From Medscape Medical News
Laurie Barclay, MD
January 13, 2011 — The American Geriatrics Society (AGS) and the British Geriatric Society (BGS) have updated their 2001 guidelines on preventing falls in older persons and have published a summary of the new recommendations online January 13 in the Journal of the American Geriatrics Society. All healthcare practices for older adults should include fall screening and prevention, with new assessments involving feet and footwear, fear of falling, and ability to carry out daily living activities. All interventions for fall prevention should include an exercise component, with additional interventions to be considered including starting tai chi and reducing medications.
"Falls are one of the most common health problems experienced by older adults and are a common cause of losing functional independence," said guidelines panel co-chair Mary E. Tinetti, MD, from Yale University School of Medicine in New Haven, Connecticut, in a news release. "Given their frequency and consequences, falls are as serious a health problem for older persons as heart attacks and strokes."
"There is emerging evidence that the rate of serious fall injuries, such as hip fractures, is decreasing modestly in areas in which fall prevention is integrated into clinical practice," Dr. Tinetti said. "By making fall prevention part of the clinical care of older adults this trend can continue."
A new assessment recommendation is that clinicians ask older patients if they have fallen recently or if their gait is unsteady, as a first step toward evaluating their falling risk. Questions should include frequency of falling, symptoms at the time of fall, and injuries from the fall.
Patients with no evidence or history of gait problems or recurrent falls do not require a fall risk assessment. However, those with gait unsteadiness or recent falls should undergo multifactorial fall risk assessment, including evaluation for muscle weakness, balance problems, or orthostatic changes in blood pressure. Any identified problems should be addressed with specific interventions.
New specific recommendations for evaluation of fall risk also include examination of the feet and footwear, functional evaluation including activities-of-daily-living skills and use of adaptive equipment and mobility aids, self-report of functional ability and fears concerning falling, and environmental evaluation including home safety.
"New recommendations specify that direct interventions adjusted for the identified risk factors, performed by the health professionals who performed the assessment or other healthcare professionals referred by them must follow the multifactorial fall risk assessment," the guidelines authors write.
New Recommendations
Recommendations for interventions that are new since the 2001 guidelines include the following:
* Multifactorial interventions should always include an exercise component, such as tai chi, physical therapy, or other exercise for balance, gait, and strength training, in group programs or as individual programs at home. Endurance and flexibility training may be prescribed, but not apart from strength training. On the basis of currently available evidence, exercise programs are recommended only for community-dwelling older persons.
* Environmental adaptation by a healthcare professional should be considered to reduce factors in the home and in daily activities that could increase fall risk.
* Cataract surgery should be performed if indicated, but this or other vision intervention should not be administered in isolation apart from a multifactorial assessment and intervention strategy.
* Medication reduction or withdrawal is recommended, particularly for sedatives, antidepressants, and other drugs affecting the central nervous system, regardless of the number of medications prescribed. This is a change from the 2001 guidelines, which recommended reducing medications only if patients were taking 4 or more.
* Orthostatic hypotension, arrhythmias, and heart rate abnormalities should be managed appropriately as part of a multifactorial intervention strategy. Older persons with cardioinhibitory carotid sinus hypersensitivity who have unexplained recurrent falls may benefit from dual-chamber cardiac pacing.
* All older adults at risk for falls, and those with known or suspected vitamin D deficiency, should receive a daily Vitamin D supplement (800 IU).
"We found that the most effective trials for preventing falls in older people looked at multiple interventions rather than just one," Dr. Tinetti said. "Previous studies have indicated that it is more effective to focus on one intervention, but because we looked at not only what recommendations were given, but also which [were] carried out, we’re confident that multifactorial [intervention] is the best course of action."
J Am Geriatr Soc. Published online January 13, 2011.
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