageing ResearchInstitute Dr KirstenHowardSenior Lecturer, Health Economics, School ofPublic Health, The UniversityofSydney Ms LorraineLovittLeader, New South Wales Falls Prevention Program, Clinical ExcellenceCommission Ms RozelleWilliamsDirector ofNursing/Site Manager, Rice Village, Geelong, Victoria, Mercy Health and AgedCare
Projectmanager
Mr GrahamBedfordPolicy Team Manager,ACSQHC
External qualityreviewers
Associate Professor NgaireKerseAssociate Professor, General Practice and Primary Health Care, School ofPopulation Health, Faculty ofMedical and Health Sciences, The University ofAuckland, NewZealand Professor DavidOliverPhysician and Clinical Director, Royal Berkshire Hospital, Reading, UnitedKingdom Professor ofMedicine for Older People, School ofPopulation and Health Science, City University, London, UnitedKingdom Associate Professor ClareRobertsonResearch Associate Professor, Department ofMedical andSurgical Sciences, Dunedin School ofMedicine, University ofOtago, NewZealand
Technical writing andediting

Ms MegHeaslopBiotext Pty Ltd,Brisbane Dr JanetSalisburyBiotext Pty Ltd,Canberra
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Summary ofrecommendations and goodpracticepoints
This section contains asummary ofthe guidelines recommendations and good practice points. These are also presented atthe start ofeach chapter, with accompanying references andexplanations.
Part B
Chapter 4
Standard falls preventionstrategies

Falls preventioninterventions
Recommendations
Intervention
A multifactorial approach topreventing falls should bepart ofroutine care for all older people inhospitals. (LevelI) 31,36 Develop and implement atargeted and individualised falls prevention plan ofcare based onthe findings ofafalls screen orassessment. (LevelII) 37-39 As part ofdischarge planning, organise anoccupational therapy home visit for people withahistory offalls, toestablish safety athome. (LevelII) 40 Patients considered tobe athigher risk offalling should bereferred toan occupational therapist and physiotherapist for needs and training specific tothe home environment andequipment, tomaximise safety and continuity from hospital tohome. (LevelI) 41
Good practicepoints
Interventions should systematically address the risk factors identified, either during the admission or, ifthis isnot possible, through discharge planning and referral tocommunityservices. Screen patients for falls risk and functional ability, and ensure that referrals for follow-up falls prevention interventions areinplace. Managing many ofthe risk factors for falls (eg delirium orbalance problems) will have widerbenefits beyond fallsprevention.
Chapter 5
Falls risk screening andassessment
Recommendations
Screening andassessment
Document the patients history ofrecent falls, oruse avalidated screening tool toidentify people with risk factors for fallsinhospital. Use falls risk screening and assessment tools that have good predictive accuracy, and have been evaluated and validated across different hospitalsettings. As part ofamultifactorial program for patients with increased falls risk inhospital, conduct asystematic and comprehensive multidisciplinary falls risk assessment toinform the development ofan individualised plan ofcare topreventfalls. When falls risk screens and assessments are introduced, they need tobe supported by education for staff and intermittent reviews toensure appropriate and consistentuse.
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Good practicepoints
Falls riskscreening
Screening tools are particularly beneficial because they can form part ofroutine clinical management and inform further assessment and care for all patients even though clinicaljudgment isas effective asusing ascreening tool inacutecare. All older people who are admitted tohospital should bescreened for their falls risk, and this screening should bedone assoon aspracticable after they areadmitted. The emergency department represents agood opportunity toscreen patients for their fallsrisk. A falls risk screen should beundertaken when achange inhealth orfunctional status isevident, orwhen the patients environmentchanges.

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Falls riskassessment
A falls risk assessment should bedone for those patients who exceed the threshold ofthe falls risk screen tool, who are admitted for falls, orwho are from asetting inwhich most people are considered tohave ahigh risk offalls (eg astroke rehabilitationunit). For patients who have fallen more than once, undertake afull falls risk assessment for each fall (approximately 50% offalls are inpatients who have alreadyfallen). Interventions delivered asaresult ofthe assessment provide benefit, rather than the assessment itself; therefore, itis essential that interventions systematically address the risk factorsidentified.

Chapter 6 Balance and mobilitylimitations
Recommendation
Intervention
Use amultifactorial falls prevention program that includes exercise and assessment ofthe need for walking aids toprevent falls insubacute hospital settings. (LevelII) 39
Good practicepoints
Refer patients with ongoing balance and mobility problems toapost-hospital falls prevention exercise program when they leave hospital. This should include liaison with the patients generalpractitioner. To assess balance, mobility and strength, use anassessment toolto: quantify the extent ofbalance and mobility limitations and muscleweaknesses guide exerciseprescription measure improvements inbalance, mobility andstrength assess whether patients have ahigh riskoffalling.
Chapter 7
Cognitiveimpairment
Recommendations
Assessment
Older people with cognitive impairment should have their risk factors for fallsassessed.
Intervention
Identified falls risk factors should beaddressed aspart ofamultifactorial falls prevention program, and injury minimisation strategies (such asusing hip protectors orvitaminD and calcium supplementation) should beconsidered. (LevelII) 37-39
Good practicepoints
Patients presenting toahospital with anacute change incognitive function should beassessed for delirium and the underlying cause ofthischange. Patients with gradual onset, progressive cognitive impairment should undergo detailed assessment todetermine diagnosis and, where possible, reversible causes ofthe cognitivedecline. Patients with delirium should receive evidence based interventions tomanage the delirium (eg follow the Australian guidelines, Clinical Practice Guidelines for the Management ofDelirium inOlderPeople ). If apatient with cognitive impairment does fall, reassess their cognitive status, including presence ofdelirium (eg using the Confusion Assessment Methodtool). Where possible and appropriate, involve family and carers indecisions about which implementations touse, and how touse them, for patients with cognitive impairment. (Family and carers know the patient and may beable tosuggest ways tosupportthem.) Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations; however, interventions for people with cognitive impairment may need tobe modified and supervised,asappropriate.
Chapter8
Continence
Recommendations
Intervention
Ward urinalysis should form part ofaroutine assessment for older people with arisk offalling. (LevelII) 37 As part ofmultifactorial intervention, toileting protocols and practices should bein place for patients atrisk offalling. (LevelIII-2) 43,133 Managing problems with urinary tract function iseffective aspart ofamultifactorial approach tocare. (LevelII) 37
Good practicepoint
Incontinence can bescreened inhospital aspart ofavalidated falls risk screen assessment, such asthe StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY) orthe Peter James Centre Fall Risk Assessment Tool(PJC-FRAT).
http://www.health.vic.gov.au/acute-agedcare/delirium-cpg.pdf
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Chapter 9
Feet andfootwear
Recommendations
Assessment
In addition tousing standard falls risk assessments, screen patients for ill-fitting orinappropriate footwear upon admissiontohospital.
Intervention
Include anassessment offootwear and foot problems aspart ofan individualised, multifactorial intervention for preventing falls inolder people inhospital. (LevelII) 37 Hospital staff should educate patients and provide information about footwear features that may reduce the risk offalls. (LevelII) 37

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Good practicepoints
Safe footwear characteristicsinclude: soles: shoes with thinner, firmer soles appear toimprove foot position sense; atread sole may further prevent slips onslipperysurfaces heels: alow, square heel improvesstability collar: shoes with asupporting collar improvestability. As part ofdischarge planning, refer patients toapodiatrist,ifneeded.
Chapter10 Syncope
Recommendations
Assessment
Patients who report unexplained falls orepisodes ofcollapse should beassessed for the underlyingcause.
Intervention
Patients with unexplained falls orepisodes ofcollapse who are diagnosed with the cardioinhibitory form ofcarotid sinus hypersensitivity should betreated byinserting adual-chamber cardiac pacemaker. (LevelII) 189 Assessment and management ofpostural hypotension and review ofmedications, including medications associated with presyncope and syncope, should form part ofamultifactorial assessment and management plan for falls prevention inhospitalised older people (this can also bepart ofdischarge planning). (LevelI) 31
Chapter 11 Dizziness andvertigo

Recommendations
Assessment
Vestibular dysfunction asacause ofdizziness, vertigo and imbalance needs tobe identified inthe hospital setting. Ahistory ofvertigo orasensation ofspinning ishighly characteristic ofvestibularpathology. Use the Dix-Hallpike test todiagnose benign paroxysmal positional vertigo, which isthe most common cause ofvertigo inolder people and can beidentified inthe hospital setting. This isthe only cause ofvertigo that can betreatedeasily.
Note: there isno evidence from randomised controlled trials that treating vestibular disorders willreduce the rateoffalls.
Good practicepoints
Use the Epley manoeuvre tomanage benign paroxysmal positionalvertigo. Use vestibular rehabilitation totreat dizziness and balance problems, whereindicated. Screen patients complaining ofdizziness for gait and balance problems, aswell asfor postural hypotension. (Patients who complain ofdizziness may have presyncope, postural dysequilibrium, orgait orbalancedisorders.) All manoeuvres should only bedone byan experiencedperson.
Chapter12 Medications
Recommendations
Intervention
Older people admitted tohospital should have their medications (prescribed and nonprescribed) reviewed and modified appropriately (and particularly incases ofmultiple drug use) asacomponent ofamultifactorial approach toreducing the risk offalls inahospital setting. (LevelI) 31 As part ofamultifactorial intervention, patients onpsychoactive medication should have their medication reviewed and, where possible, discontinued gradually tominimise side effects and toreduce their risk offalling. (LevelII-*) 37,235
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Chapter13 Vision
Recommendations
Assessment
Use hospitalisation asan opportunity toscreen systematically for visual problems that can have aneffect both inthe hospital setting and afterdischarge. For arough estimate ofthe patients visual function, assess their ability toread astandard eye chart (eg aSnellen chart) orto recognise aneveryday object (eg pen, key, watch) from adistance oftwometres.

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Intervention
As part ofamultidisciplinary intervention for reducing falls inhospitals, provide adequate lighting, contrast and other environmental factors tohelp maximise visual clues; for example, prevent falls byusing luminous commode seats, luminous toilet signs and night sensor lights. (LevelIII-3) 43 Where apreviously undiagnosed visual problem isidentified, refer the patient toan optometrist, orthoptist orophthalmologist for further evaluation (this also forms part ofdischarge planning). (LevelII) 37 When correcting other visual impairment (eg prescription ofnew glasses), explain tothe patient and their carers that extra care isneeded while the patient becomes used tothe new visual information. (LevelII-*) 249 Advise patients with ahistory offalls oran increased risk offalls toavoid bifocals ormultifocals and touse single-lens distance glasses when walking especially when negotiating steps orwalking inunfamiliar surroundings. (LevelIII-2-*) 250 As part ofgood discharge planning, make sure that older people with cataracts have cataract surgery assoon aspracticable. (LevelII-*) 251,252
Note: there have not been enough studies toform strong, evidence based recommendations about correcting visual impairment toprevent falls inany setting (community, hospital, residential aged care facility), particularly when used assingle interventions. However, considerable research has linked falls with visual impairment inthe community setting, and these results may also apply tothehospitalsetting.
Good practicepoints
If apatient uses spectacles, make sure that they wear them, and that they are clean (useasoft, clean cloth), unscratched and fitted correctly. Ifthe patient has apair ofglasses for reading and apair for distance, make sure they are labelled accordingly, and that they wear distance glasses whenmobilising. Encourage patients with impaired vision toseek help when moving away from their immediate bedsurrounds.
Chapter 14 Environmentalconsiderations
Recommendations
Assessment
Regular environmental reviews are advisable; procedures should bein place todocument environmental causes offalls; and staff should beeducated inenvironmental risk factors forfallsinhospitals.
Intervention
Environmental modifications should beincluded aspart ofamultifactorial intervention. (LevelII) 37,38 As part ofamultifactorial intervention, falls can bereduced byusing luminous toilet signs and night sensor lights. (LevelIII-3) 43
Good practicepoints
Make sure that the patients personal belongings and equipment are easy and safe for themtoaccess. Check all aspects ofthe environment and modify asnecessary toreduce the risk offalls (egfurniture, lighting, floor surfaces, clutter and spills, and mobilisationaids). Conduct environmental reviews regularly (consider combining them with occupational health and safetyreviews).
Chapter 15 Individual surveillance andobservation

Recommendations
Intervention
Include individual observation and surveillance ascomponents ofamultifactorial falls prevention program, but take care not toinfringe onpeoples privacy. (LevelIII-2) 43 Falls risk alert cards and symbols can beused toflag high-risk patients aspart ofamultifactorial falls prevention program, aslong asthey are followed upwith appropriate interventions. (LevelII) 39 Consider using avolunteer sitter program for patients who have ahigh risk offalling, anddefine the volunteer roles clearly. (LevelIV) 42,64
Good practicepoints
Most falls inhospitals are unwitnessed. Therefore, the key toreducing falls isto raise awareness among staff ofthe patients individual risk factors, and reasons why improved surveillance may reduce the riskoffalling. If appropriate, hospital staff should discuss with carers, family orfriends the patients risk offalling and their need for closemonitoring. Family members orcarers can begiven aninformation brochure touse indiscussions withthe patient about fallsinhospitals. Encourage family members orcarers tospend time sitting with the patient, particularly inwaking hours, and encourage them tonotify staff ifthe patient requiresassistance. A range ofalarm systems and alert devices are available, including motion sensors, video surveillance and pressure sensors. They should betested for suitability before purchase, andappropriate training and response mechanisms should beoffered tostaff. Alternatively, find another hospital that already has aneffective alarm system, see what their program includes, and try theirsystem. Patients who have ahigh risk offalling should becheckedregularly. A staff member should stay with patients with cognitive impairment and ahigh risk offalls while the patient isin thebathroom.
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Chapter16 Restraints
Recommendations
Assessment
Causes ofagitation, wandering and other behaviours should beinvestigated, and reversible causes ofthese behaviours (eg delirium) should betreated, before restraint useisconsidered.
Note: there isno evidence that physical restraints reduce the incidence offalls orserious injuries inolder people.290-293 However, there isevidence that they can cause death, injury orinfringement ofautonomy.294,295 Therefore, restraints should beconsidered the last option for patients who are atriskoffalling.296
Good practicepoints
The focus ofcaring for patients with behavioural issues should beon responding tothe patients behaviour and understanding its cause, rather than attempting tocontrolit. All alternatives torestraint should beconsidered and trialled for patients with cognitive impairment, includingdelirium. If all alternatives are exhausted, the rationale for using restraints must bedocumented andananticipated duration agreed onby the health careteam. If drugs are used specifically torestrain apatient, the minimal dose should beused and the patient should bereviewed and monitored toensure their safety. Importantly, chemical restraint must not beasubstitute for quality care. Follow hospital protocol ifphysical restraints mustbeused. Any restraint use should not only beagreed onby the health team, but also discussed withfamilyorcarers.
Part D
Minimising injuries fromfalls
Chapter 17 Hipprotectors
Recommendations
Assessment
When assessing apatients need for hip protectors inhospital, staff should consider the patients recent falls history, age, mobility and steadiness ofgait, disability status, andwhether they have osteoporosis oralow body massindex. Assessing the patients cognition and independence indaily living skills (eg dexterity indressing) may also help determine whether the patient will beable touse hipprotectors.
Intervention
Hip protectors must beworn correctly for any protective effect, and the hospital should introduce education and training for staff inthe correct application ofhip protectors. (LevelII-*) 302 When using hip protectors aspart ofafalls prevention strategy, hospital staff should check regularly that the patient iswearing their protectors, and ensure that the hip protectors are comfortable and the patient can put them oneasily. (LevelI-*) 303
xxvi
Good practicepoints
Although there isno evidence ofthe effectiveness ofhip protectors inthe hospital setting, their use can beconsidered inindividual cases where the patient isable totolerate wearing them, and has ahigh risk ofinjuriousfalls. If hip protectors are tobe used, they must befitted correctly and worn atalltimes. The use ofhip protectors inhospitals ischallenging but feasible insubacute wards. Inhospital wards where patients are acutely ill (acute wards), effective use ofhip protectors has not been shown tobepossible. Hip protectors are apersonal garment and should not beshared betweenpatients.
Chapter 18 VitaminD and calciumsupplementation

Recommendations
Assessment
To screen for possible vitaminD deficiency, dieticians, nutritionists orhealth professionals can collect information onthe patients eating habits, food preferences, meal patterns, food intake and sunlight exposure. Alternatively, ablood sample canbetaken.
Intervention
VitaminD and calcium supplementation should berecommended asan intervention strategy toprevent falls inolder people. Benefits from supplementation are most likely tobe seen inpatients who have vitaminD insufficiency (25(OH)D of<50 nmol/L) ordeficiency (25(OH)D of<25 nmol/L), comply with the medication, and respond biochemically tosupplementation. (LevelI-*) 31
Note: itis unlikely that benefits from vitaminD and calcium supplementation will beseen inhospital (particularly inacute care orshort stays), but there isevidence both from the community and residential aged care settings tosupport dietary supplementation, particularly inpeople who are deficient invitaminD.
Good practicepoints
Hospitalisation ofan older person provides anopportunity for comprehensive health care assessment and intervention. There isno direct evidence tosuggest that calcium and vitaminD supplementation will prevent falls inhospital; however, because most older people will return home orto their residential aged care facility, hospitalisation should beviewed asan opportunity toidentify and address falls risk factors, including adequacy ofcalcium and vitamin D. This information should beincluded indischargerecommendations. As part ofdischarge planning, any introduction ofvitaminD and calcium supplementation should beconveyed tothe persons general practitioner orhealthpractitioner.
xxvii
Chapter 19 Osteoporosismanagement
Recommendations
Assessment
Patients with ahistory ofrecurrent falls should beconsidered for abone health check. Also, patients who sustain aminimal-trauma fracture should beassessed for their riskoffalls.
Intervention
People with diagnosed osteoporosis orahistory oflow-trauma fracture should be offered treatment for which there isevidence ofbenefit. (LevelI) 283 Hospitals should establish protocols toincrease the rate ofosteoporosis treatment inpatients who have sustained their first osteoporotic fracture. (LevelIV) 340
Good practicepoints
The health care team should consider strategies for minimising unnecessary bedrest (to maintain bone mineral density), protecting bones, improving environmental safety and vitaminD prescription, and this information should beincluded indischargerecommendations. When using osteoporosis treatments, patients should beco-prescribed vitaminDwithcalcium.
Part E
Respondingtofalls
Chapter 20 Post-fallmanagement
Good practicepoints
Hospital staff should report and document allfalls. It isadvisable toask apatient whether they remember the sensation offalling orwhether they think that they blacked out, because many patients who have syncope are unsure whether they blackedout. Staff should follow the hospital protocol orguidelines for managing patients immediately afterafall. After the immediate follow-up ofafall, determine how and why afall may have occurred, and implement actions toreduce the risk ofanotherfall. Analysing falls isone ofthe key ways toprevent future falls. Organisational learning from this analysis can beused toinform practice and policies, and toprevent future falls. Apostfall analysis should lead toan interdisciplinary care plan toreduce the risk offuture falls and injuries, and address any identified comorbidities orfalls riskfactors. An in-depth analysis ofthe fall (eg aroot-cause analysis) isrequired ifthere has been aserious injury following afall, orif adeath has resulted fromafall.
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xxix
PartA Introduction
PartA Introduction
PartA Introduction
2 Preventing Falls and Harm From Falls inOlderPeople
1 Background
PartA Introduction
1.1 About theguidelines

These guidelines aim toimprove the safety and quality ofcare for older people. They are designed for health professionals providing care inAustralian hospital settings and offer anationally consistent approach topreventing falls based onbest practice recommendations. The development ofthese guidelines was funded and managed bythe Australian Commission onSafety and Quality inHealth Care(ACSQHC). The guidelines advocate autonomy, independence, enablement and rehabilitation inthe context ofacceptable risk offalling. Adegree ofrisk isinevitable inpromoting autonomy inolderpeople. Any fall needs tobe considered inthe context ofthe care provided relative tobest practice for the individual within the specific environment. Some falls may continue tooccur even when best practice isfollowed. Insuch cases, there remains aneed for vigilant monitoring, review ofthe care plan, and implementation ofactions tominimise injuryrisk.
1.2 Scope oftheguidelines

1.2.1 Targeting olderAustralians
Falls can occur atall ages, but the frequency and severity offalls-related injury increases with age.2 Theseguidelines have been developed with older people defined aspeople aged 65 years and over inmind. When considering Indigenous Australians, older people commonly refers topeople aged over 50 years.3 These guidelines may also apply toyounger people atincreased risk offalling, such asthose with ahistory offalls, neurological conditions, cognitive problems, depression, visual impairment orother medical conditions leading toan alteration infunctional ability.4
PartA Introduction
1.2.2 Specific toAustralianhospitals

These guidelines have been developed for Australian hospitals, including emergency departments, the acute and subacute care settings, and specialised units. Separate guidelines have been developed for thecommunity and residential aged caresettings.
1.2.3 Relevant toall hospitalstaff

All hospital staff have arole toplay inpreventing falls inolder people. These guidelines have been developed for all those who either deliver orare responsible for the care ofolder people. This includes support services aswell asclinical, management and corporatestaff.
1.3 Terminology
1.3.1 Definitionofafall
For anationally consistent approach tofalls prevention within Australian facilities, itis important that astandard definition ofafall beused. For the purpose ofthese guidelines, the following definitionapplies: fall isan event which results inaperson coming torest inadvertently onthe ground orfloor A orother lowerlevel.5
To date, nonational data definition for afall exists inthe National Health Data Dictionary (run bythe Australian Governments Australian Institute ofHealth andWelfare).
1.3.2 Definition ofan injuriousfall

These guidelines use the Prevention ofFalls Network Europe (ProFaNE) definition ofan injurious fall. TheProFaNE definition considers that the only injuries that could beconfirmed accurately using existing data sources are peripheral fractures defined asany fracture ofthe limb girdles orof the limbs. Head,maxillofacial, abdominal, soft tissue and other injuries are not included inthe recommendation foracoredataset. However, other definitions ofan injurious fall include traumatic brain injuries (TBIs) asafalls-related injury, particularly asfalls are the leading cause ofTBIs inAustralia (representing 42% ofTBI-related hospitalisationsin2004-05).6
1.3.3 Definition ofassessment and riskassessment

In these guidelines, assessment isdefined asan objective evaluation ofthe older persons functional level bytheir ability toperform certain tasks and activities ofdaily living (eg dressing, feeding, grooming,mobilising). Falls risk assessment isadetailed and systematic process used toidentify apersons risk factors offalling. Itis used tohelp identify which interventions toimplement. Falls risk assessment tools should bevalidated prospectively inmore than one group orstudy (see Chapter 5 for moredetail).
http://meteor.aihw.gov.au/content/index.phtml/itemId/367274 http://www.profane.eu.org
1.3.4 Definitionofinterventions
An intervention isatherapeutic procedure ortreatment strategy designed tocure, alleviate orimprove acertain condition. Interventions can bein the form ofmedication, surgery, early detection (screening), dietary supplements, education, orminimisation ofriskfactors. In falls prevention, interventions canbe: targeted atsingle risk factors singleinterventions targeted atmultiple riskfactors multiple interventions where everyone receives the same, fixed combinationofinterventions multifactorial interventions where people receive multiple interventions, but the combination ofthese interventions istailored tothe individual, based onan individualassessment. This classification ofinterventions targeting multiple risk factors isbased onthe classification ofinterventions used bythe Cochrane Collaboration (which isbased onthe ProFaNEclassification). In general, trials have shown that interventions that target multiple risk factors (that is, both multiple and multifactorial interventions) are more effective than single interventions for preventing falls and associated injuries for older people who are inhospital for relatively long periods.7 The effectiveness ofsingle interventions inthis setting isnot known. Similarly, itis not known whether interventions are effective for people with relatively short (ie fewer than 14 days) hospital stays.7 Part Ccontains more information about the types ofinterventions that are available inthe hospitalsetting.
PartA Introduction
1.3.5 Definitionofevidence
These guidelines use adefinition ofevidence based onHealth-evidence.ca aCanadian online resource funded bythe Canadian Institutes ofHealth Research and run byMcMaster University. Itdefines evidenceas: nowledge from avariety ofsources, including qualitative and quantitative research, K programevaluations, client values and preferences, and professionalexperience.
Furthermore, these guidelines were developed using the principles ofevidence based practice, which isthe process ofintegrating clinical expertise, and patient preferences and values, with the results from clinical trials and systematic reviews ofthe medical literature. This approach also involves avoiding interventions that are shown tobe less effectiveorharmful. See Section 1.4 for more details onthe development ofthe guidelines using anevidence basedapproach.
http://www.profane.eu.org http://health-evidence.ca/
1 Background
1.4 Development oftheguidelines

1.4.1 Expert advisorygroup
To guide and provide advice tothe project, amultidisciplinary expert panel (the Falls Guidelines Review Expert Advisory Group) was established in2008. The panel included specialists inthe areas offalls prevention research, measurement and monitoring, quality improvement, change management and policy, aswell ashealth care professions from fields including geriatric medicine, allied health and nursing. Whenever necessary, the expert panel accessed resources outside its membership. Anadditional external quality reviewer was appointed toreview the guidelines from anAustralianperspective. Furthermore, aninternationally renowned, independent quality reviewer (with expertise inthe hospital setting) reviewed theseguidelines.
PartA Introduction
1.4.2 Reviewmethods
The guidelines were developed drawing onthe followingsources: the previous version oftheguidelines a search ofthe most recent literature for each risk factororintervention the most recent Cochrane review offalls prevention interventions inthe hospitalsetting feedback from health professionals and policy staff implementing the previousguidelines clinical advice from the expert advisorygroup guidance from external expertreviewers guidance from international external expertreviewers guidance from specialist groups (such asthe Royal Australian College ofGeneral Practitioners, Australian Association ofGerontology, and Continence FoundationAustralia). The review methods used were nonsystematic, because asystematic review ofeach aspect offalls prevention, for each setting (community, hospital and residential aged care facility) was beyond the capacity and timeframe ofthis update oftheguidelines. Due tothese constraints, itwas not possible tofollow the National Health and Medical Research Councils (NHMRCs) detailed requirements for developing and grading clinical practice guidelines.8 Inparticular, search terms and details ofstudy inclusion and exclusion criteria were not recorded; data extraction tables were not compiled for included studies; quality appraisal criteria were not systematically applied; and the body ofevidence was not graded inthe way set out bytheNHMRC. However, the expert group was mindful ofthe need for athorough review ofthe evidence supporting each recommendation. The methods used toreview assessment and intervention recommendations are described brieflybelow.
Assessment
Assessment recommendations were based oninformation supplied bythe clinical experts, supplemented bygeneral literature reviews, where relevant. The text ofeach section describes the supporting information and provides arationale for each recommendation. AsNHMRC methods for reviewing diagnostic questions have not been followed, noattempt has been made toapply levels ofevidence orto grade theserecommendations.
Interventions
Rapid literature searches were carried out with the aim ofidentifying the highest quality information for each intervention (systematic reviews particularly Cochrane reviews as well as, meta-analyses, and randomised controlled trials). This isin line with recommended methods for evidence based practice, where answers are needed quickly toclinical questions based onrapid identification ofthe best quality literature.9 The information retrieved inthis way was checked and supplemented byinformation from the extensive personal research databases ofthe clinical experts. Each chapter was reviewed byan external expert reviewer, before whole-of-guidelines review byan expert for eachsetting.
Economicevaluation
A systematic review ofpublished economic evaluations was undertaken. Literature searches were carried out inMedline (1950 toendJuly 2008), CINAHL (1982 toendJuly 2008), and EMBASE (1980 toendJuly 2008). MeSH terms (Economics/; orEconomics, Medical/; orEconomics, Hospital/; orTechnology Assessment, Biomedical/; orModels, economic/) and text words for economic evaluations (cost-effectiveness, cost utility, cost benefit, economic evaluation) were combined with MeSH and text words relating tofalls orto hip protectors. Reference lists ofrelevant studies and reviews were also searched, and Australian researchers werecontacted. The search identified 388 abstracts. All abstracts were reviewed, and excluded ifthey did not appear tobe economic evaluations ofeither falls prevention interventions orhip protectors. Studies that included relevant data orinformation were retrieved, and their full-text versions were analysed and examined for study eligibility. Across all interventions, atotal of27 papers were identified that considered the costs oreconomic benefits offalls prevention interventions orhip protectors. The methods, results and limitations ofthese papers are discussed inthe relevant interventionsections.
PartA Introduction
1.4.3 Levelsofevidence
The NHMRCs six-point rating system for intervention research was used toclassify each paper according tothe strength ofevidence that can bederived given the specific methods used inthe paper. Table 1.1 lists the six levelsofevidence.
Table 1.1 National Health and Medical Research Council levelsofevidence
Level
I II III-1 III-2
Description
Evidence obtained from asystematic review ofall relevant randomised controlledtrials Evidence obtained from atleast one properly designed randomised controlledtrial Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation orsome othermethod) Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies, orinterrupted time series with acontrolgroup Evidence obtained from comparative studies with historical control, two ormore singlearm studies, orinterrupted time series without aparallel controlgroup Evidence obtained from case series, either post-test, orpretest andpost-test
III-3 IV
NHMRC = National Health and Medical ResearchCouncil Source:NHMRC10
It ispossible tohave methodologically sound (Level I) evidence about anarea ofpractice that isclinically irrelevant orhas such asmall effect that itis oflittle practical importance. These issues were not formally reviewed during this update ofthe guidelines (see above), but relevant issues are described inthe text ofeach section and were taken into account bythe expert group indeveloping therecommendations. A particular problem inassessing evidence for falls prevention isthat research studies ofan intervention have often been carried out inadifferent setting (eg inaresidential aged care setting but not inahospital setting). Inthese guidelines, the highest level ofevidence for anintervention isreported regardless ofthe setting; however, when the research setting isnot ahospital, an* isadded tothe level (eg Level I-*). This shows that caution isneeded when applying economic implications for that recommendation tothe hospitalsetting. The guidelines will bereviewedin2014.
1 Background
1.5 Consultation
The consultation process involved acall for submissions, anonline survey, multiple nationwide workshops (in all state and territory capitals and anumber ofregional centres), teleconferences, and targeted interviews with key stakeholders. Anextensive range ofuseful, high-quality responses tothese processes assisted inthe development ofthe guidelines (and subsequent implementation process), aswell asto identify other areasofaction. In addition, specialist groups provided invaluable feedback onprevious guidelines and draft versions ofthese guidelines. They included the National Injury Prevention Working Group, the Australian Association ofGerontology, the Royal Australian College ofGeneral Practitioners and the Continence FoundationofAustralia. Development ofthe 2005 guidelines was underpinned byan extensive consultative process, from which these guidelinesbenefit.
PartA Introduction
1.6 Governance ofthe Australian falls prevention project for hospitals and residential aged carefacilities
The Falls Guidelines development project was directed byACSQHC inconjunction with its Inter-Jurisdictional, Private Hospital Sector and Primary Care Committees. Itwas managed bythe Office ofthe Australian Commission onSafety and Quality inHealth Care onthe advice ofthe Falls Guidelines Review Expert Advisory Group, which recommended the final guidelines for endorsementtoACSQHC.
1.7 How touse theguidelines

1.7.1 Overview
Figure 1.1 provides astep-by-step overview ofhow touse the guidelines toprevent falls and falls injuries inolder people inAustralian hospitals, inthe context ofconsumer involvement. Itis split into two linkedsections: The bold arrows inthe outer circle represent the strategic level. This isa15-step approach inthreesections plan afalls and falls injury preventionprogram implement afalls and falls injuries preventionprogram evaluate afalls and falls injuries preventionprogram. The inner circle represents interventions that can beapplied atthe point ofcare (that is, the site ofpatientcare). Abest practice approach ofindividualised assessment followed bytargeted, individualisedinterventions ispresented inParts BtoD of the guidelines (Standard falls prevention strategies, Management strategies for common falls risk factors and Minimising injuries fromfalls) .
In
he et olv
patien
t and their
Plan
car
ers
ll fa
e v en t i o n s s pr tra te
g
ie
n p la c e re i sa
PartA
Ensure s tan
da
Conduct individualised assessment
Review and monitor
Introduction
Evaluate
Implement targeted, individualised fall and injury prevention interventions
Implement
Plan
Plan for implementation
Step 1: Identify teams Step 2: Identify, consult, analyse and engage key stakeholders Step 3: Assess organisational readiness Step 4: Analyse falls
Plan for evaluation

Step 5: Establish a baseline
Plan for quality improvement

Step 6: Review current clinical practice
Implement
Step 7: Decide on implementation approaches Step 8: Determine process for implementation Step 9: Conduct trial Step 10: Learn from trial Step 11: Proceed to widespread implementation for improvement Step 12: Sustain implementation
Evaluate
Step 13: Measure process Step 14: Measure outcomes Step 15: Report and respond to results
Figure 1.1 Using the guidelines toprevent fallsinAustralia
1 Background
1.7.2 How the guidelines arepresented

The guidelines are presented infiveparts: Part AIntroduction Part B Standard falls preventionstrategies single and multiple falls preventioninterventions falls risk screening andassessment Part C Management strategies for common falls riskfactors strategies for managing common riskfactors 11 specific assessments andinterventions PartD Minimising injuries fromfalls hipprotectors vitaminD and calciumsupplementation osteoporosismanagement Part E Respondingtofalls. For ease ofreference, Parts CandD consider each falls risk factor and assessment orintervention inseparate chapters. However, these interventions are generally most successful when used incombination. Interventions and assessments tominimise falls risk factors are discussed first (Part C), followed byinterventions tominimise harm from falls (Part D). This does not imply importance ofone chapter overanother. Health care professionals and carers should consider the advantages and risks ofusing injury-prevention strategies, asoutlined inPart D, togive older people inthe hospital setting extra protection from falls and related injury. These strategies can beused after afall orapplied systematically tothe populationatrisk. Chapters onintrinsic and extrinsic risk factors inParts CandD begin with aset ofevidence based recommendations (assessment orintervention, orboth, asappropriate). The supporting information forthese recommendations ispresented inthe remainder ofthe chapter, which isorganisedinto: background information contains anoverview ofthe risk factor orintervention, and asummary oftherelevant literature onclinicaltrials principles ofcare explains how toimplement the interventionofinterest special considerations provides information relevant tospecific groups (eg Indigenous and culturally and linguistically diverse groups, rural and remote populations, people with cognitiveimpairment) economic evaluation summarises the relevant literature onhealtheconomics.
PartA Introduction
10
The guidelines contain text boxes for important information, asoutlinedbelow.
Evidence basedrecommendations
Evidence based recommendations are presented inboxes atthe start ofeach section, accompanied byreferences. They were selected based onthe best evidence and accepted bythe projects expert advisory group and external qualityreviewers. Where possible, separate recommendations for assessment and interventions are given. Assessment recommendations have been developed bythe expert group based oncurrent practice and areview ofthe literature discussed inthe text ofeachsection. Intervention recommendations are based onareview ofthe research onthe use ofthe intervention. Each recommendation isaccompanied byareference tothe highest quality study upon which itis based, aswell asalevel ofevidence (see Section 1.4.3 for anexplanation oflevelsofevidence). Recommendations based onevidence nearer the Iend ofthe scale should beimplemented, whereas recommendations based onevidence nearer the IVend ofthe scale should beconsidered for implementation onacase-by-case basis, taking into account the individual circumstances ofthepatient.
PartA Introduction
Good practicepoints
Good practice points have been developed for practice where there have not been any studies; for example, where there are nostudies assessing aparticular intervention, orwhere there are nostudies specific toaparticular setting. Inthese cases, good practice isbased onclinical experience orexpertconsensus.
Pointofinterest
These boxes indicate points ofinterest. Most points ofinterest were revealed bythe Australiawide consultation process orfrom grey literature (conference proceedings,etc).
Casestudy
These boxes indicate case studies. The case studies provide information onlikely scenarios, which are used asillustrativeexamples. Boxes containing additional information, such asuseful websites, organisations orresources, are also provided. References are listed atthe end oftheguidelines.
1 Background
11
PartA Introduction
2 Falls and falls injuriesinAustralia
PartA Introduction
The following isabrief summary ofthe background information derived from the literature inrelation tofalls inhospitals. Specific literature related torisk factors for falling isoutlined inthe relevantsections.
2.1 Incidenceoffalls
Falls-related injury isone ofthe leading causes ofmorbidity and mortality inolder Australians, with more than 80% ofinjury-related hospital admissions inpeople aged 65 years and over due tofalls and fallsrelated injuries.11 Fall rates are greater for older people.11 Fall rates of412 per 1000 bed days have been described inthis age group.12 Incident rates vary between wards and departments inhospitals. Inthesubacute orrehabilitation hospital setting, more than 40% ofpatients with specific clinical problems, suchasstroke, experience one ormore falls during their admission.2 Injuries result from approximately 30%ofsuch fallsinhospital.13 Australian data onfalls inhospitals donot distinguish between injuries that occur before and after admission. Ifapatient isadmitted tohospital for one reason and falls while inhospital care, itis not recorded asaseparateevent.14
2.2 Fall rates inolderpeople

Injuries requiring hospitalisation increase with age (beginning at65 years old), and falls are the biggest reason for these injuries.14 Falls are the single biggest reason for injury-related admission tohospital and presentations tothe emergency department inpeople over 65 years.14 Every year, approximately 30% ofAustralians over 65 years old fall, with 10% ofthese falls leading toinjury.15 Approximately 8%offallsrelated overnight admissions donot gohome, asopposed to4.5% ofotheradmissions.16 An increase infalling aspeople age isassociated with decreased muscle tone, strength and fitness asaresult ofphysical inactivity. Certain medications can contribute toan increased risk offalling. Alcoholconsumption can also lead tomore falls, particularly ifthe alcohol interacts with certain medications.14 Impaired vision also contributestofalls.14 Falls are also associated with anincreased incidence ofdeath inolder people, particularly people older than 80years. In2002, the death rate from falls ranged from 18 deaths per 100000 people (aged 6584 years) to81 deaths per 100000 people (aged 85 years and older, inall settings not specific tothe hospital setting).17 Age-standardised fall injury cases (leading tohospitalisation) increased to2415 injuries per 100000 people (in 200506) from 2295 injuries per 100000 people (in200304).18 The potential for falls increases once older people enter health care facilities. Even with high rates offalls, there may still beunder-reportingofevents.19
2.3 Impactoffalls
The hip and thigh are the most commonly injured areas requiring hospitalisation inboth men and women sustaining falls.18 Femur fractures from falls have decreased since 1999200018 by1.3% per year for men and 2.2% for women. Head injuries are also common, more sofor men, and indicate that injury prevention mechanisms for the head should beconsidered, aswell asfor hips andthighs.18 Hip fractures are one ofthe most common reasons for hospital admission (in relation toinjury), and most (91%) hip fractures are caused byfalls.14 Hip fractures impose heavily onthe Australian community due toincreased death and morbidity, decreased independence, increased burden onfamily members and carers, increased costs due torehabilitation, and increased admission into residential aged carefacilities.14
13
Falls also result inwrist fractures; when people fall, they put their arms out tobreak thefall.14 Falls may lead tocomplications, including afear offalling oraloss ofconfidence inwalking, alonger stay inhospital orother facility, additional diagnostic procedures orsurgery, and potential litigation.2 Additionally, falls may result incaregiver stress, and fear oflitigation for clinical and administrativestaff.2
2.4 Costoffalls
In addition toinjuries, falls are costly tothe individual interms offunction and quality oflife2 and also tothe community. Research across all settings shows that, inthe face ofan ageing population, ifnothing more isdone toprevent fallsby2051: 20 the total estimated health cost attributable tofalls-related injury will increase almost threefold from A$498.2 million per year in2001 toA$1375 million per yearin2051 in hospitals, 886 000 additional bed days per year, orthe equivalent of2500 additional beds, will bepermanently allocated totreating falls-relatedinjuries. To maintain the current health costs, there will need tobe a66% reduction inthe incidence offalls-related hospitalisationsby2051.20
PartA Introduction
2.5 Economic considerations infalls preventionprograms

In health care, resources are limited there are insufficient resources toprovide all programs toall people. Therefore, health care providers and funders need tochoose programs toensure they are getting good value for money. This means that itis nolonger enough todemonstrate that anintervention iseffective itshould also beagood use ofscarce health care resources. Individual and organisational components ofprograms for preventing falls should beselected byweighing upthe costs and the benefits (healthoutcomes). Health care providers must decide how they can facilitate improvements inhealth outcomes with finite resources, choosing the most effective intervention they canafford. Economic evaluation offalls prevention programs isan important element ofthe overall decision-making process when comparing different options for falls prevention. Aneconomic evaluation (often called acosteffectiveness analysis) compares both costs and health outcomes ofalternative health care programs. Health outcomes from afalls prevention intervention can becounted innatural units, such asfalls prevented, fractures prevented, deaths prevented, and survival often expressed aslife years saved (LYS) oras multidimensional health outcomes, which include both survival and quality oflife inasingle composite measure (such asaquality-adjusted life years QALYs). The cost effectiveness ofanew program isassessed bycomparing the costs and health outcomes ofthe new program with the costs and health outcomes ofan alternative program (often current clinical practice orusual care) bycalculating anincremental cost-effectiveness ratio (ICER). The ICER represents the extra cost for each additional unit ofhealth outcome, and isameasure ofvalue for money. Programs with lower ICERs offer better value for money (they are more cost effective) than programs with higherICERs.
2.6 Characteristicsoffalls
The literature contains numerous studies reporting onthe epidemiology offalls. These include the characteristics and circumstances ofolder people who fall, such asthe time and place ofthe fall and resultantinjury.18,21 Falls are associated with anumber offactors, such asenvironmental obstacles, dementia, delirium, incontinence and medications. Although not proven through controlled trials, the relationship between time offall and level ofstaffing suggests that most falls inhospitals occur indaylight hours when staffing levels are attheir highest but when there isthe greatest level ofconcurrent workdemands.22 A snapshot ofstudies that have reported fall data22-24 has revealed the following consistent information: the bedside isthe most common place for falls tooccur, and the bathroom isfrequently mentioned; ahigh percentage offalls are associated with elimination and toileting; falls occur across all age groups, but there isan increasing prevalence offalls inolder people; and ahigh percentage offalls areunwitnessed.25-27 The pattern offalls depends onsetting and case mix. More mobile patients (for instance, inrehabilitation ormental health settings) are more likely tofall when walking than from abed orchair. This may, inturn, influence the emphasisofinterventions.
14
2.7 Risk factors forfalling

There are anumber ofrisk factors for falling among older people inhospital settings, and apersons risk offalling increases astheir number ofrisk factorsaccumulates.28 Risk factors may bedivided into intrinsic risk factors (factors that relate toapersons behaviour orcondition) and extrinsic risk factors (factors that relate toapersons environment ortheir interaction withthe environment). Table 2.1 summarises the intrinsic and extrinsic risk factors for fallinginhospital.
PartA
Table 2.1 Risk factors for falling hospitals2
Intrinsic riskfactors
Previousfall Postural instability, muscleweakness Cognitive impairment, delirium, disturbedbehaviour Urinary frequency,incontinence Posturalhypotension Medications (eg psychoactivemedications) Visualimpairment
Extrinsic riskfactors
Hospitalisation for 19 daysormore Environmental risk factors (most falls inhospital occur around the bedside and inthebedroom) Time ofday (falls occur most commonly attimes when observational capacity islow ieshower and meal times, and outside visitinghours)
Introduction
Some risk factors (eg confusion, unsafe gait and antidepressant medications) are associated with anincreased risk ofmultiple falls inthe hospital setting.2,29 Patients whose medical condition impacts directly onone ormore falls risk factors, such asstroke, have high fall rates inthe hospitalsetting.2,30 A best practice approach for preventing falls inhospitals includes four key components: first, theimplementation ofstandard falls prevention strategies; second, the identification offalls risk; third, theimplementation ofinterventions targeting these risks toprevent falls; and finally, the prevention ofinjury tothose people who dofall. Previous programs inthe hospital setting have only been successful inreducing falls when multiple interventions are included. Implementation ofone part does not seem enough toimprove outcomes. Tobe most effective, falls prevention should betargeted atboth point ofcare and strategiclevels. While the body ofknowledge regarding the risks offalls and how toreduce these risks iscontinually growing, one key message prevails: multifactorial, multidisciplinary approaches are best inthe hospital setting.31 Implicit inthis multifactorial approach isthe engagement ofthe patient and their carer(s) (whereappropriate) asthe centre ofany falls preventionprogram. Falls after hospital discharge have been reported asoccurring in15% ofolder people within amonth ofdischarge, with 11% ofthese resulting inserious injury.32 Although the scope ofthese guidelines isspecifically the prevention offalls inhospitals, best practice would also ensure that falls prevention strategies continue after discharge. Byworking inan integrated manner, the needs ofthe patient across thebroader spectrum ofservice delivery ismore likely tobe achieved. This may bedemonstrated byreduced levels ofreadmission, improved quality oflife and levels offunctional independence, and enhanced population health outcomes; however, comprehensive studies ofpost-discharge intervention evaluating quality oflife and population outcomes arelacking.
2 Falls and falls injuriesinAustralia
15
PartA Introduction
3 Involving older people infallsprevention

PartA
Consumer participation inhealth iscentral tohigh-quality and accountable health services. Italso encourages shared responsibility inhealth care. Consumers can help facilitate change inhealth carepractices. Health care professionals should consider the following things toencourage patients toparticipate infallsprevention: Make sure the falls prevention message ispresented within the context ofpeople staying independent forlonger.33 Be aware that the term falls prevention could beunfamiliar and the concept difficult tounderstand formany patients inthis older agegroup.33 Provide relevant and usable information toallow patients and their carers totake part indiscussions anddecisions about preventing falls 34 (see the fact sheets onpreventingfalls). Find out what changes apatient iswilling tomake toprevent falls, sothat appropriate and acceptable recommendations canbemade.34 Offer information inlanguages other than English, where appropriate; 34 however, donot assume literacy inthe patients nativelanguage. Explore the potential barriers that prevent patients from taking action toprevent falls (such aslow selfefficacy and fear offalling) and support patients toovercome thesebarriers.34 Develop falls prevention programs that are flexible enough toaccommodate the patients needs, circumstances andinterests.34 Place falls prevention posters inthe ward incommon areas used bypatients and familymembers. Ask family members toassist infalls preventionstrategies. Ensure that strategies topromote the continued involvement ofpatients are included indischarge planning (also called post-hospital care planning) andrecommendations. Trial arange ofinterventions with thepatient.35
Introduction
17
PartB
PartB Standard falls preventionstrategies

4 Falls preventioninterventions
Recommendations
Intervention
A multifactorial approach topreventing falls should bepart ofroutine care for all older people inhospitals. (LevelI) 31,36 Develop and implement atargeted and individualised falls prevention plan ofcare based onthe findings ofafalls screen orassessment. (LevelII) 37-39 As part ofdischarge planning, organise anoccupational therapy home visit for people with ahistory offalls, toestablish safety athome. (LevelII) 40 Patients considered tobe athigher risk offalling should bereferred toan occupational therapist and physiotherapist for needs and training specific tothe home environment and equipment, tomaximise safety and continuity from hospital tohome. (LevelI) 41
Good practicepoints
Interventions should systematically address the risk factors identified, either during the admission or, ifthis isnot possible, through discharge planning and referral tocommunityservices. Screen patients for falls risk and functional ability, and ensure that referrals for follow-up falls prevention interventions areinplace. Managing many ofthe risk factors for falls (eg delirium orbalance problems) will have wider benefits beyond fallsprevention.
21
4.1 Background andevidence

In these guidelines, the term standard falls prevention interventions refers toroutine care. This section outlines evidence, recommended actions and resources toaddress specific falls risk factors and interventions. These interventions have been components ofmultifactorial programs that have proven successful inthe hospital setting. Because falls are multifactorial and complex innature, interventions should beimplemented incombination rather than inisolation.7 Evidence from hospitals, residential aged care facilities and community settings has indicated the clear benefit ofmultifactorial approaches tofallsprevention.2 Where possible, these guidelines suggest how strategies could beimplemented, bywhom and atwhat point intime. However, given the unique features ofeach hospital, and ofwards and units within hospitals, thehealth care team will need tomake local decisions onhow tobest integrate falls prevention actions into apatients plan for daily care. Each patient has aunique set offalls risk factors and personal preferences, and requires anindividualised plan ofaction tominimise falls and harm fromfalls. To prevent falls, arange ofstandard precautionary strategies should beput into place for all older people inhospitals. This approach isbased ongood aged care practice and the assumption that all older people inhospitals are atrisk offalling, with their level ofrisk requiring furtherassessment. After standard falls prevention strategies are inplace and after the assessment process isundertaken, thosefactors identified ascontributing toapatients risk offalling can beaddressed inan individualised plan for daily care focused onpreventing falls. Patients with multiple risk factors have ahigher rate offalls than those with fewer falls risk factors.4 See Chapter 5 for information onrisk screening andassessment.
4.1.1 Evidence fromtrials

A Cochrane review showed that trials inhospitals targeting multiple risk factors appeared tobe effective inreducing the risk offalls for patients with long lengths ofstay.31 The multifactorial interventions included different combinations ofsupervised exercise and balance training, education, medication review, vitaminD with calcium supplementation, environmental review, walking aids and hipprotectors. Another randomised controlled trial used ascreening tool ineach patients notes toprompt recommendations for four basic interventions byreferring toallied health staff.39 This multifactorial intervention, which was done inan Australian population, reduced the incidence offalls inthe subacute hospitalsetting. A third randomised controlled trial successfully incorporated staff education; multidisciplinary care planning; investigation, screening and treatment ofdelirium and pain; and other interventions inasystemised way toprevent inpatient falls and injuries inpatients admitted for femoral neckfractures.38 A meta-analysis ofinterventions supports amultifactorial approach for reducing falls inhospitals.36 Thestudies included inthis meta-analysis were successful inreducing falls, and all had mean hospital staysranging from 18 to38days. However, since this meta-analysis, astudy ofacute wards (median length ofstay ofseven days) applied interventions similar tothose inother randomised controlled trials using dedicated multidisciplinary research staff over athree-month period.42 Itwas the largest study todate, and was done onan Australianpopulation. The rates offalls inthis study were not reduced. This may have beenbecause: 42 the intervention was too short ornot sufficientlyintense the use ofexternal staff meant that regular hospital staff did not change their practice tomaintain theinterventions outofhours some interventions (eg exercise programs) most likely required longer than aseven-day period toimproveoutcomes the population ofan acute care ward may differ significantly from the rehabilitation wards inthe prevalence ofcognitively impaired oracutely unwell patients who may require additional interventions andsupervision. The success offalls prevention interventions may beaffected bywhat interventions are already inplace, bythe level oforganisational reinforcement orsupport, and bythe duration ofthe intervention (interventions that last for only afew months may not belong enough tochange theorganisationalculture).
22
Many multifactorial programs toprevent falls inacute hospital wards have been evaluated inbefore-after studies. Most, but not all, ofthese studies found that falls were reduced inthe intervention period.36 Although the design ofbefore-after studies isnot asrigorous asrandomised controlled trials (particularly because before-after studies cannot control for changes that may have occurred over time, unrelated tothe interventions), they can provide complementary information about effective approaches tofalls prevention. For example, anAustralian study used abefore-after design toevaluate amultifactorial falls prevention approach phased inover three months.43 This intervention involved data gathering, risk screening with appropriate interventions, work practice changes, environmental and equipment changes, and staff education. Over atwo-year period, the number offalls decreased by19% per 1000 occupied bed days (P = 0.001), and the number offalls resulting inserious injuries decreased by77% per 1000 occupied bed days (P < 0.001). Staff adherence tocompleting the falls risk assessment tool increased from 42% to70%, and 60% ofstaff indicated they had changed their work practices topreventfalls. Overall, these findings indicate that amultidisciplinary, multifactorial approach tofalls prevention can besuccessful inhospital settings; however, inmore acute wards, there isperhaps anecessity for more intensive long-term interventions, with anincreased focus oncognitive impairment and awhole-system approach toward-based falls prevention (with associated work practice change) led bywardstaff.43
4.2 Choosing falls preventioninterventions

As mentioned above, successful interventions inhospitals use acombination offalls prevention interventions that should bedelivered together aspart ofamultifactorial program. Using any one intervention onits own isunlikely toreduce the numberoffalls. All staff members (including support, clinical, administrative and managerial staff), aswell asthe patient and their carers (where appropriate), have arole toplay infalls prevention, asoutlinedbelow. The following standard falls prevention interventions have been used asinterventions insuccessful inhospital trials and should beincluded inroutinepractice: Screen orassess all older people inhospitals for risk offalling, using avalidatedtool.39 Identify high-risk patients byusing falls risk alert cards abovebeds.39 Ensure that patients have their usual spectacles and visual aids tohand. Refer the patient toan optician, orthoptist orophthalmologist for undiagnosed visualproblems.37 Review medications. Inparticular, identify high-risk medications, such assedatives, antidepressants, antipsychotics and centrally acting pain relief, and ask the medical team orpharmacists toreview the needfor thesemedications.37 Measure postural blood pressure aspart ofamedical review toidentify patients with asignificant drop inblood pressure. Investigate the cause, and provide slow and careful transfers with assistance for thesepeople.37 Organise routine screening urinalysis toidentify urinary tract infections, with medical reviewifpositive.37,38 Organise routine physiotherapy review for patients with mobility difficulties, includingtransfers 37-39 communicate tostaff and the patient the limits ofthe patients mobility status 4 using written, verbaland visualcommunication put walking aids onthe side ofthe bed that the patient prefers toget upfrom44 and, where possible, assign abed that allows them toget upfrom their preferredside supervise orhelp the patientifrequired45,46 make sure that, while mobilising, the patient wears fitted, nonslip footwear45,46 (discourage the patient from moving about insocks, surgical stockingsorslippers) encourage the patient toparticipate infunctional activities and exercise (minimise prolonged bedrest and encourage incidentalactivity) 46,47 in rehabilitation settings, organise physiotherapist-led exercise sessions toimprove balance (eg tai chi and functional activities that are progressive and tailored toindividualneeds).39
23
Educate and discuss (with regular review) falls risks and falls prevention strategies with all staff, patientsand theircarers.38,39,46,48 Record falls prevention education ofstaff, patients and their carers.48 Document screening, assessment andinterventions. Establish aplan ofcare tomaintain bowel and bladderfunction.46 Instruct patients who are being discharged ortransferring between facilities about their medication time and dose; side effects; and interactions with food, other medications and supplements.46 Make sure that unnecessary medications are not prescribed and that information about medications isshared accurately with all relevant medicalpractitioners. Make the environment safe37 byensuringthat the bed isat the appropriate height for the patient (in most cases, itshould beat aheight that allows the patients feet tobe flat onthe floor, with their hips, knees and ankles at90-degree angles when sitting onthe bed), and the wheels orbrakes are locked when the bed isnot beingmoved45,46,48 the room iskept free from clutterorspills 48 adequate lighting issupplied, based onthe patients needs (particularlyatnight) 46,48 the patient knows where their personal possessions are and that they can access them safely (includingtelephone, call light, bedside table, water, eyeglasses, mobility aid,urinal) 4,45,46,48 floor surfaces are clean and dry, and wet floor signs are used whenappropriate.46 Orientate the patient tothe bed area, room, ward orunit facilities and tell them how they can obtain help when they need it.4,46,48 Some patients need repeated orientation because ofcognitive impairment; theyalso might need appropriate signage insuitable script and language toreinforcemessages. Instruct and check that patients understand how touse assistive devices (eg walking frames) before theyareprescribed.46 Have apolicy inplace tominimise the use ofrestraints and bedside rails,37,46 orto ensure that they are used appropriately and only when alternatives have been exhausted, and where their use islikely toprevent injury. Inaddition, the policy for restraint use should ensure that the risk ofinjury and falls isbalanced against the potential problems ofusingrestraints.49 Consider vitaminD supplementation with calcium asaroutine management strategy inolder patients who are able towalk, orif apatient lives inaresidential aged care facility. Ifapatient has alow-trauma fracture, consider osteoporosismanagement.38 Place high-risk patients within view of, and close to, the nursingstation.37 Consider hip protectors 39 and alarm devices (eg bed orchair alarms) for patients athigh risk offalling (see Chapter 15 onindividual surveillance and observation for moreinformation).
4.3 Dischargeplanning
Interventions toreduce the risk offalls and harm from falls should beincluded indischarge planning (alsocalled post-hospital care planning) for those patients who have been identified ashaving anincreased risk offalls and fall injury during the hospitaladmission. Patients may present toacute services with arange ofrisk factors, and may leave with some orall ofthese risk factors (eg poor vision). Other risk factors may beacquired aspart ofthe events ofthe admission; forexample, gait changes ordizziness. Falls risk isincreased for one month after discharge fromhospital. Some risk factors for falls (eg certain medications) can bemanaged during anadmission. However, some falls risk factors (eg muscle weakness) require longer term interventions. Anexercise program can bestarted during admission, but needs tocontinue for some weeks after discharge toachieve optimal musclestrength. Discharge planning should therefore start early during admission (or during pre-admission, ifadmission isplanned). Itshould involve appropriate members ofthe multidisciplinary care team, and include referral toappropriate primary health provider(s) and community services. Communication with the individual and carer(s) will help toensure that the benefits and rationale ofdischarge planning are understood, and that plans arefollowed.
24
4.3.1 Discharge planning from the emergencydepartment

Identifying falls and risk factors for falls injuries iscrucial while the patient isin the emergency department. The emergency department also provides anideal opportunity for developing plans tominimise these risk factors through discharge planningprocesses.50,51 Approximately 43% ofolder people presenting toan emergency department after afall are not admitted tohospital.52 Anobservational study from the United Kingdom found that older people have anincreased risk ofsubsequent hospitalisation and even death,53 and 6% will return tothe emergency department after another fall within 24 hours.54 One-fifth ofthe older people who present with minor injuries and who are not admitted tohospital are atrisk ofongoing functional decline for upto three months after discharge.55 There isevidence that anolder person will have anelevated risk offurther falls ifthey have experienced afall and were unable toget upindependently, and have ahistory ofprevious falls.56 Inaddition, older people presenting tothe emergency department with other issues may also beunsteady and atrisk offuturefalls and fallinjury. A randomised controlled trial from the United Kingdom investigated astructured, interdisciplinary falls assessment for emergency department patients. The assessment (which included amedical and occupational therapy assessment, and referral toappropriate services) was associated with asignificant reduction inrisk offurther falls inthe intervention group compared with usual care.57 Table 5.2 (inSection5.2.1) lists the details ofthe PROFET the assessment tool recommended inthis study. Astudyofasimilar intervention demonstrated a36% reduction infalls duringfollow-up.58 Position Statement 14 The Management ofOlder Patients inthe Emergency Department ofthe Australian and New Zealand Society for Geriatric Medicine59 encourages the completion ofavalidated screening tool toreduce re-presentation tothe emergency department, orpoor outcomes after discharge. The position statement recommends the emergency department asan appropriate place toscreen and initiate referrals for ongoing management.59 Auseful falls-specific screening tool for this setting isthe FROP-Com screen (for details, see Table 5.2 inSection5.2.1).60 In its work with the Falls Risk for Hospitalised Older People (FRHOP), the National Ageing Research Institute (NARI) developed the following five key recommendations for preventing falls inthe emergency departmentsetting: 54 All emergency departments should have apolicy that outlines procedures for screening, management andreferral ofolder people presenting tothe emergency department asaresultofafall. All emergency department staff should have anopportunity for orientation training and ongoing education that includes falls prevention policy and procedures, and research evidence tosupportthese. An evidence based screening procedure that identifies older people who present tothe emergency department and have arisk offuture falls should beimplemented independently, orwithin anoverall fallsriskscreen. All older people with anelevated falls risk should have modifiable falls risk factorsaddressed. All older people with ahigh falls risk identified during screening should have acomprehensive falls riskassessment conducted byatrained practitioner using avalidatedtool. NARI also identified the following four best practice points for falls prevention inthe emergencydepartment: 61 The patients primary health provider should beinformed ofthe risk screening result and subsequentreferrals. The emergency department should identify aclear referral pathway for patients who have ahigh risk offalls orhave modifiable falls riskfactors. Emergency department staff should communicate clearly topatients and their carer(s) about the potential benefit and rationale for referrals and interventions for reducing fallsrisk. Emergency departments should review the completion offalls risk screening and referral aspart oftheir routine audit ofmedicalrecords.
25
4.3.2 Fallsclinics
Falls clinics are conducted byamultidisciplinary team with skills infalls assessment and management for patients who have fallen.62 Limited numbers offalls clinics are available, and areferral isusually required. Falls clinics are usually conducted asapart ofan outpatient service. The team usually develops anintervention strategy for the patient, aswell asadvice, education and training for the patient, their carer and other members ofthe health care team. Falls clinics can also refer the patient tomainstream services for ongoingmanagement.
Falls clinics should not bethe first intervention for apatient who has fallen, orwho isat riskoffalling.
Multifactorial case study decreasing the number ofrisk factors can reduce the riskoffalling4
Mrs Ris a79-year-old woman who was transferred byambulance tohospital from her residential aged care facility (RACF) after fracturing her left inferior pubic ramus (pelvis). This injury was the result ofafall onto the floor while she was rushing tothetoilet. The orthopaedic team admitted Mrs Rfrom the emergency department. Because the fracture was stable, they decided that she would beallowed towalk and weight bear aspain permitted. From the outset, nursing staff implemented standard strategies for falls prevention and, because Mrs Rwas admitted asthe result ofafall, staff completed afalls risk assessment rather than aless detailed falls riskscreen. Information from the falls risk assessment and the accompanying transfer letter from Mrs Rs RACF revealed that she had multiple risk factors for falling, including thatshe: was older than 65years had fallen three times inthe previousyear was taking five different medications, including asleeping tablet anddiuretic on last attempt (a month ago), was only able tocomplete the Timed Upand Gotest (TUG) in19 seconds with her wheelie walker; the mean time for healthy 7179-year-olds is15seconds63 was frequently incontinent ofurine atnight and regularly rushed tothetoilet had aMini Mental State Examination (MMSE) score of22/30 before falling and was frequently agitated (a score ofless than 24 indicates cognitiveimpairment) had left foot pain asthe result ofsevere halluxvalgus wore bifocal glasses for all activities, despite having asecond pair ofdistance glasses forwalking did not like toventure outdoors and received nodirectsunlight. In addition tothe standard strategies and inresponse tothe risk assessment, the hospital staff implemented targeted, individualised interventions toreduce Mrs Rs risk offalling. These interventions included amedication review and advice onthe importance ofgetting enough sunlight for vitaminD by the medical officer; advice from the occupational therapist about wearing well-fitting shoes with nonslip soles; and some simple exercises for strengthening core body muscles for better balance, demonstrated bythe physiotherapist. Asaresult ofthese multifactorialinterventions: the possibility ofmedication interactions and adverse medicine events wasminimised Mrs Rhad amore restful sleep due tophysical exertion throughout theday Mrs Rs urinary incontinence was bettermanaged Mrs Rexperienced fewer episodesofagitation Mrs Rhad less pain inher left foot from herbunion Mrs Rwas able toclearly see the floor infront ofher whilewalking the condition ofMrs Rs muscles and bones wasoptimised. The health care teams atboth the hospital and the RACF were all made aware ofchanges toMrs Rs care through chart entries, case conferences and appropriate discharge correspondence. Mrs Rand her family were made aware ofthe changes toher care through ascheduled meeting with the health careteam.
26
4.4 Specialconsiderations
4.4.1 Cognitiveimpairment
The national consultation process that informed the first edition ofthese guidelines indicated that falls and cognitive impairment are key concerns ofpatients and health care workers alike. Consequently, cognitive impairment continues tohave adedicated chapter (Chapter 7), aswell asbeing included asaspecial consideration within eachsection.
PartB
Cognitive impairment (including agitation, delirium and dementia) isamajor risk factor for falls; however, patients who have cognitive impairment can benefit from fallsinterventions. For older patients suffering from delirium orcognitive impairment, where itis unsafe for them tomobilise ortransfer without help, individual observation and surveillance must beincreased, and help with transfers must beprovided asrequired. Ideally, one-on-one supervision should beapplied for those patients with amobility impairment for which they lack insight (eg cognitive impairment), and who impulsively attempt toexit their bed orchair without assistance. There isevidence for the benefits ofthis approach from nonrandomised controlledtrials.64 Bed exit alarms have not been assessed adequately inappropriate trials, but they are increasingly being usedfor similar patients, toalert nursing staff when ahigh-risk patient attempts toleave their bed orchair. More research isrequired tosee whether these devices are effective inreducing falls ratesinhospitals.
4.4.2 Rural and remotesettings

A common problem inrural and remote settings isashortage ofsome health professionals. Where this isthe case, options tosupport available expertise include telephoning and videoconferencing with experts orfacilities with advanced programs inother areas orregions. Ininstances where this approach isused, local staffshould: ensure they have standard strategies inplace before calling for support from external specialiststaff carry out necessary screening, assessments and identification ofappropriate interventions sothat the basic assessments and interventions are inplace bythe time they are linked with the externalsupport.
4.4.3 Indigenous and culturally and linguistically diversegroups

The risk offalls may begreater ifpeople from Indigenous and culturally and linguistically diverse groups cannot read signs orunderstand information given bystaff2 orbe assessed adequately due tolanguagedifficulties. There issome evidence that falls prevention strategies may work differently among culturally and linguistically diverse groups (eg due tocultural differences inexercise preferences and dietary intake ofcalcium from dairyproducts).65 General points toconsider when conveying falls prevention messages toIndigenous and culturally andlinguistically diverse groupsinclude: the importanceofinterpreters the use ofcommunication and translationboards seeking and using written information inthe appropriate language and culturalcontext learning some basic words from the persons firstlanguage.
4.5 Economicevaluation
An economic evaluation compares the costs and health outcomes ofafalls prevention program with the costs and health outcomes ofan alternative (often current clinical practice orusual care). Results ofeconomic evaluations ofspecific falls prevention interventions are presented inthe relevantinterventionchapters.
27

5 Falls risk screening andassessment
Recommendations
Screening andassessment
Document the patients history ofrecent falls oruse avalidated screening tool toidentify people with risk factors for fallsinhospital. Use falls risk screening and assessment tools that have good predictive accuracy, and have been evaluated and validated across different hospitalsettings. As part ofamultifactorial program for patients with increased falls risk inhospital, conductasystematic and comprehensive multidisciplinary falls risk assessment toinform thedevelopment ofan individualised plan ofcare topreventfalls. When falls risk screens and assessments are introduced, they need tobe supported with education for staff and intermittent reviews toensure appropriate and consistentuse.
Good practicepoints
Falls riskscreening
Screening tools are particularly beneficial because they can form part ofroutine clinical management and inform further assessment and care for all patients even though clinical judgment isas effective asusing ascreening tool inacutecare. All older people who are admitted tohospital should bescreened for their falls risk, and this screening should bedone assoon aspracticable after they areadmitted. The emergency department represents agood opportunity toscreen patients for their fallsrisk. A falls risk screen should beundertaken when achange inhealth orfunctional status isevident, orwhen the patients environmentchanges.
Falls riskassessment
A falls risk assessment should bedone for those patients who exceed the threshold ofthe falls risk screen tool, who are admitted for falls, orwho are from asetting inwhich most people are considered tohave ahigh risk offalls (eg astroke rehabilitationunit). For patients who have fallen more than once, undertake afull falls risk assessment for each fall (approximately 50% offalls are inpatients who have alreadyfallen). Interventions delivered asaresult ofthe assessment provide benefit, rather than the assessment itself; therefore, itis essential that interventions systematically address the riskfactorsidentified.
29

The terms falls risk screening and falls risk assessment are sometimes used interchangeably, but there are some clear differences and, inthese guidelines, they are considered separate but related processes. Screening isaprocess that primarily aims toidentify people atincreased risk. Inthe hospital setting, afallsrisk screen can beused toidentify patients who require ahigh level ofsupervision and more detailed falls risk assessment.66 Falls risk assessments aim toidentify factors that increase falls risk, and that may beamenable tointervention. Even where risk factors for falling cannot bereversed, there are usually other things that can bedone tominimise the risk offalling orto prevent injury ifan increased riskisidentified. Many falls risk screening and assessment tools have been developed for use inhospitals. However, only some ofthese have been evaluated for reliability and predictive validity inprospective studies and have areasonable sensitivity and specificity. That is, they have acceptably high accuracy inpredicting fallers who dofall inthe follow-up period, and high accuracy for predicting nonfallers who donot fall inthe followup period. Most have also only been validated inone hospital usually the hospital where the tool was developed. While this provides some useful information, risk screening and assessment tools have reduced validity (eg predictive accuracy offallers and nonfallers) when used outside the original research setting.67 From aresearch perspective, further testing isneeded ofrisk assessment tools inavariety ofclinical settings toestablish their validity and reliability for generaluse.68 Screening and assessment are not stand-alone actions infalls prevention. They need tobe linked toan action plan toaddress any modifiable falls risk factors they identify. Even where risk factors for falling cannot bereversed, alternative strategies can beimplemented tominimise the risk offalling orto preventinjury.
5.1.1 Falls riskscreening

Falls risk screening isabrief process ofestimating apersons risk offalling, classifying people asbeing ateither low risk orincreased risk. Falls risk screening usually involves reviewing only afew items. Althoughitis not designed asacomprehensive assessment, positive screening oncertain screen items canalso provide information about interventionstrategies. The purpose ofscreening isto identify those patients with increased falls risk who need tohave increased supervision oradetailed falls risk assessment. Insome hospital settings, such asageriatric assessment unit inan acute hospital, orastroke rehabilitation unit inasubacute hospital, most patients would beconsidered tohave anincreased risk offalling. Therefore, the falls risk screening process may beof limited value. Inthese high-risk areas, itmay bebeneficial toskip the screening process and implement afull falls risk assessment onallpatients. A number offalls risk screening tools are reported inthe literature. One ofthe most researched tools isthe StThomas Risk A ssessment Tool inFalling Elderly In-patients (STRATIFY). The original study reporting the tool showed that ithad good accuracy for classifying falls risk inthe acute and subacute rehabilitation settings.69 The tool contains five clinical factors associated with falling, and uses asimple scoring system (see Table 5.1 and AppendixA2.1). More recent studies evaluating the STRATIFY tool inother hospitals have reported lower prediction accuracy.67,68,70-73 One cohort study modified the original STRATIFY tool byconstructing aweighted risk score based onthe components ofthe STRATIFY tool (see Table 5.1 and Appendix A2.2).74 The screening accuracy ofthe modified STRATIFY tool for falls risk showed 91% sensitivity and 60% specificity.74 Asystematic review ofeight studies investigating the STRATIFY tool (four ofthese studies were included inameta-analysis) concluded that its prediction accuracy inparticular, the sensitivity and negative predictive values limits the utility ofthis tool.75 Nonetheless, the STRATIFY tool remains the most widely researched and widely used falls risk screening tool for the hospitalsetting. A systematic review and meta-analysis that assessed falls risk screening tools showed that using clinical judgment toclassify apatient ashigh risk for falls isat least asgood asusing ascreening tool inacute care.70,76 One potential benefit ofascreening tool, ifused appropriately, isthat itwill form part ofroutine clinical management, which should inform further assessment and care for all patients. This isin contrast toclinical judgment, which depends onan individual nurses consideration offalls risk inthe context ofarange ofother medical problems, rather than anassessment ofthe falls risk inisolation. Documenting ahistory ofrecent falls isalso agood screening question for identifying people athigher risk offalls during their stay inthe hospital.67,71 When afalls risk screen isintroduced, itneeds tobe supported with education for staff and intermittent reviews toensure that itis used appropriately andconsistently.
30
Many hospitals use nonvalidated tools that they have developed themselves. Using such tools may bedetrimental (eg bywasting staff time tocomplete atool that does notwork).
5.1.2 Falls riskassessment

Falls risk assessment isamore detailed process than screening and isused toidentify underlying risk factors for falling. Some falls risk assessments also classify people into low and high falls risk groups. Fourrandomised trials included specific falls risk assessments aspart amultifactorial falls prevention intervention inthe hospital setting. Falls were reduced inthree ofthese trials,37-39 and wereunchangedinone.42 Falls risk assessment tools vary inthe number ofrisk factors they include, and how each risk factor isassessed. Many assessment tools use adichotomous classification (present orabsent) for each risk factor; for example, the Prevention ofFalls inthe Elderly Trial (PROFET) tool, which contains screening andassessment components (see Table 5.2 and Appendix A2.8). Others include agraded categorisation (nil, mild, moderate, high risk) for each risk factor; for example, the Falls Risk for Hospitalised Older People tool (FRHOP; see Table 5.3 and Appendix A2.5.).77 Other tools use adetailed assessment tool for each risk factor; for example, the Peninsula Health Falls Risk Assessment Tool (FRAT) (cognitive status) uses the Hodkinson Abbreviated Mental Test Score(AMTS). One systematic review identified the following risk factors asthe most important among hospitalpatients: 71 gaitinstability lower-limbweakness urinary incontinence orfrequency, orneed for assistedtoileting previousfalls agitation, confusion orimpairedjudgment prescription ofculprit drugs (particularly centrally acting sedativehypnotics). Factors such aslow bone mineral density, low body mass index and fragile skin also increase the risk ofinjury ifafalloccurs. The authors ofthe systematic review concluded that none ofthe existing falls assessment tools could berecommended for implementation across all hospital settings. Instead, they suggest that better, validatedfalls risk assessment tools are needed inhospital settings, oradifferent approach isneeded for identifying common, modifiable risk factors inall patients and ensuring anappropriate post-fall assessment for people who dofallinhospital.71
31
5.2.1 Falls riskscreening
Falls risk screening can bedone byamember ofthe multidisciplinary health care team who understands the process, and can administer the tool, interpret the results, and make referrals where indicated. Falls risk screening should occur assoon aspracticable after every older person isadmitted tohospital. Apersons risk offalling can change quickly; therefore, screening for falls risk should bedone when changes are noted inapersons health orfunctional status, and also when their environmentchanges. Table 5.1 summarises validated falls risk screening tools for the hospital setting. Where publicly available, copies ofthe screening tools reported here are provided inAppendix 2. Other validated screening tools for the hospital setting are the Downton index and Morsescale.78,79
Table 5.1 Screeningtools
St Thomas Risk Assessment Tool inFalling Elderly In-patients(STRATIFY) 69

Description Timeneeded Criterion The tool contains five clinical factors associated with falling, and asimple scoringsystem. 12minutes Positive score on2 out of5 items indicates increased risk offalls and need for adetailed riskassessment.
Ontario ModifiedSTRATIFY74
Description The tool contains six clinical factors associated with falling (falls history, mental status, vision, toileting, transfer between chair and bed, and mobility score). Management strategies are provided, according tothe participants overallscore. 12minutes A score of 05 = lowrisk A score of 616 = mediumrisk A score of 1730 = highrisk The screen should beused toguide more detailed assessment and subsequent targeted interventions. The outcomes ofthe screen should bedocumented, reported toother health care staff, and discussed withthe patient and their carer(s) (where appropriate). When the threshold score ofascreening toolis: exceeded, afalls risk assessment should bedone assoonaspracticable not exceeded, the patient isconsidered tobe atlow risk offalling, and standard falls prevention strategiesapply. If any item onamultiple risk factor screen isidentified asbeing at risk, interventions should beconsidered for that risk factor even ifthe patient has alow falls risk score overall. For example, ifapatient has anoverall score of1 onthe STRATIFY tool (consisting ofascore of1 for transfer limitations and 0 for otherscreening items), anintervention toaddress their mobility impairment shouldbeconsidered.
Timeneeded Criterion
Screening risk inthe emergencydepartment

The emergency department provides auseful opportunity toscreen older people for their risk offalling, andtorefer them for assessment. Risk screening tools have been devised for use inthe emergency department for measuring falls risk factors and identifying older people atincreased risk offalling after they return home. Two are recommended inTable 5.2. See also Section 4.3 for more information onassessing falls risk inthe emergencydepartment.
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Table 5.2 Risk screening tools for the emergency departmentsetting
FROP-Com screeningtool60
Description A three-item screening tool, developed based onresearch using the FROP-Com assessment tool inasample ofolder people presenting toan emergency department after afall. The three items are steadiness during walking and turning, history offalls inthe past 12 months, and the need for assistance with activities ofdaily living before the presentingfall. 12minutes A score of4 ormore indicates highrisk.
PartB
Prevention ofFalls inthe Elderly Trial(PROFET) 56

Description Timeneeded Criterion The first four questions ofthe PROFET trial include falls history, medical history, social circumstances and aphysicalexamination. 12minutes No criterion for high falls risk. Individual risk factors identified are addressed accordingtoguidelines.
5.2.2 Falls riskassessment

To develop anindividualised plan for daily care focused onpreventing falls, the factors contributing toapatients increased risk offalling need tobe identified systematically andcomprehensively.37,38 A falls risk assessment should bedone for those patients who exceed the threshold ofthe falls risk screen tool, who are admitted for falls, orwho are from asetting inwhich most people are considered tohave ahigh risk offalls (eg astroke rehabilitationunit). A falls risk assessment should bedone assoon aspossible after the patient isadmitted into ahigh-risk setting, oras soon aspossible ifafalls risk screen exceeds the threshold. Additionally, afalls risk assessment may need toberepeated: when the patients environmentischanged when the patients health orfunctional statuschanges afterafall when the patient istobedischarged. When afalls risk assessment isintroduced, itneeds tobe supported byeducation for staff and intermittent reviews toensure itis used appropriately and consistently. Where publicly available, copies ofassessment tools are provided inAppendix2. Due tothe multifactorial nature offalls, itis preferable that different members ofthe multidisciplinary health care team (rather than asingle member) assess the falls risk. However, ifthe multidisciplinary health care team isinvolved inthe assessment process, responsibility for ensuring its timely completion should beallocated toone staff member. Ifamultidisciplinary approach isnot possible, nursing staff may beprimarily responsible, bringing inmedical and other health care professionals where needed. For example, inacute hospitals, amultidisciplinary assessment isunlikely tobe the best choice, because not all patients are seen (or could beseen) for anassessment byan allied health professional within one totwo daysofadmission.
33
Pointofinterest
In its work with the Falls Risk for Hospitalised Older People (FRHOP), the National Ageing Research Institute (NARI) found anumber oflimitations when different health care professionals are performing elements ofan assessment, compared with asingle-discipline assessment.66 These limitationsinclude: delays infilling inparts oftheassessment confusion over who iscoordinating theassessment confusion over who isensuring the interventions areimplemented. Establishing clear protocols for using falls risk assessment tools (ie which staff member(s) completes them, when they are completed, and how referrals and management options are initiated); aclear process for integrating components ofthe risk assessment; and effective communication strategies toall staff about the process, level ofrisk and interventions being recommended for each patient are needed toovercome theselimitations.66 Several falls risk assessment tools have been developed for use inthe hospital setting. Given that anumber offalls risk assessment tools have been validated for use inthis setting, itis preferable that avalidated tool beused, rather than developing anew tool. However, the health care team should becareful when adapting existing tools totheir particular location, because this limits the applicability ofany previous validationstudies. In any falls risk assessment, both intrinsic and extrinsic risk factors related toapersons health, functional status and environment need tobe considered. Most tools focus onintrinsic falls risk factors only, soaseparate environmental assessment may beindicated toidentify extrinsic falls risk factors (see Chapter 14). The recommended risk assessment tools that are included asappendices inthese guidelineswere chosen based ontheir applicability toAustralian hospitals (see Table5.3).

Criterion Criterion
34
Table 5.3 Risk assessmenttools
In the acute hospitalsetting

Care plan assessmentitems37
Description Twelve items are incorporated into the daily care plan, including intrinsic risk factors (medications, vision, blood pressure, mobility, etc), aswell asenvironmental risk factors (safe environment, appropriate bed height, nurse call bell accessible,etc). Approximately 510minutes No criterion for high falls risk. Individual risk factors identified are addressed accordingtoguidelines.
Timeneeded
In the subacute orrehabilitationsetting

Peninsula Health Falls Risk Assessment Tool(FRAT) 80 Description The FRAT has three sections: Part 1 falls risk status, Part 2 risk factor checklist, and Part 3 action plan. The complete tool (including the instructions for use) isafull falls risk assessment tool. However, Part 1 can beused asafalls riskscreen. Approximately 1520minutes A score of 12 indicates anincreased riskoffalls.
Timeneeded
In the subacute orrehabilitationsetting

Falls Risk for Hospitalised Older People(FRHOP)77
Description The FRHOP isacomprehensive risk assessment tool that includes abroad rangeoffalls risk factors, most ofwhich are graded from nil (0) tohigh (3) risk. The tool has accompanying strategies that can beused todevelop anaction list. Italso has additional actions for minimising overallrisk. Approximately 20minutes An overall score of23 ormore, ormore than four items rated ashigh risk, indicates anincreased riskoffalls.
PartB
Peter James Centre Fall Risk Assessment Tool(PJC-FRAT)76

Description The PJC-FRAT isamultidisciplinary falls risk assessment tool (medical, nursing, physiotherapy and occupational therapy staff assessment components), which was used asthe basis for developing intervention programs inarandomised controlled trial inthe subacute hospital setting that successfully reduced patient orresident falls. Fourmain interventions are linked tothe assessment: falls risk alert card, additional exercise, falls prevention education, and hipprotectors. Approximately 15minutes No criterion for high falls risk. Individual risk factors identified are addressed accordingtoguidelines.
So far, there isno consensus onwhich falls risk factors should beincluded inafalls risk assessment tool. Three reviews have been published onfalls risk assessment, which identified several risk factors asbeing more prevalent infallers than innonfallers.71,81,82 Therefore, more specific assessments may beindicated for some risk factors (see Table 5.4). Adescription ofthe appropriate assessment tools can befound intherespective chapters, asindicated inthetable.
Table 5.4 Specific risk factorassessments
Characteristic orfeature
Impaired balanceormobility
Functional measure Assessment

Impairedbalance Reducedmobility Functionalreach Mobility interaction fall chart, SixMetre Walk Test, Timed UpandGoTest Sit-to-StandTest Folstein Mini Mental State Examination (MMSE), Rowland Universal Dementia Scale (RUDAS), Confusion Assessment Method(CAM) Questionnaires, assessment, physicalexamination Safe shoechecklist Podiatristassessment
Description
Chapter6
Muscleweakness Cognitiveimpairment Dementiaordelirium
Chapter7
Incontinence Feet andfootwear
Urinary andfecal Footwearanalysis Foot problems (ie bunions, corns) anddeformities
Chapter8 Chapter 9 and Appendix3
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Characteristic orfeature
Syncope
Functional measure Assessment

Posturalhypotension Carotid sinus hypersensitivity Lying and standing blood pressuremeasurements Carotid sinus massage byamedicalspecialist Dix-Hallpiketest Medicationreview
Description
Chapter10
Dizziness Medications
Benign paroxysmal positionalvertigo Benzodiazepines
Chapter11 Chapter12
Selective serotonin Medicationreview reuptake inhibitors and tricyclicantidepressants Antiepileptic drugs and drugs that lower bloodpressure Some cardiovascular medications Vision Environment Individual surveillance andobservation Restraints Visualacuity Impaired mobility, visualimpairment Impaired mobility, high fallsrisk Delirium, short-term elevated fallsrisk Medicationreview
Medicationreview Snellen eyechart General environmentalchecklist Flagging, sitter programs, response systems, review andmonitoring Restraintpolicy Chapter13 Chapter 14 and Appendix4 Chapter15 Chapter16
Effective falls prevention programs have combined risk assessment with interventions. Interventions delivered asaresult ofthe assessment, rather than the assessment itself, provide benefit; therefore, itis essential that interventions toaddress the identified risks are appliedsystematically. The outcomes ofthe falls risk assessment, together with the recommended strategies toaddress identified risk factors, need tobe documented, reported toother health care staff, and discussed with the patient and, where applicable, with theircarer(s).
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Casestudy
Mrs Spresented toher local hospital after afall with substantial bruising and apossible broken hip. X-ray revealed nofracture; however, she was admitted because severe pain limited her walking sothat she could take only afew hobbling steps. Falls risk screening using the StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY) indicated ahigh risk offalling, with ascore offour. (Mrs Shad had three falls inthe past 12 months, and had impaired vision, nocturia and urinary frequency, and difficulty with transfers and mobility.) Once Mrs Swas given pain relief, her pain settled, and her mobility improved over three days. The nurse performed adetailed falls risk assessment using the Falls Risk for Hospitalised Older People (FRHOP), and areferral and management program was implemented (mostly linked toMrs Ss discharge planning, because she was discharged home two days later). This included anassessment bythe ward physiotherapist, who gave Mrs Sa balance andstrengthening exercise program todo athome. Mrs Swas also referredto: a community physiotherapist for ongoing management ofher resolving hip pain and balanceproblems an ophthalmologist, who identified cataracts and booked Mrs Sinto cataractsurgery an occupational therapist, who ran ahome environment assessment and recommended multiple homemodifications a continence specialist tomanage her continenceproblems. Six months later, Mrs Ss family was pleased tonote that Mrs Shad resumed all her previous activities, and had experienced nofurtherfalls.
Identifying the presence ofcognitive impairment should form part ofthe falls risk assessment process. However, the falls prevention interventions that are chosen, based onthe assessment, may need tobe modified tomake sure they are suitable for the individual, and often the carer orfamily members will also play animportant role inimplementing falls prevention actions,83 particularly inpreparation for discharge and after returnhome. Two hospital-based randomised controlled trials that evaluated screening orassessment aspart ofamultifactorial falls prevention program included participants with cognitive impairment, aswell asthosewithout.37,39 The trials found that the intervention reduced falls across the fullsample. Another randomised controlled trial assessed amultifactorial falls prevention program inpeople after surgery for hip fracture.38 The trial found asignificant reduction infalls inasubgroup analysis ofthose participants withdementia.

Falls risk factor assessments can usually beperformed byany trained member ofthe health care team. With medical, nursing and health professional shortages insome rural and remote settings, flexibility and upskilling ofteam members may berequired for successful assessment and interventions tobeimplemented.

To adequately assess the falls risk ofpatients from Indigenous and culturally and linguistically diverse groups, the health care team should consider assessing the patient intheir primary language and inaculturally appropriate manner. This may require using atranslation and interpretationservice.
37
PartC
Management strategies forcommon falls riskfactors
PartC Management strategies forcommon falls riskfactors
PartC
40
6 Balance and mobilitylimitations
Recommendation
Intervention
Use amultifactorial falls prevention program that includes exercise and assessment ofthe need for walking aids toprevent falls insubacute hospital settings. (LevelII) 39
Good practicepoints
Refer patients with ongoing balance and mobility problems toapost-hospital falls prevention exercise program when they leave hospital. This should include liaison with the patients generalpractitioner. To assess balance, mobility and strength, use anassessment toolto: quantify the extent ofbalance and mobility limitations and muscleweaknesses guide exerciseprescription measure improvements inbalance, mobility andstrength assess whether patients have ahigh riskoffalling.
41

Balance isahighly complex skill inwhich the bodys centre ofmass iscontrolled within the limits ofstability. Thisrequires integration ofaccurate sensory information (such asvision and proprioception) andawellfunctioning musculoskeletal system (not affected adversely bymuscle weakness, pain orcontracture) toexecute appropriate movements. Different combinations ofmuscle actions are required tomaintain balance (ie prevent falling) during the wide range ofeveryday mobility tasks (eg standing, reaching, walking, climbing stairs). Increasing age, inactivity, disease processes and muscle weakness can impairbalance.84 Many patients receive exercise and other rehabilitation strategies aspart ofusual in-hospital care. Therefore,the effect ofin-hospital interventions toaddress balance and mobility impairments isdifficulttomeasure. People who have been inhospital often have aparticularly high risk offalling once they return home. Forexample, studies have found that one inseven patients fell within one month ofreturning home85 andthat three infour patients with stroke fell within six months ofleaving hospital.30 This shows the importance ofdischarge planning (also known aspost-hospitalcare).
6.1.1 Identifying the risk factors forfalls

Balance and mobility are often poorer when aperson isin hospital, compared with their usual level ofmobility. This may bedue tothe effects ofmedications (including anaesthetics), acute events (eg stroke orahip fracture) and acute illnesses (eg infections). Balance and mobility may further deteriorate during ahospital stay ifthe patient isless active than usual due totheir medical condition, ordue tothe hospital environment, which discourages mobility. Therefore, aspart ofamobility assessment, itis important toestablish whether apatients level ofmobility inhospital isusual forthem. Assessment ofbalance ormobility asasingle factor appears not tobe the best way topredict falls inhospital patients, even ininpatient rehabilitation settings.86 Rather, multiple risk factors for falls inhospitals have been identified. The most common ofthese are cognitive impairment oragitation, useofpsychoactive medications, gait instability, urinary incontinence orfrequency, and fallshistory.71
6.1.2 Exercise aspart ofamultifactorialintervention

Mobility inhospital patients with particular conditions can beimproved with exercise programs delivered aspart ofusual rehabilitation care. Systematic reviews have found better outcomes inpatients with stroke87 orhip fracture88 who undergo inpatientrehabilitation. The effects onfall rates ofin-hospital interventions that involve exercise alone are not known.31 There have been two trials ofadditional exercise asasingle intervention with falls asan outcome.89,90 These trials gave some indication that additional exercise could reduce falls inrehabilitation settings; however, the trials were too small for firm conclusions tobedrawn.31
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Subacute hospitalsettings
In subacute hospital settings with lengths ofstay ofat least three weeks, three randomised controlled trials showed that intervention programs that include interventions toimprove balance and mobility can prevent falls. The pooled results from these three trials indicated a36% reduction inthe number offalls (rate ratio=0.64, 95%CI 0.51 to0.81) and areduction infallers ofsimilar size that was not statistically significant (risk ratio=0.61, 95%CI 0.33 to1.13). This pooled result should beviewed with caution due tothedifferences between study settings and populations. The details ofthe three studies areasfollows:
PartC
Exercise, education, falls risk alert cards and hip protectors inaddition tousualcare This combination ofinterventions reduced fall rates by30% (rate ratio=0.70, 95%CI 0.55 to0.90). The risk ofbeing afaller was reduced by22%, but this was not statistically significant (relative risk=0.78, 95%CI 0.56 to1.06). Effects were more evident after 45 daysofintervention.39 Rehabilitation wards instead oforthopaedic wards for care after ahipfracture A 62% lower fall rate (incident rate ratio=0.38, 95%CI 0.20 to0.76) was found inpatients who were cared for inarehabilitation ward rather than anorthopaedic ward after ahip fracture.38 The rehabilitation ward used ateam approach that included agreater focus onsystematic assessment and intervention toprevent falls and other postoperative complications, more occupational therapy staff, and agreater focus onfunctional daily task training with ward staff. The ratio ofphysiotherapy staff topatients was similar inthe twowards. A risk factor assessment and referral bynursing staff aspart ofusualcare A 30% greater reduction infalls (rate ratio=0.79, 95%CI 0.65 to0.95) was found inan intervention ward where amultifactorial intervention was conducted bynursing staff. Patients who had difficulties with mobility were referredtoaphysiotherapist.37 Systematic reviews have also found that rehabilitation programs that include exercise can improve mobility, which islikely todecrease the risk offuture falls inpatients who have had astroke87 orahipfracture.88
Acute aged care and short-stay subacutesettings

Acute aged care and short-stay subacute settings have anaverage stay ofone week. Systematic reviews have shown that, among older medical inpatients, extra exercise programs can lead toan average one-day reduction inlength ofhospital stay, agreater chance ofreturning home,91 and better functionaloutcomes.92 However, amore recent cluster randomised trial (not included inthe two systematic reviews above) found that, when delivered inaddition tousual care, multifactorial programs that include exercise did not prevent falls (incidence rate ratio=0.96, 95%CI 0.72 to1.2842 ). This was despite providing anadditional 25 hours aweek ofnursing and physiotherapisttime. There are many challenges toconducting randomised trials ofhospital falls prevention programs inshortstay wards. The need torandomise bycluster means that many participants are required for such trials. Widespread adoption offalls prevention programs isalso needed, which would make itdifficult tohave controlwards.13
6.1.3 Discharge planning andexercise

A systematic review showed that well-designed exercise programs can prevent falls inolder people who live inthe community.93 Therefore, itmakes sense that when people leave hospital, referrals should bemade for ongoing exercise programs. However, notrials have directly evaluated the effect onfalls ofsuchastrategy.
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6.2.1 Assessing balance, mobility andstrength
A number ofdifferent approaches can beused toassess balance, mobility and strength inolder hospital patients. Some ofthe clinical assessments that may beof use are outlined inTable 6.1. The choice oftool willdepend onthe time and equipmentavailable. There isan expanding field ofresearch devoted toevaluating different properties oftools for measuring balance, mobility and strength. These tools are evaluated according totheir reliability (whether the tool isconsistent when used bydifferent people atdifferent times), validity (whether the tool measures what itaims tomeasure) and responsiveness tochange (how much change isrequired before itis certain that the change reflects improved performance rather than measurement variability, and how well the tool can detect meaningful changes). Several studies have evaluated these aspects oftools for use inthe older population and rehabilitation94 and inolder medical inpatients.95 Some preliminary work has developed methods for evaluating balance assessment tools infalls preventionprograms.96
Table 6.1 Clinical assessments for measuring balance, mobility andstrength
Balance
Postural sway and leaning balancetests97
Description As part ofthe Physiological Profile Assessment (PPA), sway ismeasured using aswaymeter that measures displacements ofthe body atwaistlevel. During standing balance tests, the person has tostand asstill aspossible for 30seconds, with the eyes open and closed, once onthe floor and once onapiece ofmedium-density foam rubber (15cmthick). During leaning balance tests, the person has tolean forward and backward asfar aspossible, orfollowatrack. Timeneeded Criterion Rating 5-10minutes Computer software program compares individuals performance tonormative database compiled from populationstudies. 75% accuracy for predicting falls over a12month period incommunity and institutional settings; reliability within clinically expected range (R =0.50.7).97
Functional reach(FR) 98
Description FR isameasure ofbalance and isthe difference between apersons arm length and maximal forward reach, using afixed baseofsupport. FR isasimple and easy-to-use clinical measure that has predictive validity inidentifying recurrentfalls. Timeneeded Criterion 12minutes 6 inches: fourfoldrisk 10 inches: twofoldrisk Rating 76% sensitivity; 34%specificity91
Alternate Step Test(AST) 99

Description The AST isameasure oflateral stability. Itinvolves the time taken tocomplete eightsteps, alternating between left and right foot, asfast aspossible, onto astep 19cmhigh and 40cmdeep. 12minutes 10seconds 69% sensitivity; 56%specificity
Timeneeded Criterion Rating
44
Mobility
Six-Metre Walk Test(SMW)100
Description Timeneeded Criterion Rating The SMW measures apersons gait speed inseconds along acorridor (over adistance ofsix metres) attheir normal walkingspeed. 12minutes
PartC
6seconds 50% sensitivity; 68%specificity100
Timed Upand GoTest(TUG)100

Description The TUG measures the time taken for aperson torise from achair, walk three metres atnormal pace and with their usual assistive device, turn, return tothe chair and sitdown. 12minutes86 15seconds 76% sensitivity; 34%specificity63
Timeneeded Criterion Rating
Strength
Sit-to-Stand Test(STS) 86,99
Description Timeneeded Criterion Rating The STS isameasure oflower limb strength and isthe time needed toperform five consecutive chair stands from aseatedposition. 12minutes 12seconds 66% sensitivity; 55%specificity100
Springbalance97
Description As part ofthe PPA, the strength ofthree leg muscle groups (knee flexors and extensors and ankle dorsiflexors) ismeasured while participants areseated. In each test, there are three trials, and the greatest forceisrecorded. Timeneeded Criterion Rating 5minutes Computer software program compares individuals performance tonormative database compiled from populationstudies. 75% accuracy for predicting falls over a12-month period incommunity and institutional settings; reliability coefficients within expected range(0.50.7).97
45
Compositescales
Berg BalanceScale101
Description Timeneeded The Berg Balance Scale isa14-item scale designed tomeasure balance ofthe older person inaclinical setting, with amaximum total score of56points. 1520minutes 20 = high riskoffalls 40 = moderate risk offalls (potential ceiling effect with less frailpeople) Rating High test-retest reliability (R = 0.97); low sensitivity an8-point change isneeded toreveal genuine changesinfunction.
Criterion
Tinetti Performance-Oriented Mobility Assessment Tool(POMA)102

Description The POMA measures apersons gait and balance. The POMA-T (total) score consists oftwo subscales: POMA-G (gait) and POMA-B(balance). It isscored onthe persons ability toperform specific tasks, with amaximum total score of28points. Timeneeded Criterion 1015minutes A score of <19 = high riskoffalls A score of <24 = moderate riskoffalls Rating High test-retest reliability for POMA-T and POMA-B (R = 0.740.93); lower test-retest reliability for POMA-G (R = 0.720.89). POMA-T sensitivity (62.%) and specificity (66.1%) indicate poor accuracy infallsprediction.
Confidence and falls efficacyscale

Falls Efficacy Scale International(FESI)103
Description The FESI provides information onlevel ofconcern onafour-point scale (1 = not atall concerned to4 = very concerned) across 16 activities ofdaily living (eg cleaning the house, simple shopping, walking onunevensurfaces). 5minutes A score of 22 = low tomoderate levelofconcern A score of 23 = high levelofconcern Rating High test-retest reliability (R =0.96) 103
In addition tostructured training programs, hospital staff should provide the patient with opportunities tobe asactive aspossible throughout the day. For example, the patients bedrest should beminimised during the day, and the patient should beencouraged tobe mobile byincreasing the amount ofincidental activity (egwalking tothe toilet with appropriatesupervision).30,104
Casestudy
Mrs Bis 83 years old and was admitted tohospital with aurinary tract infection. She was confused and unable towalk onher own asshe normally did. Nursing staff ensured that MrsBdid not walk unsupervised, that frequently used items were within easy reach, and that family members visited toprovide additional supervision. Aspart ofamultifactorial falls prevention program, the physiotherapist assessed Mrs Band provided daily balance and mobility training, which improved her function and mobility sothat she was independent with awalking stick before she was discharged. The physiotherapist also referred Mrs B to acommunity-based balance and strength program after she lefthospital.
http://www.chcr.brown.edu/geriatric_assessment_tool_kit.pdf
46
Risk factors for falls (eg gait and balance problems) are more prevalent inolder people with cognitive impairment than inpeople without cognitive impairment.105 People with cognitive impairment should therefore have their falls risk investigated ascomprehensively asthose without cognitiveimpairment. Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations, unless there isaproblem with ability tofollow orcomply with instructions (seeChapter 7 oncognitive impairment). Simplifying instructions, and using picture boards and demonstrations, are strategies that may improve the quality ofexercise for patients with cognitive impairment. Family members, carers and other volunteers may beable tohelp insupervising and motivatingpatients who are following exerciseprograms.

Ideally, exercise interventions for older people inhospitals would beprescribed byaphysiotherapist after individualised assessment. However, inrural and remote settings, this may need tobe done byother staff, with appropriate guidance from aphysiotherapist toensure that programs are challenging, yetsafe.

When developing exercise programs for Indigenous and culturally and linguistically diverse groups, hospital staff should ensure they are informed about requirements specific tothat cultural group that may affect the intervention. For example, some cultural groups require single-sex exercise classes. Staff should consider using interpreters and other communication strategies,asnecessary.
No economic evaluations were identified that specifically considered interventions based onexercise orphysical activity inthe hospital setting. Some community interventions have been found tobe effective and cost effective; however, itis unclear whether the results are applicable tothe hospital setting given that these interventions are mainly home-based exercise programs (see Chapter 6 inthe community guidelines for moreinformation).
Additionalinformation
The Physiotherapy Evidence Database (PEDro) provides information from randomised controlled trials, systematic reviews and evidence based guidelinesinphysiotherapy: http://www.pedro.fhs.usyd.edu.au The following organisations, manuals, exercise programs and resources areavailable: Otago Exercise Programme. This program isaimed atpreventing falls inolder people who live inthe community, but itis also relevant for the aged care setting. The manual can bepurchasedonline: http://www.acc.co.nz/preventing-injuries/at-home/older-people/information-for-older-people/ PI00030 Hill KD, Miller K, Denisenko S, Clements Tand Batchelor F(2005). Manual for Clinical Outcome Measurement inAdult Neurological Physiotherapy, 3rd edition, APA Neurology Special Group (Vic). Available from the Australian Physiotherapy Association for A$30 for students, A$60for group members and A$75 forothers: http://www.physiotherapy.asn.au Chartered Society ofPhysiotherapy (United Kingdom) outcome measures online database: http://www.csp.org.uk/
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PartC
48
7 Cognitiveimpairment
Recommendations
Assessment
Older people with cognitive impairment should have their risk factors for fallsassessed.
Intervention
Identified falls risk factors should beaddressed aspart ofamultifactorial falls prevention program, and injury minimisation strategies (such asusing hip protectors orvitaminD and calcium supplementation) should beconsidered. (LevelII) 37-39
Good practicepoints
Patients presenting toahospital with anacute change incognitive function should beassessed for delirium and the underlying cause ofthischange. Patients with gradual onset, progressive cognitive impairment should undergo detailed assessment todetermine diagnosis and, where possible, reversible causes ofthe cognitivedecline. Patients with delirium should receive evidence based interventions tomanage the delirium (eg follow the Australian guidelines, Clinical Practice Guidelines for the Management ofDelirium inOlderPeople ). If apatient with cognitive impairment does fall, reassess their cognitive status, including presence ofdelirium (eg using the Confusion Assessment Methodtool). Where possible and appropriate, involve family and carers indecisions about which implementations touse, and how touse them, for patients with cognitive impairment. (Family and carers know the patient and may beable tosuggest ways tosupportthem.) Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations; however, interventions for people with cognitive impairment may need tobe modified and supervised,asappropriate.
http://www.health.vic.gov.au/acute-agedcare/delirium-cpg.pdf
49

Cognitive impairment iscommon among hospital patients. Although cognitive impairment ismost commonly associated with increasing age, itis acomplex problem that may exist inall age groups due toacquired brain injury, mental health conditions and other pre-existing conditions. Cognitive impairment implies adeficit inone ormore cognitive domains, such asmemory, visuospatial skills orexecutivefunction. Dementia and delirium are the two most common forms ofcognitive impairment inolderpeople: Dementia isasyndrome ofprogressive decline inmore than one cognitive domain; itaffects the persons ability tofunction. Dementia has agradual onset, usually involves aprogressive decline inarange ofcognitive abilities (such asmemory, orientation, learning, judgment and comprehension), and isoften accompanied bychanges inpersonality andbehaviour.106 Delirium isasyndrome characterised bythe rapid onset ofvariable and fluctuating changes inmental status. Delirium iscommon inhospitalised patients; most estimates ofprevalence ofdelirium range from 15% to56% ofolder inpatients.107 The risk ofdeveloping delirium associated with certain kinds ofsurgery isespecially high (eg 43%-61% ofpeople having orthopaedic surgery for hip fractures108 and approximately 30% ofpeople who have had heart surgery109 ). Delirium usually develops over hours ordays and has afluctuating course that can involve changes inarange ofcognitive abilities, such asattention and concentration, orientation, mood, perceptions, psychomotor activity and the sleepwakecycle.107 Distinguishing between dementia and delirium can bedifficult, and they can coexist inmany older people. Older people with existing cognitive impairment are more likely todevelop adelirium from anacute event.107 Informants are often used togain aninsight into timing, chronicity and severity todifferentiate dementia anddelirium.
7.1.1 Cognitive impairment associated with increased fallsrisk

Older people with cognitive impairment have anincreased risk offalls.110 The presence ofconfusion ordisorientation has been independently associated with falls110-114 and fracture115 inhospital patients. Dementia has also been associated with fallsinhospitals. Risk factors for falls are more prevalent inolder people with cognitive impairment than incognitively intact people. For example, impairments ofgait and balance are more severe,105 psychoactive medications are more commonly prescribed,116,117 and orthostatic hypotension ismoreprevalent.118 Cognitive impairment may increase risk offalling bydirectly influencing the patients ability tounderstand and manage environmental hazards, through atendency toincreased wandering,119 and through altered gait patterns and impaired postural stability.120 Examples ofthe different behaviours that contribute toincreased falls risk inpeople with cognitive impairment include agitation, wandering, reduced awareness ofenvironmental hazards, impaired ability tosolve problems and impulsiveness.121,122 Any changes inthe environment can increase confusion and agitation, and may also increase risk offalls for example, transfers between home and hospital, orbetween hospital and home oraresidential aged care facility, oreven just transfers within orbetween rooms withinahospital. Some types ofcognitive impairment are associated more strongly with falls than others. Forexample: delirium isassociated with acute medical illness, metabolic disturbance, drugs and sepsis,107 which may lead topoor balance, postural hypotension and muscleweakness some forms ofdementia (eg Lewy body disease orvascular dementia) may beassociated with gait instability and ahigher incidence oforthostatichypotension.123
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7.1.2 Cognitive impairment and fallsprevention

Three successful hospital-based randomised controlled trials (RCTs) toprevent falls have included people with cognitive impairment. Although there islimited evidence tosupport any specific strategy toprevent falls incognitively impaired older people, older people with cognitive impairment and dementia can comply with falls preventionprograms.37-39 Delirium isalmost always due toatreatable underlying cause and should beaddressed assoon aspossible. Patients with pre-existing dementia are more susceptible todelirium from events such asconstipation, urinary tract infections, chest infections and pain.107 Patients are also more likely todevelop delirium ifthey have visual orauditory impairment, are older, are malnourished, are physically restrained, have aurinary catheter inplace ortake more than threemedications.107
7.2.1 Assessing cognitiveimpairment
Although there isno specific evidence for falls prevention interventions for older people with cognitive impairment, the following strategies reflect bestpractice: Repeatedly and regularly check for the presence ofdelirium, and treat medical conditions that may contribute toan alteration incognitive status. Rapid diagnosis and treatment ofadelirium and its underlying cause (eg infection, dehydration, constipation, pain) arecrucial.124 Older patients with aprogressive decline incognition should undergo detailed assessment todetermine diagnosis and, where possible, treat reversible causes ofthe cognitivedecline.106 Older patients with cognitive impairment should have falls risk factors assessed, asdiscussed inother chapters, and should beoffered interventions tomodify risk.36 Some interventions need the patient tobe able tofollow instructions orcomply with aprogram (eg exercise). Where there isdoubt about apersons ability tofollow instructions safely, the health care team should conduct anindividualised assessment anddevelop afalls prevention plan using the information from theassessment. Many tools can beused toassess cognitive status; some are summarised inTable7.1.
Table 7.1 Tools for assessing cognitivestatus
Folstein Mini Mental State Examination(MMSE)125

Description The MMSE isawidely used method for assessing cognitive mentalstatus. It isan 11-question measure that tests five areas ofcognitive function: orientation, registration, attention and calculation, recall, andlanguage. The maximum scoreis30. Timeneeded Criterion 510minutes A score 23 indicates mild cognitiveimpairment. A score 18 indicates severe cognitiveimpairment.
Rowland Universal Dementia Scale(RUDAS)126,127

Description The RUDAS isasimple method for detecting cognitiveimpairment. RUDAS isvalid across cultures, portable and administered easily byprimary health careclinicians. The test uses six items toassess multiple cognitive domains, including memory, praxis, language, judgment, drawing and bodyorientation. Timeneeded Criterion Rating 10minutes Cut-point of23 (maximum scoreof30) 89% sensitivity; 98%specificity
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Confusion Assessment Method(CAM)128

Description CAM isacomprehensive assessment instrument that screens for clinical featuresofdelirium. It comprises four features, which are determined bythe patient, nurse and familyinterview: an onset ofmental status changes orafluctuatingcourse inattention disorganisedthinking an altered level ofconsciousness (ie other thanalert). Timeneeded Criterion Rating 5minutes Patient isdiagnosed asdelirious ifthey have both the first two features, and either the third orfourthfeatures. 94% sensitivity; 90%specificity129

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7.2.2 Providinginterventions
Identified falls risk factors should beaddressed aspart ofamultifactorial falls prevention program, and injury minimisation strategies (such asusing hip protectors orvitaminD and calcium supplementation) could beinstituted. One RCT specifically investigated the effect ofamultifactorial program inpatients with ahip fracture and found that ateam applying comprehensive geriatric assessment and rehabilitation, including prevention, detection and treatment offalls risk factors, can successfully prevent inpatient falls and injuries, even inpatients with dementia.38 Three other studies (two RCTs and alower quality observational study) included people with cognitive impairment, among other patients, and found anoverallreduction infalls. The results wereasfollows: An RCT showed that atargeted falls prevention program inaddition tousual care including the use ofafalls risk alert card with aninformation brochure, anexercise program, aneducation program and hipprotectors reduced the incidence offalls inthe subacute hospitalsetting.39 A second RCT showed that the use ofacore care plan, targeting reduction ofrisk factors inolder patients, was associated with areduction inthe relative risk ofrecordedfalls.37 An observational study ofamultiple-intervention falls prevention program inan aged care hospital setting involving risk screening with appropriate interventions, work practice changes, environmental and equipment changes, and staff education significantly reduced the number offalls and serious fallsrelatedinjuries.43 The following falls prevention strategies are ofparticular relevance toolder patients with cognitiveimpairment: Address reversible causes ofacute orprogressive cognitivedecline.83 Review previously prescribed medications for conditions that the patient nolonger has (egantidepressants, antipsychotics, antihypertensives,antianginals).83 Treat orthostatic hypotension (which iscommon inpatients withdementia).83 Use physical training programs toimprove gait, balance, mobility andflexibility.83 Modify the environment toreduce slips and trips, such asloweringbeds.83 Avoid the use ofrestraints orimmobilising equipment (including indwellingcatheters).36 Provide more frequent observation, supervision and assistance toensure that older patients with delirium ordementia who are not capable ofstanding and walking safely receive help with alltransfers.83 Use fall-alarm devices toalert staff that patients are attemptingtomobilise.36
The symptoms ofcognitive impairment and delirium should bemanaged byaddressing agitation, wanderingand impulsive behaviour (behaviour management)asfollows:107,130 Identify causes ofagitation, wandering and impulsive behaviour, and reduce oreliminatethem. Avoid the risk ofdehydration byhaving fluids available and within apatients reach, orby offering fluidsregularly. Avoid extremes ofsensory input (eg too much ortoo little light, too much ortoo littlenoise). Promote exercise and activity programs; more intensive activity programs may need tobe offered inthe late afternoon orearly evening toredirect agitated behaviours (eg pacing may beredirected into walking ordancing; noises may beredirected into singing ormusicplaying). Promote companionship,ifappropriate. Establish orientation programs using environmental cues and supports (including having personal orfamiliar items available). Repeat orientation and safety instructions regularly, keeping instructions simple andconsistent. Encourage sleep without the use ofmedication, and promote and support uninterrupted sleep patterns byreducing noise and minimisingdisturbance. Encourage patients toparticipate inactivities toavoid excessive daytimenapping. Ensure personal needs are met onaregularbasis. When communicating with cognitively impaired people, try toinstil feelings oftrust, confidence and respect (thereby minimising the chance ofprovoking anaggressive response). This can beachieved byapproaching the person slowly, calmly and from the front; respecting personal space; addressing theperson byname and introducing yourself; using eye contact; and speaking clearly and simply. Gentletouch and gestures, aswell asauditory, pictorial and visual cues used appropriately, may also help with communication. Itis important that the patient understands what isbeing said; this can behelped byusing repetition and paraphrasing, and allowing time for them toprocess theinformation.
Point ofinterest: strategies for maintaining hydration inolderpeople

Older people with cognitive impairment may become dehydrated easily, which can lead todelirium. AnAustralian study used strategies developed bythe Joanna Briggs Institute Practical Application ofClinical Evidence System (JBI-PACES) 131 tomaintain oral hydration inresidents ofresidential aged care facilities.132 Although adherence was problematic, the following strategies recommended bythe JBI-PACES maybebeneficial: Drinks (cordial, juice and water, but not caffeinated drinks) were offered bystaff every 1.5hours (as well asmorning tea, afternoon tea and supperrounds). Residents with cognitive impairment were either helped orpromptedtodrink. An accessible water fountain was set upwith asupplyofcups. Jugs ofwater were placed onall tables, withcups. Drinks were always given withmedication. Icy poles, jellies and ice-cream were offered throughout the day assnacks and enjoyabletreats. Fruit with ahigh water content (eg grapes, peeled mandarins) was placed onkitchen tables for easy access andpicking. Light broths were given withmeals. Happy hour was introduced twice aweek, with nonalcoholic wines, mocktails, soft drinks andnibbles. Warm milk drinks were given tohelp people settleatnight. These strategies may also beapplicable for older people with cognitive impairmentinhospital.
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Casestudy
Mr Tis anindependent, cognitively intact 79-year-old man living with his wife inthe community. Hewas admitted tohospital with respiratory distress and ahistory ofpartial blindness and diabetes. Following his admission, MrTs condition deteriorated, and hebecame acutely confused secondary toarespiratory tract infection. Hepulled out his intravenous line through which hewas receiving antibiotics. During the phase ofsignificant agitation, the staff onthe ward organised aroster with MrTs wife and family sothat afamily member was able tosit with him. Ashis delirium began tosettle, the need for constant one-on-one supervision decreased, but the staff did use aseat alarm device toalert them ifMr Ttried toget upwithout the needed supervision. After active treatment ofthe infection, MrTs delirium resolved and the alarm mat wasremoved.

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The Folstein Mini Mental State Examination (MMSE) isthe most widely used screening tool for dementia inAustralia; however, ithas significant limitations inmulticultural and poorly educated populations. The Rowland Universal Dementia Scale (RUDAS) isdesigned toovercome these impediments. Itperforms atleast aswell asthe MMSE, but with the added advantage ofbeing simpler touse inamulticulturalpopulation.126,127 A study funded bythe National Health and Medical Research Council investigated the validity ofanew assessment ofcognitive function developed specifically for Indigenous Australians. Itis called the KimberleyIndigenous CognitiveAssessment.
No economic evaluations were found that examined the cost effectiveness ofaprogram related toidentifying and managing cognitive impairment inthe hospitalsetting.
A range ofresources are available from the following associations andwebsites: Living with Dementia AGuide for Veterans and theirFamilies: http://www.dva.gov.au/aboutDVA/publications/health/dementia/Pages/index.aspx Alzheimers Australia, which can provide further information, counselling and support for people with dementia, their families andcarers: http://www.alzheimers.org.au/
Further details can befoundathttp://www.nari.unimelb.edu.au/research/dementia.htm.
8 Continence
Recommendations
Intervention
Ward urinalysis should form part ofaroutine assessment for older people with arisk offalling. (LevelII) 37 As part ofmultifactorial intervention, toileting protocols and practices should bein place for patients atrisk offalling. (LevelIII-2) 43,133 Managing problems with urinary tract function iseffective aspart ofamultifactorial approach tocare. (LevelII) 37
Good practicepoint
Incontinence can bescreened inhospital aspart ofavalidated falls risk screen assessment, such asthe StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY) orthe Peter James Centre Fall Risk Assessment Tool(PJC-FRAT).
55

People with urinary incontinence are atincreased risk ofhospital admission.134 The relationship between incontinence and falls islikely confounded byimpairments ofmobility and cognition, suggesting that multiple interventions are necessary toprevent falls. Although evidence from observational studies shows anassociation between incontinence and falls, there isno direct evidence that incontinence interventions affect the rateoffalls.135 There are also few data onthe prevalence ofincontinence inthe Australian hospital setting. However, inasample of627 patients inacute care inthe United Kingdom, 20.7% were incontinent ofurine, 4.2% were incontinent offeces, and 9.2% were doubly incontinent.136 Although urinary incontinence might beseen asamodifiable risk factor, there islittle evidence that continence-promotion strategies are included within falls preventionstrategies. Incontinence ofany kind isviewed with embarrassment bymany sufferers.134 Therefore, itis important for health care practitioners toask openly about incontinence symptoms. Symptoms ofincontinence can beassessed inthe hospital setting using validated assessment tools. The StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY) 114 and the Peter James Centre Fall Risk Assessment Tool (PJCFRAT) are two validated falls risk assessment tools that include questions about bladder and bowel control. PJCFRAT isamultidisciplinary falls risk screening and intervention deploymentinstrument.39
8.1.1 Incontinence associated with increased fallsrisk

Urinary and fecal incontinence affect both men and women but are not routinely considered part ofthe normal ageing process. About two-thirds ofhospital patients ingeriatric wards experience urinary incontinence.136 Episodes ofincontinence are often transitory and may berelated toacute illness. Transientincontinence ispresent in50% ofolder hospitalpatients.137 Incontinence,19,112 urinary frequency69 and assisted toileting112,114 have been identified asrisk factors for falls inthe hospital. People will often make extraordinary efforts toavoid anincontinent episode, includingplacing themselves atincreased riskoffalling. Different types ofbladder and bowel symptoms include thefollowing: Stress incontinence isleaking urine associated with rises inabdominal pressure during physical activity.104 Although this isacommon symptom inyounger women, institutionalised elderly women are more likely tohave mixed symptoms ofstress incontinence and symptoms ofoveractive bladder (OAB).138 Asystematic review ofstudies related tourinary incontinence and falls revealed noassociation between falls and stressincontinence.139 Overactive bladder syndrome isdefined asurgency with orwithout urge incontinence, usually with frequency and nocturia.140 Asystematic review ofstudies related tourinary incontinence and falls revealed asignificant association between falls and urge-incontinence symptomsofOAB.139 Urgency isdefined asthe sudden compelling desire tovoid, which isdifficult todefer.140 The symptom ofurgency may besuffered without any concomitant lossofurine.141 Urge (urinary) incontinence isinvoluntary urine leakage accompanied orimmediately preceded byurgency.104 Research suggests that itincreases the risk ofaperson falling and fracturing bones.142 This ispresumably because urge incontinence (as opposed tostress incontinence) isassociated with frequent rushed trips tothe toilet toavoid incontinent episodes. Additionally, performing asecondary task, such aswalking and concentrating ongetting tothe toilet, may compromise walking stability.141 Urinary incontinence issignificantly associated with self report ofconstipation inolder Australian womenwho live inthecommunity.143 Frequency isdefined asthe complaint bythe patient who considers that they void too often during theday.140 Nocturia isdefined asbeing woken atnight bythe desire tovoid.104 Itis commonly reported and significantly associated with falls inambulatory older people who live inthe community.144 Nocturia can beparticularly problematic when lighting ispoor orwhen the patient isnot fully awake. Nocturia isone ofthe most common causes ofpoor sleep and carries ahigh risk offalling and fractures inolderpeople.145 Constipation isacommon problem inolder people and isrelated todecreased mobility, reduced fluid intake and the use ofanumber ofhigh-risk medications. Asaconsequence, and inrelation tofalls, constipation may cause delirium and agitation, which may inturn cause falls. Straining during defecation may also shunt blood away from the cerebral circulation, leading todizziness orsyncope (temporary loss ofconsciousness) due tothe vasovagalphenomenon.146
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Relieving constipation improves lower urinary tract symptoms, including urinaryincontinence.146 Diarrhoea may cause agitation aswell asmetabolic disturbance, which may inturn causefalls. Urinary dysfunction caused bybenign prostatic hyperplasia (noncancerous enlargement ofthe prostate) iscommon inolder men. Itaffects 50% ofmen at60 years and 90% ofmen over 85 years ofage. Symptoms include urinary frequency, nocturia, urgency, poor stream, hesitancy, straining tovoid, andasensation ofincomplete bladder emptying and post-voiddribbling.147 Bladder dysfunction iscommon inolder women asaresult ofdeficiencies inthe pelvic floor muscles and connective tissue supporting the urethra and the urethral sphincter mechanism.148 Adecline inoestrogen levels after menopause can lead toatrophic changes affecting the vagina and urethra, and also increases awomans susceptibility tourinary tract infections. Symptoms include urinary frequency, stress incontinence and urgeincontinence.138
Definitions
Refer toAbrams etal (2002) for acomprehensive list ofdefinitions ofthe symptoms, signs, urodynamics, observations and conditions associated with lower urinary tract dysfunction and urodynamics studies, for use inall age groups.104 Also, refer toAbrams (2003) for further explanations ofrecommendedterminology.140 Numerous falls inhospitals occur when older people goto orreturn from the toilet, but causal factors associated with falls inolder people with and without cognitive impairment are many and various.149 Theclose associations reported between incontinence, dementia, depression, falls and level ofmobility suggest that these conditions, which are socommon ingeriatric patients, may have shared risk factors rather than causalconnections.150 Other mechanisms bywhich urinary and fecal incontinence can increase falls risk include thefollowing: An incontinence episode increases the risk ofaslip onthe soiled orwet floorsurface.135 Urinary incontinence has been identified asasignificant risk factor for falls inpeople who cannot standunaided.139 The patients most atrisk offalling are those who need touse anassistive device for walking and are incontinent atnight, with most ofthe falls occurring inthe early hours ofthemorning.140 Urinary tract infections can cause delirium, drowsiness, hypotension, pain, urinary frequency and urinaryurgency. Medications used totreat incontinence (eg anticholinergics oralpha-blockers) can themselves cause postural hypotension and falls; anticholinergics can also causedelirium. Drugs such asdiuretics used predominantly tomanage heart failure can potentially increase the risk offalls through increased urinary frequency orhypovolaemia (low bloodvolume). Deteriorating vision isacommon condition inthe elderly and isstrongly associated with falls;112 itmay also increase the likelihood offalls that are associated with getting out ofbed atnight andnocturia.
8.1.2 Incontinence and fallsintervention

The combination ofshort length ofstay and chronic conditions suffered bymany patients means that incontinence isnot always identified byhospital staff asafalls risk factor. Patients are often reluctant todiscuss issues around urinary and fecal continence. Health care practitioners should beencouraged toenquire routinely about continence, rather than rely onthe patient tomention itduring aconsultation. Many patients will not offer the information without prompting. One study showed that frequent nursing rounds, also including offering toilet assistance, can reduce the frequency ofpatients use ofcall lights, increase their satisfaction with care, and preventfalls.151 Pelvic floor muscle training isthe most commonly recommended and most effective intervention for women with stress incontinence. Arandomised controlled trial showed that well-designed falls prevention interventions aimed atpatients with relatively short hospital stays were ineffective.137 However, other continence promotion interventions that were aimed atstaff training, changes towork practices, and environmental and equipment changes (rather than individual patient interventions) had positive outcomes.43,149 The strategies for promoting continence outlined below have not been part ofrigorously conducted, successful, multifactorial falls prevention programs. However, appropriate management isgoodgerontological practice that may translate into alower riskoffalling.
8 Continence
57
A Cochrane systematic review showed that pelvic floor muscle training can beused totreat women with mixed incontinence, and less commonly for urge incontinence.141 However, limitations ofthe data make itdifficult tojudge whether pelvic floor muscle training was better orworse than other treatments inmanaging OAB symptoms.141 There isevidence from asystematic review tosupport conservative management offecalincontinence.152 Toileting-assistance programs are animportant and practical approach tomaintaining continence for many patients, and may also reduce the risk offalls.104 The three types oftoileting-assistance programs (timed voiding, habit retraining, prompted voiding) are discussed inSection 8.2. Cochrane systematic reviews onthese interventions found limited evidence for their effectiveness; further investigationisneeded.143,144,153 Several successful in-hospital falls prevention programs included strategies topromote continence aspart ofamultifactorial intervention program. Fonda etal (2006) reviewed toileting protocols and practices aspart oftheir effective multifactorial falls prevention program inan aged care hospital setting.43 Bakarichetal (1997) found that patients inan acute hospital setting who were toileted regularly had fewer falls than patients who were not toileted frequently.133 Finally, Healey etal (2004) included assessment and management ofurinary tract problems aspart oftheir successful intervention for preventing falls.37 Urinaryand fecal incontinence inolder hospitalised patients isassociated with higher frequency ofdischarge toan aged care facility rather than dischargehome.154
8.2.1 Screeningcontinence
The STRATIFY tool identifies continence status byasking Are there any alterations inurination (ie frequency, urgency, incontinence,nocturia)?69 The PJC-FRAT tool identifies continence status byasking whether the patient isin need ofespecially frequent toileting (day andnight).39 The cause ofincontinence should beestablished through athorough assessment. Patients may have more than one type ofurinary incontinence, which can make assessment findings difficult tointerpret.155 Patientsshould bescreened for urinary tract infections using ward urinalysis.37 Otherwise, the following strategies can beused toassess the patients continencestatus: Obtain acontinence history from the patient. This might include abladder chart (a frequency/volume chart) oracontinence diary, which could beused torecord aminimum oftwo days tohelp with assessment and diagnosis. Sometimes abowel assessment isrequired, and the patients normal bowel habits and any significant change must bedetermined, because constipation can considerably affect bladderfunction. Address, onan individual basis, the suitability ofdiagnostic physical investigations. Consent from the patient must beobtained before the physical examination, which should bedone byasuitably qualified healthprofessional. Always check post-void residuals inincontinent olderpatients. Consider risk factors for falling related toincontinence, along with the symptoms and signs ofbladder andboweldysfunction. Assess and address functional considerations, such asreduced dexterity ormobility, which can affecttoileting. Assess the toilet for accessibility (especially ifthe patient uses awalking aid), and adjust the toilet height ifthe patient has any hip jointdysfunction.
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8.2.2 Strategies for promotingcontinence

Appropriate management ofincontinence may improve overall care. However, itis difficult tomake strong recommendations, because specific continence-promotion strategies have not been part ofsuccessful falls prevention programs inany health care setting.112 Apractical, stepwise management approach for mobile and nonmobile patients, aswell aspatients with and without cognitive impairment, should beconsidered. Such anapproach could bebased onrecommendations made bythe United States Government relating toquality management ofurinary incontinence inresidential aged carefacilities.156
PartC
The following strategies, adapted from those recommended bythe Third International Consultation onIncontinence 2005,133 can beused topromotecontinence: Make sure the patient has access toacomprehensive and individualised continence assessment that identifies and treats reversible causes, including constipation and medication sideeffects. Use anadequate trial ofconservative therapy asthe first lineofmanagement. Establish treatment strategies assoon asincontinence has been diagnosed. The aim ofmanaging urinary incontinence isto alter the factors causing incontinence and toimprove the continence status ofthe patient. Management ofincontinence isamultidisciplinary task that ideally involves doctors, nurse continence advisers, physiotherapists, occupational therapists and other suitably qualified healthprofessionals. Address all comorbidities that canbemodified. Make sure toileting protocols and practices are inplace for patients atriskoffalling.43,151 Offer toileting assistance during frequent nursing rounds (every one totwo hours), because this can prevent falls inhospitalpatients.135 Encourage habit retraining, prompted voiding ortimed voiding programs tohelp improve the patients control over their toileting regime, and reduce the likelihood ofincontinenceepisodes timed voiding ischaracterised byafixed scheduleoftoileting habit retraining isbased onidentifying apattern ofvoiding and tailoring the toileting schedule tothepatient prompted voiding aims toincrease continence byincreasing the patients ability toidentify their own continence status and torespondappropriately. Minimise environmental risk factorsasfollows keep the pathway tothe toilet obstacle free and (where relevant) leave alight onin the toiletatnight ensure the patient iswearing suitable clothes that can beeasily removedorundone recommend appropriate footwear toreduce slippinginurine use anonslip mat onthe floor beside the bed for patients who experience incontinence onrising from the bed, particularly ifon anoncarpeted floor inthe bedroom; however, care must betaken when using mats toensure the person does not trip onthemat check the height ofthe toilet and the need for rails toassist the patient sitting and standing from the toilet (reduced range ofmotion inhip joints, which iscommon after total hip replacement orsurgery forfractured neck offemur, might mean the height ofthe toilet seat shouldberaised). Where possible, consult with acontinence adviser ifusual continence management methods, asdescribed above, are not working orthe patient iskeen tolearn simple exercises toimprove their bladder orbowel control. Some men are resistant tothe idea ofdoing pelvic floor exercises. This should berecognised and the benefitsexplained. Consider the use ofcontinence aids asatrial managementstrategy.
Casestudy
Mrs Uis an85year-old woman who was admitted tohospital after falling and breaking her arm. When the nurse asked why she fell, she said she was rushing tothe toilet. Aurinalysis done bythe nurse showed leucocytes and nitrites. The sample was sent for culture and sensitivity. Mrs Uhad aconfirmed urinary tract infection, which was then treated with ashort course ofantibiotics. Her urinary frequency and urgency settled with the treatment. Havingsustained alow-trauma fracture, she was referred ondischarge for abone mineral density scan and formal assessment ofbonehealth.
8 Continence
59
Acute delirium can becaused byboth urinary and gastrointestinal problems. Cognitive impairment and dementia can also lead toproblems with both urinary and fecal continence. Inpatients with cognitive impairment, regular toileting isrecommended. Patients with cognitive impairment may benefit from prompted voiding,144 scheduled toileting and attention tobehaviour signals indicating the desire tovoid. Aim toidentify each patients toileting times and prompt them togo around those times. Patients with severe dementia may need tobe reminded where the bathroomis.

It isimportant that the strategies outlined above are also inplace inrural and remote locations. Ifaccess tospecialist continence assessment and advice isdifficult, additional strategies, such asteleconferencing, may support health practitioners toimplement best practice. Resources (such asleaflets) providing advice onmanaging incontinence areavailable.

Hospital staff and all members ofthe health care team need tobe aware ofcultural and religious requirements with respect totoileting. Generic signage for toileting facilities and requirements could beused. Insome cultures, incontinence isataboo topic. Specific information ondealing with these issues may beobtained from the person, their carers orthe Continence FoundationofAustralia. Incontinence isnot acondition that iswell understood byIndigenous Australians, and itcauses shame for many. When discussing incontinence, itis important tobe aware that Indigenous men will frequently discuss this matter only with amale health worker and women only with afemale healthworker. Specific Indigenous resources may beaccessed from the Continence FoundationofAustralia.
No economic evaluations were found that examined the cost effectiveness ofcontinence management inthe hospitalsetting.
The Continence Foundation ofAustralia and the National Continence Helpline have leaflets and booklets ondifferent continence-related topics, Indigenous-specific resources and information leaflets translated into 14 communitylanguages: http://www.continence.org.au The Continence Foundation ofAustralia manages the National Continence Helpline for the Australian Government. This free service, staffed bynurse continence advisers, provides confidential information onincontinence, continence products and localservices: National Continence Helpline: 1800 33 0066 The National Public Toilet Map gives information ontoilet facilities along travel routes throughout Australia. Access the map via their website, orby contacting the National Continence Helpline, which can mail out copies oftoilets along your plannedjourney: http://www.toiletmap.gov.au The fact sheet, Continence: caring for someone with dementia, can befound onthe Alzheimers Australiawebsite: http://www.alzheimers.org.au/content.cfm?infopageid=83#co The National Institute for Health and Clinical Excellence, based inthe United Kingdom, provides guidance onpromoting good health and preventing and treating ill health. See its evidence based guidelines onmanaging urinaryincontinence: http://www.nice.org.uk/
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9 Feet andfootwear
Recommendations
Assessment
In addition tousing standard falls risk assessments, screen patients for ill-fitting orinappropriate footwear upon admissiontohospital.
Intervention
Include anassessment offootwear and foot problems aspart ofan individualised, multifactorial intervention for preventing falls inolder people inhospital. (LevelII) 37 Hospital staff should educate patients and provide information about footwear features that may reduce the risk offalls. (LevelII) 37
Good practicepoints
Safe footwear characteristicsinclude soles: shoes with thinner, firmer soles appear toimprove foot position sense; atread sole may further prevent slips onslipperysurfaces heels: alow, square heel improvesstability collar: shoes with asupporting collar improvestability. As part ofdischarge planning, refer patients toapodiatrist,ifneeded.
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9.1.1 Footwear associated with increased fallsrisk
The use ofinappropriate footwear byolder people inhospital settings isasignificant issue. One study of 65older patients admitted toahospital rehabilitation ward found that 72% wore ill-fitting footwear.157 Footwear isacontributing factor tofalls158 and fractures inolder people.159 Studies (of varying design andquality) have reported the followingresults:
Poorly fitting footwear orfootwear inappropriate for the environmental conditions impairs foot position sense inboth younger and oldermen.160 Wearing shoes with inadequate fixation (ie shoes without laces, buckles orvelcro fastening) has been associated with anincreased riskoftripping.159 Wearing high-heeled shoes impairs balance compared with low-heeled shoes orbeingbarefoot.161 Mediumhigh-heeled shoes and shoes with anarrow heel significantly increase the likelihood ofsustaining all types offracture, while slip-on shoes and sandals increase the risk offoot fractures asaresultofafall.162 Slippers are often the indoor footwear ofchoice for many older people, but have been associated with anincreased risk ofinjuriousfalls.163 Walking barefoot orin socks isassociated with a1013-fold increased risk offalling, and athletic shoes are associated with the lowestrisk.164 A retrospective observational study showed that three-quarters ofpeople who suffered afall-related hip fracture inthe community were wearing footwear with atleast one suboptimal feature atthe time ofthe fall.159 Older people should wear appropriately fitted shoes, both inside and outside the house. However, many older people wearing inappropriate footwear believe itto beadequate.165 Areview ofthe best footwear forpreventing falls identified the following shoe characteristics assafe for olderpeople:166 Soles : shoes with thinner, firmer soles appear toimprove foot position sense; atread sole may further prevent slips onslipperysurfaces. Heels : alow, square heel improvesbalance. Collar: shoes with asupporting collar improvebalance. Figure 9.1 shows anoptimal safe shoe, and atheoretical unsafe shoe. However, the level ofevidence for these recommendations isvery low, since there are noexperimental studies offootwear that have examined falls asanoutcome.
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PartC
What makes a shoe safe?

Laces or strong fastening to hold the foot firmly Supporting collar, preferably high
Low, square heel to improve stability Thin firm midsole for the feet to read the underlying surface Slip-resistant sole
What makes a shoe unsafe?
Soft or stretched uppers make the foot slide around in the shoe
Lack of laces means the foot can slide out of the shoe
High heels should be avoided as they impair stability when walking
Narrow heels make the foot unstable when walking
Slippery or worn soles are a balance hazard, particulary in wet weather
Source: Lord(2007)135
Figure 9.1 The theoretical optimal safe shoe, and unsafeshoe
9 Feet andfootwear
63
9.1.2 Foot problems and increased fallsrisk

Foot problems are common inolder people, affecting 6080% ofolder people who live inthe community.167,168 Women report ahigher prevalence offoot problems than men, which might beinfluenced byfashion footwear.169 The most commonly reported foot problems reportedare:168,170,171 pain from corns, calluses andbunions foot deformities, such ashallux valgus, hammer toes and nailconditions. Foot problems are well recognised ascontributing tomobility impairment inolder people. Older people with foot pain walk more slowly than those without and have more difficulty performing daily tasks.167 The presence offoot problems, such aspain, toe deformities, toe muscle weakness and reduced ankle flexibility, can alter the pressure distribution beneath the feet, impairing balance and functional ability.172,173 Additionally, these foot problems are associated with increased falls risk,174 and the risk rises asthe number offoot problemsincreases.175 Ageing isassociated with reduced peripheral sensation, and several prospective studies have found that people who fall perform worse intests oflower limb proprioception,176 vibration sense177 and tactile sensitivity.178 Reduced plantar tactile sensitivity has also been mentioned asarisk factor for falls,173 because itmight influence the ability tomaintain postural control when walking, particularly onirregular surfaces.179 This isparticularly relevant inpeople with diabetes.180 People with diabetic neuropathy have impaired standing stability181 and are atincreased risk for falls and fractures.182 Podiatry may help manage theseconditions.183-185
9.2.1 Assessing feet andfootwear
Hospital staff should arrange for the patients feet and footwear tobe assessed upon admission tohospital. Aspart ofamultifactorial falls prevention program, this assessment should bedone byahealth professional skilled inthe assessment offeet and footwear, such asapodiatrist. The following components ofthe assessment are mostrelevant: Footwear Use the safe shoe checklist toassess footwear. This checklist isareliable tool for evaluating specific shoe features that could potentially improve postural stability inpatients186 (see Appendix3). Discourage patients from walking insocks, because this isassociated with a10-fold increased risk offalling.164 This isparticularly relevant inthe hospital setting: patients should not walk inantiembolism stockings without appropriate footwear ontheirfeet. Footproblems Assess foot pain and other foot problems regularly. Apatient with anundiagnosed peripheral neuropathy should beassessed for potentially reversible ormodifiable causes ofthe neuropathy. Some ofthe more common causes ofaperipheral neuropathy include diabetes, vitamin B12 deficiency, peripheral vascular disease, alcohol misuse and side effects ofsomedrugs.182 Refer the patient toahealth professional who isskilled inthe assessment offeet and footwear (egapodiatrist) for additional investigations and management,asrequired.187 A detailed assessment byapodiatrist for afalls-specific examination offeet and footwear shouldinclude:188 fall history: including foot pain andfootwear dermatological assessment: skin and nail problems,infection vascular assessment: peripheral vascularstatus neurological assessment: proprioception; balance and stability; sensory, motor and autonomicfunction biomechanical assessment: posture, foot and lower limb joint range ofmotion testing, evaluation offoot deformity (eg hallux valgus), gaitanalysis footwear assessment: stability and balance features; prescription offootwear, footwear modifications orfoot orthoses, based onassessment ofgaitinshoes education: foot care and footwear, link between footwear orfoot problems and fallsrisk.
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9.2.2 Improving foot condition andfootwear

All health care professionals can play animportant rolein: identifying ill-fitting orinappropriatefootwear37,43 providing information about footwear topatients andcarers 37 ensuring shoes are repaired asneeded, and cleanedregularly recognising that patients who have ashuffling gait may beat higher risk offalling ifthey wear nonslipshoes oncertain carpetedfloors ensuring that patients with urinary incontinence have dry, cleanfootwear ensuring that patients have more than one pair ofshoes, incase shoes are soiledordamaged discouraging walking while wearing slippery socks andstockings discouraging the use oftalcum powders, which may make floorsslippery screening patients for foot pain orfootproblems educating patients and carers about basic footcare referring apatient toapodiatrist for further assessment and management, asappropriate, ifany ofthefollowing conditions orclinical signs areevident footpain foot problems, such asswelling, arthritis, bunions, toe deformities, skin and nail problems (especiallycorns and calluses) orother foot abnormalities (eg collapsed arch orhigh-archedfoot) conditions affecting balance, posture orproprioception inthe lower limbs, such asdiabetes, peripheralneuropathy orperipheral vasculardisease unsteady orabnormalgait inappropriate orill-fitting footwear orarequirement for footorthoses.
Casestudy
Mr Ris inhospital for management ofhis diabetes. Hehas arecent history offalls. Aspart ofamultifactorial falls prevention program, nursing staff ran abasic foot screening and found that MrRhad poor sensation and some calluses and lesions onhis feet. Asaresult ofthe assessment findings, they organised apodiatry assessment. The podiatrist found that MrRhad mild peripheral neuropathy and was unsteady onhis feet because hewore oversized sports shoes with athick, cushioned sole tohelp his calluses. The podiatrist treated his lesions and referred him toacommunity podiatry service ondischarge. The podiatrist also taught MrRhow tobuy better fitting footwear that will improve his stability, but that isstill safe for his neuropathic feet. MrRfound that his balance improved after hebought more appropriatefootwear.
9 Feet andfootwear
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Patients with cognitive impairment may not report discomfort reliably. Therefore, when they have their footwear checked, hospital staff should check their feet for lesions, deformity and pressure areas. Footwearand foot care issues should also bediscussed indetail withcarers.

The Australasian Podiatry Council ineach state can provide details ofpractitioners visiting rural and remote areas. Inareas where podiatry services are infrequent orunavailable, other health care providers willneed toscreen feet and footwear. Services for Australian Rural and Remote Allied Health are developing resources that may help rural and remote practitioners (see the website for moreinformation).

Culturally appropriate resources are currently being developed byServices for Australian Rural and Remote Allied Health aspart ofan Indigenous Diabetic Foot Program (see the box containing additional information,below).
No economic evaluations were found that examined the cost effectiveness ofaprogram related tofeet andfootwear assessment inthe hospital setting. Some multiple-intervention approaches tofalls prevention inthe community have included feet and footwear assessments; however, itis unclear whether the results ofthese analyses are applicable inthe hospital setting (see Section 4.4 inthe community guidelines fordetails).
Australasian PodiatryCouncil: http://www.apodc.com.au Footwear: Safe shoe checklist (See Appendix3) Queensland Government Stay onYour Feet falls prevention resources: http://www.health.qld.gov.au/stayonyourfeet Foot care and ageingfeet: American Podiatric Medical Association has brochures, fact sheets and other information ontopics such asageingfeet: http://www.apma.org/MainMenu/Foot-Health/FootHealthBrochures/ GeneralFootHealthBrochures.aspx Indigenous Diabetic Foot Program, Services for Australian Rural and Remote AlliedHealth: http://www.sarrah.org.au/site/index.cfm?display=65940 Society ofChiropodists andPodiatrists: http://www.feetforlife.org
http://www.apodc.com.au http://www.sarrah.org.au
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10 Syncope
Recommendations
Assessment
Patients who report unexplained falls orepisodes ofcollapse should beassessed for the underlyingcause.
Intervention
Patients with unexplained falls orepisodes ofcollapse who are diagnosed with the cardioinhibitory form ofcarotid sinus hypersensitivity should betreated byinserting a dual-chamber cardiac pacemaker. (LevelII) 189 Assessment and management ofpostural hypotension and review ofmedications, including medications associated with presyncope and syncope, should form part ofamultifactorial assessment and management plan for falls prevention inhospitalised older people (this can also bepart ofdischarge planning). (LevelI) 31
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Syncope isdefined asatransient and self-limiting loss ofconsciousness. Itis commonly described asblacking out orfainting. Presyncope describes the sensation offeeling faint ordizzy and can precede anepisode ofloss ofconsciousness. Anumber ofconditions can present with syncope, and all share the final common pathway ofcerebral hypoperfusion, leading toan alteration inconsciousness. Older people are more predisposed tosyncopal events due toage-related physiological changes that affect ability toadapt tochanges incerebralperfusion.
The overall incidence ofsyncope inolder people who live inthe community has been reported as6.2 per 1000 person years.190 Some ofthe more common causes ofsyncope inolder people are vasovagal syncope, orthostatic hypotension, carotid sinus hypersensitivity, cardiac arrhythmias, aortic stenosis and transient ischaemic events. Epilepsy may present asasyncopal-like event. Less common causes ofsyncope include micturition, defecation, cough and postprandialsyncope.
10.1.1 Vasovagalsyncope
Vasovagal syncope (usually described asfainting) isthe most common cause ofsyncope and has been reported tobe the cause ofup to66% ofsyncopal episodes presenting toan emergency department.190 Vasovagal syncope isoften preceded bypallor, sweatiness, dizziness and abdominal discomfort, although these features are not always seen inthe older person.190 Commonly reported precipitants ofvasovagal syncope include prolonged standing (particularly inhot orconfined conditions), fasting, dehydration, fatigue, alcohol, acute febrile illnesses, pain, venepuncture andhyperventilation. The diagnosis ofvasovagal syncope isusually made clinically, although formal assessment with noninvasive cardiac monitoring and prolonged tiltingispossible. Treatment islargely nonpharmacological and istargeted atavoiding the cause. This may include avoiding prolonged standing inhot weather and ensuring that the patient drinks enough tomaintain hydration. People also need tobe reassured that vasovagal syncope isabenigncondition.
10.1.2 Orthostatic hypotension (posturalhypotension)

Orthostatic hypotension (also called postural hypotension) refers toadrop inblood pressure onstanding, from either the sitting orthe lying position. The drop inblood pressure can beenough tocause symptoms ofdizziness orprecipitate asyncopal event.135,191 Orthostatic hypotension isassociated with anincreased riskoffalls.135,190 A formal diagnosis ofpostural hypotension ismade byrecording adrop insystolic blood pressure ofat least 20 mmHg, oradrop indiastolic blood pressure ofat least 10 mmHg, within three minutes ofstanding. The patient should belying still for atleast five minutes before blood pressure ismeasured (while the patient remains lying down). Multiple measurements may berequired todefinitively identify the presence ofposturalhypotension. Medications and volume depletion are the two most common causes ofpostural hypotension inolder people. Medications commonly associated with postural hypotension include the antihypertensive agents, antianginals, antidepressants, antipsychotics, antiparkinsonian medications and diuretics. Diuretics can have adirect effect onblood pressure and can also cause volume depletion, which initself can cause postural hypotension. Certain diseases (eg Parkinsons disease, stroke and diabetes) can directly affect autonomic function and interfere with blood pressure regulation. Prolonged periods ofimmobility can also disrupt postural control ofbloodpressure. Treatment involves identifying the precipitating cause and drug modification, where possible. Maintaining adequate hydration, particularly during hot weather, isimportant inthe patient (see the point ofinterest box onmaintaining hydration inSection 7.2.2). Pharmacological intervention isneeded totreat postural hypotension inasmall number ofcases. Drugs that might beused include fludrocortisone and midodrine (analpha-agonist).
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10.1.3 Carotid sinushypersensitivity

Carotid sinus hypersensitivity isan abnormal haemodynamic response tocarotid sinus stimulation. When associated with symptoms, itis referred toas acarotid sinussyndrome. Carotid sinus hypersensitivity may occur when the head isrotated orturned, orwhen pressure isplaced onthe carotid sinus. Triggers might include carotid massage, shaving, wearing tight collars orneckwear, ortumourcompression.192 Three abnormal responses can benoted ondirect massage ofthe carotid sinus. Acardioinhibitory response isdefined asathree-second period ofasystole following massage ofthe carotid sinus. The vasodepressor response isdefined bya50 mmHg drop inblood pressure inthe absence ofsignificant cardioinhibition. Acombination ofthe vasodepressor and cardioinhibitory responses defines the mixed form ofcarotid sinushypersensitivity. Carotid sinus hypersensitivity isthe cause ofasmall percentage offalls inolder people, and ispotentially amenable tointervention.189,193-195 Arandomised controlled trial showed that detailed cardiovascular assessment, including carotid sinus massage ofolder people attending anemergency department after anunexplained fall, led toasubsequent reduction infurtherfalls.189
10.1.4 Cardiacarrhythmias
Abnormal heart rhythms can lead todizziness and syncope. Sick sinus syndrome isan abnormal slowing ofthe heart caused bydegeneration ofthe cardiac conducting system. Itis associated with advanced age. Sick sinus syndrome ismanaged with the insertion ofacardiac pacemaker. Slowing ofthe heart rate can also beassociated with certain medications (beta-blockers and digoxin), and treatment inthese cases isreducing orstopping thesemedications. Rapid heart rates from abnormal cardiac rhythms can also cause dizziness and syncope. Diagnosis ofan abnormal heart rate requires aperson tobe monitored atthe time ofthe abnormal heart rate and can often bechallenging. Treatment depends onthe nature ofthe abnormalrhythm.
It isimportant toensure that patients reporting dizziness, presyncope orsyncope undergo appropriate assessment and intervention. Depending onthe history and results ofthe clinical examination, anumber oftests and further investigations may bewarranted. These may include anelectrocardiogram, echocardiography, Holter monitoring, tilt table testing and carotid sinus massage, orinsertion of animplantable loop recorder. The European Taskforce onSyncope has produced asimple algorithm forinvestigating syncope (see the box containing additional information,below).191 Two randomised controlled trials have taken amultifactorial approach tofalls prevention inhospitalised older people toprevent falls. The trials included blood pressure and medication reviews aspart ofthe assessment andintervention.37,39 Permanent cardiac pacing issuccessful intreating certain types ofsyncope. Pacemakers prevent falls by70% inpeople with accurately diagnosed cardioinhibitory carotid sinushypersensitivity.189 Most older people who are inhospital are discharged home. Anumber ofsuccessful multifactorial falls prevention strategies inthe community setting have included assessments ofblood pressure andorthostatic hypotension, and medication review andmodification.57,58,196,197 The symptoms oforthostatic hypotension can bereduced using the followingstrategies: Ensure good hydration ismaintained, particularly inhotweather.4,198,199 Encourage the patient tosit upslowly from lying, stand upslowly from sitting, and wait ashort time beforewalking.198,199 Minimise exposure tohigh temperatures orother conditions that cause peripheral vasodilation, includinghotbaths.199 Minimise periods ofprolonged bedrest andimmobilisation. Encourage patients torest with the head ofthe bedraised. Increase salt intake inthe diet ifnotcontraindicated. Where possible, avoid prescribing medications that may causehypotension. Identify any need for using appropriate peripheral compression devices, such asantiembolicstockings.199 Monitor and record postural bloodpressure.4
10 Syncope
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Casestudy
Mr Lis an82-year-old man who was brought tothe emergency department with acute pulmonary oedema secondary tohis ischaemic heart disease. Hewas admitted and given diuretics tooff-load the excess fluid. During the admission, hewas also started onan angiotensin-converting enzyme inhibitor and beta-blocker. However, hestarted toreport symptoms ofdizziness onstanding and almost blacked out onthe way tothe bathroom. MrLs lying and standing blood pressures were checked, and hewas found tohave significant and symptomatic postural hypotension. His medications were reviewed, and his diuretic dose was reduced. Over the next few days, MrLs lying and standing blood pressures were check regularly toensure resolution ofthe postural changes, and his chest was examined toensure that the oedema did notrecur.

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People with cognitive impairment may have problems recalling the events surrounding afall. Postural hypotension iscommon inpeople with vascular dementia, and many people with cognitive impairment and dementia may betaking medications that are associated with postural hypotension and cardiac arrhythmias (eg antihypertensives, antidepressants andantipsychotics).
No economic evaluations were found that examined the cost effectiveness ofinterventions for syncope inthe hospitalsetting.
The following reference maybeuseful: Brignole M, Alboni P, Benditt D, Bergfeldt L, Blanc JJ, Thomsen PE, etal (Task Force onSyncope, European Society ofCardiology) (2004). Guidelines onmanagement (diagnosis and treatment) ofsyncope update 2004. European Heart Journal25(22):2054-2072. Also available at:http://eurheartj.oxfordjournals.org/cgi/content/full/25/22/2054
11 Dizziness andvertigo
Recommendations
Assessment
Vestibular dysfunction asacause ofdizziness, vertigo and imbalance needs tobe identified inthe hospital setting. Ahistory ofvertigo orasensation ofspinning ishighly characteristic ofvestibularpathology. Use the Dix-Hallpike test todiagnose benign paroxysmal positional vertigo, which isthe mostcommon cause ofvertigo inolder people and can beidentified inthe hospital setting. This isthe only cause ofvertigo that can betreatedeasily.
Note: there isno evidence from randomised controlled trials that treating vestibular disorders will reduce the rateoffalls.
Good practicepoints
Use the Epley manoeuvre tomanage benign paroxysmal positionalvertigo. Use vestibular rehabilitation totreat dizziness and balance problems, whereindicated. Screen patients complaining ofdizziness for gait and balance problems, aswell asfor postural hypotension. (Patients who complain ofdizziness may have presyncope, posturaldysequilibrium, orgait orbalancedisorders.) All manoeuvres should only bedone byan experiencedperson.
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Dizziness and vertigo are common presenting symptoms inhospital emergency departments.200 Theconditions are seen inpeople ofall ages, but are more prevalent inthose older than 50 years.201 TheNational Hospital Ambulatory Medical Care Survey identified that patient visits toemergency departments inthe United States for vertigo ordizziness accounted for 2.5% ofall emergency department presentations over a10-year period.200 However, dizziness inthe hospital setting remains adifficult diagnostic problem because ithas many potential causes and may result from disease inmultiple systems.202 Apopulation-based study ofpeople presenting with dizziness symptoms toan emergency department, ordirectly admitted tohospital, found that stroke ortransient ischaemic attack was diagnosed inonly 3.2% ofall patients and that the most common cause ofvertigo and dizziness inthis population was abenign peripheral vestibular dysfunction (33%).203 Inthe community setting, benign paroxysmal positional vertigo (BPPV) isone ofthe most common vestibular conditions, accounting for upto 50% ofpatients with aperipheral vestibular disorder.204 This islikely tobe the case inthe hospital settingaswell. When patients describe being dizzy, giddy orfaint, this may mean anything from ananxiety orfear offalling, topostural dysequilibrium, vertigo orpresyncope. Therefore, adetailed historyiscrucial.
11.1.1 Vestibular disorders associated with anincreased riskoffalling

Vestibular dysfunction isacommon cause ofdizziness inthe older population; 204 however, the association between vestibular dysfunction and falls remains unclear.205 There islimited research inthis area inthe hospitalsetting. A case-series study looked atapproximately 3000 patients who presented toahospital emergency department after afall. Aportion (16%) ofthese patients had noknown cause for the fall. Avestibular symptom scale questionnaire completed bythis group showed ahigh incidence ofthe symptoms ofvestibular impairment (eg nausea, vomiting,dizziness).206 Age-related changes inthe vestibular system can beidentified inpeople older than 70 years.207 These changes include asymmetrical degenerative changes, which may contribute tofalls and falls injury byproviding inaccurate information about the direction and magnitude ofhead orbody movements, and impairing balance control. Astudy of66 adults found that older people who lived inthe community and who had fractured their wrist because ofan accidental fall were more likely tohave vestibular asymmetry ontesting than anage-matched groupofnonfallers.208 It isnot clear whether BPPV isarisk factor for falling inolder people; however, almost one in10 older people presenting toan outpatient clinic with arange ofchronic medical conditions had undiagnosed BPPV. These people are more likely tohave sustained afall inthe previous threemonths.209
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11.2.1 Assessing vestibularfunction
An important step inminimising the risk from falls associated with dizziness isto assess vestibular function. This can bedone using the following steps and tests (these tests should only bedone byan experiencedperson): Ask the patient about their symptoms. Dizziness isageneral term that isused todescribe arange ofsymptoms that imply asense ofdisorientation.210 Dizziness may beused asaterm byapatient todescribe poor balance. Vertigo, asubtype ofdizziness, ishighly characteristic ofvestibular dysfunction and isgenerally described asasensationofspinning.211 Assess peripheral vestibular function using the Halmagyi head-thrust test.212 This test should only bedone byan experienced person. Ithas good sensitivity only ifthe vestibular dysfunction issevereorcomplete.213 Use audiology testing toquantify the degree ofhearing loss. The auditory and vestibular systems are closely connected, and therefore auditory symptoms (hearing loss, tinnitus) commonly occur inconjunction with symptoms ofdizziness andvertigo.214 Use hospitalisation asan opportunity torequest computed tomography ormagnetic resonance imaging toidentify anacoustic neuroma orcentral pathology, ifclinicallyindicated.211 Use the Dix-Hallpike manoeuvre todiagnose BPPV inthe hospital setting. This manoeuvre isconsidered mandatory inall patients with dizziness and vertigo after head trauma.215 BPPV should bestrongly considered aspart ofthe differential diagnosis inolder people who report symptoms ofdizziness orvertigo following afall that involved some degree ofheadtrauma.
11.2.2 Choosing interventions toreduce symptomsofdizziness

The following strategies can beused inthe hospital setting totreat dizziness and balance problems caused byvestibular dysfunction. They can beused aspart ofamultifactorial falls prevention program toreduce the risk offalls relatedtodizziness.
Medicalmanagement
A randomised controlled trial showed that treatment inthe hospital emergency department with methylprednisolone within three days ofacute onset ofvestibular neuritis (viral infection ofinner ear structures) improves vestibular function at12-month follow-up, with complete oralmost complete recoveryofvestibular function in76% ofthe studypopulation.216 Based onclinical experience, treatment inthe acute hospital setting with antiemetics and vestibular suppression medication may berequired totreat the unpleasant associated symptoms ofnausea andvomiting. These medications should only beused for ashort duration (one totwo weeks) because they adversely affect the process ofcentral compensation following acute vestibulardisease.217
TreatingBPPV
A range ofoptions for the treatment ofBPPV have been described inthe literature. Theseinclude: Brandt and Daroff exercises these can bedone regularlyathome218 the Epley manoeuvre this isused commonly byclinicians and involves taking the patient slowly through arange ofpositions that aim tomove the freely mobile otoconia back into the vestibule; 219 ametaanalysis showed that this manoeuvre ishighly successful for treatingBPPV.220 Older people with diagnosed BPPV respond aswell totreatment asthe general population; therefore, nospecial approaches are needed inthis older group.221 Itis important todiagnose and treat BPPV assoon aspossible, because treatment improves dizziness and generalwellbeing.221
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Vestibularrehabilitation
Vestibular rehabilitation (VR) isamultidisciplinary approach totreating stable vestibular dysfunction. The physiotherapy intervention component focuses onminimising apersons complaints ofdizziness andbalance problems through aseries ofexercises, which are tailored toeach person.222 The occupational therapy intervention component involves incorporating the movements required todo these exercises into daily activities.223 Psychology input addresses the emotional impact ofvestibulardysfunction.224 The literature emphasises the following characteristicsofVR:
VR ishighly successful intreating stable vestibular problems inpeople ofallages.225 Starting VRearly isrecommended inthe hospital setting after surgical removal ofan acoustic neuroma226 and vestibular ablation surgery.227 Delayed initiation ofVR isasignificant factor inpredicting unsuccessful outcomes overtime.228 VR can improve measures ofbalance performance inpeople living inthe community who are older than 65 years.229 Noresearch has been done onspecific vestibular interventions for preventing falls inthe hospital setting. However, inthe first six weeks after acoustic neuroma surgery, older people receiving VRhad greater improvements inbalance than those who received general instructions only.230 This may translate toreduced riskoffalling. Regular training courses inVR are held across Australia, and anincreasing number ofphysiotherapists working inacute and subacute hospital systems are now trained toassess and manage dizziness. Thesephysiotherapists can befound bycontacting the Australian Physiotherapy Association orthe Australian VestibularAssociation.
Dischargeplanning
Discharge planning (or post-hospital care planning) isacritical part ofan integrated program ofpatient care, and should ensure that interventions started inhospital continue inthe home, asnecessary and possible. Older people who are discharged from hospital may still need care and support tomanage dizziness when they return totheir own homes orresidential aged care facilities. Discharge planning may include thefollowing: Use avestibular function test toevaluate the integrity ofthe peripheral (inner ear) and central vestibular structures. These tests are available atsome specialised audiology clinics and may berecommended following discharge fromhospital.231 Refer the patient toaspecialist, such asan ear, nose and throat specialistoraneurologist.211 Arrange ongoing management ofBPPV; this can bedone onan outpatientbasis.
Casestudy
Ms Tis a75-year-old woman who was admitted tothe orthopaedic ward with aColles fracture ofher left wrist after afall athome. Since her admission, MsThas been reporting anintense sensation ofspinning and nausea when lying flat inbed and now sleeps with the head ofher bed elevated. The sensation ofspinning isso severe when she lies down that MsThas become very anxious and feels that she will beunable tomanage byherselfathome. The orthopaedic physiotherapist onthe ward was trained toassess and manage benign paroxysmal positional vertigo (BPPV) and identified this condition inMs Ts right inner ear using the Dix-Hallpike test. MsTwas subsequently treated with anEpley manoeuvre, and felt much better within 24 hours. Repeat Dix-Hallpike testing identified that the BPPV hadresolved. Ms Twas discharged one day later and can now lie flat inbed with nosymptoms ofspinning. She was taught Brandt-Daroff exercises todo athome should the symptomsreturn.
http://members.physiotherapy.asn.au http://www.dizzyday.com/avesta.html
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Dix-Hallpike testing should not bedone onpatients with anunstable cardiac condition orahistory ofsevere neck disease,232 but can bemodified inolder people with othercomorbidities.233 Patients with symptoms ofdizziness should bemedically reviewed before starting arehabilitation program asoutlinedabove.
No economic evaluations were found that examined the cost effectiveness ofinterventions for dizziness andvertigo inthe hospitalsetting.
The following reference maybeuseful: Herdman S(2007). Vestibular Rehabilitation (Contemporary Perspectives inRehabilitation) , FADavis Company,Philadelphia.234 More information onnoncardiac dizziness and avideo demonstration ofthe Dix-Hallpike manoeuvre can befound at:http://www.profane.eu.org/CAT/
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PartC
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12 Medications
Recommendations
Intervention
Older people admitted tohospital should have their medications (prescribed and nonprescribed) reviewed and modified appropriately (and particularly incases ofmultiple drug use) asacomponent ofamultifactorial approach toreducing the risk offalls inahospital setting. (LevelI) 31 As part ofamultifactorial intervention, patients onpsychoactive medication should have their medication reviewed and, where possible, discontinued gradually tominimise side effects and toreduce their risk offalling. (LevelII-*) 37,235
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A number ofepidemiological studies have shown anassociation between medication use and falls inolder people. The risk offalls can beincreased bymedication interaction, unwanted side effects (such asdizziness) and even the desired effects ofmedications (such assedation). Itis important that the health care team recognises that pharmacological changes with ageing can lead topotentially avoidable events inolder people, including falls andfractures.
12.1.1 Medication use and increased fallsrisk

A number offactors affect anolder persons ability todeal with and respond tomedications, which can lead toan increased risk offalls.135 These factors include thefollowing: The ageing process, aswell asdisease, can result inchanges inpharmacokinetics (the time course bywhich the body absorbs, distributes, metabolises and excretes drugs) and pharmacodynamics (theeffect ofdrugs oncellular and organfunction). Nonadherence with drug therapy, including medication misuse and overuse, and inappropriate prescribing, can increase the risk ofadverseeffects. Certain classes ofmedication are more likely toincrease the risk offalls inolder people; forexample: Central nervous system drugs, especially psychoactive drugs, are associated with anincreased risk offalls.236 Inhospital, psychoactive medications are associated with anincreased risk offalls due totheirside effects, such assedation, postural hypotension and impaired balance andmobility.114,115,237-240 Benzodiazepine use isaconsistently reported risk factor for falls and fractures inolder people, both after anew prescription and over the long term. These drugs also affect cognition, gait andbalance.236 Antidepressants are associated with higher fall risk; 241 inparticular, selective serotonin reuptake inhibitors and tricyclicantidepressants.242 Antiepileptic drugs and drugs that lower blood pressure are weakly associated with anincreased riskoffalls.236 Cardiovascular medications (diuretics, digoxin238,243 and type IQanti-arrhythmic drugs) are weakly associated with anincreased riskoffalls.243 Other types ofcardiac drugs, and analgesic agents, are not associated with anincreased riskoffalls.243 Taking more than one medication isassociated with anincreased risk offalls.57,236,244 This may bearesult ofadverse reactions toone ormore ofthe medications, detrimental drug interactions, orincorrect use ofsome orall ofthe medications. According toone study, the relative risk offalling for people using only one medication (compared with people not taking any medication) is1.4, increasing to2.2 for people using two medications, and to2.4 for people using three ormoremedications.244 For each drug, the potential falls risk modification should bebalanced against the benefit ofthedrug.
12.1.2 Evidence forinterventions

Review ofmedication should beacore part ofthe assessment ofan older person whileinhospital. A randomised controlled trial reviewed medications aspart ofamultifactorial intervention for hospital patients with ahistory offalls.37 Aspart ofthe intervention, suspect medications (including sedatives, antidepressants and diuretics) were evaluated, aswell asmultiple drug use. The intervention included amedical review ofprescribed drugs associated with increased falls risk. Compared with acontrol group, patients who were screened using the multifactorial risk-factor prevention plan had asignificant reduction inthe risk offalls. Therefore, addressing medication history iseffective when combined with other riskreducing interventions. However, more research isneeded tosee what effect ithas when usedalone.
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12.2.1 Assessingmedications
Appropriateness ofmedication should bereviewed routinely inall hospitalised older people. Each hospital should take aproactive organisational approach tomedication review, which should include thefollowing: reviewing the patients medications onadmission to, and discharge from,hospital47,245-247 reviewing medication charts regularly during the patients stay inhospital (because medical conditions can change quickly inthe hospitalsetting).245 Given that changes are often made toapatients medication during ahospital stay, itis important toensure that all changes made are conveyed tothe local prescribing practitioner. Ahome medicines review may also besuggested where substantial changes have been made tomedications orwhere there are concerns about adherence followingdischarge. Older people who live inthe community are eligible for ahome medicines review, which isaservice that encourages collaboration between the older person, their general practitioner and their pharmacist toreview medication use. The home medicines review isavailable following areferral from ageneral practitioner; see the Pharmacy Guild ofAustraliawebsite.
12.2.2 Providing in-hospitalinterventions

The following interventions can beused aspart ofamultifactorial falls risk preventionprogram: Withdraw psychoactive medication gradually and under supervision toprevent falls significantly.235 TheNational Prescribing Service has guidelines onwithdrawingbenzodiazepines. Limit multiple drug use toreduce side effects and interactions and the tendency towards proliferation ofmedicationuse.37 If centrally acting medications such asbenzodiazepines are prescribed, increase surveillance and support mechanisms for older people during the first few weeks oftaking these drugs, because the risk offalling isgreatest during thisperiod.248 Drugs that act onthe central nervous system, especially psychoactive drugs, are associated with anincreased risk offalls; therefore, they should beused with caution and only after weighing uptheirrisks andbenefits.242 In addition, the following strategies help toensure quality use ofmedicines, and are good practice forminimising falls inolder people inthe hospitalsetting: Prescribe the lowest effective dosage ofamedication specific tothesymptoms. Provide support and reassurance topatients who are gradually stopping the use ofpsychoactivemedication(s). If the patient needs totake medications known tobe implicated inincreasing the risk offalls, trytominimise the adverse effects (drowsiness, dizziness, confusion and gaitdisturbance). Provide the patient (and their carer) with anexplanation ofnewly prescribed medications orchangestoprescriptions. Avoid initiating psychoactive medications inan older person while they are inhospital. Alternative approaches (eg behavioural and psychosocial treatments) tomanage sleep disorders, anxiety and depression should betried before pharmacological treatment. This may avoid the longer term problems associated with side effects and difficulties with withdrawal from themedications. Educate the whole multidisciplinary team, patients and their carers toimprove their awareness ofthe medications associated with anincreased riskoffalls. Document information when implementing, evaluating, intervening in, reviewing, educating and making recommendations about the patients medicationuse.
http://www.guild.org.au/mmr/content.asp?id=421 http://www.nps.org.au/__data/assets/pdf_file/0004/16915/ppr04.pdf
12 Medications
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12.2.3 Providing post-hospitalinterventions

Patients who have complex medication regimes should beconsidered for ahome medications review when they are discharged fromhospital.
Casestudy
Mrs Cis a90-year-old woman who was admitted tohospital after falling athome and fracturing her hip. During admission, hospital staff reviewed Mrs Cs medications, and noticed that she had been taking abenzodiazepine for anumber ofyears. After discussion with MrsC, the health care team agreed that awithdrawal program beinstituted. Bythe time Mrs C had undergone aperiod ofinpatient rehabilitation, she had managed tosuccessfully stop her benzodiazepine. Because ofher recent hip fracture, she was also started oncalcium, vitaminD and abisphosphonate while inhospital. The cessation ofthe benzodiazepine was communicated tothe general practitioner onMrs Cs discharge fromhospital.

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Adherence with medication can beaproblem inolder people with cognitive impairment. Blister packs and other technical prompts can beused toaid adherence. Some people will require medication supervision. Prescribers should aim tokeep drug regimens simple and, where possible, keep frequency ofmedication intake toamaximum ofdaily ortwicedaily. Where there isconcern about cognition and the ability ofapatient totake medications, the health care team should consider atrial ofself medication, including trialling ablister pack, while the older person isinhospital, toidentify potentialproblems. Possible communication difficulties experienced byolder people with cognitive impairment can make subjective assessments unreliable. Special attention needs tobe given toaltered behaviours and nonverbal cues inthispopulation.

The health care team may need toseek further professional advice inaremote facility. The websites oftheNational Prescribing Service and the Therapeutic Advice and Information Service maybeuseful.
No economic evaluations were found that specifically considered amedication-related intervention inthehospital setting. Some interventions have been found tobe effective orcost effective inother settings; however, itis unclear whether the results are applicable tothe hospital setting (see Chapter 12 inthe community guidelines, and Chapter 12 inthe residential aged care guidelines fordetails).
http://www.nps.org.au/ http://www.nps.org.au/health_professionals/consult_a_drug_information_pharmacist
Physician and pharmacist roles inassessment and evaluation procedures are governed bythe relevant professional practice standards andguidelines: Australian PharmaceuticalFormulary Pharmaceutical SocietyofAustralia: http://www.psa.org.au Society for Hospital Pharmacists(SHPA): http://www.shpa.org.au
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Useful resources forstaff

Australian Medicines Handbook, 5th edition (2004), produced byAustralian Health Consumers Forum, the Australasian Society ofClinical and Experimental Pharmacologists and Toxicologists, the Pharmaceutical Society ofAustralia, and the Royal Australian College ofGeneralPractitioners. Australian Medicines Handbook: Drug Choice Companion: Aged Care 2001 includes afalls preventionsection. National Medicines Policy: http://www.health.gov.au/internet/main/publishing.nsf/Content/National+Medicines+Policy-1 National Strategy for Quality Use ofMedicines: http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdf-natstrateng-cnt.htm Australian Pharmaceutical Advisory Council: http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-advisory-apac_mem.htm National Prescribing Service incorporates adrug information service for health professionals: http://www.nps.org.au Therapeutic Advice and Information Service can becontacted on1300 138677 Relevant state and territory drug informationcentres Relevant state and territory pharmaceutical advisoryservices SHPA Committee ofSpeciality Practice inDrug Use Evaluation (2004). SHPA Standards ofPractice for Drug Use Evaluation inAustralian Hospitals, JPharm Pract Res34(3):220-223. Australian Pharmaceutical Formulary and Handbook, 19th edition (2004), published bythe Pharmaceutical Society ofAustralia, includes guidelines and practice standards formedication managementreview: http://www.psa.org.au MIMS medicines database includes full and abbreviated information andoverthecounterinformation Contact: CMPMedicaAustralia Phone: 02 99027700 http://www.mims.com.au Pharmaceutical Health and Rational Use ofMedicines Committee: http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-advisory-apac-pharm
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Useful resources forpatients

Adverse Medicine EventsLine Phone: 1300 134237 National Prescribing Service incorporates adrug information service for patients onthe MedicinesLine Phone: 1300 888763 Pharmaceutical Society ofAustralia (PSA) self-care health information cards entitled Preventing falls and Wise use ofmedicines are available from the PSA, local pharmacy orat: http://www.psa.org.au Pharmacy GuildofAustralia Phone: 02 62701888 Fax: 02 62701800 Email:guild.nat@guild.org.au http://www.guild.org.au/index.asp

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13 Vision
Recommendations
Assessment
Use hospitalisation asan opportunity toscreen systematically for visual problems that can have aneffect both inthe hospital setting and afterdischarge. For arough estimate ofthe patients visual function, assess their ability toread astandard eye chart (eg aSnellen chart) orto recognise aneveryday object (eg pen, key, watch) from adistance oftwometres.
Intervention
As part ofamultidisciplinary intervention for reducing falls inhospitals, provide adequate lighting, contrast and other environmental factors tohelp maximise visual clues; for example, prevent falls byusing luminous commode seats, luminous toilet signs and night sensor lights. (LevelIII-3) 43 Where apreviously undiagnosed visual problem isidentified, refer the patient toan optometrist, orthoptist orophthalmologist for further evaluation (this also forms part ofdischarge planning). (LevelII) 37 When correcting other visual impairment (eg prescription ofnew glasses), explain tothe patient and their carers that extra care isneeded while the patient gets used tothe new visual information. (LevelII-*) 249 Advise patients with ahistory offalls oran increased risk offalls toavoid bifocals ormultifocals and touse single-lens distance glasses when walking especially when negotiating steps orwalking inunfamiliar surroundings. (LevelIII-2-*) 250 As part ofgood discharge planning, make sure that older people with cataracts have cataract surgery assoon aspracticable. (LevelII-*) 251,252
Note: there have not been enough studies toform strong, evidence based recommendations about correcting visual impairment toprevent falls inany setting (community, hospital, residential aged care facility), particularly when used assingle interventions. However, considerable research has linked falls with visual impairment inthe community setting, and these results may also apply tothehospitalsetting.
Good practicepoints
If apatient uses spectacles, make sure that they wear them, and that they are clean (useasoft, clean cloth), unscratched and fitted correctly. Ifthe patient has apair ofglasses for reading and apair for distance, make sure they are labelled accordingly, and that they wear distance glasses whenmobilising. Encourage patients with impaired vision toseek help when moving away from their immediate bedsurrounds.
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Vision plays amajor role infalls risk inthe community setting, but there islimited research onspecific visual interventions for preventing falls inhospitals. Asystematic review71 identified two studies using crude assessments ofvision that reported visual impairment asan independent risk factor for falls69 and in-hospital hipfracture.115 A study indicated that the prevalence ofvisual impairment ishigh (45%) inhospital inpatients, with cataracts and refractive errors being the main causes ofvisual impairment.253 Detection and specialist referral led toimproved visual outcomes inonly 2% ofcases. The biggest predictor ofnonattendance was being discharged before eye specialistreview. A 2004 Cochrane review found that there have not been enough studies toform evidence based recommendations about correcting visual impairment toprevent falls inany setting (community, hospital, residential aged care facility).7 Furthermore, studies have shown that multidisciplinary interventions are the most effective for falls prevention; little evidence showed that single interventions are effective, indicating that interventions toimprove vision should form part ofamultidisciplinary approach tofallsprevention. Considerable research inthe community setting has linked reduced vision (including visual acuity, aswell asdepth-of-field and contrast sensitivity) with anincreased risk offalls orfractures. These findings may beapplicable tothe hospital setting and highly relevant tothis high-risk group, given their higher rate ofvisual impairment and increased frailty. This chapter outlines interventions that can beconsidered good practice, despite limited data toevaluate their effectiveness when usedinisolation.
Pointofinterest
Much ofthe information inthis chapter isbased onresearch inolder people living inthecommunity. Inmost cases, the findings and recommendations can beextrapolated tothehospital setting; however, recommendations should befollowed with duecaution.
13.1.1 Visual functions associated with increased fallrisk

A retrospective observational study showed that the risk ofmultiple falls increases 2.6 times ifvisual acuity isworse than 6/7.5.254 Similarly, aprospective observational study showed that visual acuity of6/15 orworse almost doubles the risk ofhip fracture, and this risk isgreater with even lower visual acuity levels.255 Other visual functions have also been associated with anincreased risk offalling inprospective cohort studies. These visual functions include reduced contrast sensitivity,205,256 poor depth perception (measured inthe community setting) 205,257 and reduced visual fieldsize.254,258-261
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13.1.2 Eye diseases associated with anincreased riskoffalling

Visual changes resulting from cataracts (see Figure 13.2) are associated with increased postural instability262 and falls risk inolder people who live inthe community.263 People with glaucoma can present with arange ofloss ofperipheral visual fields (side vision), depending ondisease severity, which can affect apersons postural stability264 and their ability todetect obstacles and navigate through cluttered environments (seeFigure 13.3).259,265 Macular degeneration can cause loss ofcentral vision, depending upon disease severity (see Figure 13.4) and isassociated with impaired balance266,267 and anincreased riskoffalls.266
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Figure 13.1 shows normal vision,asacomparison.
Source: Vision 2020Australia
Figure 13.1 Normalvision
Figure 13.2 Visual changes resulting fromcataracts
Figure 13.3 Visual changes resulting fromglaucoma
Figure 13.4 Visual changes resulting from maculardegeneration
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13.2.1 Screeningvision
Hospitalisation provides anopportunity for systematic screening for visual problems that have animpact both inthe hospital setting and afterdischarge. Methods ofscreening vision include thefollowing: Visual function can bescreened aspart ofthe StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY): Is the patient visually impaired tothe extent that everyday function isaffected?75 (See Chapter 5 onscreening and assessment for moreinformation.) A randomised controlled trial offalls risk factor prevention included avision test aspart ofamultifactorial intervention. The trial concluded that vision could betested inaquick and simple way, bychecking apatients ability torecognise aneveryday object (eg apen, key orwatch) from adistance oftwo metres.37 However, this test will only pick upmajor visionproblems. The following additional visual function assessments can also beused asgoodpractice: Ask the patient about their vision and record any visual complaints and history ofeye problems and eyedisease. Check for signs ofvisual deterioration. These can include aninability tosee detail inobjects, read (including avoiding reading) orwatch television; apropensity tospill drinks; orapropensity tobump intoobjects. Measure visual acuity orcontrast sensitivity quantitatively using astandard eye chart (eg aSnellen eye chart) orthe Melbourne Edge Test (MET), respectively (see Table13.1). Check for signs ofvisual field loss using aconfrontation test (see Table 13.1) and refer for afull automated perimetry test byan optometrist orophthalmologist ifany defects are found. Large prospective studies found that anincrease infalls occurred when there was aloss offield sensitivity, rather than loss ofvisual acuity and contrastsensitivity.259 Table 13.1 summarises the characteristics ofeye-screeningtests.
Table 13.1 Characteristics ofeye-screeningtests
Snellen eye chart (for testing visualacuity)

Description Standardised eye test ofvisualacuity. Comprises aseries ofsymbols (usually letters) inlines ofgradually decreasingsizes. Participant isasked toread the chart from adistance of6 m for standard charts (chartsdesigned for shorter test distances are available; the examiner should check that they are using the correct working distance for thechart). Visual acuity isstated asafraction, with 6 being the numerator and the last line read the denominator (the larger the denominator, the worse the visualacuity). Pocket versions ofSnellen charts are available for aclinical screen ofvisual acuity (these smaller charts can beused atashorter distance than the standard 6 m totest visualacuity). Timeneeded Criterion 5minutes A score of6/12 indicates visual impairment; however, this depends onthe age of the person (the cut-off score will decrease with increasingage).
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Melbourne Edge Test (MET) (for testing contrast sensitivity) 97

Description The test presents 20 circular patches containing edges with reducingcontrast. Correct identification ofthe orientation ofthe edges onthe patches provides ameasure ofcontrast sensitivity indecibel units, where dB= 10log10 contrast, where contrast defines the ratio ofluminance levels ofthe two halves ofthe circularpatch. Timeneeded Criterion 5minutes Score ofless than 18/24 indicates visual impairment; however, the results are agedependent.268
Confrontation Visual Field Test269

Description Crude test ofvisualfields. Participant and examiner sit between 66 cmand 1mapart atthe same height, withtheexaminers back towards ablank wall. Totest the right eye, the participant covers thelefteye with the palm oftheir hand and stares atthe examinersnose. The examiner holds upboth hands inthe upper half ofthe field, one either side ofthe vertical, and each with either 1 or2 fingers extended, and asks the participant, Whatisthe total number offingers Iam holding up? The procedure isrepeated for thelower half ofthe field but changing the number offingers extended ineach hand. The procedure isrepeated for the left eye. Ifthe participant incorrectly counts the number offingers inthe upper orlower field, the test should berepeated and then recorded. Ifthe participant moves fixation toview the peripheral targets, repeat thepresentation. Results are recorded asfinger counting fields R and L ifthe patient correctly reports the number offingers presented. For those who fail this screening, adiagram should bedrawn toindicate the part ofthe field inwhich the participant madeanerror. Timeneeded Criterion 4minutes If the participant incorrectly reports the number offingers held upin either eye, theyshould bereferred for afull visual fieldtest.
If more detailed visual assessment isneeded once the patient has been assessed using the crude visual screening methods described above, orif the patient scores poorly onthese tests, hospital staff should referthem toan optometrist, orthoptist orophthalmologist for afull visionassessment.
13.2.2 Providinginterventions
The following interventions shouldbeapplied: Make sure that patients have their prescription spectacles with theminhospital.37 Where apreviously undiagnosed visual problem isidentified, refer the patient toan optometrist orophthalmologist for furtherevaluation.37 Provide adequate lighting, contrast and other environmental factors tohelp maximise visualcues.43 Additionally, make sure that ifthe person wears spectacles, they are clean, ingood repair, and fitted properly. Encourage people with impaired vision toseek help when moving away from their immediate bedsurrounds.
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13.2.3 Dischargeplanning
If anundiagnosed visual problem isdetected, encourage the patient tosee aneye specialist when they are discharged from hospital. Healey etal (2004) suggested referral toan optometrist ifthe patient has lost their glasses, and toan ophthalmologist ifthere isno known reason for poorvision.37 When avisual deficit isidentified, the health care team should seek adiagnosis and offer anintervention. Several visual improvement interventions should beconsidered after discharge from thehospital: Expedited cataract surgery. This isthe only evidence based intervention todate that has been shown tobeeffective inreducing both falls and fractures inolderpeople.251,252 Occupational therapy interventions inpeople with moderate tosevere visual impairment, tomanage the function and safety aspects ofvisual impairment. Home safety should beassessed byan occupational therapist toidentify potential hazards, lack ofequipment, and risky behaviour that might lead tofalls. Interventions that help tomaximise visual cues and reduce visual hazards should also beused. Theseinclude providing adequate lighting and contrast (eg painting white strips along the edges ofstairs and pathways) 270,271 (see Chapter 14 onenvironmental considerations for moreinformation). Prescription ofoptimal spectacle correction, with caution. Make sure the patients prescription iscorrect, and refer them toan optometrist ifnecessary. However, caution isrequired infrail older people: arandomised controlled trial found that comprehensive vision assessment with appropriate treatment does not reduce and may even increase the risk offalls.249 The authors speculated that large changes invisual correction may have increased the risk offalls, and that more time may beneeded toadapt toupdated prescriptions ornewglasses. Advice onthe most appropriate type ofspectacle correction. Wearing bifocal ormultifocal spectacle lenses when walking outside the home and onstairs has been associated with increased falls inolder people who live inthe community, doubling the risk offalls.250 These results may also apply toolder people inahospital setting. The health care team should advise patients with ahistory offalls oridentified increased falls risk touse single-vision spectacles (instead ofbifocals ormultifocals) when walking, especially when negotiating steps ormoving about inunfamiliar surroundings. Astudy also suggested telling older people who wear multifocals and distance single-vision spectacles toflex their heads rather than just lowering their eyes tolook downwards toavoid posturalinstability.272 Education. Educating health care workers onhow tomanage patients with reduced visual function may help toreduce the riskoffalls.
Point ofinterest: mobilitytraining

Vision Australia specialises insafe mobility training for visually impairedpeople.
Casestudy
Mrs Jis a75-year-old hospital inpatient who fell while walking over astep inadoorway. Onadmission tothe ward, Mrs Jwas assessed byan ophthalmologist, who found that MrsJ had severe visual impairment caused bymacular degeneration. Hospital staff inspected MrsJs spectacles for scratches, and made sure that they were clean and fitted her correctly. Staff also made sure that there was adequate lighting inher room atall times. Mrs Jwas given clear instructions about how tomove around and was encouraged tocall for help when walking inunfamiliar surroundings. Ondischarge, she was advised tohave afull eye examination toensure optimal spectacle correction. Given her severe visual impairment, MrsJwas also referred for anoccupational therapy homeassessment.
http://www.visionaustralia.org.au
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Where possible, patients with cognitive impairment should have their vision tested using standard testing procedures. Where this isnot possible, visual acuity can beassessed using aLandolt Cor Tumbling Echart. These tests contains near-vision, distance and reduced Snellen tests, and can beused tomeasure and record visual acuity inthe same way asstandard lettercharts.
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The Landolt Cis astandardised symbol (a ring with agap, similar toacapital C) used totest vision. The symbol isdisplayed with the gap invarious orientations (top, bottom, left, right), and the person being tested must say which direction itfaces. The Tumbling Echart issimilar, but uses the letter Ein differentorientations.

Health care practitioners orcarers can contact their local Optometric Association Australia intheir state orterritory for anup-to-date list ofoptometrists providing services inrural and remote areas. The patients general practitioner oroptometrist can provide areferral toalocal ophthalmologist. Alternatively, contact the Royal Australian and New Zealand College ofOphthalmologists on+61 2 9690 1001. The strategies outlined earlier inthis chapter should beimplemented before areferral toan ophthalmologistismade.

Where appropriate, visual acuity can bemeasured for Indigenous patients using aculturally appropriate chart known asthe Turtle Chart,273 which has aseries ofturtles ofdifferent sizes and orientations. Similarly, there isaseries ofculturally appropriate brochures and posters that describe different eye diseases and conditions, and different types ofspectaclecorrections.
13.3.4 Patients with limitedmobility

Home visits byoptometrists orophthalmologists may benecessary for housebound older people. TheOptometric Association Australia ineach state orterritory will provide acurrent list ofoptometrists willing toprovide suchservices.
No economic evaluations were identified that specifically considered interventions for vision inthe hospital setting. Some community interventions have been found tobe effective and cost effective; however, itis unclear whether the results are applicable tothe hospital setting (see Chapter 13 inthe community guidelines for moreinformation).
The following organisations maybehelpful: Optometrists AssociationAustralia: Phone: 03 96688500 Fax: 03 96637478 Email:oaanat@optometrists.asn.au http://www.optometrists.asn.au (contains details for state and territorydivisions) Vision Australia provides services for people with low vision and blindness acrossAustralia: http://www.visionaustralia.org.au Macular Degeneration Foundation promotes awareness ofmacular degeneration and provides resources andinformation: http://www.mdfoundation.com.au Guide dog associations inAustralia help people with visual impairment togain freedom and independence tomove safely and confidently around the community and tofulfil theirpotential: http://www.guidedogsaustralia.com
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14 Environmentalconsiderations
Recommendations
Assessment
Regular environmental reviews are advisable; procedures should bein place todocument environmental causes offalls; and staff should beeducated inenvironmental risk factors for fallsinhospitals.
Intervention
Environmental modifications should beincluded aspart ofamultifactorial intervention. (LevelII) 37,38 As part ofamultifactorial intervention, falls can bereduced byusing luminous toilet signs and night sensor lights. (LevelIII-3) 43
Good practicepoints
Make sure that the patients personal belongings and equipment are easy and safe for themtoaccess. Check all aspects ofthe environment and modify asnecessary toreduce the risk offalls (eg furniture, lighting, floor surfaces, clutter and spills, and mobilisationaids). Conduct environmental reviews regularly (consider combining them with occupational health and safetyreviews).
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For older people, the risk offalling while inhospital may begreater than inother settings, because ofrisk factors such asacute conditions (stroke, hip fractures, illness, etc) orunfamiliar surroundings.31 Thoseidentified ashaving the highest risk for falls inhospital are people with unsteady gait, confusion, urinary incontinence orfrequency ofusing the toilet, orahistory offalls, and those taking sedatives.81 Theconsequences offalls inhospitals are great, with ahigh associated mortality and morbidity: olderpeople who fracture their hip while staying inhospital have poorer outcomes than older people who fracture their hip inthe community.81 The cost ofacute public hospital care for fallers accounts for24%oftotal costs but only 11% oftotal fallinjuries.274 Falls prevention programs inhospitals have trialled different ways ofreducing falls, including modifying the hospital room orenvironment toreduce obvious risk factors. Environmental review and modification refers tochecking the hospital room for hazards that might cause people tofall, and then modifying orrearranging the environment toremove orminimise these hazards. For example, this could include removing clutter, improving lighting and installinghandrails. A Cochrane review looked atthe effectiveness ofdifferent interventions for preventing falls inolder people inhospitals ornursing care facilities. The review found that multifactorial interventions targeting several different risk factors (eg falls prevention programs that include environmental modification inasuite ofinterventions) may help toprevent falls inhospitals.31 However, these multifactorial interventions seemed tobe more effective for long-term patients (that is, people who were inhospital for more than three weeks). Also, interventions are most effective for people who already have anincreased risk offalls (egthose with cognitive impairment orheart conditions, orthose who have sufferedastroke).7 It isdifficult toanalyse rates offalls inhospitals because there have been few randomised controlled trials. Aswell, these trials have looked atdifferent types ofhospitals settings (eg acute wards, longer-term wards, geriatric wards), which greatly affects the falls rates because they contain different populations who have varying risk factors for falls. Also, there isadifference between short-term and long-termpatients.2
14.2.1 Targeting environmentinterventions
Environmental modification interventions are most likely tobe effective inpatients who already have anincreased risk offalls.7 Various tools are available for screening older people for falls risk inhospitals (seeChapter5).
14.2.2 Designing multifactorial interventions that include environmentalmodifications

As mentioned earlier, there are not enough data tomake recommendations about single interventions used alone toprevent falls and injuries inhospitals. However, multifactorial interventions should incorporate environmental modifications, suchas: 2,21,274-276 ensuring chairs and beds are atthe correct height (ie when the patients feet are flat onthe ground, their hips are slightly higher than theirknees) installing even lighting atstairs and way-finding night lighting tothe toilet; making sure night lighting isused consistently andsafely installing slip-resistant floorsurfaces cleaning spills and urinepromptly reducing clutter and other trip hazards inpatients rooms andwards providing and repairing walkingaids providing stable furniture for handhold distances between furniture, beds, chairs andtoilets ensuring bed, wheelchair and commode brakes are onwhen apatientistransferring using aflooring pattern that does not create anillusion ofslope orsteps for patients with impaired eyesight orcognitiveimpairment making sure the patient wears safe footwear and avoids ill-fitting footwear with slipperysoles moving patients who have ahigh risk offalling closer tothe nursesstation reducing the unnecessary use ofphysical restraints, and reviewing the use ofrestraintsregularly using electronic warningdevices.
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14.2.3 Incorporating capital works planning anddesign

When hospitals orhospital wards are being built orrenovated, the following issues shouldbeconsidered: Safety and practicality are just asimportantasaesthetics. Facilities should conform tolegislated safetyrequirements.274,277 A design that allows observation orsurveillance ofpeople isimportant forsafety.277 Lighting and handrails atsteps and stairs, and design ofstairs toallow safer descent areimportant.274 Slip-resistant flooring orproducts should beused inall wetareas.274 Impact-absorbent flooring (or underlay) shouldbeused.
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14.2.4 Providing storage andequipment

The risk offalls needs tobe considered when new equipment isacquired, orwhen equipment arrangements are being designed ormodified (eg new seating orshower chairs).277 Health professionals and hospital staff should beinvolved indecisions about buyingequipment. Clutter should bereduced byproviding adequate storage space for equipment,277 and equipment should bereviewed atleastmonthly.135
14.2.5 Conducting environmentalreviews

Regular environmental reviews should bedone with the following pointsinmind: Make modifications based onthe findings ofthereview. Prioritise reviews byconsidering the followingenvironments high-risk environments (bedrooms, dining areas, bathrooms andtoilets) environments identified through incident monitoring, hazard identification ornear-missreporting environments identified through environmental checklists (Appendix 4 contains ageneral environmental checklist that may beuseful when reviewing theenvironment). Include external environments inenvironmentalreviewing.277 Consider how environmental reviews may fit inwith existing workplace health and safetyreviews. Involve arange ofdisciplines inenvironmental reviews and interventions, including health professionals such asoccupational therapists, workplace health and safety personnel, infection-control personnel,277 staff working inthat particular environment, specialists ingeriatric assessment orergonomics, technical advisers, and older peoples carers, whereappropriate. Ensure amechanism isin place for reporting environmentalhazards. When considering environmental change, hospital staff should explore arange ofproducts, equipment and solutions. Keep inmind that changing apersons environment could have anegative impact. For example, reorganising furniture may becontraindicated for people who are visually impaired orhavedementia. Appendix 4 contains useful information onmodifying flooring, lighting, bathrooms and toilets, hallways, stairways and steps, furniture, beds, chairs, alert orcall systems, and externalenvironments.
14.2.6 Orientating newresidents

Many falls occur during apersons first few days inanew setting.278 Therefore, hospital staff should help patients tobecome familiar with new environments and teach them touse equipment.279 This orientation could include teaching the patient totransfer themselves between furniture orequipment that they are unfamiliarwith.
14.2.7 Review andmonitoring

Environmental strategies are likely tobe done inconjunction with other interventions. Asdiscussed earlier, their effectiveness inisolation from other risk factors isdifficult tomeasure. The effectiveness ofenvironmental interventions islikely tobe reflected infalls indicators, such asachange inthe location offalls and areduction infalls associated with particular environmentalhazards. Staff should review and assess environments inhospitals regularly (particularly high-risk environments, such asbedrooms, bathrooms and dining areas). Afloor plan ofthe hospital isauseful tool for mapping falls locations and for showing the number offalls and near misses inparticular environmental hotspots. Such mapping before and after environmental modification can provide feedback onthe effectiveness ofenvironmentaladjustments.
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Casestudy
Mr Bhas been hospitalised inasubacute rehabilitation ward following arecent stroke. Hehas regained most movement; however, hefinds itdifficult toget out ofbed and into his armchair, and togo tothe toilet. His geriatrician undertook amedical review, and occupational therapy staff assessed his activities ofdaily living. His chair and bed height were adjusted; his family replaced his slippers with safer footwear; and LED night lights were provided inthe toilet and asaway-finding guide tothe bathroom. The staff were instructed onhow tobest help him with transfers, given his condition. MrBnow attends regular group sessions with the physiotherapist. Asaresult ofthis process, MrBis now safer inhis activities ofdaily living andhas alower riskoffalling.

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The physical environment takes ongreater significance for people with diminished physical, sensory orcognitive capacity.279 The unique characteristics ofpeople who are cognitively impaired may adversely affect their interaction with the environment. Aswell asreviewing the environmental factors noted inAppendix 4, staff inhospitals should make sure that residents who are agitated orshow behavioural disturbances are monitoredadequately. Specific environmental changes can help patients with cognitive impairment tobe more comfortable and independent, and reduce confusion and the risk offalls. For example, consider positioning the patient close tonursing staff, using bed orchair alarms, orusing electronic surveillance systems.280 Other things that may helpinclude: using calming colour schemes toreduceagitation2 making sure the hospital layout supports improved continence (toilet close by, easy tofind, clearlymarked) 279 providing apredictable, consistentenvironment using suitable furniture without sharpedges247 providing adequate lighting with enough coverage toensure clear vision and toprevent castingshadows.247

Many ofthe environmental strategies suggest multidisciplinary involvement, and this may not bereadily available inrural and remote settings. Videoconferencing, teleconferencing and interagency collaboration maybebeneficial. In facilities where only avisiting occupational therapist isavailable, itwould beuseful toconduct anenvironmental review (see Appendix 4) and anequipment review (see Appendix 5) and take corrective action before the therapists visit. This would help toidentify key areas requiring specialistadvice.
14.3.3 Nonambulatorypatients
Falls occurring innonambulatory patients are more likely toinvolve equipment and occur while the patient isseated orduring transfers.281 Therefore, interventions toreduce the risk offalls for these patients should consider transfer and equipmentsafety.
Some community interventions have been found tobe effective and cost effective; however, itis unclear whether the results are applicable tothe hospital setting (see Chapter 14 inthe community guidelines for moreinformation).
The following associations and organisations maybehelpful: OTAUSTRALIA Phone: 03 94152900 Fax: 03 94161421 Email:info@ausot.com.au http://www.ausot.com.au Independent living centres, which are available inmost states and territories, provide independent information and advice onthe ranges ofequipment, floor surfacing products, etc. See Independent Living CentresAustralia: http://www.ilcaustralia.org/home/default.asp Home Modification Information Clearinghouse collects and distributes information on home maintenance and modifications and has anumber ofuseful environmental reviews: http://www.homemods.info/
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15 Individual surveillance andobservation
Recommendations
Intervention
Include individual observation and surveillance ascomponents ofamultifactorial falls prevention program, but take care not toinfringe onpeoples privacy. (LevelIII-2) 43 Falls risk alert cards and symbols can beused toflag high-risk patients aspart ofamultifactorial falls prevention program, aslong asthey are followed upwith appropriateinterventions. (LevelII) 39 Consider using avolunteer sitter program for patients who have ahigh risk offalling, anddefine the volunteer roles clearly. (LevelIV) 42,64
Good practicepoints
Most falls inhospitals are unwitnessed. Therefore, the key toreducing falls isto raise awareness among staff ofthe patients individual risk factors, and reasons why improved surveillance may reduce the riskoffalling. If appropriate, hospital staff should discuss with carers, family orfriends the patients riskoffalling and their need for closemonitoring. Family members orcarers can begiven aninformation brochure touse indiscussions withthe patient about fallsinhospitals. Encourage family members orcarers tospend time sitting with the patient, particularly inwaking hours, and encourage them tonotify staff ifthe patient requiresassistance. A range ofalarm systems and alert devices are available, including motion sensors, video surveillance and pressure sensors. They should betested for suitability before purchase, andappropriate training and response mechanisms should beoffered tostaff. Alternatively, find another hospital that already has aneffective alarm system, see what their program includes, and try theirsystem. Patients who have ahigh risk offalling should becheckedregularly. A staff member should stay with patients with cognitive impairment and ahigh risk offalls while the patient isin thebathroom.
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Many falls that occur inhospitals are unwitnessed.24,25 Arange ofapproaches have been reported for identifying when aperson athigh risk offalling isgetting out ofabed orchair unsupervised (particularly for patients with cognitive impairment). Theseinclude: locating the patient inan area ofhighervisibility24,37 flagging those athigh risk (eg byusing falls risk alert cardsorsymbols) 39 observing high-risk patientsfrequently48 using sitterprograms24,64,282 using alarm systems and alertdevices.2,283,284 Observational studies have looked attechnologies for reducing falls, such asinfrared movement detectors, fall alarms (which sound when the patient isalready onthe floor), bed and chair alarms, and movement alarms. However, these studies are generally ofpoor quality. Asystematic review concluded that trials inhospitals and care homes that investigate specific interventions, such asalarms, arelacking.36 The use ofsurveillance can have ethical and legal considerations (deprivation ofliberty, mental capacity and infringement ofautonomy). Care must betaken that surveillance does not infringe onthe patients autonomy ordignity. Hospitals must have clear policies and procedures inplace for using surveillance. Seealso Chapter16 onthe use ofrestraints and associated ethical and legalconsiderations.
The following general principles ofobservation and surveillance represent expert opinion ofbest practice inthe hospital setting, inthe absence oftrials testing theireffectiveness. The choice ofsurveillance and observation approaches will depend onacombination ofthe findings from the assessment ofeach patient, clinical reasoning and access toresources and technology. More than one surveillance and observation approach should beused, thereby avoiding dependence onasingleapproach. An important strategy toconsider for improving surveillance isto review staff practices, such asstaff handover practices and timing oftea and lunch breaks, toensure that adequate supervision isavailable when required. Personal preference for the frequency ofshowers orpersonal hygiene needs tobe considered onan individual basis and balanced against existing routines inthehospital.43 Where possible, high-visibility beds or rooms (such asnear nurses stations) should beallocated topatients who require more attention and supervision, including patients who have ahigh risk offalling.24 Positioning patients with ahistory offalls close tonurses stations was anintervention inarandomised controlled trial that investigated atargeted risk factor care plan. Overall, the trial significantly reduced falls inthe intervention group compared with the control group. However, the individual contribution ofbed positioning was not clear, nor was the number ofpatients who wererepositioned.37
15.2.1 Flagging
Patients who have ahigh risk offalling should betold about their risk. Inhospitals, the patients risk offalling should beidentified (flagged) insuch away that considers the persons privacy, yet isrecognised easily bystaff and the patients family and carers. Arange ofmethods other than verbal and written communication may beused toensure ongoing communication ofhigh-risk status (flagging),including: coloured stickers ormarkers (positioned oncase notes, walking aids, bedheads) 285 signs, pictures orgraphics onor near the bedhead.39,285 Flagging reminds staff that aperson has ahigh risk offalling, and should trigger interventions that may prevent afall. These interventions must beavailable; otherwise, the flagging may not bebeneficial. Flaggingmay also improve apatients own awareness oftheir potential tofall.247 Amultifactorial trial inthree Australian subacute hospital wards included arisk alert card bythe bedside.39 The researchers deliberately used asymbol, rather than words, onthe A4-sized card, tominimise violating patient privacy orcausing distress topatients ortheir families. Across the study duration, noofficial complaints were made about the alert card being displayed. Other components ofthe intervention included aninformation brochure, anexercise program, aneducation program and hip protectors. The incidence offalls inthe intervention group was reduced compared with the controlgroup.
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15.2.2 Colours for stickers and bedsidenotices

The Australia-wide consultation process that facilitated the production ofthese guidelines found that green ororange were frequently used colours for stickers and bedside notices tosignify high risk offalling. Although some falls prevention studies have used high-risk alert stickers, the results are conflicting. Inthe absence ofdata tothe contrary, itmay bebeneficial for staff toflag high-risk patients, using colours orsymbols consistently. Ongoing staff education about the purpose and importance offlaggingisessential. Ideally, inthe hospital setting, patients who have ahigh risk offalling should bechecked regularly and offered assistance.48 Astaff member should remain with the high-risk patient while they are inthebathroom.48
15.2.3 Sitterprograms
Some hospitals have introduced sitter programs. These programs use volunteers, families orpaid staff tosit with patients who have ahigh risk offalling.286 Apretestpost-test comparative study intwo SouthAustralian hospitals evaluated the effectiveness ofusing volunteer sitters inreducing falls.282 Volunteers worked four-hour shifts between the hours of9 amand 5 pm. Nofalls were reported ateither hospital during the hours that volunteers were present. Volunteers maintained journals throughout the study, and the journals indicated high satisfaction with their roles. Semistructured interviews with family members indicated high satisfaction with the volunteers. However, some nurses (n=7; 29%) reported that volunteers could bedemanding oftheir time and required too muchsupervision. A second Australian study looked atthe effect ofvolunteer companion-observers inpreventing falls inan acute aged care ward.64 Patients were situated inafour-bed room ifthey were identified tohave ahigh fallsrisk. Volunteers completed aminimum shift oftwo hours, between 8 amand 8 pmon weekdays. The key role ofthe volunteers was toalert nursing staff ifpatients showed high-risk behaviours, such asbecoming agitated orattempting toclimb out ofbed. After 20 months, nofalls were reported inthe observation room, and falls inthe ward were reduced by51%. Family members expressed satisfaction with the volunteers; however, the volunteers role needed clarification, because nurses sometimes asked volunteers towalk orfeed patients, and volunteers sometimes became frustrated ifnurses were slow torespond topatient callbells. A limitation ofvolunteer sitters isthat they are typically only available inbusiness hours.64 Providing 24/7surveillance coverage byvolunteers would require anadditional 15 volunteers per week inahospitalward.282
15.2.4 Responsesystems
Response systems are usually aform ofmonitor, incorporating analarm that sounds when apatient moves. Anumber ofresponse systems are commercially available. Insome systems, analarm isactivated byapressure sensor when apatient starts tomove from abed orchair. Arandomised controlled trial ofresidents ofageriatric evaluation and treatment unit did not find any statistically significant difference between anintervention group (who received abed alarm system) and acontrol group (who did not).287 However, the authors concluded that bed alarm systems may still bebeneficial inguarding against bed falls and may bean acceptable method ofpreventing falls. Therefore, itis difficult tomake recommendations about using bed alarm systems inthe hospitalsetting. An Australian study conducted in12 hospitals included alarms inamultifactorial falls prevention intervention.42 Adherence was high: 40 ofthe 49 participants who were given the recommendation complied with wearing the alarm. The alarm was apressure switch under the heel that, when stood on, activated ahigh-pitched sound, amplified byaspeaker concealed inapocket inthe wearers sock. Theintervention had noeffect onfall rates, and the authors suggested that the median length ofstay (seven days) was too short for interventions totakeeffect. In other alarm systems, analarm sounds when any part ofapatients body moves within aspace monitored bythe alarm. Yet another style ofalarm activates when apatient falls but does not get up. Response systems require capital investment and rely onathird party (eg hospital staff orthe patients carer) torespond when the alarm sounds. The issues ofwho responds and how, and what impact this has onwardpractice including what itmay take away from other areas ofcare need tobe considered before any systemisimplemented.
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Alarms may perceivably pose risk-management problems for hospitals, inthat failure torespond toan alarm because oflack ofstaffing could beseen asafailure incare. Moreover, itis not necessarily correct toassume that ifsomeone lacks mental capacity due todementia, they should besubjected tointrusive surveillance toprevent falls.288 Care should betaken that alarms donot infringe autonomy. The lack ofclear research results (probably due tothe difficulties inresearching this area), and the ethical and legal considerations ofmonitoring people should befactored intodecisions.

Evaluation ofthe effectiveness ofsurveillance and observation systems will depend onthe range and mix ofsystems that are used. Indicators ofthe acceptance ofthese systems mayinclude: 64,282 frequency ofuse ofsurveillance and observationmethods satisfaction ofstaff, patients, their family, carers orfriends with surveillance and observationmethods. An indicator ofthe effectiveness ofsurveillance and observation systems may include the number offalls after animproved surveillance program has been introduced, compared with the number offalls before itwasintroduced.
Casestudy
Mr Pis 81 years old and normally lives alone athome. Hewas admitted tothe medical ward because hewas malnourished, dehydrated and falling over onaweekly basis. Hewas delirious onadmission and wandered frequently out ofthe ward and into other patients rooms, sometimes getting into the wrong bed. Medical assessment indicated the presence ofan acute delirium, and appropriate medical and nursing management was instituted. Hebecame quite agitated ifmade tosit byhis bed and remain inthe ward all day. Staff decided toplace achair near the nurses station for him tosit onwhen hewanted. The physiotherapist assessed his mobility and arranged for family and available staff totake MrPfor awalk outside when possible. Hospital volunteers, trained inthe facilitys patient sitter program, were also recruited tosit with MrPand alert staff ifhe attempted towalk without supervision. Asthe delirium settled with medical and nursing management, MrPbecame safer with his mobility and orientation, and the observation strategies were graduallywithdrawn.
Surveillance and observation approaches are particularly useful for patients who forget ordo not realise their limitations. Improved surveillance and observation may bepreferable tothe use ofrestraints asan injury minimisationstrategy.2

In some cultures, itis accepted practice tosit for long periods with ill relatives and elders. This may afford agreater role tocarers, family members and friends insupervising the persons activity toreduce the riskoffalls.
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Three studies have examined the costs and effects ofhospital-based individual surveillanceprograms. Spetz etal (2007) reported aneconomic evaluation ofamedical vigilance system (LG1) that incorporated abed exit alert module.286 The evaluation was based onasmall, nonrandomised study inapostneurosurgery ward, and ran for eight weeks. The medical vigilance system was compared with the adhoc use ofpatient sitters (sitters were not used for all patients, oron all shifts). Anaverage fall rate of1.94% inthe LG1group was reported, compared with 3.23% inthe control group. There was amean incremental cost per fall prevented ofbetween US$5959 and US$6301 for the LG1 system, compared with usual care byad hoc patientsitters. Giles etal (2006) conducted apretest-post-test feasibility study that looked atthe effect ofvolunteer companions onpreventing falls among patients intwo four-bed safety bays inmedical wards in Australianhospitals.282 Volunteers observed patients insafety bays from 9 amto 5 pm, Monday toFriday, and for four hours onSaturday. Nofalls occurred when volunteers were present. During the baseline (pre-)period, there was afall rate of14.5 falls per 1000 occupied bed days, compared with 15.5 falls per 1000 occupied bed days during the implementation period. Volunteers donated atotal of2345 hours over the trial period. Ifthis labour had tobe paid for (at arate ofA$24.25 per hour), the total cost would have been A$56866 (excluding travel time and travel costs). Acost per fall prevented was not calculated, because the fall rate was higher during the intervention period. Similarly, Boswell etal (2001) 289 also reported that patient falls increased slightly for each sitter shift, and thus acost-effectiveness ratio was notcalculated.
Successful observation practices have targeted changes innursing practice, sothat nurses are able toobserve patients for longer periods during the course oftheir shift bymodifying long-established practices related tonurse documentation, nursing handover, patient hygiene practices, staff meal breaks and patient eating times, and creation ofahigh-observationbay.43 The Australian Resource Centre for Health Care Innovations provides information and resources for health care professionals, including information onpreventingfalls: http://www.archi.net.au/e-library/safety/falls
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16 Restraints
Recommendations
Assessment
Causes ofagitation, wandering and other behaviours should beinvestigated, and reversible causes ofthese behaviours (eg delirium) should betreated, before restraint useisconsidered.
Note: there isno evidence that physical restraints reduce the incidence offalls orserious injuries inolder people.290-293 However, there isevidence that they can cause death, injury orinfringement ofautonomy.294,295 Therefore, restraints should beconsidered the last option for patients who are atriskoffalling.296
Good practicepoints
The focus ofcaring for patients with behavioural issues should beon responding tothe patients behaviour and understanding its cause, rather than attempting tocontrolit. All alternatives torestraint should beconsidered and trialled for patients with cognitive impairment, includingdelirium. If all alternatives are exhausted, the rationale for using restraints must bedocumented andananticipated duration agreed onby the health careteam. If drugs are used specifically torestrain apatient, the minimal dose should beused and the patient should bereviewed and monitored toensure their safety. Importantly, chemical restraint must not beasubstitute for quality care. See the alternative methods ofrestraint outlined inthischapter. Follow hospital protocol ifphysical restraints mustbeused. Any restraint use should not only beagreed onby the health team, but also discussed withfamilyorcarers.
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A restraint isamechanism used tocontrol ormodify apersons behaviour. Physical restraints include lap belts, table tops, meal trays and backwards-leaning chairs (or stroke chairs) that are difficult toget out of, and possibly bed alarm devices. Covert restraint practices may occur, such astucking bed clothes intoo tight, wedging cupboards against beds orlocking doors. Drugs, such assedatives, have sometimes been used aschemical restraints. Inmost situations, this isregarded asan inappropriate form ofrestraint. However, when apatients behaviour isdisturbed and their risk offalling isincreased, there may beacase for chemical restraint. Bed rails are also sometimes used asatypeofrestraint. Physical restraint ofpatients during admission tohospital has been common practice for many years.291 The prevention offalls iscited asthe most common reason for the use ofphysical restraints.297 Studieshave shown that some health care workers believe that restraining patients will prevent afall; 298 however,evidence suggests that restraints may have the opposite effect and that patients who are restrained are more likely tofall.247,297 Insome instances, reducing the use ofrestraints may actually decrease the riskoffalling.284 An observational study from Finland recorded the use ofpsychoactive and other drugs aschemical restraints inlong-term hospital care. They found that, out of154 participants, 33% received three ormore psychoactive drugs regularly, and 24% received two ormore benzodiazepine derivatives orrelated drugs regularly. The authors concluded that psychoactive drugs were used aschemical restraints inthese longterm carewards.299 If used, restraints should bethe last option considered.300 Asystematic review ofuse ofphysical restraint and injuries found anassociation between restraint use and increased risk ofinjury anddeath.291 If drugs are used specifically torestrain apatient, the minimal dose should beused, and the patient should bereviewed and monitored toensure their safety. Importantly, chemical restraint must not beasubstitute for alternative methods ofrestraint outlined inthischapter.
16.2.1 Assessing the need for restraints and consideringalternatives
Hospitals should have clear policies and procedures onthe use ofrestraints, inline with state orterritory legislation and guidelines. Causes ofagitation, wandering orother behaviours should beinvestigated, and reversible causes ofthese behaviours (eg delirium) should betreated before restraint use isconsidered.4,301 Restraints should not beused atall for patients who can walk safely and who wander ordisturb other patients.247 Wandering behaviour warrants urgent exploration ofother management strategies, including behavioural and environmental alternatives torestraint use. These alternatives mayinclude: 300 using strategies toincrease observationorsurveillance providingcompanionship providing physical and diversionaryactivity meeting the patients physical and comfort needs (according toindividual routines asmuch aspossible, rather than facilityroutines) using lowbeds decreasing environmental noise andactivity exploring previous routines, likes and dislikes, and attempting toincorporate these into the careplan. Hospital staff should beprovided with appropriate and adequate education about alternatives torestraints. Education can reduce the perceived need touse restraints, aswell asminimise the risk ofinjury when restraints areused.
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16.2.2 Usingrestraints
When the patients health care team has considered all alternatives torestraints, and agreed that the alternatives are inappropriate orineffective, restraints could beconsidered. Insuch cases, restraints should only beused temporarilyto: prevent orminimise harm tothepatient prevent harmtoothers optimise the patients healthstatus. The health care team must also take into account the rights and wishes ofthe patient, their carers and family.4 Any decision touse restraints should bemade bydiscussing their use and possible alternatives withthe patient, their carers andfamily. When the use ofrestraints isunavoidable, the type ofrestraint chosen should always bethe least restrictive toachieve the desired outcome. Furthermore, restraint use should bemonitored and evaluated continually. Restraints should not beasubstitution for supervision, orused tocompensate for inadequate staffing orlack ofequipment,45,300 and they should not beapplied without the support ofawritten order.300 Theminimum standard ofdocumentation for restraint useincludes: 296 date and timeofapplication name ofthe person ordering therestraint typeofrestraint reasons for therestraint alternatives considered andtrialled discussion with the patient, carers orsubstitute decisionmakers any restrictions onthe circumstances inwhich the restraint maybeapplied intervals atwhich the patient mustbeobserved any special measures necessary toensure the patients proper treatment while the restraintisapplied duration oftherestraint.

Hospitals should have arestraint policy, which should bereviewed regularly. Staff should also beassessed ontheir knowledge and skill inusing alternatives torestraints, aswell astheir knowledge ofthe hospitals restraint policy. Trends inthe use ofrestraints should also bemonitored; for example, why arestraint isused, for how long, and what alternatives were considered.300 Arestraint-use form may beuseful for thispurpose.
Casestudy
Mr Mis 70 years old and was recently admitted tohospital for aroutine hernia operation. Hehad nohistory ofconfusion but had recently fallen anumber oftimes athome and suffered minor injuries. Immediately after the operation, MrMbecame very confused, agitated and restless. Hetried several times toget out ofbed. Medical review indicated acute delirium, and medical management was instituted toaddress the cause. Given MrMs current lack ofawareness ofhis potential high risk offalling, hewas allocated abed inan area ofhigh supervision and checked more frequently bynursing staff, and his family was contacted and asked tohelp bysitting with him. The family preferred this option rather than using restraints, when MrMs cognitive impairment and risk offalling were explainedtothem.
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For patients with cognitive impairment who cannot stand ormobilise safely ontheir own, restraints should beused only after their falls risk has been evaluated and alternatives torestraint have been considered. Ifrestraints are applied, they should beused only for limited periods and should bereviewed regularly. The use ofphysical restraints has been associated with delirium, and therefore their use should bekept toaminimum.301 See Chapter 7 for more informationondelirium.
No economic evaluations were found that examined the cost effectiveness ofrestraints inthe hospitalsetting.
Below are some useful guidelines, policy statements and tools for the use ofrestraints andalternatives: Australian Government Department ofHealth and Ageing (2004). Decision-Making Tool: Responding toIssues ofRestraint inAged Care. This isacomprehensive resource that includes useful tools and flowcharts: http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-decision-restraint.htm Nursing Board ofTasmania (2008). Standards for the Use ofRestraint for Nurses and Midwives2008 : http://www.nursingboardtas.org.au/domino/nbt/nbtonline.nsf/$LookupDocName/publications (and click onStandards for the Use ofRestraint for Nurses and Midwives2008 ) Australian Medical Association (2001). Restraint inthe Care ofOlder People 2001, positionstatement: http://www.ama.com.au/node/1293 Nurses Board ofSouth Australia (2008). Restraints: Guidelines for Nurses and Midwives inSouthAustralia : http://www.nmbsa.sa.gov.au/documents/Restraints-GuidelineforNursesandMidwives.pdf
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PartD

17 Hipprotectors
Recommendations
Assessment
When assessing apatients need for hip protectors inhospital, staff should consider thepatients recent falls history, age, mobility and steadiness ofgait, disability status, andwhether they have osteoporosis oralow body massindex. Assessing the patients cognition and independence indaily living skills (eg dexterity indressing) may also help determine whether the patient will beable touse hipprotectors.
Intervention
Hip protectors must beworn correctly for any protective effect, and the hospital should introduce education and training for staff inthe correct application ofhip protectors. (LevelII-*) 302 When using hip protectors aspart ofafalls prevention strategy, hospital staff should check regularly that the patient iswearing their protectors, and ensure that the hip protectors are comfortable and the patient can put them oneasily. (LevelI-*) 303
Good practicepoints
Although there isno evidence ofthe effectiveness ofhip protectors inthe hospital setting, their use can beconsidered inindividual cases where the patient isable totolerate wearing them, and has ahigh risk ofinjuriousfalls. If hip protectors are tobe used, they must befitted correctly and worn atalltimes. The use ofhip protectors inhospitals ischallenging but feasible insubacute wards. Inhospital wards where patients are acutely ill (acute wards), effective use ofhip protectors has not been shown tobepossible. Hip protectors are apersonal garment and should not beshared betweenpatients.
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Hip fractures are fractures tothe top ofthe femur (thigh bone) immediately below the hip joint, and are usually the result ofafall.303 Hip fractures occur inapproximately 1.65% offalls 304 and are one ofthe more severe injuries associated with afall. They usually require surgery and lengthy rehabilitation, and many patients donot regain their previous level ofmobility even after 12 months.122 Pelvic fractures can also occur, although these are lesscommon. Hip protectors are one approach toreducing the risk ofhip fracture. They come invarious styles, and are designed toabsorb ordissipate forces atthe hip ifafall onto the hip area occurs. Hip protectors consist ofundergarments with protective material inserted over the hip regions. They are sometimes called hip protector pads, protector shields orexternal hip protector pads. These guidelines refer tothem all ashipprotectors.
17.1.1 Studies onhip protectoruse

Early studies (up to2001) onhip protectors seemed toshow that they reduced the incidence ofhip fractures ininstitutional settings, and sothey were introduced widely into practice. However, design flaws inthese studies limit the strength oftheir conclusions.303 Nevertheless, there issome evidence that, whenworn correctly, hip protectors may prevent hip fractures inolder people inhospitals orresidential aged care facilities although more recent research indicates that their benefits may beless than originally thought.303 Hip protectors can therefore beused aspart ofamultifactorial falls and injury prevention intervention inhospitals, although they will not prevent falls orprotect other parts ofthebody.305 Whatever their effectiveness, hip protectors must beworn and worn correctly ifthey are tohave any benefit. AnAustralian study looked atthe feasibility ofintroducing hip protectors into the hospital ward environment.306 Patients with the highest risk offalling were identified, using afalls risk assessment tool, and then encouraged towear hip protectors for the rest oftheir time inhospital (n=30). Ofthese 30patients, 29 wore the hip protectors for their remaining time inhospital, and 27 still wore the hip protectors two weeks after discharge. Aquestionnaire showed that nursing staff had high acceptance ofhip protectors and only experienced minor problems with adherence and wearing hip protectors during the day. Thisstudy indicates that the use ofhip protectors inthe hospital setting may beuseful; however, larger studies areneeded.
17.1.2 Types ofhipprotectors

There are three types ofhipprotectors: Soft hip protectors (type A) are available inavariety ofdesigns. Their common feature isthat they are made from asoft material, rather than arigid plasticshell. Hard hip protectors (type B) consist ofafirmer, curved shell, sewn orslipped into apocket inalycra undergarment similar tounderpants orbike pants. Most research onhip protectors has evaluated hard hipprotectors. Adhesive hip protectors (type C) are stuck directly tothe skin ofthe wearer. Few studies investigate this type ofhipprotector. As ageneral observation, type Ais preferred inhospitals, because type Bis difficult touse due tolaundering difficulties. The key factor for success appears tobe the commitment ofstaff topatient care and quality improvement, particularly when this issupported bysenior staff. Adherence ofboth the patient and staff isan issue inall environments and islower inwarmer climates (see Section17.3.3).
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17.1.3 How hip protectorswork

Hip protectors work byabsorbing the energy created byafall ordispersing itaway from the hip joint, sothat the soft tissues and muscles ofthe surrounding thigh absorb the energy instead. The hard plastic hip protector shields divert the force ofthe fall from the bones ofthe hip tothe surrounding muscles ofthe thigh. The soft hip protectors seem towork mainly byabsorbing the energy ofthe fall. Hip protectors must beworn over the greater trochanter ofthe femur tobeeffective. More than 95% ofhip fractures occur from afall with direct impact onthe hip,235 with only asmall number ofspontaneous fractures caused byosteoporosis orother bone pathology. Other hip fractures may occur ifaperson falls onto their buttock orif arotational force through the neck ofthe femurisapplied.307 The force generated byafall from astanding height islarge and has the potential tobreak the hip ofaperson ofalmost any age. The force applied tothe femur near the hip inafall from standing height isapproximately 6000 newtons. The most effective padding system can reduce this toapproximately 2000newtons inalaboratorytest.308 It isnot necessary towear ahip protector over ahip that has been surgically repaired with internal fixation orhip replacement, because the neck ofthe femur has been either replaced orreinforced (byhemiarthroplasty, orapin and plate,etc).307 A randomised controlled trial ofhip protectors noted adverse effects in5% ofpeople.309 Hip protectors cancause bruising ifthe person falls onto the hip protector. Skin infections and pressure ulcers (bedsores) can develop under oraround the area where ahip protectorisworn. Hip protectors can make toileting difficult for frail, older people. For example, older people can become less independent ineveryday activities because ofthe extra time and effort needed toput onand take off the hip protectors (this can also cause incontinence insome people; see Chapter 8 oncontinence formoreinformation).
17.1.4 Adherence with use ofhipprotectors

A disadvantage ofhip protectors isalow level ofadherence because ofdiscomfort, practicality,310 the extra effort needed toput them on, orurinary incontinence.311-314 Insome settings, cost might also beabarrier tohip protectoruse.315 Adherence with use ofhip protectors iscrucial totheir effectiveness.316 Inthe first reported randomised trial ofhip protectors, only 24% ofasubgroup ofparticipants were wearing hip protectors when they fell.317 This trial was included ina2005 Cochrane review ofhip protectors, and the other trials included also reported low adherence rates, which may have influenced theoutcome.303 To help patients tokeep wearing their hip protectors, the patients needs and preferences must bematched with the availability ofdifferent types ofundergarment material, removable orsewn-in hip protector shields and different styles ofundergarments, including those allowing use ofcontinence aids.318 Inmany cases, adherence ismost affected bythe patients motivation towear the hip protectors,318 and bythe type ofhip protector (eghard, soft).303 Inother cases, wearing hip protectors may beavisual reminder ofthe consequences offalling, and cause the patient ortheir carer tomodify their behaviour tominimiserisk.303 The attitudes ofstaff inhospitals may have asubstantial effect onwhether apatient wears hipprotection.319 Queensland Health developed aset ofbest practice guidelines for residential aged care facilities (which may also beuseful for the hospital setting) that included the following feedback from focus groups and health professionals onwhy hip protectors were difficult tointroduce asstandardpractice: 247 They caused skin rashes and increasedperspiration. They were uncomfortable tosleep inand had the potential tocause pressuresores. They were difficult tolaunder, particularly for people withincontinence. Replacing hip protectors wascostly. There were infection-controlissues. Some older people refused towear, orpulled out, hipprotectors. They were considered too big orbulky, particularly with incontinence pads, catheters anddressings. They moved and could becomeuncomfortable. There was not enough information onhow tofit hipprotectors. Some staff did not always support older people touse hip protectors, orwere sceptical about theirefficacy. There were problems with price, style and comfort for the wearer, including imageperception.
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Point ofinterest: Cochrane review ofhip protector use andadherence

The 2005 Cochrane Collaboration review ofhip protectors 303 contains tables that summarise the randomised trials ofhipprotectors.
Because ofthe diversity ofpatients, service settings and climates, patients should have achoice oftypes and sizes ofhip protectors. Soft, energy-absorbing shields are often reported asmore comfortable for wearing inbed. Achoice ofunderwear styles and materials means that problems with hot weather, discomfort and appearance canbeaddressed.
17.2.1 Assessing the use ofhipprotectors

When assessing apatients need for hip protectors, hospital staff should consider the patients recent history offalls, their age, their mobility, whether they have adisability, whether they are unsteady ontheir feet, and whether they have osteoporosis orosteomalacia. Assessing the patients cognition and independence indaily living skills (eg dexterity indressing) may also help determine whether they will beable touse hip protectors. Hospital staff can use afalls risk assessment tool (see Chapter 5) tohelp decide whether someone has ahigh risk offalling and therefore may beconsidered for the useofhipprotectors.
17.2.2 Using hip protectorsatnight

Older patients risk offalling can increase during the evening and night. Therefore, patients who have ahigh risk offalling, orosteoporosis, orahistory offalling atnight, may benefit from wearing hip protectors when they goto bed. The soft pads (type A) are relatively comfortable when correctly positioned and can beworn more easily inbed than the hard shell protectors (type B) because they are lessobtrusive.247
17.2.3 Cost ofhipprotectors

Cost ofhip protectors appears tobe afactor influencing uptake, particularly where they are supplied bythe facility. Reimbursement byprivate health funds orby appliance supply schemes may improve this problem. Itis unclear towhat degree cost affects adherence with longer term use ofhip protectors (see Section 17.4 oneconomicevaluation).
17.2.4 Training inhip protectoruse

Fitting and managing hip protectors are often the responsibilities ofaparticular member ofthe health team. Nurses and other care staff are inakey position toencourage adherence with use ofhip protectors, because they often help frail older people with dressing, bathing and toileting. Nurses and other care staff should have education and support indeveloping strategies toencourage adherence with, and correct application of, hipprotectors. Two studies have researched the benefits oftraining staff inthe correct application, rationale for use, and importance ofencouraging the use ofhip protectors.302,320 Training the individual wearer may also improve adherence, byaddressing any barriers that the person sees inwearing hip protectors and providing precise instructions and demonstration onhow towearthem. Before the patient starts wearing hip protectors, health care staff and carers should discuss arrangements for cleaning the hip protectors. Washing indomestic washing machines and dryers isfeasible, but some hip protectors will not withstand commercial laundering. Although self-adhesive hip protectors may beappealing insome respects (eg the patient can use their own undergarments), itis unclear whether theycan besafely used inthe longterm.
See http://www.thecochranelibrary.org and search for hipprotectors.
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Currently, the design and production ofhip protectors isunregulated, and there are nonational orinternational testing procedures for theireffectiveness.303 A standard definition ofadherence with use ofhip protectors should beused when reviewing and monitoring their use.321 The most easily measured marker ofadherence isthe number ofprotected falls, which isthe proportion offalls inwhich ahip protectorisworn.
PartD
Casestudy
Mrs Jwas hospitalised after afall inwhich she sustained afractured pelvis. Inthe rehabilitation ward, she agreed touse hip protectors. The ward nurses showed her how touse the hip protectors and encouraged their use inhospital. She continued towear them athome after discharge from hospital. Mrs Js adherence with use ofthe hip protectors was checked when she attended the clinic for afollow-up visit. While watering her garden, Mrs Jfell onto the hip protectors. Itis likely that afracture was prevented asshe had abruise onher upper thigh under the hipprotector.
Patients with cognitive impairment have ahigher prevalence offalls and fractures 322 and should beconsidered for hip protector use. These patients often need help touse hip protectors inthe first instance, and then tocontinue wearing them. Hip protectors may need tobe used with anadditional risk management strategy for patients known tohave balance difficulties and whowander.

The use ofhip protectors inpeople from Indigenous and culturally and linguistically diverse groups has not been researched specifically. Firmly fitting underwear may beunfamiliar insome cultures, but the extent towhich this may influence adherence with use ofhip protectorsisunknown.
17.3.3 Climate
Much ofthe research inrelation tohip protectors has been done incooler climates. Adherence inwarmer and more humid areas maybeproblematic.
The effectiveness ofhip protectors inhospitals isuncertain. Noeconomic evaluations have examined the cost effectiveness ofhip protectors inthe hospital setting. Anumber ofanalyses considered the use ofhip protectors inother settings (such asresidential care ormixed residential care/community settings); however, itis uncertain whether the results ofthese analyses are applicable inthe hospital setting because ofdifferences inpatient characteristics and likely resource use across the settings. Inaddition, many ofthe analyses conducted inamixed orresidential care setting have methodological limitations, such asthe use ofoptimistic estimates ofefficacy, adherence, and quality oflife impacts ofwearing hip protectors (see Chapter 16 inthe community guidelines and Chapter 17 inthe residential aged care guidelines for moreinformation).
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The following appendices and website provide additionalinformation: Appendix 6 contains achecklist ofissues toconsider before using hipprotectors.318 Appendix 7 isasample hip protector careplan. Appendix 8 isasample hip protector observationrecord. The description ofthe educational program used inthe study ofMeyer and colleagues302 provides aguide tohip protector implementation inresidential aged care facilities (Appendix9). Cochrane Collaboration website the CochraneLibrary: http://www.thecochranelibrary.org (and search for hipprotectors).

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18 VitaminD and calciumsupplementation

Recommendations
Assessment
To screen for possible vitaminD deficiency, dieticians, nutritionists orhealth professionals can collect information onthe patients eating habits, food preferences, meal patterns, food intake and sunlight exposure. Alternatively, ablood sample canbetaken.
Intervention
VitaminD and calcium supplementation should berecommended asan intervention strategy toprevent falls inolder people. Benefits from supplementation are most likely tobe seen inpatients who have vitaminD insufficiency (25(OH)D of<50 nmol/L) ordeficiency (25(OH)D of<25 nmol/L), comply with the medication, and respond biochemically tosupplementation. (LevelI-*) 31
Note: itis unlikely that benefits from vitaminD and calcium supplementation will beseen inhospital (particularly inacute care orshort stays), but there isevidence both from the community and residential aged care settings tosupport dietary supplementation, particularly inpatients who are deficient invitaminD.
Good practicepoints
Hospitalisation ofan older person provides anopportunity for comprehensive health care assessment and intervention. There isno direct evidence tosuggest that calcium and vitaminD supplementation will prevent falls inhospital; however, because most older people will return home orto their residential aged care facility, hospitalisation should beviewed asan opportunity toidentify and address falls risk factors, including adequacy ofcalcium and vitamin D. This information should beincluded indischargerecommendations. As part ofdischarge planning, any introduction ofvitaminD and calcium supplementation should beconveyed tothe persons general practitioner orhealthpractitioner.
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Low vitaminD levels have been associated with reduced bone mineral density, high bone turnover and increased risk ofhip fracture.323 Furthermore, vitaminD may prevent falls byimproving muscle strength andpsychomotor performance, independently ofany other role inmaintaining bone mineraldensity.324,325
Point ofinterest: how vitaminD reduces the riskoffalling

The active vitaminD metabolite (25-hydroxyvitamin D) binds toahighly specific nuclear receptor inmuscle tissue. This improves muscle function, which may bethe reason that vitaminD reduces the risk offalling.324 Furthermore, vitaminD deficiency has also been associated with osteoporosis, urinary incontinence, cognitive decline and maculardegeneration.326 VitaminD levels are measured byblood 25-hydroxyvitaminD (25(OH)D) levels. The levels of25(OH)D that were previously recommended for adequate vitaminD stores are now thought tobe too low.323,327 The incidence ofvitaminD deficiency (25(OH)D levels less than 25 nmol/L) inAustralia has been reported as2286% inresidential aged care, 67% ofgeriatric hospital admissions, and 61% ofpeople experiencing hip fractures.323 Another study found that, inAustralia, 86% ofwomen and 68% ofmen inresidential aged care facilities (RACFs) have frank vitaminD deficiency, and virtually all the remainder have alevel inthe lower half ofthe referencerange.328 People athigh risk ofvitaminD deficiency include older people (particularly inRACFs), those with skin conditions that require them toavoid the sun, dark-skinned people (particularly ifveiled), and people with malabsorption.323 VitaminD deficiency issignificantly more common among people with dementia and people from culturally and linguistically diversegroups.329 Intervention toimprove levels ofvitaminD has used arange ofapproaches with varying success levels, including vitaminD supplementation alone, vitaminD supplementation with calcium supplementation, andexposure tosunlight. Older people inhospital are discharged toboth the community and RACF settings; therefore, the evidence and recommendations for both settings are considered here. These are explained inthe followingsections. Nutrition management isan important element ofgood aged care practice, and can play animportant role insome aspects offalls prevention, directly and indirectly (eg good nutrition isrequired togain optimal effect from anexercise program). Other than vitaminD and calcium supplementation (andrelated nutritional involvement inosteoporosis management), nutrition isnot included asaseparate core falls prevention activity inthese guidelines, because itis anarea with limited research toguide best practice infalls prevention todate (see Appendix 10 for achart for monitoring food and fluid intake, andAppendix11 for food guidelines for calcium intake for preventing falls inolderpeople).

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18.1.1 VitaminD supplementation (with orwithout calcium) inthe communitysetting

A high-quality systematic review (a Cochrane review) analysed 111 randomised controlled trials (RCTs) ofvarious falls prevention interventions for older people living inthe community.31 The review included RCTs that assessed vitaminD supplementation, with orwithout calcium supplementation (among other interventions, such asexercise and multifactorial falls prevention programs). The review found noevidence for aneffect ofvitaminD (with orwithout calcium supplementation) onthe rate orrisk offalling. However, asubgroup analysis ofpeople with vitaminD deficiency showed asignificant reduction inboth the rate and risk offalls although this result must beinterpreted with caution and followed upwith furtherresearch. A study ofthe alfacalcidol form ofvitaminD supplementation inolder people who live inthe community, and who are not vitaminD deficient, supports the hypothesis that treatment with vitaminD (or its analogues) requires aminimum daily calcium intake of500mg/day toproduce clinically significant results.327 The Australian recommended daily intake (RDI) for calcium inolder people is800mgfor men and 1000mgfor women.330 However, this level may betoo low, with other sources recommending daily intake of1500mgfor both men andwomen.331
VitaminD analogues (eg calcitriol 1,25(OH)2D3) are associated with adverse effects, such as hypercalcaemia. Inaposition paper onvitaminD and adult bone health, the Australian Working Group ofthe Australian and New Zealand Bone and Mineral Society, the Endocrine Society ofAustralia and Osteoporosis Australia state that calcitriol isnot appropriate for treating patients with deprivational vitaminD deficiency because ithas anarrow therapeutic window, may result inhypercalcaemia orhypercalciuria, and does not increase serum 25(OH)Dlevels.332
18.1.2 VitaminD combined with calcium supplementation inthe RACFsetting

A high-quality systematic review (a Cochrane review) looked atinterventions including vitaminD supplementation for preventing falls inthe hospital and RACF settings.31 The review included five trials intotal, two ofwhich were similar enough for the data tobe pooled. The pooled results showed that vitaminD with calcium appeared tobe effective inpreventing falls inlong-term residents ofRACFs, andthat the benefits ofsupplementation were more certain inpeople who had low serum vitaminD.
18.1.3 VitaminD supplementation alone inRACFsettings

There isuncertainty about the effect ofvitaminD supplementation without calcium. Ameta-analysis found that vitaminD supplementation appears toreduce the risk offalls among ambulatory orinstitutionalised older people with stable health bymore than 20%.324 Although not looking atthe same outcome, anearlier Cochrane review ofvitaminD for preventing fractures associated with osteoporosis reported uncertainty about the efficacy ofregimens.242 Inthis review, vitaminD without any calcium cosupplementation was not associated with areduced risk ofhip fracture orother nonvertebral fractures.242,333 The position paper onvitaminD and adult bone health from the Working Group ofthe Australian and New Zealand Bone and Mineral Society, the Endocrine Society ofAustralia and Osteoporosis Australia states that calcium islikely tobe needed with vitaminD to reduce fracture rates, because most studies have used acombination ofvitaminD and calciumsupplementation.332
18.1.4 Vitamin D, sunlight and winter inthe communitysetting

The main source ofvitaminD is from sunlight.330 Evidence suggests that sourcing vitaminD from dietary intake alone isnotsufficient.323 Sun exposure may not work ifthe skin ofolder adults does not convert cholesterol precursors tovitaminD efficiently. Additionally, sun exposure recommendations are difficult toimplement infrailer people. Inthe absence ofroutine fortification offood with vitamin D, sunlight exposure orvitaminD supplementation are the only reasonable options toensure adequate levelsofcalcitriol. The Geelong Osteoporosis Study found that inwinter there was reduced serum vitamin D, increased bone resorption and anincrease inthe proportion offalls resulting infracture.334 The role ofvitaminD supplementation during the Australian winter has yet tobeinvestigated.
Point ofinterest: vitaminD andlatitude

Little vitaminD is produced beyond latitudes ofabout 35 (ie Victoria and Tasmania) inwinter, especially inolder people. This isbecause ofan increase inthe zenith angle ofthe sun (anglebetween directly overhead and aline through the sun), resulting inmore photons being absorbed bythe stratospheric ozonelayer.335
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18.1.5 Toxicity anddose

Toxicity ofvitaminD cannot becaused byprolonged sun exposure; however, itcan occur from supplementation with vitamin D.330 Hypercalcaemia may occur ifvitaminD is given, particularly inthe form ofthe vitaminD analogues,242 and calcitriol isnot recommended.332 However, toxicity with cholecalciferol (vitamin D3) upto 10000 IUdaily israre and occurs predominantly ifdietary ororal calcium supplements are high, orif granulomatous disorders are present. There isno RDI for vitamin D, although trials that show benefit from vitaminD have used aminimum of800 IUdaily. The United States Institute ofMedicines Food and Nutrition Board proposes adaily vitaminD intake of600 IUin people over 71 years ofage.323 InAustralia and NewZealand, aminimum daily dose of400 IUis recommended, with higher doses required for those with vitaminD (25(OH)D) levels lower than 50nmol/L.332
18.2.1 Assess vitaminDadequacy
Dieticians, nutrition and dietetic support staff, ornursing and medical staff, can collect information oneating habits, food preferences, meal patterns, food intake and sunlight exposure. Todo this, theycanuse: food preferencerecords food and fluid intake records (see Appendix10) 25(OH)D bloodlevels.
18.2.2 Ensure minimum sun exposure toprevent vitaminDdeficiency

Osteoporosis Australia (in association with the Cancer Council Australia) recommends that, for most older Australians, vitaminD deficiency can beprevented by515 minutes exposure ofthe face and upper limbs tosunlight four tosix times each week, although deliberate exposure tosunlight between 10 amand 3pmin the summer months for more than 15 minutes isnotadvised. If this modest sunlight exposure isnot possible, avitaminD supplement ofat least 800 IUper day is recommended.
18.2.3 Consider vitaminD and calciumsupplementation

Hospitalisation ofan older person provides anopportunity for comprehensive health care assessment and intervention. There isno direct evidence tosuggest that calcium and vitaminD supplementation will prevent falls inhospital; however, because most older people will return home orto their RACF, hospitalisation should beviewed asan opportunity toidentify and address falls risk factors, including adequacy ofcalcium and vitaminD. For confirmed cases ofvitaminD deficiency, supplementation with 30005000 IUper day for atleast one month isrequired toreplenish body stores. Increased availability oflarger dose preparations ofcholecalciferol (vitamin D3) would beauseful therapy inthe case ofseveredeficiencies.323,332,336 For most older adults inlong-term care inAustralia, itis appropriate tosupplement with 1000 IUvitaminD without measuring 25(OH)D blood levels. This isbased onthe prevalence ofdeficiency, and the low risk and benefit ofsupplementing with vitaminD in this untargeted way toprevent hipfractures.323,337,338
18.2.4 Encourage patients toinclude foods high incalcium intheirdiet

The food guidelines inAppendix 11, which outline calcium and vitamin dietary suggestions and hints, are useful for encouraging people toinclude more calcium intheir diet.339 Referral toadietician may beappropriate ifaperson ishaving trouble consuming adequate calcium, has lactose intolerance, does not include calcium asanormal part oftheir diet (culturally) ordoes not consume dairy foods (eg they follow avegandiet).
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18.2.5 Discourage patients from consuming foods that prevent calciumabsorption

Oral calcium intake needs tomeet the RDI. Patients should bediscouraged from consuming too many foodstuffs that lower orprevent calcium absorption (eg caffeine, soft drinks containing phosphoric acid). Instead, they should beencouraged toinclude foods high incalcium intheirdiet. Analysis offood intake records ordiet history should show adaily intake ofcalcium of800 mgfor men and1000 mgforwomen.339
PartD
Casestudy
Mrs Fwas admitted tohospital following afall. Inkeeping with her culture and religious beliefs, she only allows her face, hands and feet tobe exposed. Blood tests revealed severe vitaminD deficiency avitaminD level of12 nmol/L. Mrs Fs deficiency was initially managed with onemonth of3000 IUunits ofvitaminD each day. This was reduced to800 IUdaily after the initial periodofreplacement. Because Mrs Fwas admitted tohospital after afall, hospital staff reviewed her medications while she was inhospital, and anoccupational therapist undertook ahome assessment before she wasdischarged.
Cognitive impairment can beassociated with nutritional deficiencies, including areduced calcium and vitaminD intake inthe diet. Hospital staff should monitor patients oral intake closely, and refer them toadietician ifintake islow. Oral calcium and vitaminD supplementation are frequently required tomaintain levels ofboth calcium and vitaminD in thispopulation.

Increased skin pigment reduces the amount ofvitaminD production after sun exposure, sodark-skinned people are more susceptible tolow vitaminD levels. People who are heavily clothed and veiled for religious orcultural reasons are also atincreased risk oflow vitaminDlevels.
A number ofvitaminD and calcium-based compounds are publicly funded via the Pharmaceutical Benefits Scheme. See Chapter 19 onosteoporosis management for moreinformation.
The following useful publications provide information ondietary intake ofvitaminD andcalcium: National Health and Medical Research Council (2003). Dietary Guidelines for AllAustralians: http://www.nhmrc.gov.au/publications/synopses/dietsyn.htm Nowson CA, Diamond TH, Pasco JA, Mason RS, Sambrook PNand Eisman JA(2004). VitaminD in Australia: issues and recommendations. Australian Family Physician 33(3):133-138: http://www.osteoporosis.org.au/files/research/vitamind_nowson_2004.pdf Osteoporosis Australia (2005). Recommendations from the VitaminD and Calcium Forum (Melbourne, 28-29July 2005). Medicine Today6(12):43-50: http://www.osteoporosis.org.au/files/research/Vitdforum_OA_2005.pdf Working Group ofthe Australian and New Zealand Bone and Mineral Society, Endocrine Society ofAustralia and Osteoporosis Australia (2005). VitaminD and adult bone health inAustralia and New Zealand: aposition statement. Medical Journal ofAustralia 182:281-285. Osteoporosis Australia provides information and resources toreduce fractures and improve bone health inthecommunity: http://www.osteoporosis.org.au/
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19 Osteoporosismanagement
Recommendations
Assessment
Patients with ahistory ofrecurrent falls should beconsidered for abone health check. Also, patients who sustain aminimal-trauma fracture should beassessed for their riskoffalls.
Intervention
People with diagnosed osteoporosis orahistory oflow-trauma fracture should beoffered treatment for which there isevidence ofbenefit. (LevelI) 283 Hospitals should establish protocols toincrease the rate ofosteoporosis treatment inpatients who have sustained their first osteoporotic fracture. (LevelIV) 340
Good practicepoints
The health care team should consider strategies for minimising unnecessary bedrest (to maintain bone mineral density), protecting bones, improving environmental safety and vitaminD prescription, and this information should beincluded indischargerecommendations. When using osteoporosis treatments, patients should beco-prescribed vitaminD withcalcium.
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19.1.1 Falls andfractures
Only asmall proportion offalls result infractures and most, ifnot all, fractures occur after falls.341 Bonemineral density isan important measure inpredicting fractures inboth men and women, and quadriceps strength and postural sway are ofsimilar importance inpredicting fractures.342 Notherapy islikely tonormalise bone mineral density, but small improvements can reduce fracturerisk.343
With this inmind, interventions that prevent falls risk may prevent fractures, even ifbone density isnot altered. This isof particular relevance tothe very old, whose low bone density places them atparticular risk, and inwhom each additional fall increases the likelihoodofafracture.
19.1.2 Diagnosingosteoporosis
Osteoporosis Australia (a national nongovernment organisation that aims toreduce fractures and improve bone health inthe community) states that the presence ofosteoporosis can sometimes berecognised byafracture, usually ofthe wrist, hip orspine; anincreased curve ofthe thoracic (mid) spine; orloss ofheight.344 A30%loss ofanterior vertebral height issufficient todiagnose osteoporosis for the Pharmaceutical Benefits Scheme(PBS). Osteoporosis isdiagnosed byhaving abone mineral density test. There are several methods for testing bone density. The most reliable and accurate test isthe DXA test (dual energy X-ray absorptiometry), whichiswidely available inAustralia. All bone mineral density tests measure the amount ofmineral inaspecific area ofbone. The DXA test will give results asthe following twoscores: 344 T score, which compares bone density with that ofan average young adult ofthe same sex. A Tscore ofzero means that bones are the same density asthe average younger population, and notreatment isnecessary. A Tscore above one means that bones are denser than the average younger population. A Tscore below zero means that bones are less dense than the average younger population. Treatment should beconsidered ifthe score isbelow one (osteopaenia = 1 to2.5) and there are several clinical risk factors for osteoporosis. Tscores below 2.5 indicate osteoporosis, and treatment isstrongly recommended tostop further bone loss andfractures. Z score, which compares bone density with the average for the persons age group and sex. Ifthe Zscore iszero, bones are average for the persons age and sex. Below zero indicates that bones are below average density, and above zero indicates that bones are above average density for age. AZ score below 2 means that bone isbeing lost more rapidly than inmatched peers, sotreatment needs tobe monitored carefully. AZ score below 2 may also indicate that anunderlying disease isresponsible for theosteoporosis. Hospital staff (particularly inemergency departments) should bevigilant indetecting anyone who has obvious manifestations ofosteoporosis (eg thoracic kyphosis, anew low-trauma fracture). Also, people with multiple risk factors for osteoporosis may bedetected opportunistically inhospitals, particularly ingeneral medicalinpatients.
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19.1.3 Evidence forinterventions

A previous fracture isone ofthe strongest risk factors for future fracture.340 However, studies suggest that many people who sustain fractures donot undergo investigation ortreatment for osteoporosis, orare not treated adequately toreduce future fracture risk, even when adiagnosis ofosteoporosis has beenmade.345,346 Despite this, several effective drug treatments are now available. Ameta-analysis and various randomised controlled trials have shown beneficial effects oforal orintravenous bisphosphonates inpostmenopausal women who have low bone density; 347,348 asystematic review has shown the benefits ofselective oestrogen receptor modulators inpostmenopausal women with osteoporosis; 349 and arandomised controlled trial has shown the benefits ofstrontium ranelate for preventing osteoporosis inpostmenopausal women.350 These drugs are now considered the first-line treatments forosteoporosis. As most ofthe randomised controlled trials ofantiresorptive agents have used concomitant calcium and vitaminD (see Chapter 18), itis appropriate toensure that vitaminD deficiency iscorrected and toadd acalcium supplement tothese therapies when dietary calcium intakeissuboptimal.
Bisphosphonates
Bisphosphonates are potent inhibitors ofbone resorption. They stick tothe bone surface and make the cells that destroy bone tissue less effective. This allows bone-rebuilding cells towork more effectively, resulting inincreased bone density.344,348 Currently, four bisphosphonates are available onthe PBS totreatosteoporosis. The following three medications are available for men and postmenopausal women with anosteoporoticfracture: 344 risedronate (Actonel, Actonel Combi and Actonel Combi D), which increases bone density and reduces the risk orfrequency offractures atthe spine and hip inpostmenopausal women who have lowbonedensity348 alendronate (Fosamax, Fosamax Plus, Alendro), which increases bone density and reduces frequency offractures atthe hip andspine zoledronic acid (Aclasta), which isalso used totreat osteoporosis inpostmenopausal women orto prevent additional fractures inmen and women who have recently had ahip fracture; because zoledronic acid works for along time, only asingle dose isrequired each year, making this osteoporosis therapy advantageous for frail older people living inthe community orresidential agedcare. A fourth bisphosponate medication isalso available forosteoporosis: etidronate (Didrocal), which increases bone density and reduces risk offractures inthe spine, but not thehip.283,344,351 An association between bisphosponate use and arare dental condition termed osteonecrosis ofthe jaw has been reported.348 Osteoporosis Australia recommends that the small risk ofthis condition needs tobe considered against the significantly reduced risk offracture and other skeletal complications inolder people with established osteoporosis. One approach isto ensure appropriate oral health and dental treatment before prescription, particularly ifhigh doses orintravenous drugs are prescribed, orif adental extraction isalreadyplanned.352 Alendronate and risedronate have been associated with adverse gastrointestinal effects (eg dyspepsia, abdominal pain, oesophageal ulceration).348 Therefore, patients who have reflux oesophagitis orhiatus hernia should bescreened before use.352 Most studies have shown that the overall risk ofadverse gastrointestinal events associated with risedronate oralendronate use islow, although asmall number ofstudies report the opposite.353 There isalso evidence that risedronate isless risky than alendronate.354 Thepotential for gastrointestinal side effects from either drug islowered when the dosing isdecreased toonce per week.354
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Selective oestrogen receptormodulators

Selective oestrogen receptor modulators (SERMs) are aspecial class ofdrug with many features similar tooestrogen used inhormone replacement therapy; however, they donot stimulate the breast and uterus tissues. Asaresult, SERMs have the positive effect ofoestrogens onbone without increasing the risk ofbreast and uterine cancer. Raloxifene (Evista) increases bone density and reduces the risk offractures inthe spine. Evidence also shows itreduces the incidence ofbreast cancer.283,344,351 However, SERMS have been associated with anincreased risk ofvenousthromboembolism.355
Strontiumranelate
Strontium ranelate has been shown inrandomised controlled trials toreduce the risk ofboth vertebral and peripheral fractures.350 Strontium ranelate isthe only antiosteoporotic agent that both increases bone formation markers and reduces bone resorption markers, resulting inarebalance ofbone turnover infavourofboneformation.
Screening for osteoporosis isimportant for minimising falls-related injuries. Itis important torecognise that patients sustaining low-trauma fractures after the age of60 years probably have osteoporosis and anincreased risk ofsubsequent fracture.356,357 Bone densitometry and specific antiosteoporosis therapy should beconsidered inthese patients. Also, older patients with ahistory ofrecurrent falls should beconsidered for abone healthcheck. In both cases (recurrent fallers and those sustaining low-trauma fractures), the health care team should consider strategies for optimising function, minimising along lie onthe floor, protecting bones, improving environmental safety and vitaminDprescription.358,359 Postmenopausal women who have low bone density, orwho have already had one fracture intheir spine orwrist, should betreated with abisphosphonate (such asrisedronate) toreduce their risk offurther fractures inthe spine orhip.348 Consider using bisphosphonates, strontium orraloxifene toreduce the risk ofvertebral fractures and increase bone density inolder men atrisk ofosteoporosis (ie those with alow body mass index). Bisphosphonates work best inpeople with adequate vitaminD and calcium levels, andshould thereforebecoprescribed. Hospitals should establish protocols toincrease the rate ofosteoporosis treatment inpatients who have sustained their first osteoporoticfracture.340

A good practice clinical indicator among hospital populations may beto review medication charts tosee whether vitaminD supplements are being ordered and adjust for the number ofpatients who gooutside regularly and for the latitude ofthe facility. Also, identify whether patients sustaining fractures are reviewed with regard tothe possible diagnosis ofosteoporosis. Finally, itmay bepossible tocompare fracture rates inpatients treated with specific antiosteoporosis therapy with those inpatients not receiving therapy, ifpatients can bematched onanumber ofother key domains, such asage, sex and fallsrisk.
Casestudy
Mrs E, who is75 years old, fell and fractured her humerus (upper arm), and was admitted toher local hospital. Specific questioning revealed that she had anearly menopause and that she rarely goes outside because ofconcern about skin cancer. The orthopaedic surgeon treated her fracture. The nurse atthe hospital clinic asked the doctor whether the fracture was related toosteoporosis and whether there was some way toreduce the chance offurther similar falls and fractures. Asaresult oftheir discussion, the surgeon suggested that Mrs Estart taking calcium and vitaminD and referred her tothe osteoporosis clinic for aweekly bisphosphonate review, anutritional review, and strength and balancetraining.
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Some people with cognitive impairment need tobe supervised inthe correct and safe manner oftaking some oral bisphosphonates. This isbecause there are restrictions onlying down oreating after taking thesemedications.
PartD
A number ofantiresorptive agents (such asbisphosphonates and strontium) and vitaminD analogues (alone orin combination with antiresportive agents) are available onthe PBS for treatment ofosteoporosis (prevention offracture) inspecific patient populations. The safety, effectiveness and cost effectiveness ofthese agents have been reviewed bythe Pharmaceutical Benefits Advisory Committee. The fact that theseagents are subsidised bythe PBS indicates that they offer acceptable value for money inthe Australian context, for specific patientpopulations. Table 19.1 shows specific PBS subsidy details for various agents affecting bone mineral density (currentat27August2009).
Table 19.1 Pharmaceutical Benefits Scheme details for osteoporosisdrugs
Drug
Alendronate Alendronate +cholecalciferol Risedronate Risedronate + calciumcarbonate
Subsidisedindications
Treatment asthe sole PBS-subsidised antiresorptive agent for osteoporosis inapatient aged 70 years orolder with abone mineral density T-score of3.0orless.
Treatment asthe sole PBS-subsidised antiresorptive agent for established osteoporosis inpatients with fracture due Risedronate + calcium carbonate tominimaltrauma. +cholecalciferol Etidronate + calciumcarbonate Treatment asthe sole PBS-subsidised antiresorptive agent for established osteoporosis inpatients with fracture due tominimaltrauma. Treatment asthe sole PBS-subsidised antiresorptive agent for (a) established osteoporosis inwomen with fracture due tominimal trauma; (b) established osteoporosis inmen with hip fracture due tominimal trauma; or(c) osteoporosis inwomen aged 70years orolder, with abone mineral density T-score of3.0 orless (only one treatment each year for three consecutive years per patientissubsidised). Treatment for established osteoporosis inpatients with fracture due tominimaltrauma. Treatment asthe sole PBS-subsidised antiresorptive agent for established postmenopausal osteoporosis inpatients with fracture due tominimaltrauma. Treatment asthe sole PBS-subsidised antiresorptive agent for osteoporosis inawoman aged 70 years orolder with abone mineral density T-score of3.0orless. Treatment asthe sole PBS-subsidised antiresorptive agent for established postmenopausal osteoporosis inpatients with fracture due tominimaltrauma.
Zoledronicacid
Calcitriol Raloxifene
Strontiumranelate
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Drug
Teriparatide
Subsidisedindications
Treatment asthe sole PBS-subsidised agent byaspecialist orconsultant physician, for severe, established osteoporosis inapatient with avery high risk offracture who (a) has abone mineral density T-score of3.0 orless; and (b) has had two ormore fractures due tominimal trauma; and (c) has experienced atleast one symptomatic new fracture after atleast 12 months continuous therapy with anantiresorptive agent atadequatedoses.

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Note: All agents require authority permission forprescription.
For readers seeking definitive information onosteoporosis management, particularly related tomedication management, the following resources arerecommended: The National Institute for Health and Clinical Excellence, anindependent organisation inthe United Kingdom, produces clinical practice guidelines, including guidelines onosteoporosis management, based onthe best available evidence. The guidelines contain recommendations onthe appropriate treatment and care ofpeople with specific diseases andconditions: http://www.nice.org.uk/. Osteoporosis Australia isanational organisation that aims toreduce fractures and improve bone health inthe community. Itprovides information kits onfalls andfractures. Phone: 02 95188140 Fax: 02 95186306 Toll free: 1800 242141 http://www.osteoporosis.org.au/html/index.php
PartD
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PartE Respondingtofalls
20 Post-fallmanagement
Good practicepoints
Hospital staff should report and document allfalls. It isadvisable toask apatient whether they remember the sensation offalling orwhether they think that they blacked out, because many patients who have syncope are unsure whether they blackedout. Staff should follow the hospital protocol orguidelines for managing patients immediately afterafall. After the immediate follow-up ofafall, determine how and why afall may have occurred, and implement actions toreduce the risk ofanotherfall. Analysing falls isone ofthe key ways toprevent future falls. Organisational learning from this analysis can beused toinform practice and policies, and toprevent future falls. Apost-fall analysis should lead toan interdisciplinary care plan toreduce the risk offuture falls and injuries, and address any identified comorbidities orfalls riskfactors. An in-depth analysis ofthe fall (eg aroot-cause analysis) isrequired ifthere has been aserious injury following afall, orif adeath has resulted fromafall.
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20.1 Background
Hospital staff must take all falls seriously, because falls may bethe first and main indication ofanother underlying and treatable problem inapatient.45 Older people who fall are also more likely tofall again.360 All hospital staff should beaware ofwhat constitutes afall (see Section 1.3.1 for adefinition), what todo when apatient falls, and what follow-up isnecessary (including completing afalls form). This chapter describes the responsibilities ofhospital staff after apatient hasfallen.
20.2 Respondingtofalls
Hospital staff should review the circumstances ofevery patient fall (eg doaroot-cause analysis; see below), because doing somay guide the actions taken toreduce the incidence offurther falls.43 Staff should also complete afalls report, including recommendations for the immediate and longer term care required tomanage consequences ofthe falls (injuries, loss ofconfidence) and tominimise risk offuturefalls.4 The circumstances surrounding afall are ofcritical importance. However, this information isoften difficult toobtain and may need tobe sourced from people other than the patients themselves, including staff, visitors and other patients sharing the same ward. This may beparticularly important ifthe patient does not recall, ondirect questioning, the circumstances ofthe fall orhitting theground. Hospitals should have their own falls policy, orfollow aclinical practice guideline for preventing and responding tofalls. Staff should bemade aware of, and have access to, these policies orguidelines. Thefollowing checklist for hospital staff isaguide towhat should beincluded inafallspolicy.
Checklist for managing the patient immediately afterafall

Offer basic life support and providereassurance
Check for ongoingdanger. Check whether the patient isresponsive (eg responds toverbal orphysicalstimulus). Check the patients airways, breathing andcirculation. Reassure and comfort thepatient.45,247
Take baselinemeasurements
Conduct apreliminary assessment that includes taking baseline measurements ofpulse, blood pressure, respiratory rate, oxygen saturation and blood sugar levels. Ifthe patient has hit their head, orif their fall was unwitnessed, record neurological observations (eg using the Glasgow ComaScale).45
Check forinjuries
Check for signs ofinjury, including abrasion, contusion, laceration, fracture and headinjury.45,247,361 Observe changes inthe level ofconsciousness, headache, amnesiaorvomiting.
Move thepatient
Assess whether itis safe tomove the patient from their position, and identify any special considerations inmoving them. Staff members should use alifting device rather than trying tolift the person ontheir own. Follow the hospitals policy orguidelineonlifting.45,362
Monitor thepatient
Observe patients who have fallen and who are taking anticoagulants orantiplatelets (blood-thinning medications) carefully, because they have anincreased risk ofbleeding and intercranial haemorrhage. Patients with ahistory ofalcohol abuse may bemore pronetobleeding. Arrange for ongoing monitoring ofthe patient, because some injuries may not beapparent atthe time ofthe fall.247 Make sure that hospital staff know the type, frequency and duration ofthe observations that arerequired.
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Report thefall
Report all falls toamedical officer, even ifinjuries are not apparent.361 Document all details inthe patients medical record, including their observations, appearance orresponse; evidence ofinjury; location ofthe fall; notification ofmedical provider; and actionstaken.247,361 Complete afalls reporting form according tolocal policy guidelines for all falls,45,247,361 regardless ofwhere the fall occurred, orwhether the patient wasinjured. Note any details ofthe fall for reference inreporting the fall, including the patients description ofthe fall, ifpossible.45,361 Asaminimum, this should include the location and time ofthe fall, what the patient was doing immediately before they fell, the mechanisms ofthe fall (eg slip, trip, overbalance, dizziness), and whether they lost consciousness orhad aconsciouscollapse.
Discuss the fall and future riskmanagement

Communicate toall relevant staff, family and carers that the patient has fallen and has anincreased risk offalling again.361 Atthe earliest opportunity, notify the person nominated tobe contacted incase ofanemergency.45,361 Discuss the circumstances ofthe fall, its consequences, and actions planned toreduce future falling risk with the patient and theirfamily. Assume that once apatient has fallen, they automatically become athigh risk offalling again until they have beenassessed.247 Follow local guidelines for identifying patients asbeing atincreased riskoffalling.
20.2.1 Post-fallfollow-up
After the fall, determine how and why afall may have occurred, and implement actions toreduce the risk ofanother fall. Todo this, complete the followingsteps: Investigate the cause ofthe fall, including assessing fordelirium. Review the implementation ofexisting falls preventionstrategies.247,361 Complete afalls risk assessment (see Chapter 5), because new risk factors maybepresent.247,361 Implement atargeted, individualised plan for daily care, based onthe findings ofthe falls risk assessment tool. Multifactorial interventions should becarried out asappropriate. They may include, but are not limited to, gait assessment, balance and exercise programs, footwear review, medication review, hypotension management, increased observation, environmental modification and treatment ofcardiovascular disorders.363 This will often involve referral toother members ofthe health careteam. Encourage the patient toresume their normal level ofactivity, because many older people are apprehensive after afall, and the fear offalling isastrong predictor offuturefalls.322 Consider the use ofinjury-prevention interventions (see PartD).247,361 Consider investigations for osteoporosis inthe presence oflow-traumafractures. Ensure effective communication ofassessment and management recommendations toeveryoneinvolved.247,361
20.3 Analysing thefall

A more in-depth analysis ofthe fall may berequired, particularly where there has been aserious injury oradverse outcome for the patient. Areview ofaserious fall can address both individual and broader system issues toprovide greater understanding ofcausation and future prevention. This issometimes known asaroot-cause analysis. Aroot-cause analysis isalways required ifafall results inserious injury ordeath. Insome jurisdictions, afall inhospital that results indeath must bereported tothe state coroner. Each hospital should have afalls review processinplace.
135
20.4 Reporting and recordingfalls

Accurate reporting offalls will occur only inaculture that isfair and just that is, ano blame culture. Staff often feel anxious when having tocomplete afalls form and can associate the fall with feelings ofguilt and blame. For accurate reporting offalls, the leaders inthe health service must promote falls reporting asapart ofthe improvement process, rather than apunitive tool toidentify potential staff negligence.364 This requires afair and just culture for achieving safe and high-quality health careservices. For high-quality care and risk management, information about falls must becollected and collated tomonitor falls incidence, identify falls patterns, identify ways ofpreventing future falls and provide feedback onthe effectiveness offalls prevention programs.4,45 Feedback should also beprovided tostaff regularly (eg monthly) sothat local trends can beidentified ataward orunit level, and can beaddressed aspart ofthe routine continuous qualitycycle. Any data collected should beused toinform changes inhospital practice aimed atreducing patient falls rates. This requires analysing collected data regularly, monitoring trends, comparing falls data with that from other hospitals, and making changes tousual ward care basedonfindings.
20.4.1 Minimum dataset for reporting and recordingfalls

A minimum dataset should becollected about all falls toimprove the safety and quality ofhealth care. This includes the following information, which isbased onexpert opinion ofbestpractice: What risk factors for falls and injury werepresent? What was the activity atthe time ofthefall? Has the patient had afalls riskassessment? What was the mechanism ofthefall? What interventions were inplace atthe time ofthefall? Was itaconfirmed orsuspectedfall? Based onthe Queensland Health Falls Prevention Guidelines (2003) and the Australian Incident MonitoringSystem, amore comprehensive list may include the following additional data aboutfalls: 364 type offall (eg slip, trip, bumping into orfalling onan object), and activity atthe time ofthe fall (egattempting tostand,walking) whether the person depends onacarer, aids orhospitalstaff if the person has ahigh risk offalls, what steps they have taken previously toprevent falls risk and injuryrisk relevant information about clothing, footwear, eyewear and mobility aids used atthe time ofthefall any restraintsinuse any recent change inmedications that might beassociated with fallsrisk any staff supervision provided atthe time ofthefall factors contributing tothe fall, such asenvironmental conditions (eg floor, lighting, clutter) orstaffinglevels status following the fall (eg baseline observations,injuries) interventions tobe implemented following the fall, and medical treatmentrequired the persons perception ofthe fall, including description ofany preceding sensations orsymptoms andwhat they consider could have prevented thefall any witnesses tothefall any othercomments. Information should becompleted whenever afall ornear miss occurs inahospital. Ifinformation isalready being collected, the hospitals current falls monitoring processes may not need tobe altered. Hospitals may need toput processes inplace torecord falls incidences and outcomes ifthis information isnot routinely collected, and this may beincorporated into existing fallsreports. To achieve the most accurate information about the fall, the description ofthe fall should also allow for free text. There should beroom onthe falls form for additional comments tobe made. Staff should beencouraged tocomplete all sections ofthe falls report tominimise missing information when the fall isbeingreviewed.
136
20.5 Comprehensive assessment followingafall

Patients who fall repeatedly (eg two ormore times per year) and people prone toinjurious falls require acomprehensive and detailed assessment.363 For amore detailed assessment, refer the patient toaspecialist (eg geriatrician), where possible, orto afallsclinic.
20.6 Loss ofconfidence afterafall

A common but often overlooked consequence ofafall isthe development ofaloss ofconfidence inwalking, orafear offalling,365 which can occur even inthe absence ofany injury. Inthe period after afall, staff should observe the patient tonote any change inusual activity that might indicate the presence of, oranincrease in, fear offalling. Discussion with the patient about any concerns about falling might also bean opportunity toidentify afearoffalling. In community and residential aged care settings, common approaches toimproving loss ofconfidence orfear offalling include participation inabalance and mobility training exercise program, and other falls prevention activities, including use ofhip protectors.365,366 Similar approaches are likely tobe beneficial forolder patients who fall whileinhospital.
The following are useful resources andwebsites: Department ofHuman Services (2001). Falls and Mobility Clinics: Program Guidelines and Performance Indicators, Department ofHuman Services, Acute Health Division,Melbourne. Victorian Falls ClinicCoalition: http://www.nari.unimelb.edu.au/vic_falls/vic_falls_contact.htm
137
Appendices
Appendices
Appendices
Appendix 1
Contributors totheguidelines
Appendices
Chapter authors andreviewers

Chapter
Preliminaries
Author(s)
Ms MegHeaslop
Reviewer
Mr GrahamBedford
Part AIntroduction
Background Falls and falls injuriesinAustralia Involving older people infallsprevention Dr Janet Salisbury Ms MegHeaslop Dr ConstanceVogler Mr GrahamBedford Assoc Prof StephenLord Dr ConstanceVogler
Part B Standard falls preventionstrategies

Falls preventioninterventions Falls risk screening andassessment Ms MegHeaslop Dr KimDelbaere Dr ConstanceVogler Prof KeithHill

Balance and mobilitylimitations Cognitiveimpairment Continence Feet andfootwear Syncope Dizziness andvertigo Medications Vision Dr CathieSherrington Dr KimDelbaere Dr KimDelbaere Dr KimDelbaere Dr JanetSalisbury Dr KateMurray Assoc Prof JacquelineClose Assoc Prof StephenLord Assoc Prof JacquelineClose Dr KimDelbaere Environmentalconsiderations Individual surveillance andobservation Restraints Ms MegHeaslop Ms JacindaWilson Ms MegHeaslop Assoc Prof LindyClemson Assoc Prof DavidFonda Assoc Prof DavidFonda Dr CathieSherrington Dr JeffreyRowland Assoc Prof PaulineChiarelli Assoc Prof HyltonMenz Assoc Prof JacquelineClose Assoc Prof JacquelineClose Assoc Prof JacquelineClose Prof JoanneWood

Hipprotectors VitaminD and calciumsupplementation Ms MegHeaslop Assoc Prof JacquelineClose Prof IanCameron Prof TerryDiamond
141
Chapter
Osteoporosismanagement
Author(s)
Assoc Prof StephenLord
Reviewer
Dr PeterEbling
Part E Respondingtofalls
Post-fallmanagement Guideline Community Residential aged carefacility Hospital Ms MegHeaslop Australianreviewer Dr NancyePeel Ms MandyHarden Assoc Prof JacquelineClose Assoc Prof MichaelDorevitch Internationalreviewer Assoc Prof ClareRobertson Assoc Prof NgaireKerse Prof DavidOliver
Appendices
Additionalwork
Economicevaluations Editors Dr KirstenHoward Ms MegHeaslop, Biotext PtyLtd Dr JanetSalisbury, Biotext PtyLtd Design True Characters PtyLtd
Contributors
Name
Mr GrahamBedford Prof IanCameron
Position
Policy Team Manager, Australian Commission onSafety and Quality inHealthCare Professor ofRehabilitation Medicine, The University ofSydney; Head, Rehabilitation Studies Unit, The UniversityofSydney Associate Professor, Convener ofBachelor ofPhysiotherapy Program, School ofHealth Sciences, The UniversityofNewcastle Associate Professor inAgeing and Thompson Fellow, Faculty ofHealth Sciences, The UniversityofSydney Senior Staff Specialist, Prince ofWales Hospital and Clinical School, The University ofNew South Wales; Honorary Senior Fellow, Prince ofWales Medical Research Institute, The University ofNew SouthWales Postdoctoral researcher, Prince ofWales Medical Research Institute, TheUniversity ofNew SouthWales Senior Endocrinologist, StGeorge Hospital; Associate Professor inEndocrinology, The University ofNew SouthWales Senior Geriatrician, AustinHealth Professor ofMedicine, Department ofMedicine (RMH/ WH), TheUniversity ofMelbourne; Head, Endocrinology, WesternHealth
Assoc Prof PaulineChiarelli
Assoc Prof LindyClemson Assoc Prof JacquelineClose
Dr KimDelbaere Prof TerryDiamond
Assoc Prof MichaelDorevitch Dr PeterEbeling
142
Name
Assoc Prof DavidFonda Ms MandyHarden Prof KeithHill
Position
Associate Professor ofMedicine, Monash University; Consultant Geriatrician, Cabrini MedicalCentre CNC Aged Care Education/Community Aged Care Services, Hunter New England Area Health Services, NSWHealth Professor ofAllied Health, LaTrobe University/Northern Health, Senior Researcher, Preventive and Public Health Division, National Ageing ResearchInstitute Senior Lecturer, Health Economics, School ofPublic Health, TheUniversityofSydney Associate Professor, General Practice and Primary Health Care, School ofPopulation Health, Faculty ofMedical and Health Sciences, TheUniversityofAuckland Principal Research Fellow, Prince ofWales Medical Research Institute, The University ofNew SouthWales National Health and Medical Research Council Research Fellow; Director, Musculoskeletal Research Centre, Faculty ofHealth Sciences, LaTrobeUniversity Principal, Dizzy DayClinics Consultant Physician and Clinical Director, Royal Berkshire Hospital, United Kingdom; Visiting Professor ofMedicine forOlder People, SchoolofCommunity and Health Science, City University,London Research Fellow, Academic Unit inGeriatric Medicine, SchoolofMedicine, The UniversityofQueensland Research Associate Professor, Department ofMedical and Surgical Sciences, Dunedin School ofMedicine, UniversityofOtago Staff Physician, The Prince CharlesHospital Senior Research Fellow, Musculoskeletal Division, The George Institute for International Health and Faculty ofMedicine, TheUniversityofSydney Research Officer, Prince ofWales Medical Research Institute, TheUniversity ofNew SouthWales Clinical Senior Lecturer, Medicine, Northern Clinical School, TheUniversity ofSydney; Staff Specialist Geriatrician, Royal North ShoreHospital Professor, School ofOptometry and Institute ofHealth and Biomedical Innovation, Queensland UniversityofTechnology
Appendices
Dr KirstenHoward Assoc Prof NgaireKerse
Assoc Prof StephenLord Assoc Prof HyltonMenz
Dr KateMurray Prof DavidOliver
Dr NancyePeel Assoc Prof ClareRobertson
Dr JeffreyRowland Dr CathySherrington
Dr AnneTiedemann Dr ConstanceVogler
Prof JoanneWood
Appendix 1
143
Appendices
Appendix 2
Falls risk screening and assessmenttools
Appendices
A2.1 The StThomas Risk Assessment Tool inFalling Elderly Inpatients(STRATIFY) 69

STRATIFY riskscreen
1. Did the patient present tohospital with afall orhas heor she fallen inthe ward sinceadmission?
Do you think the patient (Questions25):
Yes =1 No =0
2.Isagitated? 3. Isvisually impaired tothe extent that everyday functioningisaffected? 4. Isin need ofespecially frequenttoileting? 5. Has atransfer and mobility score of3of6?
Yes =1 No =0 Yes =1 No =0 Yes =1 No =0 Yes =1 No =0
Transfer
0 = unable nositting balance, mechanicallift 1 = major help (one strong, skilled helper ortwo normal people; physical), cansit 2 = minor help (one person easily orneeds supervision forsafety) 3 = independent (use ofaids tobe independentisallowed)

Mobility
0 =immobile 1 = wheelchair independent, including corners,etc 2= walks with help ofone person (verbalorphysical) 3 = independent (but may use any aid,egcane)
Totalscore 5
145
A2.2 The Ontario ModifiedSTRATIFY

The Ontario Modified STRATIFY74 was developed toadapt the StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY), which was developed inthe United Kingdom, tothe Canadian hospitalsetting.
Appendices
Ontario Modified STRATIFY riskscreen

Fallshistory 1. Did the patient present tohospital with afall orhas heor she fallen inthe ward sinceadmission? If not, has the patient fallen within the past 2months? Mentalstatus 2. a. Isthe patient confused (ie unable tomake purposeful decisions, disorganised thinking, and memoryimpairment)? b. Isthe patient disorientated (ie lacking awareness, being mistaken about time, placeorperson)? c. Isthe patient agitated (ie fearful affect, frequent movements, andanxious)? Vision 3. a. Does the patient require eyeglassescontinuously? b. Does the patient report blurredvision? c. Does the patient have glaucoma, cataracts ormaculardegeneration? Toileting Transfer and mobility 4. Are there any alterations inurination (ie frequency, urgency, incontinence,nocturia)? 5. Transfer and mobility score of3of6? Yes =1 No =0 (on atleast onequestion) Yes =1 No =0 Yes =1 No =0 Yes =1 No =0 (on atleast onequestion) Yes =1 No =0
Transfer
0 = unable nositting balance, mechanicallift 1 = major help (one strong, skilled helper ortwo normal people; physical), cansit 2 = minor help (one person easily orneeds supervision forsafety) 3 = independent (use ofaids tobe independentisallowed)

Mobility
0 =immobile 1 = wheelchair independent, including corners,etc 2= walks with help ofone person (verbalorphysical) 3 = independent (but may use any aid,egcane)
Totalscore 5
For each item, 0 (no risk) or1 (risk) issubstituted intheequation: R = 6 (falls history) + 14 (mental status) + 1 (vision) + 2 (toileting) + 7 (transfer andmobility)
146
A2.3 Ontario Modified STRATIFY (SydneyScoring)

The Ontario Modified STRATIFY Sydney Scoring74 was developed toadapt the StThomas Risk Assessment Tool inFalling Elderly In-patients (STRATIFY) tothe Australian hospitalsetting.
Appendices
Ontario Modified Stratify Sydney Scoring

MR Number Surname Date of birth Date: / / Please fill in if no patient label is available
Item
1 History of falls
Falls risk screen

Did the patient present to hospital with a fall or have they fallen since admission? If not, has the patient fallen within the last 2 months?
Value
Score
No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes

0 1 2 3 0 1 2 3
Yes to any = 6
2 Mental Status
Is the patient confused? (ie unable to make purposeful decisions, disorganised thinking and memory impairment) Is the patient disorientated? (ie lacking awareness, being mistaken about time, place or person) Is the patient agitated? (ie fearful affect, frequent movements and anxious)
Yes to any = 14
3 Vision
Does the patient require eyeglasses continually? Does the patient report blurred vision? Does the patient have glaucoma, cataracts or macular degeneration?
Yes to any = 1
4 Toileting 5 Transfer score (TS) [means from bed to chair andback]
Are there any alterations in urination? (ie frequency urgency, incontinence, nocturia) Independent use of aids to be independent is allowed Minor help, one person easily or needs supervision forsafety Major help one strong skilled helper or two normal people; physically can sit Unable no sitting balance; mechanical lift
Yes = 2 Add transfer score (TS) and mobility score (MS) If value total between 03 then score = 0 If values total between 4-6 then score = 7
6 Mobility score (MS)
Independent (but may use an aid eg cane) Walks with help of one person (verbal or physical) Wheelchair independent including corners etc Immobile
Action total score and follow risk recommendations as per level of risk (As validated tool patient at risk if total score 9)
0 5 Low risk 616 Medium risk 1730 High risk
Totalscore
Appendix 2
147
Medication checklist
If one or more of the below medications are taken please refer for medication review. These can increase falls risk:
Antihypertensives Anticonvulsants Benzodiazepines
Aperients Antiparkinsonians Psychotropics
Opioids Diuretic Hypoglycaemics
Appendices
Strategies for managing patients risk status:

Low risk 05 points 1. Orientation to the bed area and ward facilities, ward routine and staff. 2. Lower bed if possible. Ensure brakes are on. 3. Place call bell and side table within reach, and instruct patient to call for assistance as required. 4. Ensure safe footwear when mobilising ie well-fitted shoes. 5. Provide safe footwear brochure to patient and carer. 6. Clothing to fit well and of appropriate length. 7. Clear area of hazards-spills, clutter, unstable furniture. 8. Fall prevention brochure provided to patient/carer. 9. Ensure patient has access to adequate nutrition and hydration. 10. Medication review 11. Bone protection medication review: consider vitamin D and calcium supplementation. 12. Ensure that patient has their glasses and hearing aid (if appropriate). Medium risk 616 points All of the above plus (if available): 12. Falls identifiers used (sign & sticker). 13. Supervise patient during mobilisation. 14. Supervise patient during self care and toileting. 15. Supervise patient with nutrition and hydration. 16. Regular toileting regimen, and prior to settling for the evening. 17. Use non-slip matting by the bed. 18. Referral to physiotherapy and/or occupational therapy for assessment. High risk 1730 Points All of the above plus (if available): 19. Do not leave patient unattended during planned toileting, self care or mobilising. 20. Locate patient close to the nurses station. 21. Ensure bed height is appropriate to the needs of the patient. 22. Consider constant observation particularly if confused/delirious. 23. Consider use of hip protectors.
Acknowledgments:
Northern Sydney Central Coast Area Health Service Greater Southern Area Health Service Sydney West Area Health Service Clinical Excellence Commission Prince of Wales Medical Research Institute
148
A2.4 Peninsula Health FRAT (screeningcomponent)

The Peninsula Health Falls Risk Assessment Tool (FRAT) has several parts. Itis part ofacomprehensive falls prevention package called the FRAT Pack (available for purchase), which includes detailed guidelines for use ofthe full Peninsula Health FRAT. The first part ofthe Peninsula Health FRAT can beused asafalls risk screen, and isprovided below. Permission touse this tool was provided bythe Peninsula Health Falls Prevention Service. The tool was developed through funding fromthe Victorian Department ofHumanServices.
Appendices
Acknowledgment isrequired ifthe tool isused byyour organisation. Contact details for furtherinformation:
Ms Vicki Davies and MsCarolynStapleton Peninsula Health Falls PreventionService Jacksons Road (PO Box192) Mt Eliza VIC3930 Email: VDavies@phcn.vic.gov.auorCStapleton@phcn.vic.gov.au
Peninsula Health FRAT (screeningcomponent)

Patients name: Date:
Riskfactor
Recentfalls
Level
None inthe past 12months One ormore between 3 and 12 monthsago One ormore inthe past 3months One ormore inthe past 3 months whileinpatient/resident
Riskscore
2 4 6 8 1 2 3 4 1 2 3 4 1 2 3 4
Medications Sedatives, antidepressants, antiparkinsons, diuretics, antihypertensives,hypnotics
Not taking anyofthese Takingone Takingtwo Taking more thantwo
Psychological Anxiety, depression, cooperation, insight or judgment, especially regardingmobility
Does not appear tohave anyofthese Appears mildly affected byoneormore Appears moderately affected byoneormore Appears severely affected byoneormore
Cognitivestatus m-m: Hodkinson Abbreviated Mental TestScore
m-m score 910/10 m-m score 78 m-m score 56 m-m score 4 orless

OR intact mildlyimpaired moderatelyimpaired severelyimpaired
Totalscore /20
Low risk:511 Medium risk:1215 High risk: 1620
Riskcategory
Appendix 2
149
A2.5 Falls Risk for Hospitalised Older People(FRHOP)
Appendices
Falls Risk for Hospitalised Older People (FRHOP)

(To be completed on patient admission and after an acute episode) Date of Assessment: / / Place UR sticker here or add patient details: Name: UR number:
General (do not score, but ensure appropriate actions)

Has the patient been oriented to the ward & routines, and a patient information brochure/booklet provided? Patients environment assessed and safe? (seating type and height, bed height and assistive equipment eg monkeybar/bedstick) Is English the patients preferred language?
Nursing:
Yes No Yes No Yes No
Medical staff
Recent falls (0-3) SCORE
Has the patient fallen recently?
Did they sustain an injury?
Nil in 12 months (0) 1 in the last 12 months (1) 2 or more in 12 months (2) 1 or more during their current hospitalisation (3) No (0) Minor injury, did not require medical attention (1) Minor injury, did require medical attention (2) Severe injury (fracture, etc) (3) No medication (0) 12 medications (1) 3 medications (2) 4 or more medications (3) None apply (0) 12 apply (1) 3 apply (2) 4 or more apply (3)
[ ]
[ ]
Medications (0-3) Is the patient on any medication? [ ]
Does the patient take any of the following type of medication? sedative analgesic psychotropic antihypertensive vasodilator/cardiac diuretics antiparkinsonian antidepressants vestibular supressant anticonvulsants
[ ]
Sub total for this page
[ ]
Falls Risk Classification (please circle): Low / Medium / High Patient Name: UR Number:
150
Medical staff
Appendices
Sub total from previous page Medical conditions (03) [ ]
Does the patient have a chronic medical condition/s affecting their balance & mobility? Arthritis Respiratory condition Parkinsons Disease Diabetes* Dementia Peripheral neuropathy Cardiac condition Stroke/TIA Other neurological conditions Lower limb amputation. Vestibular disorder (dizziness, postural dizziness, Menieres disease)
Sensory loss & communications
None apply (0) 12 apply (1) 34 apply (2) 5 or more apply (3)
[ ]
(* refer patients to Podiatry for a foot care review)
Does the patient have an uncorrected sensory deficit/s that limits their functional ability?
Vision
Hearing
Somato sensory
[ ]
Is there a problem with communication (eg NESB or dysphasia)?

Cognitive status: (score 03 points)
No (0) Yes (1) No (0) Yes (1)
No (0) Yes (1)
No (0) Yes (1)

[ ]
AMTS score
910 (0 point) 78 (1 point) 56 (2 points) 4 or less (3 points)
[ ]
Nursing staff
Continence
Is the patient incontinent? Do they require frequent toileting or prompting to toilet? Do they require nocturnal toileting?
Nutritional conditions (score 03 points)
No (0) Yes (1) No (0) Yes (1) No (0) Yes (1) No (0) Small change, but intake remains good (1) Moderate loss of appetite (2) Severe loss of appetite / poor oral intake (3) Nil (0) Minimal (<1 kg) (1) Moderate (13 kg) (2) Marked (>3 kg) (3)
Sub total for this page
[ ] [ ] [ ]
Has the patients food intake declined in the past three months due to a loss of appetite, digestive problems, chewing or swallowing difficulties?
[ ]
Weight loss during the last 312 months.
[ ]
[ ]
Falls Risk Classification (please circle): Low / Medium / High
Appendix 2
151
Occupational Therapist
Patient Name: UR Number:
Sub total from previous page Functional behaviour (score 0-3) [ ]
Appendices
Observed behaviours in activities of daily living &mobility indicate:
Consistently aware of current abilities/

seeks appropriate assistance as required (0)
[ ]
Generally aware of current abilities/ occasional risk-taking behaviour (1) Under-estimates abilities/
inappropriately fearful of activity (2)
Over-estimates abilities/
frequent risk-taking behaviour (3)
Feet & footwear and clothing
Does the patient have foot problems, eg corns, bunions etc.
an inaccurate fit poor grip on soles in-flexible soles across the ball of foot heels greater than 2 cm high/less than flexible heel counter** without fastening mechanism (ie lace,
velcroor buckle. slippers or other inappropriate footwear? Does the patients clothing fit well (not too long or loose fitting)? 3cmwide
The patients main footwear are/have:-
No (0) Yes (1) (specify): None apply (0) One applies (1) 2 apply (2) 3 or more apply (3)
[ ]
[ ]
(** half moon shape structure/stiffening at backofshoe)
Yes (0) No (1)
[ ]
Physiotherapist
Balance (score 03 points)
Were the patients scores on the Timed Up and Go test and the Functional Reach test within normal limits? Normal limits: Timed up and Go less than 18 seconds Functional Reach 23 cm or more
Transfers & mobility (score 03 points)
Both within normal limits (0) One within normal limits (1) Both outside normal limits (2) Requires assistance to perform (3)
[ ]
Is the patient independent in transferring and in their gait? (Includes wheelchair mobility)
Independent, no gait aid needed (0) Independent with a gait aid (1) Supervision needed (2) Physical assistance needed (3)
Total risk score
[ ]
[ ]
Score legend: 0 to 5 = Low risk; 6 to 20 = medium risk; 21 to 45 = high risk
152
A2.6 Falls Risk for Older People inthe Community Screen (FROP-ComScreen) 60
Appendices
Falls Risk for Older People in the Community (FROP-Com) Screen

Screen all people 65 years and older (50 years and older Aboriginal & Torres Strait Islander people) Date of screen: / /
FALLS HISTORY
(Affix Patient ID Label) UR No Surname Given Name
SCORE
1. Number of falls in the past 12 months?
None (0) 1 fall (1) 2 falls (2) 3 or more (3) None (completely independent) (0) Supervision (1) Some assistance required (2) Completely dependent (3) No unsteadiness observed (0) Yes, minimally unsteady (1) Yes, moderately unsteady (needs supervision) (2) Yes, consistently and severely unsteady
(needsconstant hands on assistance) (3)
[ ]
FUNCTION: ADL status
2. Prior to this fall, how much assistance was the individual requiring for instrumental activities of daily living (eg cooking, housework, laundry)? If no fall in last 12 months, rate current function
BALANCE
[ ]
3. When walking and turning, does the person appear unsteady or at risk of losing their balance? Observe the person standing, walking a few metres, turning and sitting. If the person uses an aid observe the person with the aid. Do not base on self-report. If level fluctuates, tick the most unsteady rating. If the person is unable to walk due to injury, score as 3.
[ ]
Total risk score
[ ]
Total score
Risk of being a faller Grading of falls risk Recommended actions
0
0.25
2
0.7
4
1.4
6
4.0
8
7.7
03 Low risk Further assessment and management if functional/balance problem identified (score of one or higher)
49 High risk Perform the Full FROP-Com assessment and / or corresponding management recommendations
Date: / / Name Signature Designation
Appendix 2
153
A2.7 Peter James Centre Fall Risk Assessment Tool (PJC-FRAT): risk assessment tool for the subacute rehabilitationsetting
The Peter James Centre Fall Risk Assessment Tool (PJC-FRAT) isamultidisciplinary falls risk assessment tool. Itwas used asthe basis fordeveloping intervention programs inarandomised controlled trial inthe subacute hospital setting that successfully reduced patient/resident falls. Permission toreproduce this tool was granted byPeter James Centre and BMJ PublishingGroup.
Appendices
Acknowledgment isrequired ifthe tool isused byyour organisation. Contact details for furtherinformation: Peter JamesCentre MahoneysRoad Burwood East VIC3151 Phone: 03 98811888 Fax: 03 98811801
Falls Risk Assessment Tool

(To be completed on admission) Name: UR/MR number: Ward/Unit: Date of birth: Gender: Admission Date: Tick box or add number as appropriate
Medical
Place UR sticker here or add patient details:
Does the patient suffer from frequent falls with no diagnosed cause? Is the patient suffering from an established medical condition that is currently unable to be adequately managed, that may cause a fall during their Inpatient stay (e.g. drop attacks due to vertebro-basilar artery insufficiency? Is the patient taking any medications/medication amounts/ medication combinations that you anticipate may directly contribute to a fall (e.g.sedatives)?
Refer for hip protector. Refer for hip protector.
Refer for hip protector.
Signature: Date:
Nursing
Toileting (day) F.I.M. Toileting (night) F.I.M. Would this patient benefit from a Falls Risk Alert Card and a Falls Prevention Information Brochure?
Document level of assistance required in patient/ resident record/file. Document level of assistance required in patient/ resident record/file. Refer for a Falls Risk Alert Card and a Falls Prevention Information Brochure Signature: Date:
Physiotherapy
Gait F.I.M. (Gait aid + distance) Transfer (bed <> chair F.I.M) Would this patient benefit from attending a Balance Exercise Class?
( __________/__________ ) Refer for Balance Exercise Class. Signature: Date:
154
Falls Risk Assessment Tool

Occupational Therapy
Bathing F.I.M Dressing F.I.M. Would this patient benefit from attending a Falls Prevention EducationProgram?
Refer for Falls Prevention Education Program.

Signature: Date:
Appendices
All disciplines
Has the patient demonstrated non-compliance or do you strongly anticipate non-compliance with the above prescribed level of aids/ assistance/supervision such that the patient becomes unsafe?
The Modified Functional Independence Measure (F.I.M.)
Refer for hip protector. Signature: Date:
(7) Independent with nil aids. (6) Independent with aids. (5) Supervision/prompting (4) Minimal assistance required (patient greater than 75% of the task).
(3) Moderate assistance required (patient performs between 50% and 75% of the task). (2) Maximal assistance required (Patient performs between 25% and 50% of the task). (1) Fully dependent (patient performs less than 25% of the task).
Falls Risk Assessment Tool Amendment sheet

Name: UR/MR number: Ward/Unit: Date of birth: Gender: Admission Date: Place UR sticker here or add patient details: This amendment section of the Falls Risk Assessment Tool is to be used when a patients condition changes such that the employment of interventions is now indicated or now no longer indicated. For example, if a patients confusion due to a UTI is now resolved, they may no longer require a hip protector.
Has the patients condition changed such that the patient:
Does now require a hip protector: Does no longer require a hip protector: Would now benefit from balance exercise class: Would now benefit from a falls prevention education class: Would now benefit from a falls risk alert card and information brochure:
Refer for hip protector. Note in record and make appropriate change Refer for balance exercise. Refer for falls prevention education. Refer for falls alert card. Signature: Date:
Has the patients condition changed such that the patient:
Does now require a hip protector: Does no longer require a hip protector: Would now benefit from balance exercise class: Would now benefit from a falls prevention education class: Would now benefit from a falls risk alert card and information brochure:
Refer for hip protector. Note in record and make appropriate change Refer for balance exercise. Refer for falls prevention education. Refer for falls alert card. Signature: Date:
Appendix 2 155
A2.8 Falls Assessment Proforma Emergency Department and Department ofHealth Care oftheElderly
Falls Assessment Proforma
Emergency Department & Department of Health Care of the Elderly Appendices
Name:
Hosp No
Attending Dr
Date of attendance:
Fall History
Time:
First fall:
Yes No
No of falls in previous year: Location of fall: Indoors Outdoors
(>1 = high risk) (indoors = high risk)
Was fall witnessed: Definite slip/trip: LOC: *Able to get self off floor:
Medical History
Yes No Yes No Yes No Yes No (N=high risk) Associated dizziness: Palpitations: Time on floor (mins):
*Full Drug History (4+ meds = high risk)
Yes No Yes No
Heart disease Stroke COPD/Asthma Hypertension Diabetes Degenerative joint disease Cognitive impairment Visual impairment Syncope Epilepsy Incontinence Other (please state)

Smoking: Alcohol: no/week units/week
Social Circumstances
Lives in: Flat House Bungalow Maisonette WCF Residential Home Nursing Home Lives alone: Yes No Lambeth / Southwark / Other Mobility: Independent Stick Frame Wheelchair Stairs: Yes No Usually able to go out: Yes No MOW Services: HH Personal Care District Nurse Day Centre Day Hospital None Carer: Spouse Other family Friend/neighbour
Jacqueline Close 2003
156
Examination
GCS: Temp:
AMT
BM Pulse: BP; Lying

Injuries Sustained
Standing
Appendices
Age Time (to nearest hour) Address for recall Year Location Recognition of two persons Date of Birth WW2 Present monarch Count backwards 20 1 Score: 10
Relevant Systems Examination
Head injury no laceration Head injury - laceration Fracture Laceration requiring stitches Laceration but no stitches Superficial bruising No injury
Indicate site of injury including pressure areas
Current Level of Function
No change from pre-fall level of function Decreased mobility / function but able to go home Decreased mobility / function unable to discharge
Results
Conclusions
Likely cause of fall:

Comments
simple slip/trip, acute illness, multifactorial, unexplained
* High risk recommend referral to Falls Clinic if Falls Nurse not available to assess
Outcome:
Home with GP letter Refer to Falls Clinic Refer to Rapid Response team Refer to Geriatric Out-Patients Refer for hospital admission
Signature Print Name Date / /

Appendix 2 157
Appendices
Appendix 3
Safe shoechecklist247
Appendices
The requirement for safe, well-fitting shoes varies, depending on the individual and their level of activity. The features outlined below may help in the selection of an appropriate shoe. The shoe should: Heel
Have a low heel (ie less than 2.5 cm) to ensure stability and better pressure distribution onthefoot. A straight-through sole is also recommended. Have a broad heel with good ground contact. Have a firm heel counter to provide support for the shoe. Have a cushioned, flexible, nonslip sole. Rubber soles provide better stability and shock absorption than leather soles. However, rubber soles do have a tendency to stick on some surfaces. Be lightweight. Have adequate width, depth and height in the toe box to allow for natural spread of toes. Have approximately 1 cm space between the longest toe and the end of the shoe when standing. Have laces, buckles, elastic or velcro to hold the shoe securely onto the foot. Be made from accommodating material. Leather holds its shape and breathes well; however, many people find walking shoes with soft material uppers are more comfortable. Have smooth and seam-free interiors. Protect feet from injury Be the same shape as the feet, without causing pressure or friction to the foot. Be appropriate for the activity being undertaken during their use. Sports or walking shoes may be ideal for daily wear. Slippers generally provide poor foot support and may only be appropriate when sitting. Comfortably accommodating orthoses, such as ankle foot orthoses or other supports, if required. The podiatrist, orthotist or physiotherapist can advise the best style of shoe if orthoses are used.
Sole Weight Toe box
Fastenings Uppers
Safety Shape Purpose
Orthoses
This is a general guide only. Some people may require the specialist advice of a podiatrist for the prescription of appropriate footwear for their individual needs.
159
Appendices
Appendix 4
Environmentalchecklist45
Appendices
This tool was adapted from CERA Putting your Best Foot Forward Preventing and Managing Falls inAged Care Facilities , bystaff atthe rehabilitation unit, Bundaberg Base Hospital Health Service District, aspart ofQueensland Healths Quality Improvement and EnhancementProgram.
General environment checklist

Surname First name U.R. No Date of birth / / (Please affix patient ID label here if available)
Client location:
Bathroom and toilets
Bed/room No:
Please
appropriate box
Yes
No
N/A
Grab rails are appropriately positioned and secured in the toilet, shower and bath Floors are nonslip Baths/showers have nonslip treatment and/or mats Are areas immediately around the bath and sink marked in contrasting colours? Raised toilet seats are available Toilet surrounds and/or grab rails are available in toilets Soap, shampoo and washers are within easy reach and do not require bending to reach Do all shower chairs have adjustable legs, arms and rubber stoppers on the legs? Is there room for a seat in AND near the shower? Is the shower base without steps? (not necessary for most patients) Are call buttons accessible from sitting position in shower area? Are doors lightweight and easy to use?
Furniture Please
appropriate box
Yes
No
N/A
Is furniture secure enough to support a client should they lean on or grab for balance? Are bedside lockers or tables available to clients so they can put things on safely without undue stretching and twisting? Are footstools in good repair and stoppers in good condition? Is space available for footstool when required?
161
Client location:
Floor surfaces
Bed/room No:
Please
Appendices
appropriate box
Yes
No
N/A
Are carpets low pile, firmly attached and a constant colour rather than patterned? Are walls a contrasting colour to the floor? Is non-skid wax used on wooden and vinyl floors? Do floors have a matted finish which is not glary? Are Wet Floor signs readily available and used promptly in the event of a spillage? Do steps have a non-slip edging in contrasting colour to make it easier to see? Is routine cleaning of floors done in a way to minimise risk to residents eg. well signed, out of hours?
Lighting Please
appropriate box
Yes
No
N/A
Is lighting in all areas at a consistent level so that patients are not moving from darker to lighter areas and vice versa? Do staircases have light switches at the top and bottom of them? Do patients have easy access to night lights? Are the hallways and rooms well lit (75 watts)? There is minimal glow from furniture/floorings Are all switches marked with luminous tape for easy visibility?
Passageways Please
appropriate box
Yes
No
N/A
Are all passageways kept clear of clutter and hazards? Are firm and colour contrasted handrails provided in passageways and stairwells? Is there adequate space for mobility aids? Is there adequate storage space for equipment? Are ramps/lifts available as an alternative to stairs? Do steps have a nonslip edging in contrasting colour? Is there enough room for two people with frames/wheelchairs to pass each other safely?
Passageways Please
appropriate box
Yes
No
N/A
Are all passageways kept clear of clutter and hazards? Are firm and colour contrasted handrails provided in passageways and stairwells? Is there adequate space for mobility aids? Is there adequate storage space for equipment? Are ramps/lifts available as an alternative to stairs? Do steps have a nonslip edging in contrasting colour? Is there enough room for two people with frames/wheelchairs to pass each other safely?
162
Client location:
Lifts
Bed/room No:
Please
Appendices
appropriate box
Yes
No
N/A
Do doors close slowly? Are buttons easily accessible to avoid excessive reaching? Are floor signs at eye level to prevent stretching the neck? Are handrails available?
External areas Please
appropriate box
Yes
No
N/A
Are pathways even and with a nonslip surface? Are pathways clear of weeds, moss and leaves? Are steps marked with a contrasting colour and nonslip surface? Are there handrails beside external steps and pathways? Are there any overhanging trees, branches and shrubs? Are sensor lights installed? Are there sufficient numbers of outdoor seats for regular rests?
Security of environment Please
appropriate box
Yes
No
N/A
Are all exits from the facility secured to prevent confused patients leaving? Are there clear walking routes both inside and outside where patients can wander safely without becominglost? Does the layout of the facility, or allocation of rooms, allow staff to monitor high risk patients? Remedial actions that need to be taken:
Appendix 4
163
Appendices
Appendix 5
Equipment safetychecklist361
Reproduced with permission from VANational Centre for Patient Safety 2004 Falls Toolkit, page43.
Appendices
Equipment safety checklist:

Wheelchairs
Please
Brakes Arm rest Leg rest Foot pedals Wheels Anti-tip devices
Secure chair when applied Detaches easily for transfers Adjust easily Fold easily so that patient may stand Are not bent or warped Installed, placed in proper position
Electric wheelchairs/scooters
Speed Horn Electrical

Beds
Set at the lowest setting Works properly Wires are not exposed
Side rails
Raise and lower easily Secure when up Used for mobility purposes only
Wheels Brakes Mechanics Transfer bars Over-bed table
Roll/turn easily, do not stick Secures the bed firmly when applied Height adjusts easily (if applicable) Sturdy, attached properly Wheels firmly locked Positioned on wall-side of bed
IV poles/stand
Pole Wheels Stand

Footstools
Raises/lowers easily Roll easily and turn freely, do not stick Stable, does not tip easily (should be five-point base)
Legs
Rubber skid protectors on all feet Steadydoes not rock
Top
Non-skid surface
165
Appendices
Equipment safety checklist:

Call bells/lights
Please
Operational
Outside door light Sounds at nursing station Room number appears on the monitor Intercom Room panel signals
Accessible
Accessible in bathroom Within reach while patient is in bed
Walkers/canes
Secure
Rubber tips in good condition Unit is stable
Commode
Wheels
Roll/turn easily, do not stick Are weighted and not top heavy when a person is sitting on it
Brakes
Chairs
Secure commode when applied
Chair Wheels Brakes
Located on level surface to minimize risk of tipping Roll/turn easily, do not stick Applied when chair is stationary Secure chair firmly when applied
Footplate
Removed when chair is placed in a non-tilt or non-reclined position Removed during transfers
Positioning Tray
Chair is positioned in proper amount of tilt to prevent sliding or falling forward Secure
Completed by: Date: / /
166
Appendix 6
Checklist ofissues toconsider before using hipprotectors318
Appendices
A checklist of issues to consider before using hip protectors is as follows: Is the risk of hip fracture high enough to justify their use? Will the user wear them as directed? Will the user be able to put them on and pull them down for toileting; if not, is assistance available? How will they be laundered? Who will encourage their use? Who will pay for them? Is the potential wearer aware of the different types of hip protector available? Additionally a checklist of issues when using hip protectors is as follows: Is the fit adequate? Are they being worn in the correct position? Are they being worn at the correct times and should they be worn at night? Are continence pads worn if needed? Should other underwear be worn under the hip protectors? Is additional encouragement needed to improve compliance? When should the hip protectors be replaced? Has education been provided to care staff?
167
Appendices
Appendix 7
Hip protector careplan247
Appendices
This chart was developed bystaff atEventide Nursing Home, Sandgate, Prince Charles Health Service District, aspart ofQueensland Healths Quality Improvement and EnhancementProgram.
Hip protector pad care plan

Date: / / Affix ID label
Identified/expressed needs
Negotiated outcomes
Total of hip protector pads (type).

Management plan
To allow independent mobility with less associated risks due to protective device
Review date Signature
Hip protector pads to be individually marked and stored with incontinence aids. Two pairs of hip protector pads per person. Removable cover can be changed if soiled or wet (these are washable). Stretch pants secure hip protector pads in place. For those people whoalready wear stretch pants for incontinence pads, a second pair ofstretch pants may be needed and worn over the first pair. For type A hip protector pads, position just below the persons waist with Velcro closure at the top. This allows cover for the entire hip region. Please choose clothing with a loose fit to allow for hip protector pad insertion. Please complete hip protector pad observation form with time applied and removed. Comment on compliance, fit, comfort etc. and any problems. Please contact if any problems
169
Appendices
Appendix 8
Hip protector observationrecord247
Appendices
This chart was developed bystaff atEventide Nursing Home, Sandgate, Prince Charles Health Service District, aspart ofQueensland Healths Quality Improvement and EnhancementProgram.
Hip protector pad observations

Observations (please specify): Affix ID label
Date
Time applied
Time removed
Hours in use
Comment
Initials
171
Appendices
Appendix 9
Hip protector educationplan302
Appendices
The following information is taken from Meyer G, Warnke A, Bender R, Muhlhauser I. (2003). Effect of hip fractures on increased use of hip protectors in nursing homes: cluster randomised controlled trial. British Medical Journal; 326: 7680. The education session lasted for 6090 minutes, took place in small groups (average 12 members of staff from each cluster), and was delivered by two investigators. It covered: information about the risk of hip fracture and related morbidity; strategies to prevent falls and fractures; effectiveness of hip protectors; relevant aspects known to interfere with the use of protectors, such as aesthetics, comfort, fit, and handling; and strategies for successful implementation. The session included experience based, theoretical, and practical aspects. Staff members were encouraged to try wearing the hip protector. Apart from the printed curriculum we also developed and provided 16 coloured flip charts illustrating the main objectives and leaflets for residents, relatives, and physicians.
At least one nurse from each intervention cluster was then responsible for delivering the same education programme to residents individually or in small groups. Nursing staff were encouraged to wear a hip protector during these sessions and to include residents who readily accepted the hip protector as activating groupmembers. About two weeks later we visited the intervention clusters again to encourage the administration of the programme. Otherwise frequency and intensity of contacts were similar for intervention and control groups.
173
Appendices
Appendix 10
Food and fluid intakechart
Reproduced with permission ofToowoomba Health Services District, QueenslandHealth.
Appendices
Food and fluid intake chart

Please affix client identification label here
What is the patient eating?

(please write down all foods and fluids this patient is consuming specify amounts)
Day: Consumed (please circle) Fluid (mL) Comments
Breakfast juice Fruit Cereal Yoghurt Bread/toast Drink Other (specify fluid type and volume)
Morning tea
None None None None None None
All All All All All All
Food Drink Other

Midday meal
None None
All All
Soup Meat Vegetables Bread Fruit Dessert Drink Other (specify fluid type and volume)
None None None None None None None
All All All All All All All
175
Appendices
What is the patient eating?

Afternoon tea
Food Drink Other (specify)

Evening meal
None None
All All
Consumed (please circle)
Fluid (mL)
Comments
Soup Meat Vegetables Bread Fruit Dessert Drink Other (specify fluid type and volume)
Supper
None None None None None None None
All All All All All All All
Food Drink Other (specify fluid type and volume)
None None
All All
NB: Extra fluids ie from taking medications, swallow tests, sips of water etc must be recorded in the above chart as other with a volume provided (eg Medication20 mL).
176
Appendix 11
Food guidelines for calcium intake for preventing falls inolderpeople339
Appendices
Guidelines
Men: provide 3 serves ofdairyproducts everyweek. Women: provide 4 serves ofdairy products everyweek.
More information andhints

One serve ofdairy products isequalto: 250 mLmilk (whole, reduced fat, skim, fortifiedsoy) 250mLcustard 200 mLhigh-calciummilk 200gyoghurt 45gcheese. Soft cheeses (eg cottage and ricotta cheeses) have lesscalcium. Encourage some high-calcium foods (eg aglass ofmilk) before bed, because calcium isbest absorbedovernight. Soy milk, oat milk and rice milk are not naturally high incalcium, socheck for supplementation with calcium ofat least 100 mgof calcium per 100mLmilk.
Provide amenu low insalt and advise limiting saltuse.
Sodium chloride (salt) can increase calciumloss. Provide lower salt versions ofprocessed foods, canned foods andmargarines. Low-salt foods contain 120 mgor less ofsodium per 100 goffood. Do not add salttocooking. Discourage addition ofsalt atmealtimes. Keep coffee intake to34 cups ofweak coffeeaday. Lower intake ofother drinks that contain caffeine (eg tea, cola, softdrinks). Provide nomore than 12 standard drinks perday. Have atleast 2 alcohol-free daysaweek.
Avoid providing large amounts ofcaffeine-containing drinks andalcohol.
177
Appendices
Appendix 12
Post-fall assessment and management
Appendices
Post-fall assessment and management

Falls and hits head Falls and does not hit head Unwitnessed fall
SPECIAL CONSIDERATION Patients on anticoagulant and/or antiplatelet therapy and patients with a known coagulopathy are at an increased risk of intracranial haemorrhage. Anticoagulants include: Warfarin, Heparin, Enoxaparin (Clexane), Dalteparin (Fragmin). Antiplatelet drugs include: Aspirin, Clopidogrel, Aspirin+Dipyridamole (Asasantin). Alcohol dependent persons are considered coagulopathic. Do not move initially Call for assistance Immobilise Cervical Spine if head and neck pain is reported Baseline Vital signs (BP, heart rate, respiratory rate, oxygen saturation, Blood Sugar Level (BSL)) Neurological Observations initial Glasgow Coma Scale (GCS) Observe for change in the level of consciousness, headache, amnesia or vomiting Clean and dress any wounds Contact Medical Officer for review Consider need for analgesia Liaise for appropriate test (consider CT Scan if patient has any high risk factors, see Section 6 of NSW Health PD2008_0081 HeadInjury ) Notify registrar/consultant (if required) Potential Injuries: fracture, soft tissue injury or no observable injury. Do not move initially Call for assistance Baseline Vital signs (BP, heart rate, respiratory rate, oxygen saturation, BSL) Clean and dress any wounds Potential Injuries: Head or neck injury, fracture, soft tissue injury or no observable injury. Do not move initially Call for assistance Immobilise Cervical Spine if head and neck pain is reported Baseline Vital signs (BP, heart rate, respiratory rate, oxygen saturation, BSL) Neurological Observations initial Glasgow Coma Scale (GCS) Observe for change in the level of consciousness, headache, amnesia orvomiting Clean and dress any wounds Contact Medical Officer for review Consider need for analgesia Liaise for appropriate test (eg CT Scan if patient has any high risk factors, see Section6 of NSW Health PD2008_0081 HeadInjury ) Notify registrar/consultant (if required)
Contact Medical Officer for review Consider need for analgesia Liaise for appropriate test (eg X rays)
Notify registrar/consultant (if required)
Observations
Record vital signs and neurological observations hourly for 4 hours then review Continue observations at least 4 hourly for24 hours or as required Notify MO immediately if any change inobservations Notify family If not already flagged as high risk of fall injury, flag as per hospital protocol IIMS report
Observations
Monitor vital signs for 24 hours
Observations
Record vital signs and neurological observations hourly for 4 hours then review Continue observations at least 4 hourly for24 hours or as required Notify MO immediately if any change inobservations Notify family If not already flagged as high risk of fall injury, flag as per hospital protocol IIMS report
Notify family If not already flagged as high risk of fall injury, flag as per hospital protocol IIMS report
Post Fall review

Document in medical record strategies implemented
Post Fall Review

Post Fall review

Reassess Falls Risk Status Refer to relevant staff to review, update care plan and implement Falls prevention strategies Communication All staff involved in the care of the patient to be informed of incident outcome and revised care plan
Acknowledgments:
1. Adapted From RNS and RHS Policy Per RNS2005/46 2. Hook, ML., Winchel, S (2006) Fall Related Injuries in Acute Care: Reducing the Risk of Harm, MEDSURG Nursing, Vol 15/No.6 3. NSW Department of Health, Policy Directive: Initial Management of Closed Health Injury in Adults, PD2008_0081 Head Injury, 2008. 4. NSW Institute of Trauma and Injury Management http://www.itim.nsw.gov.au
179
Appendices
Glossary
Appendices
Cognitive impairment Cognitively intact Comorbidity Consumer Delirium Dementia Extrinsic factors Facility Fall
Impairment inone ormore domains ofnormal brain function (eg memory, perception,calculation). Suffering noform ofcognitiveimpairment. Two ormore health conditions ordisorders occurring atthe sametime. Refers topatients, clients and carers inacute and subacute settings. Italso refers topeople receiving care inresidential aged care settings and theircarers. An acute change incognitive function characterised byfluctuating confusion, impaired concentration andattention. Impairment inmore than one cognitive domain that impacts onapersons ability tofunction, and that progresses overtime. Factors that relate toapersons environment ortheir interaction with theenvironment. Used torefer toboth hospitals and residential aged carefacilities. A standard definition ofafall should beused inAustralian facilities, sothat anationally consistent approach tofalls prevention can beapplied. For these guidelines, the expert panel and taskforce agreed onthe following definition: A fall isan event which results inaperson coming torest inadvertently onthe ground orfloor orother lower level. World Health Organization: http://www.who.int/ageing/publications/Falls_prevention7March.pdf Used inplace ofthe full title ofthe three guidelines, Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Hospitals 2009, Preventing Falls and Harm From Falls InOlder People: Best Practice Guidelines for Australian Residential Aged Care Facilities 2009 and Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Community Care2009. Falls risk assessment isamore detailed and systematic process than afalls risk screen and isused toidentify apersons risk factors forfalling. Falls risk screening isthe minimum process for identifying older people atgreatest risk offalling. Itis also anefficient process, because fewer than five risk factors are usually required toidentify who should beassessed more comprehensively for fallsrisk. A device worn over the greater trochanter ofthe femur, designed toabsorb and deflect the energy created byafall away from the hip joint. The soft tissues ofthe surrounding thigh absorb the energyinstead. Refers toboth acute and subacutesettings. A drop inblood pressure resulting from achange inposition from lyingtostanding. A drop inblood pressure experienced aftereating. A measure ofthe cost effectiveness ofan intervention, which iscalculated bycomparing the costs and health outcomes ofthe new program with the costs and health outcomes ofan alternative health care program. Interventions with lower ICERs are better value formoney.
Falls Guidelines
Falls risk assessment Falls risk screen
Hip protector Hospital Hypotension, orthostatic Hypotension, postprandial Incremental costeffectiveness ratio (ICER)
181
Injurious fall
These guidelines use the Prevention ofFalls Network Europe (ProFaNE) panel definition ofan injurious fall. They consider that the only injuries that could beconfirmed accurately using current data sources were peripheral fractures (defined asany fracture ofthe limb girdles and ofthe limbs). Head injuries, maxillo-facial injuries, abdominal, soft tissue and other injuries are not included inthe recommendation foracoredataset. However, other definitions ofan injurious fall include traumatic brain injuries (TBIs) asafalls-related injury, particularly asfalls are the leading cause ofTBIsinAustralia.
Appendices
Intervention Intrinsic factors Life years saved or life years generated (LYS) Multifactorial interventions Multiple interventions Older person or older people Patient Pharmacodynamics Pharmacokinetics Psychoactive medication Quality-adjusted life year (QALY) Resident Residential aged care facility (RACF) Root-cause analysis Single interventions Syncope Vision Visual acuity
A therapeutic procedure ortreatment strategy designed tocure, alleviate orimprove acertaincondition. Factors that relate toapersons behaviourorcondition. A measure ofthe gain inhealth outcomes fromanintervention. Where people receive multiple interventions, but the combination ofthese interventions istailored tothe individual, based onan individualassessment. Where everyone receives the same, fixed combinationofinterventions. The guidelines define older people as65 years ofage and over. When considering Indigenous Australians, the term older people refers topeople 50years ofage andover. Refers toboth patients and clients inacute and subacutesettings. The study ofthe biochemical and physiological effects that medications have onthebody. The study ofthe way inwhich the body handles medications, including the processes ofabsorption, distribution, excretion and localisation intissues and chemicalbreakdown. A medication that affects the mental state. Psychoactive medications include antidepressants, anticonvulsants, antipsychotics, mood stabilisers, anxiolytics, hypnotics, antiparkinsonian drugs, psychostimulants and dementiamedications. A summary measure used inassessing the value for money ofan intervention. Itis based onthe number ofyears oflife that would beadded byan intervention, and combines survival and quality oflife inasingle compositemeasure. Refers topeople receiving care inresidential aged caresettings. Refers toboth high-care and low-caresettings. An in-depth analysis ofan event, including individual and broader system issues, toprovide greater understanding ofcauses and futureprevention. Interventions targeted atsingle riskfactors. A temporary loss ofconsciousness with spontaneous recovery, which occurs when there isatransient decrease incerebral bloodflow. The ability ofthe unaided eye tosee finedetail. A measure ofthe ability ofthe eye tosee fine detail when the best spectacle orcontact lens prescription isworn. Visual acuity (VA) = d/D (written asafraction) where d= the viewing distance (usually 6 metres), andD = the number under orbeside the smallest line ofletters that the person isable tosee. Normal visual acuity is6/6 orbetter. Ifsomeone can only see the 60 line atthe top ofthe chart, the acuity isrecorded asbeing 6/60. Some people can see better than 6/6 (eg 6/5, 6/3); however, 6/6 has been established asthestandard for goodvision.
182
References
Appendices
ACSQHC (Australian Commission on Safety and Quality in Health Care) (2005). Preventing Falls and Harm From Falls in Older People Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities 2005, Australian Government, Canberra. NARI (National Ageing and Research Institute) (2004). An Analysis of Research on Preventing Falls and Falls Injury in Older People: Community, Residential Care and Hospital Settings (2004 update) , Australian Government Department of Health and Ageing, Department of Health and Ageing, Injury Prevention Section, Canberra. Aged Care Act 1997. http://scaletext.law.gov.au (Accessed July 2007) VQC (Victorian Quality Council) (2004). Minimising the risk of falls and fall-related injuries. Guidelines for acute, sub-acute and residential care settings, Department of Human Services Metropolitan Health and Aged Care Services Division, Victorian Government, Melbourne. WHO (World Health Organization). Definition of a fall. http://www.who.int/violence_injury_prevention/ other_injury/falls/links/en/index.html Rushworth N (2009). Brain Injury Australia Policy Paper: Falls-Related Traumatic Brain Injury. http://www.bia.net.au/reports_factsheets/BIA%20Paper_Falls%20related%20TBI.pdf (Accessed 29 July 2009) Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG and Rowe BH (2009). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews (2) Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub2. NHMRC (National Health and Medical Research Council) (2007). NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Stage 2 consultation. http://www.nhmrc. gov.au/guidelines/_files/Stage%202%20Consultation%20Levels%20and%20Grades.pdf (Accessed 20May 2009) Glasziou P, Del Mar C and Salisbury J (2007). Evidence-based Practice Workbook, Blackwell, Melbourne. NHMRC (National Health and Medical Research Council) (1999). A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines, Australian Government, Canberra. Kannus P, Khan K and Lord S (2006). Preventing falls among elderly people in the hospital environment. Medical Journal of Australia 184(8):372373. Oliver D, Hopper A and Seed P (2000). Do hospital fall prevention programs work? A systematic review. Journal of the American Geriatrics Society 48(12):16791689. Oliver D (2004). Prevention of falls in hospital inpatients: agendas for research and practice. Age and Ageing 33(4):328330. AIHW (Australian Institute of Health and Welfare) (2008). A Picture of Osteoporosis in Australia, Australian Institute of Health and Welfare, Australian Government, Canberra. Pointer S, Harrison J and Bradley C (2003). National Injury Prevention Plan Priorities for 2004 and Beyond: discussion paper, Australian Institute of Health and Welfare, Canberra AIHW (Australian Institute of Health and Welfare) (2007). Older Australians in Hospital, Australian Institute of Health and Welfare, Australian Government, Canberra. ABS (Australian Bureau of Statistics) (2004). The Health of Older People, Australia 2001. http://www.abs.gov.au. AIHW (Australian Institute of Health and Welfare) (2008). Hospitalisations due to falls by older people, Australia 2005-06, Australian Institute of Health and Welfare, Australian Government, Canberra.
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Preventing Falls and Harm From Falls in Older People

Best Practice Guidelines for Australian Hospitals 2009

Statement from the chief executive

iii xiii xv xvii xix

Part B Standard falls preventionstrategies

Part C Management strategies for common falls riskfactors

Preventing Falls and Harm From Falls inOlderPeople

Preventing Falls and Harm From Falls inOlderPeople

PartD Minimising injuries fromfalls

Preventing Falls and Harm From Falls inOlderPeople

167 169 171 173 175 177 179 181 183

Figure 13.4 Visual changes resulting from maculardegeneration 85

SERM SHPA SMW STRATIFY STS TBI TUG VA VR

Key messages oftheguidelines

Preventing Falls and Harm From Falls inOlderPeople

Falls Guidelines Review Expert AdvisoryGroup

Technical writing andediting

Preventing Falls and Harm From Falls inOlderPeople

Summary ofrecommendations and goodpracticepoints

Standard falls preventionstrategies

Falls risk screening andassessment

Part C  Management strategies for common falls riskfactors

Preventing Falls and Harm From Falls inOlderPeople

Summary ofrecommendations and goodpracticepoints

Preventing Falls and Harm From Falls inOlderPeople

Chapter 11 Dizziness andvertigo

Summary ofrecommendations and goodpracticepoints

Preventing Falls and Harm From Falls inOlderPeople

Chapter 15 Individual surveillance andobservation

Summary ofrecommendations and goodpracticepoints

Minimising injuries fromfalls

Preventing Falls and Harm From Falls inOlderPeople

Chapter 18 VitaminD and calciumsupplementation

Summary ofrecommendations and goodpracticepoints

Preventing Falls and Harm From Falls inOlderPeople

Summary ofrecommendations and goodpracticepoints

1.1 About theguidelines

1.2 Scope oftheguidelines

1.2.2 Specific toAustralianhospitals

1.2.3 Relevant toall hospitalstaff

1.3.2 Definition ofan injuriousfall

1.3.3 Definition ofassessment and riskassessment

Preventing Falls and Harm From Falls inOlderPeople

1.4 Development oftheguidelines

Preventing Falls and Harm From Falls inOlderPeople

Table 1.1 National Health and Medical Research Council levelsofevidence

NHMRC = National Health and Medical ResearchCouncil Source:NHMRC10

1.7 How touse theguidelines

Preventing Falls and Harm From Falls inOlderPeople

Review and monitor

Implement targeted, individualised fall and injury prevention interventions

Plan for evaluation

Plan for quality improvement

Figure 1.1 Using the guidelines toprevent fallsinAustralia

1.7.2 How the guidelines arepresented

Preventing Falls and Harm From Falls inOlderPeople

The guidelines contain text boxes for important information, asoutlinedbelow.

2 Falls and falls injuriesinAustralia

2.2 Fall rates inolderpeople

2.5 Economic considerations infalls preventionprograms

Preventing Falls and Harm From Falls inOlderPeople

2.7 Risk factors forfalling

Table 2.1 Risk factors for falling hospitals2

2 Falls and falls injuriesinAustralia

Part C Management strategies for common falls riskfactors

Figure 1.1 Using the guidelines toprevent fallsinAustralia

3 Involving older people infallsprevention