Guidelines RACF

Preventing Falls and Harm From Falls in Older People
Best Practice Guidelines for Australian Residential Aged Care Facilities 2009
ISBN:978-0-9806298-2-8 Commonwealth ofAustralia2009 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 orfrom the Ofce ofthe Australian Commission onSafety and Quality inHealth Care ontelephone:+61292633633 oremail to: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 toPreventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Community Care2009 Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Hospitals2009 Guidebook toPreventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Hospitals2009 Guidebook toPreventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for 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 residents 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 fromthe chiefexecutive
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
Page
Statement from the chiefexecutive Acronyms Preface Acknowledgments Summary ofrecommendations and good practicepoints
iii xiii xv xvii xix
PartAIntroduction
1 Background 1.1 1.2 About theguidelines Scope oftheguidelines 1.2.1 Targeting olderAustralians 1.2.2 Specic toAustralian residential aged carefacilities 1.2.3 Relevant toall residential aged care facilitystaff 1.3 Terminology 1.3.1 Denitionofafall 1.3.2 Denition ofan injuriousfall 1.3.3 Denition ofassessment and riskassessment 1.3.4 Denitionofinterventions 1.3.5 Denitionofevidence 1.4 Development oftheguidelines 1.4.1 Expert advisorygroup 1.4.2 Reviewmethods 1.4.3 Levelsofevidence 1.5 1.6 1.7 Consultation Governance ofthe review ofthe Australian FallsGuidelines 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 2.3 Impactoffalls 2.4 Costoffalls 2.5 Economic considerations infalls preventionprograms 2.6 Characteristicsoffalls 2.7 Risk factors forfalling 3 Involving residents infallsprevention
1
3 3 4 4 4 4 4 4 4 4 5 5 5 5 6 7 7 8 8 8 10 13 13 13 14 14 14 15 15 17
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Part BStandard falls preventionstrategies

4 Falls preventioninterventions 4.1 Background andevidence 4.2.1 Multifactorialinterventions 4.2.2 Singleinterventions 4.3 Specialconsiderations 4.3.1 Cognitiveimpairment 4.3.2 Rural and remotesettings 4.3.3 Indigenous and culturally and linguistically diversegroups 4.4 Economicevaluation 5 Falls risk screening andassessment 5.1 Background andevidence 5.1.1 Falls riskscreening 5.1.2 Falls riskassessment 5.2 Principlesofcare 5.2.1 Falls riskscreening 5.2.2 Falls riskassessment 5.3 Specialconsiderations 5.3.1 Cognitiveimpairment 5.3.2 Rural and remotesettings 5.3.3 Indigenous and culturally and linguistically diversegroups 5.3.4 People with limitedmobility 4.2 Choosing falls preventioninterventions
19
21 22 22 22 23 24 24 24 24 24 25 26 26 27 27 27 28 31 31 31 31 31

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Part CManagement strategies for common falls riskfactors

6 Balance and mobilitylimitations 6.1 Background andevidence 6.1.1 Risk factors forfalling 6.1.2 Improving balance and mobility withexercise 6.1.3 Exercise for preventingfalls 6.1.4 Exercise aspart ofamultifactorialintervention 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
33
35 36 40 40 40 41 41 41 43 43 44 44 44
Preventing Falls and Harm From Falls inOlderPeople
Page
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 8.1 Economicevaluation Background andevidence 8.1.1 Incontinence associated with increased fallsrisk 8.1.2 Incontinence and falls interventions inresidential aged carefacilities 8.2 Principlesofcare 8.2.1 Screeningcontinence 8.2.2 Providing strategies topromotecontinence 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 Footproblems 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 8 Continence
45 46 46 46 47 47
48 50 50 50 51 52 52 53 54 54 54 55 55 55 55 56 57 58 58 60 60 60 61 61 61 61 62 62
Contents
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Page
10 Syncope 10.1 Background andevidence 10.1.1 Vasovagalsyncope 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 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 Reviewingmedications 12.2.2 Providinginterventions 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 fallsrisk 13.1.2 Eye diseases associated with anincreased riskoffalling 13.2 Principlesofcare 13.2.1 Screeningvision 13.2.2 Providinginterventions 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 People with limitedmobility 13.4 Economicevaluation
63 64 64 65 65 65 66 66 66 67 68 68 68 68 69 70 70 71 72 72 72 73 73 74 75 75 75 75 79 80 80 80 82 82 83 84 84 84 84 85 85
10.1.2 Orthostatic hypotension (posturalhypotension) 64

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14 Environmentalconsiderations 14.1 Background andevidence 14.2 Principlesofcare 14.2.1 Assessing the resident intheirenvironment 14.2.2 Designing multifactorial interventions that include environmentalmodications 14.2.3 Conducting environmentalreviews 14.2.4 Orientating newresidents 14.2.5 Incorporating capital works planning anddesign 14.2.6 Providing storage andequipment 14.2.7 Review andmonitoring 14.3 Specialconsiderations 14.3.1 Cognitiveimpairment 14.3.2 Rural and remotesettings 14.3.3 Nonambulatorypeople 14.3.4 People whowander 14.4 Economicevaluation 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
87 88 88 88 89 90
90 90 90 91 91 91 91 92 92 92 93 94 94 94 95 95 96 96 97 97 97 97 99 100 100 100 101 101 102 102 102
Contents
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Page
Part DMinimising 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 need for hipprotectors 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 18 Vitamin Dand calciumsupplementation 18.1 Background andevidence 18.1.1 VitaminD supplementationalone 18.1.2 VitaminD combined with calciumsupplementation 18.1.3 VitaminD andsunlight 18.1.4 Toxicity anddose 18.2 Principlesofcare 18.2.1 Assess adequacyofvitaminD 18.2.2 Ensure minimum sun exposure toprevent vitaminDdeciency 18.2.3 Consider vitaminD and calciumsupplementation 18.2.4 Encourage residents toinclude foods high incalcium intheirdiet 18.2.5 Discourage residents from consuming foods thatprevent 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 Interventions for falls and falls-related injuries relevanttoosteoporosis 19.1.4 Osteoporosis inresidential agedcare 19.2 Principlesofcare 19.2.1 Review andmonitoring 19.3 Specialconsiderations 19.3.1 Cognitiveimpairment 19.4 Economicevaluation
105
107 108 108 108 109 109 110 110 110 110 111 111 111 111 111 111 112 115 116 116 116 117 117 117 117 118 118 118 118 119 119 119 119 121 122 122 122 122 123 124 124 124 124 124
Page
Part ERespondingtofalls
20 Post-fallmanagement 20.1 Background andevidence 20.2 Respondingtoincidents 20.2.1 Post-fallfollow-up 20.2.2 Analysing thefall 20.3 Reporting and recordingfalls 20.3.1 Minimum dataset for reporting and recordingfalls 20.4 Comprehensive assessmentoffalls 20.5 Loss ofcondence afterafall
127
129 130 130 132 132 132 133 133 133
Appendices
Appendix 1 Contributors totheguidelines Appendix 2 Falls risk screening and assessmenttools Appendix 3 Rowland Universal Dementia Assessment Scale(RUDAS) Appendix 4 Safe shoechecklist Appendix 5 Environmentalchecklist Appendix 6 Equipment safetychecklist Appendix 7 Checklist ofissues toconsider before usinghipprotectors Appendix 8 Hip protector careplan Appendix 9 Hip protector observationrecord Appendix 10 Hip protector educationplan Appendix 11 Food and fluid intakechart Appendix 12 Food guidelines for calcium intake for preventing falls inolderpeople Glossary References
135
137 141 143 145 147 151 153 155 157 159 161 163 165 167
Tables
Table1.1 Table2.1 Table5.1 Table5.2 Table 6.1 National Health and Medical Research Council levelsofevidence 7 Risk factors for falling inresidential aged carefacilities 15 Peninsula Health Falls Risk Assessment Tool(FRAT) 29 Specic risk-factorassessments 29 Summary offalls prevention interventions that included anexercise component used inresidentialaged care facilitysettings 37 Clinical assessments for measuring balance, mobilityandstrength 41 Tools for assessing cognitivestatus 47 Characteristics ofeye-screeningtests 82 Pharmaceutical Benets Scheme details for osteoporosisdrugs 125
Table6.2 Table7.1 Table13.1 Table19.1
Figures
Figure1.1 Figure 5.1 Using the guidelines toprevent fallsinAustralia Algorithm summarising classification ofresidents ashigh orlow fallsrisk Figure9.1 The theoretical optimal safe shoe, and unsafeshoe Figure13.1 Normalvision Figure13.2 Visual changes resulting fromcataracts Figure13.3 Visual changes resulting fromglaucoma Figure13.4 Visual changes resulting from maculardegeneration 9 28 59 81 81 81 81
Contents
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xii Preventing Falls and Harm From Falls inOlderPeople
Acronyms
ACSQHC ADLs BPPV CI ICER NHMRC OAB PBS ProFaNE QALY RACF RCT RDI RMMR VR
Australian Commission onSafety and Quality inHealthCare activities ofdailyliving benign paroxysmal positionalvertigo condenceinterval incremental cost-effectivenessratio National Health and Medical ResearchCouncil overactivebladder Pharmaceutical BenetsScheme Prevention ofFalls NetworkEurope quality-adjusted lifeyear residential aged carefacility randomised controlledtrial recommended dailyintake residential medication managementreview vestibularrehabilitation
xiii

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, some information and recommendations are specific toeach setting. Collectively, the guidelines are referred toas the FallsGuidelines. This document, Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Residential Aged Care Facilities 2009, aims toreduce the number offalls and the harm from falls experienced byolder people inresidential agedcare. The guidelines and support materials are suitable for residential aged care facilities (RACFs)that: donot 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 oftheir desire and ability, encourages shared responsibility inhealth care, better assures care quality and focusesaccountability. The guidelines are written topromote resident-centred independence and rehabilitation. RACF care inany form involves some risk for older people. The guidelines donot promote anentirely risk-averse approach tothe health care ofolder people. Some falls are preventable, some are not. However, anexcessively custodial and risk-averse approach designed toavoid complaints orlitigation from older people and their carers may infringe onapersons autonomy and limitrehabilitation. Whenever 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 ofprofessional 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, to local 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 Residential Aged Care Facilities2009 Falls Guidelines factsheets Falls Guidelines poster. The 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 benets beyond merely 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 Falls Guidelines2009. 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 communicating the review tocolleagues 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 Ofce 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 intheguidelines. A full list ofauthors, reviewers and contributors isprovidedinAppendix1. 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; Honorary 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, La Trobe 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 DavidOliverConsultant Physician and Clinical Director, Royal Berkshire Hospital, Reading, UnitedKingdom; Visiting Professor ofMedicine for Older People, School ofCommunity and Health Sciences, 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 using standard falls prevention interventions should beroutine care for all residents ofresidential aged care facilities.(LevelI) 7 In addition toamultifactorial approach using standard falls prevention interventions, develop and implement atargeted and individualised falls prevention plan ofcare based onthe ndings ofafalls screen orassessment.(LevelII) 31 Provide vitaminD with calcium supplementation toresidents with low blood levels ofvitaminD, because itworks asasingle intervention toprevent falls.(LevelI) 7 Residents should have their medications reviewed byapharmacist.(LevelII) 32
Chapter 5
Falls risk screening andassessment
Recommendations
Screening andassessment
If afalls risk screening process isused asafirst step, rather than anassessment ofall residents onadmission, all residents should bescreened assoon aspracticable thereafter, then regularly (every six months) orwhen achange infunctional statusisevident. Use separate screening tools for residents who can and cannot standunaided. The introduction offalls risk screens and assessments needs tobe supported with education for staff and intermittent reviews toensure appropriate and consistentuse. Screens and assessments will only beuseful when supported byappropriate interventions related tothe risksidentied. Identifying the presence ofcognitive impairment should form part ofthe falls risk assessmentprocess.
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Good practicepoints
Falls riskscreening
Using aformal screening tool has the benefit offorming part ofroutine clinical management, and will inform further assessment and care for allresidents. If aresident isidentified asbeing at risk for any item onamultiple risk factor screen, interventions should beconsidered for that risk factor even ifthe person has alow falls risk scoreoverall.
Falls riskassessment
Conduct falls risk assessments for residents who exceed the threshold ofafalls risk screening tool, who suffer afall, orwho move toor reside inasetting where most people are considered tohave ahigh risk offalls (eg high-care facilities, dementiaunits). Interventions delivered asaresult ofthe assessment provide benefit; therefore, itis essential that interventions systematically address the identied riskfactors.
Part C
Chapter 6
Management strategies for common falls riskfactors

Balance and mobilitylimitations
Recommendations
Intervention
Use supervised and individualised balance and gait exercises aspart ofamultifactorial intervention toreduce the risk offalls and fractures inresidential aged care facility residents.(LevelII) 58 Consider using gait, balance and functional coordination exercises assingle interventions.(LevelII) 59,60
Good practicepoints
Assessment tools can beusedto: quantify the extent ofbalance and mobility limitations and muscleweaknesses guide exerciseprescription measure improvements inbalance, mobility andstrength assess whether residents have ahigh riskoffalling. Exercise should besupervised and delivered byappropriately trainedpersonnel.
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Chapter 7
Cognitiveimpairment
Recommendations
Assessment
Residents with cognitive impairment should have other falls risk factorsassessed.
Intervention
Address identified falls risk factors aspart ofamultifactorial falls prevention program, and also consider injury minimisation strategies (such aship protectors orvitamin Dand calcium supplementation).(LevelI) 7
Good practicepoints
Address all reversible causes ofacute orprogressive cognitivedecline. Residents presenting with anacute change incognitive function should beassessed for delirium and the underlying cause ofthischange. Residents with gradual-onset, progressive cognitive impairment should undergo detailed assessment todetermine diagnosis and, where possible, reversible causes ofthe cognitive decline. Reversible causes ofacute orprogressive cognitive decline shouldbetreated. If aresident with cognitive impairment does fall, reassess their cognitive status, including presence ofdelirium (eg using the Confusion Assessment Methodtool). Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations; however, interventions for people with cognitive impairment may need tobe modied and supervisedasappropriate.
Chapter8
Continence
Recommendations
Assessment
Older residents should beoffered acontinence assessment tocheck for problems that can bemodiedorprevented.
Intervention
All residents should have aurinalysis toscreen for urinary tract infections orfunction.(LevelII-*) 112 Regular, individualised toileting should bein place for residents atrisk offalling, aspart ofmultifactorial intervention.(LevelII) 60 Managing problems associated with urinary tract function iseffective aspart ofamultifactorial approach tocare.(LevelII-*) 112
Note: although there isobservational evidence ofan association between incontinence and falls, there isno direct evidence that interventions tomanage incontinence affect the rateoffalls.113
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Chapter 9
Feet andfootwear
Recommendations
Assessment
In addition tostandard falls risk assessments, screen residents for ill-fitting orinappropriatefootwear.
Intervention
As part ofamultifactorial intervention program, prevent falls bymaking sure residents have tted footwear.(LevelII) 31

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Good practicepoints
Include anassessment offoot problems and footwear aspart ofan individualised, multifactorial intervention for preventing fallsinresidents. Refer residents toapodiatrist for assessment and treatment offoot conditionsasneeded. 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.
Chapter10
Syncope
Recommendations
Assessment
Residents who report unexplained falls orepisodes ofcollapse should beassessed for the underlyingcause.
Intervention
Assessment and management ofpresyncope, syncope and postural hypotension, and review ofmedications (including medications associated with presyncope and syncope) should form part ofamultifactorial assessment and management plan for preventing falls inresidents.(LevelI-*) 34 Older people with unexplained falls orepisodes ofcollapse who are diagnosed with the cardioinhibitory form ofcarotid sinus hypersensitivity should betreated with the insertion ofadual-chamber cardiac pacemaker.(LevelII-*) 177
Note: there isno evidence derived specically from the residential aged care setting relating tosyncope and falls prevention. Recommendations have been inferred from community and hospitalpopulations.
Chapter 11
Dizziness andvertigo
Recommendations
Assessment
Vestibular dysfunction asacause ofdizziness, vertigo and imbalance needs tobe identified inresidents inthe residential care setting. Ahistory ofvertigo orasensation ofspinning ishighly characteristic ofvestibularpathology. Use the DixHallpike test todiagnose benign paroxysmal positional vertigo. This isthe most common cause ofvertigo inolder people, and can beidentified inthe residential aged care 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 vestibular rehabilitation totreat dizziness and balance problems where indicated andavailable. Use the Epley manoeuvre tomanage benign paroxysmal positionalvertigo. Manoeuvres should only bedone byan experiencedperson.
Chapter12
Medications
Recommendations
Assessment
Residents ofresidential aged care facilities should have their medications (prescribed and nonprescribed) reviewed atleast yearly byapharmacist after afall, orafter initiation orescalation indosage ofmedication, orif there ismultiple druguse.
Intervention
As part ofamultifactorial intervention,37 oras asingle intervention,32 residents taking psychoactive medication should have their medication reviewed byapharmacist and, where possible, discontinued gradually tominimise side effects and toreduce their risk offalling.(LevelII) Limit multiple drug use toreduce side effects and interactions.(LevelII-*) 37
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Chapter13
Vision
Recommendations
Assessment
Arrange regular eye examinations (every two years) for residents inresidential aged care facilities toreduce the incidence ofvisual impairment, which isassociated with anincreased riskoffalls.
Intervention
Residents with visual impairment related tocataract should have cataract surgery assoon aspracticable.(LevelII-*) 237,238 Environmental assessment and modication should beundertaken for residents with severe visual impairments (visual acuity worse than 6/24).(LevelII-*) 239 When correcting other visual impairment (eg prescription ofnew glasses), explain tothe resident and their carers that extra care isneeded while the resident gets used tothe new visual information. Falls may increase asaresult ofvisual acuity correction.(LevelII-*) 240 Advise residents 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-*) 241
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. One trial, set inthe community, showed anincrease infalls asaresult ofvisual acuity assessment and correction. 240 However, correcting visual impairment may improve the health ofthe older person inother ways (egby increasing independence). Considerable research has linked falls with visual impairment inthe community setting, although notrials have reduced falls bycorrecting visual impairment, and these results may also apply tothe residential aged caresetting.

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Chapter 14
Environmentalconsiderations
Recommendations
Assessment
Residents considered tobe atahigher risk offalling should beassessed byan occupational therapist and physiotherapist for specic environmental orequipment needs and training tomaximisesafety.
Intervention
Environmental review and modication should beconsidered aspart ofamultifactorial approach inafalls prevention program.(LevelI) 7
Good practicepoints
Residential aged care facility staff should discuss with residents their preferred arrangement for personal belongings and furniture. They should also determine the residents preferred sleepingarrangements. Make sure residents 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, and consider combining them with occupational health and safetyaudits.
Chapter 15
Individual observation andsurveillance
Recommendations
Intervention
Include individual observation and surveillance ascomponents ofamultifactorial falls prevention program, but take care not toinfringe onresidents privacy.(LevelIII-2-*) 38 Falls risk alert cards and symbols can beused toflag high-risk residents aspart ofamultifactorial falls prevention program, aslong asappropriate interventions are used asfollow-up.(LevelII-*) 185 Falls alerts used ontheir own are ineffective.(LevelII) 35 Consider using avolunteer sitter program for people who have ahigh risk offalling, and dene the volunteer roles clearly.(LevelIV-*) 281,282 Residents with dementia should beobserved more frequently for their risk offalling, because severe cognitive impairment ispredictive oflying onthe floor for along time after afall.(LevelIII-2-*) 38
Note: most falls inresidential aged care facilities are unwitnessed.23 Therefore, asis done inthe hospital setting, the key toreducing falls isto improve surveillance, particularly for residents with ahigh riskoffalling.38
Good practicepoints
Individual observation and surveillance arelikely toprevent falls. Many falls happen inthe immediate bed orbedside area, orare associated with restlessness, agitation, attempts totransfer and stand, lack ofawareness orwandering inpeople withdementia. Residents who have ahigh risk offalling should beindentied and checkedregularly. A staff member should stay with at-risk residents while they are inthebathroom. Although many residents are frail, not all are atahigh risk offalling; therefore, surveillance interventions can betargeted tothose residents who have the highestrisk. A range ofalarm systems and alert devices are commercially available, including motion sensors, video surveillance and pressure sensors. They should betested for suitability before purchase, and appropriate training and response mechanisms should beoffered tostaff. Suppliers ofthese devices should belocated ifafacility isconsidering this intervention. However, there isno evidence that their use inresidential aged care facilities reduces falls orimprovessafety.
xxv
Chapter16
Restraints
Recommendation
Assessment
Causes ofagitation, wandering orother behaviours should beinvestigated, and reversible causes ofthese behaviours (eg delirium) should betreated before the use ofrestraintisconsidered.
Note: physical restraints should beconsidered the last option for residents who are atrisk offalling289 because there isno evidence that their use reduces incidents offalls orserious injuries inolder people.290-293 However, there isevidence that they can cause death, injury orinfringementofautonomy.294,295
Good practicepoints
The focus ofcaring for residents with behavioural issues should beon responding tothe residents behaviour and understanding its cause, rather than attempting tocontrolit. All alternatives torestraints should beconsidered, discussed with family and carers, and trialled for residents with cognitive impairment, includingdelirium. If all alternatives are exhausted, the rationale for using restraint must bedocumented and ananticipated duration agreed onby the health care team, inconsultation with family and carers, and reviewedregularly. If drugs are used specifically torestrain aresident, the minimal dose should beused and the resident reviewed and monitored toensure their safety. Importantly, chemical restraint must not beasubstitute for alternative methods ofrestraint outlined inthischapter.
Part D
Chapter 17
Minimising injuries from falls

Hipprotectors
Recommendations
Assessment
When assessing aresidents need for hip protectors inaresidential aged care facility (RACF), staff should consider the residents recent falls history, age, mobility and steadiness ofgait, disability status, and whether they have osteoporosis oralow body massindex. Assessing the residents cognition and independence indaily living skills (eg dexterity indressing) may also help determine whether they will beable touse hipprotectors.
Intervention
Use hip protectors toreduce the risk offractures for frail, older people ininstitutional care.(LevelI) 302 Hip protectors must beworn correctly for any protective effect, and the residential care facility should educate and train staff inthe correct application and care ofhip protectors.(LevelII) 303 When using hip protectors aspart ofafalls prevention strategy, RACF staff should check regularly that the resident iswearing their protectors, that the hip protectors are inthe correct position, and that they are comfortable and the resident can put them oneasily.(LevelI) 302
Good practicepoint
Hip protectors are apersonal garment and should not beshared amongpeople.
xxvi
Chapter 18
Vitamin Dand calciumsupplementation
Recommendation
Intervention
VitaminD and calcium supplementation should berecommended asan intervention strategy toprevent falls inresidents ofresidential aged care facilities.(LevelI) 7
Good practicepoint
Assess whether residents are receiving adequate sunlight for vitaminDproduction.
Chapter 19
Osteoporosismanagement
Recommendations
Assessment
Residents with ahistory ofrecurrent falls should beconsidered for abone health check. Also, residents who sustain aminimal-trauma fracture should beassessed for their riskoffalls.
Intervention
Residents with diagnosed osteoporosis orahistory oflow-trauma fracture should beoffered treatment for which there isevidence ofbenet.(LevelI) 349 Residential aged care facilities should establish protocols toincrease the rate ofosteoporosis treatment inresidents who have sustained their rst osteoporotic fracture.(LevelIV) 350
Good practicepoints
Strengthening and protecting bones will reduce the risk ofinjuriousfalls. In the case of recurrent fallers and those sustaining low-trauma fractures, health care professionals and care staff should consider strategies for optimising function, minimising along lie onthe floor, protecting bones, improving environmental safety and prescribingvitaminD. When using osteoporosis treatments, residents should beco-prescribed vitaminD withcalcium.
xxvii
Part E
Chapter 20
Respondingtofalls
Post-fallmanagement
Recommendation
Assessment
Staff ofresidential aged care facilities should complete apost-fall assessment for every resident whofalls.
Good practicepoints
Residential aged care facility (RACF) staff should report and document allfalls. It isbetter toask aresident whether they remember the sensation offalling rather than whether they think that they blacked out, because many older people who have syncope are unsure whether they blackedout. RACF staff should follow the facilitys post-fall protocol orguideline for managing residents immediately afterafall. After the immediate follow-upof afall, review the fall. This should include trying todetermine how and why afall may have occurred, and implementing actions toreduce the risk ofanotherfall. An in-depth analysis ofthe fall event (eg aroot-cause analysis) isrequired ifthere has been aserious injury following afall, orif there has been adeath fromafall.
xxviii
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 residential aged care 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 specic 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 These guidelines have been developed with older people dened aspeople aged 65years and over inmind. When considering Indigenous Australians, older people commonly refers topeople aged over 50years.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 infunctionalability.4
PartA Introduction
1.2.2 Specic toAustralian residential aged carefacilities

These guidelines have been developed for Australian residential aged care facilities (RACFs) that provide high-level orlow-level care. They are not specifically directed atretirement villages, although much ofthe content isalso applicable tothis setting. Separate guidelines have been developed for both the hospital and communitysettings.
1.2.3 Relevant toall residential aged care facilitystaff

All RACF staff have arole toplay inpreventing falls inresidents. These guidelines have been developed for all those who are involved inthe care ofresidents. This includes support services aswell asclinical, management and corporatestaff.
1.3 Terminology
1.3.1 Denitionofafall
For anationally consistent approach tofalls prevention within Australian facilities, itis important that astandard denition ofafall beused. For the purpose ofthese guidelines, the following definitionapplies: A fall isan event which results inaperson coming torest inadvertently onthe ground orfloor 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 Denition ofan injuriousfall

These guidelines use the Prevention ofFalls Network Europe (ProFaNE) definition ofan injurious fall. They consider that the only injuries that could beconrmed accurately using existing data sources are 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 for acoredataset. 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 hospitalisationsin200405).6
1.3.3 Denition ofassessment and riskassessment

In these guidelines, assessment isdened asan objective evaluation ofthe residents 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 Chapter5 for moredetail).
http://www.profane.eu.org
1.3.4 Denitionofinterventions
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 toeach person, based onan individualassessment. This classication ofinterventions targeting multiple risk factors isused 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 most single interventions for preventing falls and associated injuries for residents inRACFs.7 However, vitaminD with calcium supplementation appears tobe effective asasingle intervention for residents who have low blood levels ofvitaminD.7 PartC contains more information about the types ofinterventions that are available inthe RACFsetting.
PartA Introduction
1.3.5 Denitionofevidence
These guidelines use adenition ofevidence based onHealth-evidence.ca aCanadian online resource funded bythe Canadian Institutes ofHealth Research, and run byMcMaster University. They dene evidenceas: Knowledge from avariety ofsources, including qualitative and quantitative research, program evaluations, client values and preferences, and professionalexperience. Furthermore, these guidelines were developed using the principles ofevidence based practice, which isthe process ofintegrating clinical expertise and resident 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. Section1.4 provides more details onthe development ofthe guidelines using anevidence basedapproach.
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. This included specialists inthe areas offalls prevention research, measurement and monitoring, quality improvement, change management and policy, aswell ashealth care professionals 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 RACF setting) reviewed theseguidelines.
http://www.profane.eu.org http://health-evidence.ca/
1 Background
1.4.2 Reviewmethods
These guidelines were developed bydrawingon: the previous version oftheguidelines asearch ofthe most recent literature for each risk factororintervention the most recent Cochrane review offalls prevention interventions inthe RACFsetting 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 Foundationof Australia). The review methods used were nonsystematic, because asystematic review ofeach aspect offalls prevention, for each setting (community, hospital and residential aged care), was beyond the capacity and timeframe ofthis update oftheguidelines. Due tothese constraints, itwas not possible tofollow the National Health and Medical Research Councils (NHMRC) 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.
PartA Introduction
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 toidentify the highest quality information for each intervention (systematic reviews particularly Cochrane reviews meta-analyses, and randomised controlled trials). This isin line with recommended methods for evidence based practice where answers toclinical questions are needed quickly, 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-guideline review byan expert for eachsetting.
Economicevaluation
A systematic review ofpublished economic evaluations was undertaken. Literature was searched inMedline (1950 toendJuly 2008), CINAHL (1982 toendJuly 2008) and EMBASE (1980 toendJuly 2008). MeSH terms (Economics/; orEconomics, Medical/; or Economics, Hospital/; or Technology Assessment, Biomedical/; or Models, economic/) and text words for economic evaluations (cost effectiveness, cost utility, cost benefit, economic evaluation) were combined, together with text words relating tofalls orto hip protectors. Reference lists ofrelevant studies and reviews were also searched, and Australian researchers werecontacted. The search identified 388abstracts. All abstracts were reviewed; those that did not appear tobe economic evaluations ofeither falls prevention interventions orhip protectors were excluded. Studies that included relevant data orinformation were retrieved and their full-text versions were analysed and examined for study eligibility. Across all interventions, 27papers that considered the costs oreconomic benefits offalls prevention interventions orhip protectors were identified. The methods, results and limitations ofthese papers are discussed inthe relevant interventionsections.
1.4.3 Levelsofevidence
Using the NHMRCs six-point rating system for intervention research, each paper was classified according tothe strength ofevidence that can bederived given the specic methods used inthe paper. Table1.1 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), casecontrol studies, orinterrupted time series with acontrolgroup Evidence obtained from comparative studies with historical control, two ormore single-arm studies, orinterrupted time series without aparallel controlgroup Evidence obtained from case series, either post-test, orpretest andpost-test
PartA Introduction
III-3 IV
NHMRC = National Health and Medical ResearchCouncil Source:NHMRC10
It ispossible tohave methodologically sound (LevelI) 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 inahospital setting but not inaresidential aged care setting). Inthese guidelines, the highest level ofevidence for anintervention isreported regardless ofthe setting; however, when the research setting isnot anRACF, an* isadded tothe level (eg Level I-*). This shows that caution isneeded when applying economic implications for that recommendation tothe RACFsetting. The guidelines will bereviewedin2014.
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 asin identifying other areasofaction. In addition, specialist groups provided invaluable feedback onprevious guidelines and draft versions ofthis guideline. 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 byalarge consultative process, from which these guidelinesbenet.
1 Background
1.6 Governance ofthe review ofthe Australian FallsGuidelines

The Falls Guidelines development project was directed byACSQHC inconjunction with its InterJurisdictional, Private Hospital Sector and Primary Care committees. Itwas managed bythe Ofce ofthe Commission onthe advice ofthe Falls Guidelines Review Expert Advisory Group, which recommended the final guidelines for endorsement tothecommission.
1.7 How touse theguidelines

1.7.1 Overview
Figure1 isadiagrammatic representation providing astep-by-step overview ofhow touse the guidelines toprevent falls and falls injuries inresidents inAustralian RACFs, 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 injuries 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) .
PartA Introduction
nv
he et olv
reside
nt 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 falls and falls 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 infive parts,asfollows: 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 11specic assessments andinterventions Part D Minimising injuries fromfalls hipprotectors vitaminD and calciumsupplementation osteoporosismanagement Part E Respondingtofalls. For ease ofreference, PartsC and Dconsider each falls risk factor and assessment orintervention in separate chapters. However, these interventions are generally most successful when used incombination. Interventions and assessments tominimise falls risk factors are discussed first (PartC), followed byinterventions tominimise harm from falls (PartD). This does not imply importance ofone chapter overanother. Health care professionals and carers should consider the advantages and risks ofusing injury-prevention strategies, asoutlined inPartD, togive residents inthe RACF setting extra protection from falls and related injury. These strategies can beused after afall orapplied systematically tothe populationatrisk. Chapters onintrinsic and extrinsic risk factors inPartsC and Dbegin with aset ofevidence based recommendations (assessment orintervention, orboth, asappropriate). The supporting information for these recommendations ispresented inthe remainder ofthe chapter, which isorganisedinto: background information contains anoverview ofthe risk factor orintervention, and asummary ofthe relevant literature onclinicaltrials principles ofcare explains how toimplement the interventionofinterest special considerations provides information relevant tospecic 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 Section1.4.3 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 oftheresident.
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. These case studies provide information onlikely scenarios and 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
A brief summary ofthe background information derived from the literature about falls inresidential aged care facilities (RACFs) follows. 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.11 Residents inan RACF experienced anincidence offalls nearly five times more than people ofthe same age intheir own home.12 These falls required hospitalisation. In200506, 21% ofserious falls occurred inRACFs, and RACFs are one ofthe most frequent places tofall.12 The peak age for falls inan RACFis8589years.12
2.2 Fall rates inolderpeople

Injuries requiring hospitalisation increase with age (beginning at65years) and falls are the biggest reason for these injuries.13 Every year, approximately 30% ofAustralians older than 65years fall, with 10% ofthese falls leading toinjury.11 Along with cognitive impairment and incontinence, falls are one ofthe major factors inprecipitating admission toRACFs.14 The proportion offalls-related overnight admissions that donot gohome is80%, asopposed to4.5% ofotheradmissions.15 An increase infalling aspeople get older isassociated with decreased muscle tone, strength and fitness asaresult ofphysical inactivity. Medications can contribute toan increased risk offalling. Alcohol consumption can also lead tomore falls, particularly ifthe alcohol interacts with certain medications.13 Impaired vision also contributestofalls.13 In RACFs, fall rates vary according tocase mix, sothat the fall and injury rates are likely tobe different for mobile people with dementia compared withdependent people inhigh-level care. Fall rates inRACFs vary from 4 to 10falls per 1000resident bed days,16,17 while rates between one and ve falls per resident per year have also been reported. This means upto half ofall residents experience one ormore falls ina12-monthperiod.2 Fall injury rates inRACFs inpeople aged 65years and older were approximately 7200falls per 100000people12 in200506, which isan increase from 200304. Most falls requiring hospitalisation occurred inthe home (49%), followed byfalls inan RACF(22%).13 The potential for falls multiplies once older people enter health care facilities. Even with high rates offalls, there may still beunder-reportingofevents.18
13
2.3 Impactoffalls
The hip and thigh are the most common injured areas inboth men and women sustaining falls.12 Femur fractures from falls have been decreasing since 19992000,12 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 the hip andthighs.12 Hip fractures are one ofthe most common reasons for hospital admissions, with the majority (91%) caused byfalls.13 Hip fractures impose heavily onthe community due toincreased death and morbidity, decreased independence, increased burden onfamily members and carers, increased costs due torehabilitation and increased admittance into RACFs.13 Inpeople older than 65years ofage, 3.6% offalls-related hospital admissions resultindeath.15 Falls also result inwrist fractures, when people put their arms out tobreak thefall.13 Falls may increase the risk ofcomplications, including the likelihood ofdeveloping afear offalling orloss ofconfidence inwalking, extending the length ofstay inahospital orother facility, additional diagnostic procedures orsurgery, and litigation.2 Additionally, falls may result incaregiver stress and fear oflitigation among clinical and administrativestaff.2
PartA Introduction
2.4 Costoffalls
In addition toinjuries, the effects offalls are costly tothe individual interms offunction and quality oflife2 and tothe community. Research across all settings identifies that, inthe face ofan ageing population, ifnothing more isdone toprevent fallsby2051: the total estimated health cost attributable tofalls-related injury will increase almost threefold from A$498.2million in2001 toA$1375million per yearin2051 3320 additional RACF places willberequired. To maintain the current health costs, there will need tobe a66% reduction inthe incidence offalls-related hospitalisationsby2051.19
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 benets (health outcomes). 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 most cost effective) than programs with higherICERs.
14
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.12 Falls most commonly seen inRACFs are due totripping, slipping and stumbling (21.6%).12 Falling down stairs isrelatively uncommon inRACFs (0.7% ofallfalls).12 Falls are associated with anumber offactors, such asenvironmental obstacles, dementia, delirium, incontinence and medications. Falls data20-22 reveal the following consistentinformation: 23-25 The bedside isthe most common place for falls tooccur, while the bathroom isfrequentlymentioned. Ahigh percentage offalls are associated with elimination andtoileting. The incidence offalls occurs across all age groups, but there isan increasing prevalence offalls in olderpeople. Ahigh percentage offalls areunwitnessed. There islittle difference between the types offall experienced byolder men and women.12 However, women have more falls inRACFs (23.6%) than men (17.5%).12 Falls-related follow-up care admissions identified femur fractures asthe most common fracture inboth men and women (45.3% and 47.8% respectively) afterafall.12
PartA Introduction
2.7 Risk factors forfalling

There are anumber ofrisk factors for falling among residents inRACFsettings. A persons risk offalling increases astheir number ofrisk factors accumulates.26 Risk factors may beintrinsic (those related toapersons behaviour orcondition) orextrinsic (those related toapersons environment ortheir interaction with the environment). Table2.1 summarises the intrinsic and extrinsic risk factors for fallinginRACFs.
Table2.1 Risk factors for falling inresidential aged carefacilities
Intrinsic risk factors

Increased age Acute health status History ofpreviousfalls Wanderingbehaviour Cognitiveimpairment Maximal drop inpostprandial (after eating) systolic blood pressure ofat least 20mmHg, and indiastolic blood pressure ofat least 10mmHg within three minutesofstanding Deterioration inperformance ofactivities ofdailyliving Reduced lower extremity strengthorbalance Unsteady gait oruse ofamobilityaid Independent transfers orwheelchairmobility Use ofantidepressant medication, multiple drug use, ordrug sideeffects Impairedvision Diabetesmellitus
Source: National Ageing and ResearchInstitute 2
Extrinsic riskfactors
Relocation betweensettings Environmentalhazards
2 Falls and falls injuriesinAustralia
15
Best practice for preventing falls inRACFs includes fourcomponents: implementing standard falls preventionstrategies identifying fallsrisks implementing interventions targeting these risks topreventfalls preventing injury tothose people whodofall. While the body ofknowledge about the risks offalls and how toreduce these risks iscontinually growing, itappears that most interventions are effective when used aspart ofamultifactorial approach. However, inthe RACF setting, there isalso evidence that certain single interventions, such aship protectors, vitaminD and calcium supplementation, orpharmacist review ofmedications, prevent fractures orreduce the risk offalls insomeresidents.7,27 Implicit inthis multifactorial approach isthe engagement ofthe resident and their carers asthe centre ofany falls preventionprogram.
PartA Introduction
16
3 Involving residents infallsprevention
PartA Introduction
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 and care staff should consider the following things toencourage residents ofresidential aged care facilities toparticipate infallsprevention: Make sure the falls prevention message ispresented within the context ofstaying independent forlonger.28 Beaware that the term falls prevention could beunfamiliar and the concept difcult tounderstand for many residents inthis older agegroup.28 Provide relevant and usable information toallow residents and their carers totake part indiscussions and decisions about preventing falls29 (see the fact sheets onpreventingfalls). Find out what changes aresident iswilling tomake toprevent falls, sothat appropriate and acceptable recommendations canbemade.29 Offer information inlanguages other than English where appropriate; 29 however, donot assume literacy intheir nativelanguage. Explore the potential barriers that may prevent residents from taking action toprevent falls (such aslow self-efcacy and fear offalling) and support residents toovercome thesebarriers.29 Develop falls prevention programs that are flexible enough toaccommodate the residents needs, circumstances andinterests.29 Place falls prevention posters inthe residential aged care facility and incommon areas used byresidents and familymembers. Ask family members toassist infalls preventionstrategies. Trial arange ofinterventions with theresident.30
17
PartB
PartB Standard falls preventionstrategies

4 Falls preventioninterventions
Recommendations
Intervention
A multifactorial approach using standard falls prevention interventions should beroutine care for all residents ofresidential aged care facilities.(LevelI) 7 In addition toamultifactorial approach using standard falls prevention interventions, develop and implement atargeted and individualised falls prevention plan ofcare based onthe ndings ofafalls screen orassessment.(LevelII) 31 Provide vitaminD with calcium supplementation toresidents with low blood levels ofvitaminD, because itworks asasingle intervention toprevent falls.(LevelI) 7 Residents should have their medications reviewed byapharmacist.(LevelII) 32
21
4.1 Background andevidence

In these guidelines, the term standard falls prevention interventions refers toroutine care. This section outlines evidence, interventions and resources toaddress specific falls risk factors. Most ofthese interventions have been components ofmultifactorial programs shown tobe successful for reducing falls orthe number ofpeople who fall inthe residential aged care facility (RACF) setting. The successful interventions all required considerable human resources and expertise tocomplete the intervention packages. Without additional resources, the success offalls prevention interventions isnot guaranteed, and this should be kept inmind when designing and implementing interventions. However, there isalso evidence that certain single interventions, such aship protectors orvitaminD and calcium supplementation, prevent fractures orreduce the risk offalls insome residentsofRACFs.7,27 The causes offalls are often complex, and people with multiple risk factors have ahigher rate offalls than those with fewer risk factors.4 Toprevent falls, residents ofRACFs should first beassessed for their falls risk, and then arange ofstandard precautionary strategies should beput into place.7,27,31,33 After the assessment process has been completed and standard falls prevention strategies are inplace, those factors that are identied ascontributing toaresidents risk offalling can beaddressed with anindividualised plan for daily care, focused onpreventingfalls. Where possible, these guidelines provide suggestions onhow these strategies could beimplemented, bywhom, and atwhat point intime. However, given the unique features ofeach RACF, the health care team will need tomake local decisions about how best tointegrate falls prevention actions into aresidents plan for daily care. Each resident has aunique set offalls risk factors and personal preferences, and these require anindividualised plan ofaction tominimise falls and harm fromfalls.
4.2 Choosing falls preventioninterventions

All RACF staff members (including support, clinical, administrative and managerial staff), aswell asthe resident and their carers (where appropriate), have arole toplay infalls prevention, asoutlinedbelow.
4.2.1 Multifactorialinterventions
Multifactorial interventions have been the most studied form offalls prevention strategies for residential aged care. Adraft Cochrane review has pooled the results for seven multifactorial studies.34 This analysis showed that overall the number offallers inthe intervention arms ofthe studies was reduced by10% (risk ratio=0.90; 95%CI 0.82 to0.98). Subgroup analyses indicated that multidisciplinary team interventions and those involving comprehensive geriatric assessment were the most effective for reducing the number offallers, whereas nurse-led interventions that did not include exercise were not effective. The findings ofone study suggested low-intensity interventions may beworse than usualcare.35 Key components from the successful trialsincluded: multidisciplinary teaminterventions 31,33 comprehensive geriatricassessment 31,36 staffeducation31,33 balance exercises (seeChapter6) medication review (seeChapter12) environmental adaptations (seeChapter14) hip protectors (for preventing hip fractures) (seeChapter17) post-fall management (seeChapter20). One trial that reduced recurrent falls and was not included inthe Cochrane analysis due toits clusterrandomised design used anindividual assessment with subsequent individual treatment plans.37 Interventions comprised many ofthe key interventions listed above, including medication review, environmental adaptations, transfer and mobility assistance, and staffeducation. As with interventions inhospitals,38 there isperhaps anecessity for intensive and sustained falls prevention programs with afocus oncognitive impairment and awhole-system approach tofacility-based falls prevention (with associated work practice change) led byfacility staff. Ongoing evaluation ofprevention strategies with monitoring offalls using standard denitions (see Section1.3) iscrucial for determining the effectiveness ofpreventionstrategies.
22
4.2.2 Singleinterventions
Some interventions used inmultifactorial interventions have prevented falls and fractures assingle interventions. Theseinclude: medicationreview32 vitamin Dwith calcium supplementation inpeople with low blood levels ofvitaminD (to prevent falls andfractures) 7,39-41 hip protectors (to reduce hipfractures).27
PartB
Multifactorial case study: decreasing the number ofrisk factors can reduce the riskoffalling4
MrsR isa79-year-old woman who was transferred byambulance tohospital from her residential aged care facility (RACF) after fracturing her left inferior pubic ramus (pelvis). Thisinjury was the result ofafall onto the floor while she was rushing tothetoilet. The orthopaedic team admitted MrsR from the emergency department and, 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 MrsR was 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 MrsRs RACF revealed that she had multiple risk factors for falling, which included thatshe: is older than 65years has fallen three times inthe previousyear is taking five different medications, including asleeping tablet anddiuretic on last attempt (a month previously), was only able tocomplete the Timed Up and Go Test (TUG) in19seconds with her wheelie walker, while the mean time for healthy 7179-year-old peopleis15seconds 42,43 is frequently incontinent ofurine atnight and regularly rushes tothetoilet had aMini-Mental State Examination (MMSE) score of22/30 before falling and was frequently agitated (a score ofless than 24 indicates cognitiveimpairment) has left foot pain asthe result ofsevere halluxvalgus wears bifocal glasses for all activities, despite having asecond pair ofdistance glasses forwalking does not like toventure outdoors and receives nodirectsunlight. When MrsR returned home tothe RACF, inaddition tostandard falls prevention strategies and inresponse tothe risk assessment, staff implemented targeted, individualised interventions toreduce MrsRs risk offalling. These interventions included amedication review and advice bythe medical officer onthe importance ofgetting enough sunlight for vitaminD, advice from the occupational therapist about wearing well-tting shoes with nonslip soles and some simple exercises for strengthening core body muscles for better balance, demonstrated bythephysiotherapist. As aresult ofthese multifactorial interventions, MrsR: has aminimised risk ofmedication interactions and adverse medicineevents has amore restful sleep due tophysical exertion throughout theday has better management ofher urinaryincontinence experiences fewer episodesofagitation has less pain inher left foot from her halluxvalgus is able toclearly see the floor infront ofher whilewalking has improved the condition ofher muscles andbones. The health care teams atboth the hospital and the RACF were all made aware ofchanges toMrsRs care through chart entries, case conferences and appropriate discharge correspondence. MrsR and her family were made aware ofthe changes toher care through ascheduled meeting with the health careteam.
4 Falls preventioninterventions
23
4.3 Specialconsiderations
4.3.1 Cognitiveimpairment
The national consultation process that informed the rst edition ofthese guidelines indicated that falls and cognitive impairment are key concerns for residents and health care workers alike. Consequently, cognitive impairment continues tohave adedicated chapter (Chapter7) aswell asbeing included asaspecial consideration within mostsections.
For residents who are suffering from delirium orcognitive impairment, where itis unsafe for them tomove orbe transferred without help, individual observation and surveillance must beincreased, and help with transfers providedasrequired.
4.3.2 Rural and remotesettings

A common problem inrural and remote settings isashortage ofsome health professionals. Where this is the case, options tosupport available expertise include communicating bytelephone and videoconferencing with experts orfacilities with advanced programs inplace inother regions. Ininstances where this approach isused, local staffshould: ensure they have standard strategies inplace before calling for support from external specialiststaff complete necessary screening, assessments and identification ofappropriate interventions sothat the basic assessments and interventions are inplace bythe time they are linked with the externalsupport.
4.3.3 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 bystaff,2 orbe adequately assessed due tolanguagedifculties. There issome evidence that falls prevention strategies may work differently among culturally and linguistically diverse groups (eg cultural differences inexercise preferences and dietary intake ofcalcium from dairyproducts).44 General points toconsider when conveying falls prevention messages toIndigenous and culturally and linguistically 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 rstlanguage.
4.4 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 ofspecic falls prevention interventions are presented inthe relevant interventionchapters.
24
5 Falls risk screening andassessment
Recommendations
Screening andassessment
If afalls risk screening process isused asafirst step, rather than anassessment ofall residents onadmission, all residents should bescreened assoon aspracticable thereafter, then regularly (every six months) orwhen achange infunctional statusisevident. Use separate screening tools for residents who can and cannot standunaided. The introduction offalls risk screens and assessments needs tobe supported with education for staff and intermittent reviews toensure appropriate and consistentuse. Screens and assessments will only beuseful when supported byappropriate interventions related tothe risksidentied. Identifying the presence ofcognitive impairment should form part ofthe falls risk assessmentprocess.
Good practicepoints
Falls riskscreening
Using aformal screening tool has the benefit offorming part ofroutine clinical management, and will inform further assessment and care for allresidents. If aresident isidentified asbeing at risk for any item onamultiple risk factor screen, interventions should beconsidered for that risk factor even ifthe person has alow falls risk scoreoverall.
Falls riskassessment
Conduct falls risk assessments for residents who exceed the threshold ofafalls risk screening tool, who suffer afall, orwho move toor reside inasetting where most people are considered tohave ahigh risk offalls (eg high-care facilities, dementiaunits). Interventions delivered asaresult ofthe assessment provide benefit; therefore, itis essential that interventions systematically address the identied riskfactors.
25

The terms falls risk screening and falls risk assessment are sometimes used interchangeably; however, 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 residential aged care facility (RACF) setting, afalls risk screen can beused toidentify people who require ahigh level ofsupervision and amore detailed falls risk assessment.7 Falls risk assessments aim toidentify those factors that increase falls risks and that may beamenabletointervention.
Many falls risk screening and assessment tools have been developed for use inRACFs. However, only some ofthese have been evaluated for reliability and predictive validity inprospective studies, and only some 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 non-fallers who donot fall inthe follow-up period. Most have also been validated only inone RACF usually the facility where the tool was developed. While this provides some useful information, risk screening and assessment tools have reduced validity (eg ability todistinguish between fallers and non-fallers) when used outside the original research setting.45 From aresearch perspective, further testing isneeded ofrisk assessment tools inavariety ofclinical settings toestablish their validity and reliability for general use.46 Screening and assessment are not stand-alone actions infalls prevention. Screening and assessment need tobe linked toan action plan toaddress any modiable 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 and classifying people asbeing ateither low orincreased risk. People with ahigh risk may then bereferred for amore detailed falls risk assessment. Falls risk screening usually involves reviewing only afew items. Positive screening oncertain screen items can also provide information about interventionstrategies. In many RACF settings, more than half the residents would beconsidered tohave anincreased risk of falling; 31,47 therefore, the falls risk screening process may beof limited value. Inthese facilities, itmay bebenecial toskip the screening process and implement afull falls risk assessment ofall residents. Theintroduction ofafalls risk screen needs tobe supported with education for staff and regular reviews toensure appropriate and consistentuse. The simplest falls risk screen that can beincorporated easily into routine care should record the residents history offalls. However, aprospective cohort study concluded that staff judgment ofresidents falls risks, aswell asprevious falls, were both superior tothe performance-based Timed Up and Go and Modified GetUp and Go tests.42 Another study that compared four different risk screening and assessment tools found that the question ofwhether ornot the resident had fallen inthe previous 12months had the greatest predictive accuracy for identifying futurefallers.48 Despite these results, one potential benefit ofusing ascreening tool rather than clinical judgment asascreen isthat ascreening tool can form part ofroutine clinical management that should inform further assessment and care for residents. Incontrast, clinical judgment depends onastaff members judgment offalls risk inthe context ofarange ofother medical problems, rather than depending onconsideration ofthe falls riskinisolation. If aformal falls risk screen isused, itis important that itis reliable and valid for the RACF setting. Unfortunately, falls inRACFs are not easy topredict and most falls risk screening tools have predictive values ofless than 70% sensitivity and specificity, meaning that more than 30% ofcases are misclassified either asfallers when they are not, ornot asfallers when they are.48 Alternative methods have been investigated; for example, one study used amobility interaction fall chart todiscriminate between older people with and without ahigh risk offalling.47 However, asubsequent validation study could not replicate theresults.49
26
An Australian study developed screening tools for predicting falls over asix-month period in2005residents from 80nursing homes and 50intermediate-care hostels.50 This study concluded that two different falls risk screening tools are required inRACFs: one for people who can stand unaided and one for those who cannot.50 Importantly, the validity ofthe screening tools was assessed with split-half analyses (ieassessing whether the falls screens developed from half the RACFs were predictive offalls inthe other half), providing condence that the screens would bepredictive beyond the research studysites.
5.1.2 Falls riskassessment

Falls risk assessment isamore detailed process than screening and isused toidentify underlying risk factors for falling. Many falls risk assessments also classify people into low and high falls risk groups. Several studies have used specific falls risk assessments toidentify falls risk factors,33,35,37,51 such asgait and balance,52 exercise capacity53,54 and medication use.32 Falls risk assessment tools vary inthe number ofrisk factors they include and how each risk factor isassessed. Relatively few falls risk assessment tools have been investigated for their reliability and predictive validity, and results have been reasonable for those that have beenevaluated.48
5.2 Principlesofcare
5.2.1 Falls riskscreening
Most residents ofRACFs have anincreased risk offalling.31 While some facilities may prefer touse ascreening tool toidentify those atincreased risk who require afalls risk assessment, other facilities may decide toadminister falls risk assessments for allresidents.4 If anRACF isusing ascreening process aspart ofamultifactorial intervention toidentify residents who need afalls risk assessment, rather than conducting afalls risk assessment onall residents,then: all older people who are admitted toRACFs should bescreened for their falls risk, and this screening should bedone assoon aspracticable after they areadmitted afalls risk screen should beundertaken regularly (every six months) and when achange infunctional statusisevident. 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. Aresidents risk offalling can change quickly; therefore, afalls risk screen should bedone when changes are noted inaresidents health orfunctional status, aswell aswhen there isachange inenvironment. Additionally, afalls risk screen should beundertaken regularly (ie every sixmonths). In residents who can stand unaided, having either poor balance ortwo ofthe following risk factors aprevious fall, high level ofcare orurinary incontinence increases the risk offalling threefold inthe following six months (sensitivity=73%, specificity=55%). Inresidents who cannot stand unaided, having one ofthe following risk factors aprevious fall, low level ofcare orusing nine ormore medications increases the risk offalling twofold (sensitivity=87%, specificity=29%). Aseparate screening test should beused for residents who cannot stand unaided.50 Figure5.1 isan algorithm for classifying the falls risk ofRACFresidents.
27
Can the resident stand unaided? Yes Can the resident stand on a foam mat? No

28
No
Yes
Do any two of the followingapply? Falls history Nursing home residence Incontinent
Do any of the following apply? Falls history Hostel (low-care) residence Polypharmacy ( 9)
Yes High falls risk

Source:Delbaere 50
No Low falls risk
Yes High falls risk
No Low falls risk
Figure 5.1 Algorithm summarising classication ofresidents ashigh orlow fallsrisk

The outcomes ofthe screen need tobe documented, aswell asdiscussed with the resident. When the threshold score ofascreening toolis: exceeded, afalls risk assessment should beconducted assoonaspracticable not exceeded, the person isconsidered 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 resident has alow falls risk score overall. For example, ifaresident can stand unaided, does not have arecent history offalls and isresiding inahostel (low-level care), but does have incontinence, this would place them atalow overall falls risk. However, apreventive approach would include assessment and implementation ofan intervention toaddress the incontinence atthistime.
5.2.2 Falls riskassessment

Assessing falls risk inRACFs typically involves the use ofmultifactorial assessment tools that cover awide range offalls risk factors. When identifying the cause ofafall, itis also important toremember that most falls occur asaresult ofan interaction between intrinsic and extrinsic factors, and that multiple factors increase the risk offalls.55 Many diseases that are more common inolder people increase the risk offalls mainly through impairing cognitive functioning and postural stability. Most assessment tools focus only onintrinsic falls risk factors, soaseparate environmental assessment may beindicated toidentify extrinsic falls risk factors (seeChapter14). Falls risk should beassessed for those people who exceed the threshold ofafalls risk screening tool, who suffer afall, orwho move toor reside inasetting where most people are considered tohave ahigh risk offalls (eg dementiaunits). Relatively few general falls risk assessment tools have been developed for use inRACFs. Validated tools should beused, rather than developing anew tool. The health care team should becareful ifadapting an assessment tool totheir particular setting, because this limits the applicability ofany previous validation studies. When afalls risk assessment isintroduced, itneeds tobe supported byeducation for staff and regular reviews toensure its appropriate and consistent use.4 Usually inthe RACF setting, nursing staff are primarily responsible for completing falls risk assessments and consulting with medical and other health care professionals asindicated andpossible.
So far, there isno consensus onwhich falls risk factors should beincluded inafalls risk assessment tool. Table5.1 summarises the Peninsula Health Falls Risk Assessment Tool (FRAT), which isuseful for assessing falls risk because ofits applicability toAustralian health care facilities. Further details ofFRAT are providedinAppendix2.
Table5.1 Peninsula Health Falls Risk Assessment Tool(FRAT)

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 Medium risk: score of1215 High risk: scoreof1620
Source:Stapleton56
Time needed Criterion
The outcomes ofthe falls risk assessment, together with the recommended strategies toaddress identified risk factors, need tobe documented, aswell asreported toother health care staff, and discussed with the resident and their carer(s) (where applicable). Assessment tools provide detailed information onthe underlying decits contributing tooverall risk and should belinked tointervention and management. Interventions delivered asaresult ofthe assessment provide benefit; therefore, itis essential that interventions toaddress the risks identied are appliedsystematically. More specic assessments may beindicated for some risk factors (see Table5.2). Descriptions ofthese assessments are provided inthe respective chapters, asindicated inthetable.
Table5.2 Specic risk-factorassessments
Characteristic/ feature
Impairedbalance
Impaired balance
Functionalmeasure
Assessment
Description
Ability tostand onfloor orfoam matunaided Reduced mobility Mobility interaction fall chart, Six-Metre Walk Test, Timed Up and GoTest Sit-to-StandTest
Chapter6
Muscle weakness
Cognitiveimpairment
Dementia ordelirium Psychogeriatric Assessment Scale (PAS) Folstein Mini-Mental State Examination (MMSE); Rowland Universal Dementia Scale (RUDAS); Confusion Assessment Method(CAM) Incontinence Urinary and fecal Questionnaires, assessment, physicalexamination Safe shoe checklist Podiatristassessment Chapter8 Chapter7
Feet and footwear
Footwear analysis Foot problems (iebunions, corns) and deformities
Chapter9 andAppendix4
29
Characteristic/ feature
Syncope
Functionalmeasure
Postural hypotension Carotid sinus hypersensitivity
Assessment
Lying and standing blood pressuremeasurements Carotid sinus massage byamedicalspecialist DixHallpiketest Halmagyi head thrusttest Medicationreview Medicationreview
Description
Chapter10
Dizziness and vertigo
Benign paroxysmal positional vertigo Peripheral vestibular function
Chapter11
Medications
Benzodiazepines Specic serotonin reuptake inhibitors and tricyclic antidepressants Antiepileptic drugs and drugs that lower blood pressure Some cardiovascular medications
Chapter12
Medicationreview Medicationreview Snellen eye chart, pictorial visiontests General environmental checklist Flagging, sitter programs, response systems, review andmonitoring Restraintpolicy Chapter13 Chapter 14 and Appendix5 Chapter15
Vision Environment Individual surveillance and observation Restraints
Visual acuity Impaired mobility, visual impairment Impaired mobility, high falls risk
Delirium, short-term elevated falls risk
Chapter16
Casestudy
MrD, who lives inalow-level aged care facility, recently slipped and fell. Hehad substantial bruising, but nobroken bones. Aspart ofthe facilitys routine policy after afall, afalls risk assessment was undertaken todetermine ifthere were any risk factors contributing tothis fall. This assessment documented that MrD had recently started taking sleeping tablets, had increasing unsteadiness inhis walking and balance, and had increasing frequency ofincontinence. Areview bythe general practitioner resulted intrialling anonmedication approach toimproving sleep (including stopping afternoon naps and having his last coffee atlunchtime). The physiotherapist introduced asupervised exercise program toimprove balance, and also provided MrD with awalking stick toimprove steadiness during walking. Finally, acontinence assessment identified strategies toimprove MrDs continence, and these were implemented. Four months later, MrD had regained his previous mobility and confidence, and had nofurtherfalls.
30
Identifying the presence ofcognitive impairment should form part ofthe falls risk assessment process. The presence ofcognitive impairment may mean that desired falls prevention interventions need tobe modified tomake sure they are suitable for the individual; often RACF staff will also play animportant role inimplementing falls preventionactions.
PartB
A randomised controlled trial ofamultifactorial intervention for falls and related injuries included residents with cognitive impairment inthe study group ofresidents inRACFs.31 The multifactorial intervention included staff education, environmental modification, exercise, supply and repair ofaids, medication review, hip protectors, post-fall case conference and staff guidance. The trial used afalls risk assessment asakey element toguide interventions (although the falls risk assessment itself was not tested aspart ofthe intervention). Asubanalysis ofresidents with cognitive impairment found that this group had asignicant reduction infalls-related injuries after the intervention wasimplemented.57

Falls risk 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 assessments and interventions tobeimplemented.

To assess adequately the falls risk ofpeople from Indigenous and culturally and linguistically diverse groups, RACF staff need toconsider assessing the person intheir primary language and inaculturally appropriate manner. This may require using atranslation and interpretationservice.
5.3.4 People with limitedmobility

The FREE study showed that risk factors for falls inpeople inRACFs who could not stand unaided were different fromrisk factors for falls for people with good standing ability.50 Important risk factors for falls in people who cannot stand unaided are aprevious fall, low level ofcare and using nine ormore medications. These factors should beincluded infalls risk screens for thisgroup.
31
PartC
Management strategies forcommon falls riskfactors
PartC Management strategies forcommon falls riskfactors
PartC
34
6 Balance and mobilitylimitations
Recommendations
Intervention
Use supervised and individualised balance and gait exercises aspart ofamultifactorial intervention toreduce the risk offalls and fractures inresidential aged care facility residents.(LevelII) 58 Consider using gait, balance and functional coordination exercises assingle interventions.(LevelII) 59,60
Good practicepoints
Assessment tools can beusedto: quantify the extent ofbalance and mobility limitations and muscleweaknesses guide exerciseprescription measure improvements inbalance, mobility andstrength assess whether residents have ahigh riskoffalling. Exercise should besupervised and delivered byappropriately trainedpersonnel.
35

Balance isahighly complex skill inwhich the bodys centre ofmass iscontrolled within the limits of stability. This requires integration ofaccurate sensory information (such asvision and proprioception) and awellfunctioning musculoskeletal system (eg not adversely affected 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.61 Residents ofresidential aged care facilities (RACFs) have aparticularly high risk offalling.16,62 Residents who are able tostand have aneven higher risk offalling than those who are unable tostand. AnAustralian study of1000RACF residents found that 81% ofresidents who were able torise from achair but could not stand unaided fell during the follow-up period (which lasted for anaverage of15months); conversely, 48% ofresidents who could neither stand from achair nor stand unaided fell.63 RACF staff and the rest ofthe health care team should consider these differences when designing and evaluating exerciseinterventions. In three randomised controlled trials (RCTs) inRACFs, exercise prevented falls.59,60,64 The impact ofexercise (as asingle intervention) onfalls has not been aswell investigated inRACFs asit has incommunity settings. Many ofthe 14randomised trials that have investigated exercise-only interventions inRACFs have been small and have looked atarange ofexercise programs.58 Multifactorial interventions including exercise have the potential toprevent falls and fractures inRACF residents.7 Table6.1 provides asummary ofthe methods and results from randomised trials involving large study samples that included exercise interventions for the preventionoffalls.
36
Table 6.1 Summary offalls prevention interventions that included anexercise component used inresidential aged care facilitysettings
Author
2 days/week 75 minutes 12 months Falls: rate ratio=0.55 (95%CI 0.41 to0.73)
Sample size
Intervention description
Frequency (times/week)
Session duration
Program duration
Intervention effectonfalls/ fallers 34
Becker etal33
981
Exercise: group-based, supervised, progressive balance and resistance exercises delivered byexercise instructors. Resistance exercises individually tailored and included the use ofankle weights and dumbbells. Other: hip protectors, environmental modification, walking aid check, staff and resident education.
Fallers: risk ratio=0.75 (95%CI 0.57 to0.98) Signicant reduction infalls andfallers 40 minutes 3 months Falls: rate ratio=0.54 (95%CI 0.42 to0.69) Fallers: risk ratio=1.03 (95%CI 0.59 to1.80) Signicant reductioninfalls
Dyer65
196
3 days/week Exercise: group orindividually supervised gait, balance, flexibility, strength and endurance exercises that were linked tofunctional lifestyle tasks where possible, such assafe transfers, dressing and the use ofwalking aids. Exercises were progressed with weights and thera-bands and were delivered byexercise assistants supported byphysiotherapists. Other: medical screening and referral tooptometrist orpodiatrist, occupational therapist assessment ofenvironmental hazards, staff education. 90 minutes
Faber etal53
238
20 weeks
Falls: rate ratio=1.32 (95%CI 1.09 to1.60) Signicant increase inrisk IB: rate ratio=0.96 (95%CI 0.78 to1.18) No signicant effect Fallers: FW: risk ratio=1.31 (95%CI 0.86 to1.99) Nonsignicant increased risk
Exercise: group-based functional walking (FW) exercises compared with in-balance (IB) exercises. FWincluded 10exercises focusing ongait, balance, coordination and transfers, including: sit-to-stand (with and without use ofarms) trunk and upper limb movements while standing with minimal support moving objects between two tables heel and toe standing and walking walking along astraight line forwards, backwards and sideways stepping up, down and over astep stair ascent and descent with reducing support tandem standing and walking one-legged stance.
1 day/week for 4 weeks, then 2days/week for 16 weeks
PartC
37
Author
90 minutes No signicanteffect 1 day/week for 4 weeks, then 2days/week for 16 weeks 20 weeks IB: rate ratio=1.18 (95%CI 0.78 to1.77)
Sample size
Session duration
Program duration
Faber etal53
238
IB exercises included 7 elements oftai chi: relaxation exercises instanding position involving trunk rotation, arm swinging and weight transfer stretch and relax exercises involving arm movements and weight shifting pelvis exercises involving pelvic rotation while seated and standing seated foot and ankle exercises seated and standing leg strengthening, starting with knee extensions and progressing tosquats balance exercises starting with seated sensory lower limb stimulation and progressing towalking inslow motion balance dance asimplified form oftai chi, which combines all the previous exercises. Functional exercises including standing upfrom achair and bed, standing onthe floor, and walking with anemphasis oncorrect posture. 23 days/week Not specied 11 weeks Falls: rate ratio=0.75 (95%CI 0.51 to1.10)
Jensen etal31
384
Exercise: physiotherapist-supervised exercises focused ongait, balance, strength and safe transfers that were progressed tochallenge individual capacity. Other: medication review, modification ofenvironmental hazards, supply orrepair ofwalking aids, hip protectors, staff education. 2 days/week
Fallers: risk ratio=0.71 (95%CI 0.54 to0.94) Signicant reductioninfallers 1 hour 12 months Falls: rate ratio=0.78 (95%CI 0.62 to0.99) a Signicant reductioninfalls
Lord etal59
551
Exercise: group exercise delivered byexercise instructors: weight-bearing balance exercises including tandem foot standing, heeltoe walking, line walking, standing onone leg, altering the base ofsupport, weight transfers (from one leg toanother), rocking back and forth onto toes and heels, rotating onthe spot, lateral movement challenges, reaching and stretching movements away from the centre ofgravity (forwards, laterally and upwards) muscle strengthening coordination.
PartC
38
Author
30 minutes 6 months Falls: rate ratio=0.78 (95%CI 0.49 to1.24) Fallers: risk ratio=0.66 (95%CI 0.37 to1.18) Nonsignicantreduction 3 days/week 3045 minutes 4 months Falls: rate ratio=0.82 (95%CI 0.94 to1.84) Fallers: risk ratio=1.16 (95%CI 0.83 to1.61)
Sample size
Session duration
Program duration
McMurdo etal51
133
Exercise: supervised, seated exercise aimed atimproving balance, strength and 2 days/week flexibility. Other: medication review, optometrist review (if required), review of lighting levels.
Mulrow etal52
194
Exercise: physiotherapist-delivered, individually tailored and supervised exercises focused onimproving gait, balance, functional mobility, flexibility and strength. Resistance was progressed with the use ofweights or elastic bands.
Nonsignicant increase infalls andfallers 3 times/day 1 minute each leg/ repetition 6 months Falls: rate ratio=0.82 (95%CI 0.64 to1.04) Fallers: risk ratio=0.90 (95%CI 0.65 to1.23) Nonsignicantreduction 5 days/week, upto 4times/ day Not specied 8 months Falls: rate ratio=0.62 (95%CI 0.38 to1.0) Signicant reduction infalls Fallers: risk ratio=0.62 (95%CI 0.37 to1.06) Nonsignicant reductioninfallers
Sakamoto66
553
Exercise: single-leg stance practice with eyes open. Supervised byphysiotherapist orsimilar professional.
Schnelle etal60
190
Exercise: individually tailored and supervised byresearch staff. Walking orwheelchair ambulation, sit-to-stand, upper body resistance training (arm curls orarm raises). Other: incontinence management (toileting every 2hours) and offering fluids every 2hours.
CI = condenceinterval a Data obtained from Sherringtonetal58
PartC
39
6.1.1 Risk factors forfalling

Balance and mobility are often poor inRACF residents. Balance and mobility are likely tofurther deteriorate ifthe resident becomes less active and isnot encouraged toperform activities ofdaily living themselves, with assistance only whenrequired. Assessing balance ormobility asasingle risk factor isunlikely tobe the best way ofestablishing which RACF residents are more likely tofall. Rather, multiple risk factors for falls inresidential care have been identified, including cognitive impairment, psychoactive medication use, multiple medication use, urinary incontinence and falls history.50,62,63,67 The United Kingdom National Institute ofClinical Excellence concluded that the key risk factors for falling inRACFsare: 68 ahistoryoffalls gaitdecit balancedecit visualimpairment cognitiveimpairment.
6.1.2 Improving balance and mobility withexercise

Systematic reviews have found that well-designed exercise programs can benefit older residents ofRACFs. Specifically, rehabilitation interventions can reduce disability inlong-term residents with few adverse effects,69 and physical training can improve strength and mobility.70 Therefore, these interventions have the potential topreventfalls.
6.1.3 Exercise for preventingfalls

In two trials inRACFs, exercise prevented falls.59,60,64 However, because other studies have had conflicting results, the role ofexercise asasingle intervention needs tobe further investigated before firm conclusions can bereached regarding its effectiveness. Ameta-analysis ofthe effects ofexercise asasingle intervention onfalls did not nd exercise tohave alesser effect instudies conducted inresidential care settings than incommunitysettings.58 One RCT inAustralian hostels and retirement villages found 22% fewer falls among residents who attended weekly group exercise classes compared with those who did not (incident rate ratio=0.78, 95%CI0.62 to0.99).59 The exercise program was conducted inweight-bearing positions, and aimed toimprove the ability ofparticipants toundertake activities of daily living byincluding exercises that presented ahigh challenge tobalance (eg single-leg standing) and that emulated the requirements ofeverydayactivities. In anursing home setting, another RCT59,60,64 involved residents being seen byaresearch assistant upto four times aday for eight months. Ateach visit, residents were given acontinence prompt, given asupervised walk, asked tosit-to-stand eight times and encouraged todrink fluids. Additional upper limb resistance training was provided attailored intensity, walking distance was gradually increased ifpossible, and sit-tostand exercise was encouraged with minimal use ofupper limbs for support. This program resulted inimproved ormaintained functional abilities among the participants who exercised, while the abilities ofthe control group deteriorated (between-group differences for 14 of15 outcome measures). Additional analyses found that this intervention also decreased the rate offalls by38% (incident rate ratio =0.62, 95%CI0.38to0.98).58 While the evidence isnot conclusive, exercise that includes ahigh challenge tobalance seems tohave aneffect onfalls inresidents ofRACFs. When the results oftwo small randomised trials were pooled,71,72 the results showed areduction inthe rate offalls (rate ratio = 0.45, 95%CI 0.24 to0.85) but not inthe number offallers (risk ratio = 0.72, 95%CI 0.43 to1.19). These interventions involved exercises aimed atimproving gait, balance and coordination using amechanical apparatus todisturb balance. However, due tothe small sample sizes, these results should beviewed aspreliminary. Furthermore, interventions that depend oncomplex equipment may not bepracticable for the RACF setting. Asimple method for challenging balance with asingle-leg stance intervention66 may bean effectivealternative. There may also bearole for seated exercise for use with frail RACF residents.51 However, not all trials that have implemented exercise aimed atimproving gait, balance and mobility have led tofavourable outcomes.52,53 This indicates aneed for further investigation inthisarea.
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6.1.4 Exercise aspart ofamultifactorialintervention

Multifactorial interventions including exercise have the potential toprevent falls and fractures inRACF residents.7 However, these interventions need tobe implemented carefully, because some approaches have not been found toprevent falls. Key features ofsuccessful interventions are yet tobeidentied. A meta-analysis ofvarious multifactorial trials found apooled effect ofa22% reduction inthe number offalls (although this was not statistically significant: rate ratio = 0.78, 95%CI0.57 to1.07), astatistically significant 10% reduction inthe proportion ofpeople having one ormore falls (risk ratio = 0.90, 95%CI0.82 to0.98) and astatistically significant 52% reduction inthe risk offractures (risk ratio = 0.48, 95%CI0.24 to0.98).7 One well-designed RCT, which used afalls risk management approach with existing resources, found increased fall rates inthe interventiongroup.35 It isnot yet clear whether there are key features ofmultifactorial falls prevention programs inresidential care. However, several RCTs that have had positive effects have included agreater emphasis ondelivery ofadditional exercise. For example, the intervention program designed byBecker etal33 decreased falls rates by45% (rate ratio = 0.55, 95%CI0.41 to0.73). This program involved staff training and feedback, information and education for residents, environmental adaptations, hip protectors and twice-weekly exercise ingroups ofsix toeight people, delivered byexercise instructors. Exercises included progressive balance exercises and progressive, individually tailored resistance training with ankle weights and dumbbells. Similarly, the multidisciplinary program tested byJensen etal31 reduced falls rates by40% (incidence rate ratio=0.60, 95%CI0.50 to0.73) and also included exercise. Inthis RCT, exercise sessions were run two tothree times aweek and were deliveredbyphysiotherapists.
6.2.1 Assessing balance, mobility andstrength
Many measurement tools have been developed toassess balance, mobility and strength inolder RACF residents; the choice oftool will depend onthe time and equipmentavailable. An expanding eld ofresearch isevaluating different properties ofmeasurement tools. 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 meaningfulchanges). A study assessing the Physical Mobility Scale (a tool for assessing the mobility ofRACF residents) demonstrated good inter-user agreement and internal construct validity.48 The authors concluded that the tool may besuited toarange ofclinical and research applications inRACF settings. Some preliminary work has also developed methods for evaluating balance-assessment tools infalls preventionprograms.73 Table6.2 summarises other clinical assessment tools that may behelpful for measuring risk and assessing progress inresidents. The criteria and ratings are derived from people living inthe communitysetting.
Table6.2 Clinical assessments for measuring balance, mobility andstrength
Balance
Functional reach(FR)74
Description FR isameasure ofbalance and isthe difference between apersons arm length and maximal forward reach, using afixed base ofsupport. FR isasimple and easy-to-use clinical measure that has predictive validity inidentifying recurrentfalls. Time needed Criterion 12minutes 6 inches: fourfold risk 10 inches: twofoldrisk Rating 76% sensitivity; 34%specificity75
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Mobility
Six-Metre Walk Test(SMW)76
Description Time needed SMW measures apersons gait speed inseconds along acorridor (over adistance ofsix metres) attheir normal walkingspeed. 12minutes 6seconds 50% sensitivity; 68%specificity76
Criterion Rating
Timed Up and Go Test(TUG)77

Description Time needed Criterion Rating TUG measures the time taken for aperson torise from achair, walk three metres at normal pace and with their usual assistive device, turn, return tothe chair and sitdown. 12minutes 15seconds 76% sensitivity; 34%specificity78
Strength
Sit-to-Stand Test(STS)79
Description Time needed Criterion Rating STS isameasure oflower limb strength and isthe time needed tostand from aseated position onachair ve consecutivetimes. 12minutes 12seconds 66% sensitivity; 55%specificity76
Springbalance80
Description As part ofthe Physiological Profile Assessment, the strength ofthree leg muscle groups (knee flexors and extensors and ankle dorsiflexors) ismeasured while participants are seated. In each test, there are three trials and the greatest forceisrecorded. Time needed Criterion Rating 5minutes Computer software program compares anindividuals performance toanormative database compiled from populationstudies. 75% accuracy for predicting falls over a12-month period incommunity and institutional settings; reliability coefficients within clinically expected range(0.50.7).80
Compositescales
Berg BalanceScale81
Description The Berg Balance Scale isa14-item scale designed tomeasure balance ofthe older person inaclinical setting, with amaximum total score of56 points (seehttp://www. chcr.brown.edu/geriatric_assessment_tool_kit.pdf). 1520minutes A score of20=high risk offalls A score of40=moderate risk offalls (potential ceiling effect with less frailpeople) Rating High reliability (R=0.97); low sensitivity an8-point change needed toreveal genuine changesinfunction.82
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Compositescales
Tinetti Performance-Oriented Mobility Assessment Tool(POMA) 83
Description POMA measures apersons gait and balance. It isscored onthe persons ability toperform specific tasks, with amaximum total score of28points. Time needed Criterion 1015minutes A score of<19=high risk offalls A score of<24=moderate riskoffalls Rating High testretest reliability for POMA-T and POMA-B (R=0.740.93), lower testretest reliability for POMA-G (R=0.720.89). POMA-T sensitivity (62%) and specificity (66.1%) indicate poor accuracy infallsprediction.53,84
Condence and falls efcacyscale

Falls Efcacy Scale International(FES-I) 85
Description FES-I provides information onthe level ofconcern onafour-point scale (1=not atall concerned to4=very concerned) across 16activities ofdaily living (eg cleaning the house, simple shopping, walking onunevensurfaces). 5minutes A score of22=low tomoderate level ofconcern A score of 23= high levelofconcern50 Rating High testretest reliability(R=0.96) 85
Casestudy
MrK is88 years old and returned tohis residential aged care facility after being inhospital for pneumonia. The hospital discharge summary noted that MrK could nolonger stand upfrom his bed without help. Aspart ofamultifactorial falls prevention program, the physiotherapist reviewed his balance, mobility and strength, and designed aprogram ofsupervised exercises that could becarried out with the nursing staff orfamily. Asaresult, MrK can now stand without help and ismore stable when walking, and his family are more confident about helping him whenrequired.
Risk factors for falls (eg gait and balance problems) are more prevalent inolder people with cognitive impairment than in those without cognitive impairment.86 People with cognitive impairment should therefore have their falls risk investigatedcomprehensively. Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations, unless there isaproblem with ability tofollow orcomply with instructions (see Chapter7 oncognitive impairment). Simplifying instructions and using picture boards and demonstrations are strategies that may improve the quality ofexercise for people with cognitive impairment. Family, carers and other volunteers may beable tohelp insupervising and motivating people who are undertaking exerciseprograms.
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Ideally, exercise interventions for residents ofRACFs would beprescribed byaphysiotherapist after individualised assessment. However, inrural and remote settings this may need tobe done byother staff with appropriate guidance from aphysiotherapist toensure programs are challenging, yetsafe.

When developing exercise programs for Indigenous and culturally and linguistically diverse groups, RACF staff should ensure they are informed about requirements specic 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.
Only one economic evaluation ofexercise inanRACF setting was identified.87 This was amodelled analysis, but the effectiveness ofthis intervention inaresidential care settingisunclear. Wilson etal87 conducted asimplistic modelled economic evaluation oftai chi for preventing fractures inanursing home population, compared with usual care, assuming arelative risk offalling of0.525, and 70% adherence. The analysis considered costs (in 2000US$) and health outcomes (falls, hip fractures) over aone-year period. Modelled total costs ofthe program (including the tai chi plus falls-related costs) over one year were US$27517 compared with falls-related costs inthe intervention arm ofUS$28321, while the program prevented 0.49falls per person, onaverage. Sensitivity analyses indicated that the intervention was nolonger cost saving ifthe intervention cost per participant was greater than US$95, orif the relative risk offalling was greater than 0.566, and was sensitive tothe baseline risk offracture inthepopulation. Some community interventions have been successful inpreventing falls and cost effective; however, itis unclear whether the results are applicable tothe RACF setting, given these interventions are mainly homebased exercise programs. See Chapter6 inthe community guidelines for moreinformation.
Additionalinformation
The Physiotherapy Evidence Database (PEDro) provides evidence based 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: Chartered Society ofPhysiotherapy (United Kingdom) outcome measures online database: http://www.csp.org.uk/director/members/practice/clinicalresources/outcomemeasures/ searchabledatabase.cfm FitnessAustralia: http://www.tnessaustralia.com.au 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$60 for group members and A$75 forothers: http://www.physiotherapy.asn.au Otago Exercise Programme this program isaimed atpreventing falls incommunity dwelling older people, but itis also relevant for the aged care setting. The manual can bepurchased for NZ$60 from thewebsite: http://www.acc.co.nz/injury-prevention/home-safety/older-adults/otago-exerciseprogramme/index.htm
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7 Cognitive impairment
Recommendations
Assessment
Residents with cognitive impairment should have other falls risk factorsassessed.
Intervention
Address identified falls risk factors aspart ofamultifactorial falls prevention program, and also consider injury minimisation strategies (such aship protectors orvitamin Dand calcium supplementation).(LevelI) 7
Good practicepoints
Address all reversible causes ofacute orprogressive cognitivedecline. Residents presenting with anacute change incognitive function should beassessed for delirium and the underlying cause ofthischange. Residents with gradual-onset, progressive cognitive impairment should undergo detailed assessment todetermine diagnosis and, where possible, reversible causes ofthe cognitive decline. Reversible causes ofacute orprogressive cognitive decline shouldbetreated. If aresident with cognitive impairment does fall, reassess their cognitive status, including presence ofdelirium (eg using the Confusion Assessment Methodtool). Interventions shown towork incognitively intact populations should not bewithheld from cognitively impaired populations; however, interventions for people with cognitive impairment may need tobe modied and supervisedasappropriate.
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Cognitive impairment iscommonly experienced byresidents inresidential aged care settings. Although cognitive impairment ismost commonly associated with increasing age, itis acomplex area 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 (eg memory, visuospatial skills orexecutive function), but isnot synonymous withdementia. Dementia and delirium are the two most common forms ofcognitive impairment inolderpeople: Dementia isasyndrome ofprogressive decline inmore than one cognitive domain that affects apersons ability tofunction. There isahigh prevalence (5070%) ofresidents with dementia inresidential aged care facilities (RACFs).88 Dementia has agradual onset and usually involves aprogressive decline inarange ofcognitive abilities (such asmemory, orientation, learning, judgment and comprehension), and isoften accompanied bychanges inpersonality andbehaviour.89 Delirium isasyndrome characterised bythe rapid onset ofvariable and fluctuating changes inmental status. While there are relatively few studies ofthe prevalence ofdelirium inRACFs, itis estimated that delirium occurs in60% ofresidents innursing homes atsome time.90 Delirium isamedical emergency that frequently requires aperiod ofhospitalisation todeal with both the underlying precipitant and the manifestations ofthe delirium. Delirium usually develops over hours ordays and has afluctuating course that can involve changes inarange ofcognitive abilities, such asorientation, mood, perceptions, psychomotor activity and the sleepwakecycle.90 Differentiating between dementia and delirium can bedifficult, and they can coexist inmany older people. Older people with existing cognitive impairments are more likely todevelop adelirium from anacuteevent.90
7.1.1 Cognitive impairment associated with increased fallsrisk

Older people with cognitive impairment have anincreased risk offalls, and risk factors for falls are more prevalent inolder people with cognitive impairment than in people without cognitive impairment. For example, impairments ofgait and balance are worse,86 psychoactive medications are more commonly prescribed,91,92 and orthostatic hypotension and hypotension are moreprevalent.93 Cognitive impairment may increase the risk offalling bydirectly influencing the older persons ability tounderstand and manage environmental hazards, through atendency toincreased wandering,94 and through altered gait patterns and impaired postural stability.95 Examples ofthe different behaviours that contribute toincreased falls risk inpeople with cognitive impairment are agitation, lack ofawareness ofenvironmental hazards while wandering, impaired ability toproblem solve and impulsiveness.96,97 Any changes inthe environment can increase confusion and agitation, and may also increase the risk offalls; for example, transfers between hospital and aRACF, ortransfers within orbetween rooms withinafacility. Some types ofcognitive impairment are more strongly associated with falls than others. For example, delirium isassociated with acute medical illness, metabolic disturbance, drugs and sepsis,90 which may lead topoor balance, postural hypotension and muscle weakness. Some forms ofdementia (eg Lewy body disease orvascular dementia) may beassociated with gait instability and ahigher incidence oforthostatichypotension.98
7.1.2 Cognitive impairment and fallsprevention

All successful multifactorial falls prevention programs inRACF settings have included intheir samples residents with and without cognitive impairment.31,33,37,60 One randomised controlled trial (RCT) showed that people who beneted from the intervention were those with more marked cognitive impairment.33 However, another RCT reported subgroup analysis based onlevels ofcognitive impairment and found that amultifactorial falls and injury prevention program was effective inresidents with higher levels ofcognition, but not inresidents with impairedcognition.57 Possible explanations for lack ofeffectiveness offalls prevention inpeople with cognitive impairment ordementia include different underlying mechanisms for falls risk factors and possibly other additional risk factors.99 Some studies have shown that interventions can modify certain risk factors for falls inolder people with cognitive impairment, such asgait performance,36 balance36,100 andmobility.36 Delirium isalmost always due toatreatable underlying cause and should beaddressed assoon aspossible. People with pre-existing dementia are more susceptible todelirium from events such asconstipation, urinary tract infections, chest infections and pain.90 People 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.90
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7.2.1 Assessing cognitiveimpairment
One ofthe most important initial steps inpreventing falls inolder people isto assess for cognitive impairment. This should include the followingstrategies: Check repeatedly and regularly for the presence ofdementia ordelirium and treat possible medical conditions that may contribute toan alteration incognitive status. Rapid diagnosis and treatment ofadelirium and its underlying precipitant (eg infection, dehydration, constipation, pain) arecrucial.101 Residents with aprogressive decline incognition should undergo detailed assessment todetermine diagnosis and, where possible, treat reversible causes ofthe cognitivedecline.89 Residents with cognitive impairment should have falls risk factors assessed, asdiscussed inother chapters, and have interventions offered tomodify risk. Some interventions (egexercise) require the resident tobe able tofollow instructions orcomply with aprogram. Where there isdoubt about aresidents ability tofollow instructions safely, the health care team should conduct anindividualised assessment and develop afalls prevention plan using the information from the assessment ontheirbehalf.27 Generally, inan RACF, the registered nurse isresponsible for assessing the residents cognitive status, and can supervise the collection ofinformation onwhich the assessment isbased. This information can include baseline observations, urinalysis, changes inmedication, pain, blood sugar level, constipation, dehydration, etc. Each RACF should have adelirium protocol for collecting this baselineinformation. Many tools can beused toassess cognitive status, some ofwhich are summarised inTable7.1. Chapter5 contains more information onassessing fallsrisk.
Table7.1 Tools for assessing cognitivestatus
Psychogeriatric Assessment Scales(PAS) 102

Description PAS assesses the clinical changes seen indementia and depression. Three scales are derived from aface-to-face interview with the participant orresident (cognitive impairment, depression, stroke), and three scales are derived from aface-to-face interview with aninformant, such asacarer (cognitive decline, behaviour change, stroke). The PAS iseasy toadminister and score and can beused bylay interviewers. The PAS-Cognitive Impairment Scale (PAS-CIS) must becompleted for Australian Government funding under the Aged Care Funding Instrument. Seehttp://www.mhri.edu.au/pas Time needed Criterion 20 minutes (forPAS-CIS) A score of03: noor minimal cognitive impairment A score of49: mild cognitive impairment A score of1015: moderate cognitive impairment A score of1621: severe cognitiveimpairment
Folstein Mini-Mental State Examination(MMSE) 103

Description MMSE isawidely used method for assessing cognitive mental status. It isan 11-question measure that tests five areas ofcognitive function: orientation, registration, attention and calculation, recall and language. The maximum scoreis30. Time needed Criterion 510minutes A score 23 indicates mild cognitive impairment A score 18 indicates severe cognitiveimpairment
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Rowland Universal Dementia Scale(RUDAS) 104,105

Description RUDAS isasimple method for detecting cognitive impairment. RUDAS isvalid across cultures, portable and administered easily byprimary health care professionals. The test uses six items toassess multiple cognitive domains, including memory, praxis, language, judgment, drawing and bodyorientation.
Time needed Criterion Accuracy
10minutes Cut-point of23 (maximum scoreof30) 89% sensitivity; 98%specificity
Confusion Assessment Method(CAM) 106

Description CAM isacomprehensive assessment instrument that screens for four clinical features ofdelirium: an onset ofmental status changes orafluctuating course inattention disorganised thinking an altered level ofconsciousness (ie other thanalert). 5minutes Resident isdiagnosed asdelirious ifthey have both the first two features, and either the third orfourthfeature. 94% sensitivity; 90%specificity107
Time needed Criterion Accuracy
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) couldbeinstituted. Other interventions that may also prevent falls (as part ofamultifactorial program) include thefollowing: Educate and discuss falls prevention risks and strategies with all staff31,33,37,108 and residents.33 Holding post-fall case conferences with staff can alsobehelpful.31 Encourage all residents toparticipate inexercise classes toimprove muscle strength, balance, gait, safe transfers and use ofwalkingaids.31,33,60 Implement strategies toensure that mobile residents can walk around safely, suchas ensuring walking aids and other assistive devices are appropriate, and repairing themasneeded31,37 modifying the environment tomaximisesafety31,33,37 being cautious when using hip protectors (some trials innursing homes have found that hip protectors, ifworn, prevent hip fractures; 31,33 however, poor adherence isamajor issue limiting the effectiveness ofthisintervention). Review prescribed medications for conditions that the resident nolonger has (egantidepressants, antipsychotics, antihypertensives,antianginals).31,37 Assess and develop aplan ofcare for people with urinaryincontinence.60 Treat orthostatic hypotension asrequired (orthostatic hypotension iscommon inresidents withdementia).99 Avoid using restraint orimmobilising equipment (including indwellingcatheters).27 Provide supervision and assistance toensure that residents with delirium orcognitive impairment who are not capable ofstanding and walking safely receive help with alltransfers.99 Use fall-alarm devices (sometimes called movement alarms) toalert staff that residents with cognitive impairment are attemptingtomobilise.27
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The symptoms ofcognitive impairment and delirium should bemanaged byaddressing agitation, wandering and impulsive behaviour asfollows (note that these are general care principles and are not directly aimed atpreventingfalls): 90,109 Identify and reduce oreliminate the causes ofagitation, wandering and residents impulsivebehaviour. Avoid the risk ofdehydration byhaving fluids available and within aresidents reach, and byoffering fluidsregularly. Avoid extremes ofsensory input (eg too much ortoo little light, too much ortoo littlenoise). Promote exercise and activity programs. Activity programming may need tobe intensied inthe late afternoon orearly evening toredirect agitated behaviours (egpacing may beredirected into walking ordancing; noises may beredirected into singing orplayingmusic). Promote companionshipifappropriate. Establish orientation programs using environmental cues and supports (including having personal orfamiliar items available). Repeat orientation and safety instructions onaregular basis, keeping instructions clear andconsistent. Develop aschedule for the resident (eg regular eating times, regular activity times, regular toileting regime). Where possible, base this schedule onestablished individual routines. Make sure that staff know about the schedule sothat procedures, routines and the residents environment can bekeptconsistent. Encourage sleep without the use ofmedication, and promote and support uninterrupted sleep patterns bymaintaining abedtime routine, reducing noise and minimisingdisturbance. Encourage residents inactivities that avoid excessive daytimenapping. Ensure personal needs are met onaregular and timelybasis. When communicating with cognitively impaired residents, try toinstil feelings oftrust, confidence and respect (thereby minimising the risk ofan aggressive response). This can beachieved byapproaching the resident slowly, calmly and from the front; respecting personal space; addressing the resident byname and introducing yourself; using eye contact (only ifculturally appropriate); and speaking clearly. Gentle touch and gestures, aswell asauditory, pictorial and visual cues used appropriately, may also help with communication. Itis important that the resident 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) 110 tomaintain oral hydration inresidents ofaged care facilities.111 Although adherence was problematic, the following strategies recommended bythe JBI-PACES maybebenecial: Drinks (cordial, juice and water, but not caffeinated drinks) were offered bystaff every 1.5hours (as well asmorning tea, afternoon tea andsupper). Residents with cognitive impairment were either helped orpromptedtodrink. An accessible water fountain was set upwith asupplyofcups. Filled 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 residents settleatnight.
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Casestudy
MrsA isa79-year-old resident ofan aged care facility. She had been diagnosed with Alzheimers disease. MrsA was admitted tothe facility recently when her family was nolonger able tocare for her athome. MrsA often wanders off and gets lost inthe facility. Staff have been instructed torepeat orientation and safety instructions onaregular basis, keeping instructions clear and consistent. The family was asked tobring some personal and familiar items from home tohave inher room. MrsA was vitaminD decient and was given both calcium and vitaminD supplementation. Finally, toreduce her risk ofsuffering aninjury, MrsA was tted with soft-shield hip protectors. Staff members are checking adherence with the hip protectorsdaily.

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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 limitations, but with the advantage ofbeing simpler touse inamulticulturalpopulation.104,105 A study funded bythe National Health and Medical Research Council the Kimberley Indigenous Cognitive Assessment investigated the validity ofanew assessment ofcognitive function developed specically for IndigenousAustralians.
No economic evaluations were found that examined the cost effectiveness ofaprogram related toidentifying and managing cognitive impairment inthe RACFsetting.
A range ofresources are available from the following associations andwebsites: Alzheimers Australia can provide further information, counselling and support for people with dementia, their families andcarers: http://www.alzheimers.org.au Living with Dementia AGuide for Veterans and theirFamilies : http://www.dva.gov.au/aboutDVA/publications/health/dementia/Pages/index.aspx
http://www.nari.unimelb.edu.au/research/dementia.htm
8 Continence
Recommendations
Assessment
Older residents should beoffered acontinence assessment tocheck for problems that can bemodiedorprevented.
Intervention
All residents should have aurinalysis toscreen for urinary tract infections orfunction.(LevelII-*) 112 Regular, individualised toileting should bein place for residents atrisk offalling, aspart ofmultifactorial intervention.(LevelII) 60 Managing problems associated with urinary tract function iseffective aspart ofamultifactorial approach tocare.(LevelII-*) 112
Note: although there isobservational evidence ofan association between incontinence and falls, there isno direct evidence that interventions tomanage incontinence affect the rateoffalls.113
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Up totwo-thirds ofresidents inresidential aged care facilities (RACFs) experience urinary incontinence.114,115 About 66% ofAustralians inRACFs require atleast some support for bladder management, while 72% require some support for bowelmanagement.116 While urinary and fecal incontinence affect both males and females, they are not usually considered tobe part ofthe normal ageing process.117 However, age-related changes within the urinary tract dopredispose older people towards urinaryincontinence.118 Urinary incontinence inthe frail elderly isuniversally multifactorial. Likewise, the relationship between incontinence and falls islikely tobe confounded byimpairment ofmobility and cognition. Although there isobservational evidence ofan association between incontinence and falls, there isno direct evidence that interventions tomanage incontinence affect the rate offalls.113 However, itis likely that amultiple intervention approach isnecessary topreventfalls.119
8.1.1 Incontinence associated with increased fallsrisk

Incontinence, urinary frequency and assisted toileting have been identified asrisk factors for falls inRACFs.16 Additionally, urinary incontinence has been identified asasignificant independent falls risk factor inresidents who are not able tostand unaided.50 People will make extraordinary efforts toavoid anincontinent episode, including placing themselves atincreased risk offalling. Incontinence, assisted toileting120,121 and symptoms ofoveractive bladder (OAB) 122,123 have been identied asrisk factors for falls inthecommunity. Different types ofbladder and bowel symptoms and their relationship with falls areasfollows: Bladder dysfunction iscommon inolder women, asaresult ofdeficiencies inthe pelvic floor muscles and connective tissue supporting the urethra and the urethral sphincter mechanism.124 Adecline inoestrogen levels after menopause can lead toatrophic changes affecting the vagina and urethra, and can increase awomans susceptibility tourinary tract infections. Symptoms include urinary frequency, stress and urgeincontinence.125 Constipation isacommon problem inolder people and isrelated todecreased mobility, reduced fluid intake and the use ofanumber ofhigh-risk medications. Urinary incontinence issignicantly associated with self-report ofconstipation inolder, community-dwelling Australian women.126 Constipation may cause delirium and agitation, which inturn may cause falls. Straining during defecation may also shunt blood away from the cerebral circulation, leading todizziness orsyncope (temporary loss ofconsciousness) due tothe vasovagal phenomenon.127 Relieving constipation improves lower urinary tract symptoms, including urinaryincontinence.128 Diarrhoea may cause agitation aswell asmetabolic disturbance, which may inturn causefalls. Frequency isdened asthe complaint bythe resident who considers that they void too often during theday.129 Nocturia isdened asbeing woken atnight bythe desire tovoid.124 Nocturia iscommon and issignicantly associated with falls inambulatory older people who live inthe community.130 Itcan beparticularly problematic when lighting ispoor orwhen the older person isnot fully awake. Nocturia isone ofthe most common causes ofpoor sleep and carries with itahigher risk offalling and fractures inolderpeople.130 OAB syndrome isdefined asurgency with orwithout urge incontinence, usually with frequency and nocturia.129 Asystematic review ofstudies related tourinary incontinence and falls revealed asignicant association between falls and urge incontinence symptomsofOAB.131 Stress incontinence isdened asleaking urine associated with rises inabdominal pressure during physical activity.129 While this isacommon symptom inyounger women, institutionalised elderly women are more likely tohave mixed symptoms ofstress incontinence and OAB.132 Asystematic review ofstudies related tourinary incontinence and falls revealed noassociation between falls and stressincontinence.131 Urge (urinary) incontinence isdened asinvoluntary urine leakage accompanied orimmediately preceded byurgency.124 Ithas been suggested that urge incontinence increases the risk ofaperson falling and fracturing bones.123 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 walkingstability.
52
Urgency isdefined asthe sudden compelling desire tovoid, which isdifficult todefer.129 The symptoms ofurgency may besuffered without any associated lossofurine.133 Urinary dysfunction inmen, caused bybenign prostatic hyperplasia (noncancerous enlargement ofthe prostate) iscommon inolder men. Itaffects 50% of60-year-old men and 90% ofmen over 85years ofage. Symptoms include urinary frequency, nocturia, urgency, poor stream, hesitancy, straining tovoid and asensation ofincomplete bladder emptying and post-voiddribbling.134
Denitions
A comprehensive list ofdefinitions ofthe symptoms, signs, urodynamics, observations and conditions associated with lower urinary tract dysfunction and urodynamics studies, for use inall age groups, isprovided byAbrams etal.124 Further explanations ofrecommended terminology areprovidedbyAbrams.129 While numerous falls inRACFs occur when going toor returning from the toilet,135 causal factors associated with falls inolder people with and without cognitive impairment are many and varied.108 The close associations reported between incontinence, dementia, depression, falls and level ofmobility suggest that these geriatric syndromes may have shared risk factors rather than causalconnections.120 Other mechanisms bywhich urinary and fecal incontinence can increase falls risk include thefollowing: Anincontinence episode increases the risk ofaslip onthe soiled orwet floorsurface.113 Urinary incontinence isasignicant risk factor for falls inresidents who cannot standunaided.50 The residents 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.136 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 risk offalls through increased urinary frequency orthrough hypovolaemia (low bloodvolume). Deteriorating vision, acommon condition inthe elderly, isstrongly associated with falls;113 itmay also increase the likelihood offalls that are associated with getting out ofbed atnight, andnocturia.
8.1.2 Incontinence and falls interventions inresidential aged carefacilities

Older people are often reluctant todiscuss issues around urinary and fecal continence. Health care professionals and care staff should beencouraged toenquire routinely about continence rather than rely onthe resident tomention itduringaconsultation. Toileting-assistance programs are animportant and practical approach tomaintaining continence for many residents, and may also reduce the risk offalls.60 The three types oftoileting-assistance programs (timed voiding, habit retraining and prompted voiding) are discussed inSection8.2. Cochrane Collaboration systematic reviews onthese interventions found limited evidence ontheir effectiveness; further studies areneeded.137-139 One randomised controlled trial found that anintervention that combines low-intensity exercise with anactive toileting-management plan can improve functional outcomes and urinary and fecal continence.60 Regular toileting regimes are important inRACFs toreduce the riskoffalls. A Cochrane systematic review showed pelvic floor muscle training can beused totreat women with mixed incontinence, and less commonly totreat urge incontinence. However, limitations ofthe data make itdifficult tojudge whether pelvic floor muscle training was better orworse than other treatments inmanaging OAB symptoms.140 There isevidence from asystematic review tosupport conservative management offecalincontinence.141
8 Continence
53
8.2.1 Screeningcontinence
The cause ofincontinence should beestablished through athorough assessment. Older people may have more than one type ofurinary incontinence, which can make assessment findings difficult tointerpret.142 Otherwise, the following strategies can beused toassess the residents continencestatus: Obtain acontinence history from the resident tohelp with assessment and diagnosis. This may include abladder chart (a frequency/volume chart) orcontinence diary, which could beused torecord continence for aminimum oftwo days. Sometimes abowel assessment isrequired, and the residents normal bowel habits and any significant change must bedetermined, because constipation can considerably affect bladderfunction. The suitability ofdiagnostic physical investigations should beaddressed onan individual basis. Consent must beobtained from the resident before the physical examination, which should bedone byasuitably qualied healthprofessional. Post-void residuals should always bechecked inincontinentresidents. Falls risk factors related toincontinence need tobe considered along with the symptoms and signs ofbladder and boweldysfunction. Functional considerations, such asreduced dexterity ormobility, can affect toileting, and should beassessed andaddressed. Consideration should begiven tothe toilet environment itself; this includes accessibility (especially ifthe resident uses awalking aid), proximity, height and the number ofhousehold members using the sametoilet.
8.2.2 Providing strategies topromotecontinence

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 inthe RACF setting.113 Apractical, stepwise management approach for mobile and nonmobile residents, aswell asresidents with and without cognitive impairment, should beconsidered. Such anapproach could bebased onthe United States Government recommendations about quality management ofurinary incontinenceinRACFs.143 The following strategies, adapted from those recommended bythe Third International Consultation onIncontinence,144 can beused topromotecontinence: Make sure the resident has access toacomprehensive and individualised continence assessment that identifies and treats reversible causes, including constipation and medication sideeffects. Use anadequate trial ofconservative therapy asthe rst lineofmanagement. Establish treatment strategies assoon asincontinence has been diagnosed. The aim ofmanaging urinary incontinence isto alter those factors causing incontinence and toimprove the continence status ofthe resident. Management ofincontinence isamultidisciplinary task that ideally involves doctors, nurse continence advisers, physiotherapists, occupational therapists and other suitably qualified health professionals and carestaff. Address all comorbidities that canbemodied. Encourage habit training, prompted voiding ortimed voiding programs tohelp improve the residents control over their toileting regime, and reduce the likelihood ofincontinenceepisodes timed voiding ischaracterised byaxed scheduleoftoileting habit retraining isbased onidentifying apattern ofvoiding and tailoring the toileting schedule totheresident prompted voiding aims toincrease continence byincreasing the residents ability toassess their own continence status and torespondappropriately.
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Minimise environmental risk factorsasfollows keep the pathway tothe toilet obstacle free and leave alight onin the toiletatnight ensure the resident iswearing suitable clothes that can beeasily removedorundone recommend appropriate footwear toreduce slippinginurine consider using anonslip mat onthe floor beside the bed for residents who experience incontinence onrising from the bed, particularly ifon anoncarpeted floor inthe bedroom (care must betaken when using mats toensure the resident does not trip onthemat) check the height ofthe toilet and the need for rails tohelp the resident when sitting and standing from the toilet (reduced range ofmotion inhip joints, which iscommon after total hip replacement orsurgery for fractured neck offemur, might mean the height ofthe toilet seat shouldberaised). Where possible, consult acontinence adviser ifusual continence-management methods asdescribed above are not working, orif the resident iskeen tolearn simple exercises toimprove their bladder orbowel control. Some men are resistant tothe idea ofdoing pelvic floor exercises. This should berecognised and the benetsexplained. Consider the use ofcontinence aids asatrial managementstrategy.
Casestudy
MrW lives inalow-care residential aged care facility. Hecannot stand and adjust his clothes when going tothe toilet without losing his balance and wetting his clothes. Hecannot manage aurinal without having similar incidents. Staff implemented atoileting strategy where MrW was prompted togo tothe toilet every two hours and was changed ifhe was wet. This has resulted inno wet clothes and henow goes tothe toilet safely. Adetailed assessment and management ofhis continence istobeundertaken.
Acute delirium can becaused byboth urinary and gastrointestinal problems. Cognitive impairment and dementia can also lead toproblems with both urinary and fecal continence. Regular toileting isrecommended for residents with cognitive impairment. Residents with cognitive impairment may benet from prompted voiding,137 scheduled toileting and attention tobehaviour signals indicating the desire tovoid. Aim toidentify each residents specic toileting times and prompt them togo around those times. Residents 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 professionals inimplementing best practice. Resources (such asleaflets) providing advice onmanaging incontinence areavailable.

RACF staff 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 orfrom the 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.
http://www.continence.org.au
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No economic evaluations were found that examined the cost effectiveness ofcontinence management inthe RACFsetting.
The Continence Foundation ofAustralia (CFA) 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 CFA manages the National Continence Helpline onbehalf ofthe Australian Government. This free service, staffed bynurse continence advisers, provides confidential information onincontinence, continence products and localservices. National Continence Helpline: 1800 330066 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, who 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 (NICE), based inthe United Kingdom, provides guidance onpromoting good health and preventing and treating ill health. See their evidence based guidelines onmanaging urinaryincontinence: http://www.nice.org.uk

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9 Feet andfootwear
Recommendations
Assessment
In addition tostandard falls risk assessments, screen residents for ill-fitting orinappropriatefootwear.
Intervention
As part ofamultifactorial intervention program, prevent falls bymaking sure residents have tted footwear.(LevelII) 31
Good practicepoints
Include anassessment offoot problems and footwear aspart ofan individualised, multifactorial intervention for preventing fallsinresidents. Refer residents toapodiatrist for assessment and treatment offoot conditionsasneeded. 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.
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9.1.1 Footwear associated with increased fallsrisk
Footwear isacontributing factor tofalls145 and fractures inolder people.146 Studies (of differing design and quality) have reported the followingresults: Poorly tting footwear orfootwear inappropriate for the environmental conditions impairs foot position sense inboth younger and oldermen.147 Wearing shoes with inadequate fixation (ie shoes without laces, buckles orvelcro fastening) isassociated with anincreased riskoftripping.146 Wearing high-heeled shoes impairs balance compared with low-heeled shoes orbeingbarefoot.148 Mediumhigh heeled shoes and shoes with anarrow heel signicantly increase the likelihood ofsustaining all types offracture, while slip-on shoes and sandals increase the risk offoot fractures asaresultofafall.149 Slippers are often the indoor footwear ofchoice for many older people, but are associated with anincreased risk ofinjuriousfalls.150 Walking barefoot orin socks isassociated with a1013-fold increased risk offalling, with athletic shoes being associated with the lowestrisk.149 A retrospective, observational study showed that three-quarters ofpeople who have suffered afallsrelated hip fracture inthe community were wearing footwear with atleast one suboptimal feature atthe time ofthe fall.146 Older people should wear appropriately fitted shoes, both inside and outside the house. However, many older people wearing inappropriate footwear believe them tobe adequate.151 Areview ofthe best footwear for preventing falls identied the following shoe characteristics assafe for olderpeople:152 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. Some studies, held specifically inresidential aged care facilities (RACFs), have investigated the effects offootwear assessments. However, only one ofthese studies153 was arandomised controlled trial (and therefore ofahighquality): Footwear assessment isacommon falls prevention strategy used inRACFs; for example, itis used by80% ofRACFs inNewZealand.154 Wearing soft-soled shoes isassociated with areduced risk offalls compared with slippers, soresidents should beencouraged towear shoes rather thanslippers.150 Areduction infalls also occurred inadementia-specific setting when RACF staff provided special socks, incorporating atread, toresidents onretiring for the night.155 This protocol was adopted toreduce the risk ofresidents slipping inurine. The slipper socks were aterry cloth with rubber antisliptreads. Finally, asignificant reduction infalls was observed when appropriate footwear was incorporated aspart ofamultifactorial falls preventionintervention.31 Figure9.1 represents anoptimal safe shoe, and anunsafeshoe.
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PartC
What makes a shoe safe?

Laces or strong fastening to hold the foot rmly Supporting collar, preferably high
Low, square heel to improve stability Thin, rm 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: Lord113
Figure 9.1 The theoretical optimal safe shoe, and unsafeshoe
9 Feet andfootwear
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9.1.2 Footproblems
Foot problems are common inolder people, affecting 6080% ofolder people who live inthe community.156,157 Women report ahigher prevalence offoot problems than men, which might beinfluenced byfashion footwear.158 The most commonly reported foot problemsare:156,159,160 pain from corns, calluses andbunions foot deformities, such ashallux valgus, hammer toes and nailconditions. Foot problems are well recognised asacontributing factor tomobility impairment inolder people. Older people with foot pain walk more slowly and have more difculty performing daily tasks than those without pain.157 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.161,162 Additionally, these foot problems are associated with increased falls risk,163 and this risk rises asthe number offoot problemsincreases.164 Ageing isassociated with reduced peripheral sensation, and several prospective studies have found that participants who experience falls perform worse intests oflower limb proprioception,165 vibration sense166 and tactile sensitivity.167 Reduced plantar tactile sensitivity has also been mentioned asarisk factor for falls,162 because itmight influence the persons ability tomaintain postural control when walking, particularly onirregular surfaces.167 This isparticularly relevant inpeople with diabetes:168 people with diabetic neuropathy have impaired standing stability153 and are atincreased risk for falls and fractures.169 Podiatry may help manage theseconditions.170-172
9.2.1 Assessing feet andfootwear
RACF staff should arrange for the residents feet and footwear tobe assessed aspart ofpre-admission screening orupon admission. Aspart ofamultifactorial falls prevention program, ahealth professional skilled inthe assessment offeet and footwear, such asapodiatrist, should make this assessment although apodiatrist will usually only make this assessment ifthe registered nurse has identied the need for areferral. The following components ofthe assessment are mostrelevant: Footwear: the safe shoe checklist isareliable tool for evaluating specic shoe features that could potentially improve postural stability inresidents173 (seeAppendix4). Foot problems: staff should assess foot pain and other foot problems regularly. Aresident with anundiagnosed peripheral neuropathy should beassessed for potentially reversible ormodiable causes ofthe neuropathy. Some ofthe more common causes ofaperipheral neuropathy include diabetes, vitaminB-12 deficiency, peripheral vascular disease, alcohol misuse and adverse effects ofsomedrugs.174 Refer the resident toahealth professional skilled inthe assessment offeet and footwear (eg apodiatrist) for additional investigations and managementasrequired.175 A detailed assessment byapodiatrist for afalls-specic feet and footwear examination shouldinclude:176 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-tting orinappropriate footwear using the safe shoe checklistasaguide providing residents and carers (where appropriate) with information about footwear, aswell asashoppingguide ensuring shoes are repaired when needed, and cleanedregularly recognising that residents who have ashuffling gait may beat higher risk offalling ifthey wear nonslip shoes onsome carpetedfloors ensuring that residents with urinary incontinence have dry, cleanfootwear ensuring residents have more than one pair ofshoes incase shoes are soiledordamaged discouraging walking while wearing slippery socks andstockings discouraging the use oftalcum powder, which may make floorsslippery screening residents for foot pain orfootproblems educating residents and carers (where appropriate) about basic footcare referring residents toapodiatrist for further assessment and management, asappropriate, ifany ofthe following conditions orclinical signs areevident footpain foot problems, such asswelling, arthritis, bunions, toe deformities, skin and nail problems (especially corns and calluses) orother foot abnormalities (eg collapsed arches orahigh-archedfoot) conditions affecting balance, posture orproprioception inthe lower limbs, such asdiabetes, peripheral neuropathy orperipheral vasculardisease unsteady orabnormalgait inappropriate orill-fitting footwear, orarequirement for footorthoses.
Casestudy
MrsV, who lives inanursing home, has difficulty with her balance and wears loose-fitting slippers. The nurse discussed the benefits ofwearing well-fitting footwear, and with Mrs Vs consent ordered anew pair oftted footwear from their local provider. Aspart ofamultifactorial approach toreduce MrsVs risk ofhaving another fall, she was also referred tothe supervised exercise classes. After one month, MrsV reports aconsiderable improvement inher balance and anincrease inherwalking.
Residents with cognitive impairment may not report discomfort reliably. Therefore, when they have their footwear checked, their general practitioner orother member ofthe health care team should check their feet for lesions, deformity and pressure areas. Footwear and foot care issues should also bediscussed indetail withcarers.

Contact the Australasian Podiatry Council inyour state orterritory for details ofpractitioners visiting rural and remote areas. Inareas where podiatry services are infrequent orunavailable, other health care providers will need toscreen feet and footwear. Services for Australian Rural and Remote Allied Health (SARRAH) is developing resources that may assist rural and remotepractitioners.
http://www.apodc.com.au http://www.sarrah.org.au
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Culturally appropriate resources are currently being developed bySARRAH aspart ofan Indigenous Diabetic Foot Program (see the additional information boxbelow).
No economic evaluations were found that examined the cost effectiveness ofaprogram related tofeet and footwear assessment inthe RACF 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 toRACFs (see Section4.4 inthe communityguidelines).
Australasian PodiatryCouncil: http://www.apodc.com.au Queensland Government Stay onYour Feet falls prevention resources: http://www.health.qld.gov.au/stayonyourfeet Safe shoe checklist (SeeAppendix4) American Podiatric Medical Association: contains brochures, fact sheets and other information ontopics such asageingfeet: http://www.apma.org/s_apma/sec.asp?CID=371&DID=17070 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
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10 Syncope
Recommendations
Assessment
Residents who report unexplained falls orepisodes ofcollapse should beassessed for the underlyingcause.
Intervention
Assessment and management ofpresyncope, syncope and postural hypotension, and review ofmedications (including medications associated with presyncope and syncope) should form part ofamultifactorial assessment and management plan for preventing falls inresidents.(LevelI-*) 34 Older people with unexplained falls orepisodes ofcollapse who are diagnosed with the cardioinhibitory form ofcarotid sinus hypersensitivity should betreated with the insertion ofadual chamber cardiac pacemaker.(LevelII-*) 177
Note: there isno evidence derived specically from the residential aged care setting relating tosyncope and falls prevention. Recommendations have been inferred from community and hospitalpopulations.
63

Syncope isdened 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. While anumber ofconditions can present with syncope, all share the nal common pathway ofcerebral hypoperfusion leading toan alteration inconsciousness. Older people are more predisposed tosyncopal events due toage-related physiological changes that affect their ability toadapt tochanges incerebralperfusion.
The overall incidence ofsyncope inolder people who live inthe community has been reported as6.2 per 1000person years.178 Equivalent figures for residents living inresidential age care facilities (RACFs) donot exist. Some ofthe more common causes ofsyncope inolder people include 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.178 Vasovagal syncope isoften preceded bypallor, sweatiness, dizziness and abdominal discomfort, although these features are not always seen inthe older person.178 Commonly reported precipitants ofvasovagal syncope include prolonged standing (particularly inhot orconfined conditions), fasting, dehydration, fatigue, drinking 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 older person 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 orlying position. The drop inblood pressure can beenough tocause symptoms ofdizziness orprecipitate asyncopal event.179,180 Postural (orthostatic) hypotension isassociated with anincreased riskoffalls.178,180 A formal diagnosis ofpostural hypotension ismade byrecording adrop insystolic blood pressure ofat least 20mmHg oradrop indiastolic blood pressure ofat least 10mmHg within three minutes ofstanding. The person should belying still for atleast ve minutes before measuring blood pressure (while the person remains lyingdown). 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 and 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 (such asParkinsons disease, stroke and diabetes) can also have adirect impact onautonomic function and interfere with blood pressure regulation. Prolonged periods ofimmobility can disrupt postural control ofbloodpressure. Treatment involves identifying the precipitating cause and modifying medications, where possible. Maintaining adequate hydration, particularly during hot weather, isimportant for the older person (see the point ofinterest box onmaintaining hydration inSection7.2.2). Pharmacological intervention isneeded inasmall number ofcases totreat postural hypotension. Drugs that might beused include fludrocortisone ormidodrine (an alpha-agonist), but only for autonomic postural hypotension after all other treatments have beentrialled.
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10.1.3 Carotid sinushypersensitivity

Carotid sinus hypersensitivity (CSH) isan abnormal haemodynamic response tocarotid sinus stimulation. When associated with symptoms, itis referred toas acarotid sinussyndrome. CSH may occur when the head isrotated orturned, orwhen pressure isplaced onthe carotid sinus. Triggers may include carotid massage, shaving, wearing tight collars orneckwear, ortumourcompression.181 Three abnormal responses can benoted ondirect massage ofthe carotid sinus. Acardioinhibitory response isdened asathree-second period ofasystole following massage ofthe carotid sinus. The vasodepressor response isdened bya50mmHg drop inblood pressure inthe absence ofsignicant cardioinhibition. Acombination ofthe vasodepressor and cardioinhibitory response denes the mixed formofCSH. While carotid sinus hypersensitivity isthe cause ofasmall percentage offalls inolder people, itis potentially amenable tointervention.177,182-184 One randomised controlled trial showed that detailed cardiovascular assessment (including carotid sinus massage, tilt-table examination, echocardiogram and 24-hour Holter monitoring) of24251older people presenting toan emergency department after anunexplained fall with injury identified 257people with cardioinhibitory carotid sinus hypersensitivity, and this led toasubsequent reduction infurtherfalls.177
10.1.4 Cardiacarrhythmias
Abnormal rhythms ofthe heart can lead todizziness and syncope. Sick sinus syndrome isan abnormal slowing ofthe heart caused bydegeneration ofthe cardiac conducting system, and isassociated 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); treatment isreducing orstopping thesemedications. Rapid heart rates from abnormal cardiac rhythms can also cause dizziness and syncope. Diagnosis ofan abnormal heart rate requires aperson being monitored atthe time ofthe abnormal heart rate and can often bechallenging. Treatment depends onthe nature ofthe abnormalrhythm.
Residents reporting presyncope orsyncope should have appropriate assessment and intervention. Their symptoms should bereported totheir general practitioner, and anumber oftests and further investigations may bewarranted, depending onthe history and results ofthe clinical examination. Further tests may include anelectrocardiogram (ECG), echocardiography, Holter monitoring, tilt-table testing, and carotid sinus massage orinsertion ofan implantable loop recorder. The European Taskforce onSyncope has produced asimple algorithm for investigating syncope (see the additional informationbox).179 Permanent cardiac pacing issuccessful intreating certain types ofsyncope. Pacemakers prevent falls by70% inpeople with accurately diagnosed cardioinhibitory carotid sinus hypersensitivity.177 Anumber ofsuccessful multifactorial falls prevention strategies inthe community and hospital settings have included assessments ofblood pressure and orthostatic hypotension, and medication review andmodication.112,119,185-188 The symptoms oforthostatic hypotension can bereduced using the followingstrategies: Ensure good hydration ismaintained, particularly inhotweather.4,189,190 Encourage the resident tosit upslowly from lying, stand upslowly from sitting and wait ashort time beforewalking.189,190 Minimise exposure tohigh temperatures orother conditions that cause peripheral vasodilation, including hotbaths.190 Minimise periods ofprolonged bed rest andimmobilisation. Encourage residents 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.190 Monitor and record postural bloodpressure.4
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Casestudy
MrsB isan 89-year-old woman living inaresidential aged care facility (RACF). She has hypertension and has had astroke, which left her with speech impairment and the need for help with activities ofdaily living. Carers reported tonursing staff that, when they helped MrsB out ofbed togo tothe bathroom, her legs had given way. The carers felt that ifthey had not supported her, she would have fallen tothe floor. Staff measured MrsBs lying and standing blood pressures and found that her blood pressure onstanding dropped more than 20mmHg (systolic). They reported this toher general practitioner who reviewed MrsBs medications, including her antihypertensive agent. The dose ofher antihypertensive was reduced. Inaddition, staff were encouraged toensure that MrsBs fluid intake was sufficient and that she was provided with the necessary assistance todrink onaregular basis throughout theday. The RACF nurse manager requested staff toinitiate amedical review ifaperson was identified ashaving light-headedness ordizziness related topostural hypotension. Staff are now careful toassess for hypotension ifpeople are dizzy. The staff have implemented several new strategies toassist residents to maintain their hydration, such asensuring all residents have afull glass offluid with medications, and regular drinksbreaks.

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Some disease states that are possible causes ofpostural hypotension are associated with cognitive impairment. Cognitively impaired people may beunable toarticulate feelings ofdizziness, light-headedness orfaintness. Intermittent monitoring oflying and standing blood pressure isrecommended for people with cognitiveimpairment.
No economic evaluations were found that examined the cost effectiveness ofinterventions for syncope inthe RACFsetting.
The following reference maybeuseful: Task Force onSyncope, European Society ofCardiology (2004). Guidelines onmanagement (diagnosis and treatment) ofsyncope Update 2004. European HeartJournal 25(22):20542072. 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 inresidents inthe residential care setting. Ahistory ofvertigo orasensation ofspinning ishighly characteristic ofvestibularpathology. Use the DixHallpike test todiagnose benign paroxysmal positional vertigo. This isthe most common cause ofvertigo inolder people, and can beidentified inthe residential aged care 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 vestibular rehabilitation totreat dizziness and balance problems where indicated andavailable. Use the Epley manoeuvre tomanage benign paroxysmal positionalvertigo. Manoeuvres should only bedone byan experiencedperson.
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Dizziness and vertigo are common inall age groups, but the prevalence increases markedly with age.191 Onquestioning, one inthree older people who lived inthe community reported symptoms ofdizziness.192 Although there are noequivalent studies inthe residential aged care setting, these figures are likely tobe similar, ifnot higher, due toadvancedage. Dizziness inolder people often represents adifficult diagnostic problem, because itis asubjective sensation that may result from impairment ordisease inmultiple systems.193 The underlying cause ofdizziness isunknown in2040% ofpeople reporting symptoms ofdizziness.194 Vestibular dysfunction has been indicated inapproximately 50% ofpeople older than 70years who have been referred toadizziness orbalance clinic for evaluation,195 with the single most common diagnosis being benign paroxysmal positional vertigo(BPPV). When residents describe being dizzy, giddy, orfaint, this may mean anything from ananxiety orfear offalling topostural dysequilibrium, vertigo orpresyncope; adetailed historyiscrucial.
11.1.1 Vestibular disorders associated with anincreased riskoffalling

Vestibular dysfunction isacommon cause ofdizziness inthe older population;195 however, the association between vestibular dysfunction and falls remains unclear.196 Age-related changes inthe vestibular system can beidentied inpeople older than 70years.197 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 of66adults found that older people who lived inthe community and who had sustained wrist fractures asaresult ofan accidental fall were more likely tohave vestibular asymmetry ontesting than anage-matched groupofnonfallers.198 People with BPPV often have balance problems; however, more research isneeded toidentify whether there isan association between BPPV and falling inolder people.199 Across-sectional study of100people found that 1 in10older people presenting toan outpatient clinic with arange ofchronic medical conditions had undiagnosed BPPV, and these people were more likely tohave sustained afall inthe previous threemonths.180
11.2.1 Assessing vestibularfunction
An important step inminimising the risk from falls associated with dizziness isto assess vestibular function. This can bedone inthe residential aged care facility (RACF) setting using the following steps and tests (these tests should only bedone byan experiencedperson): Ask the resident about their symptoms. Dizziness isageneral term that isused todescribe arange ofsymptoms that imply asense ofdisorientation.197 Dizziness may beused todescribe poor balance. Vertigo, asubtype ofdizziness, ishighly characteristic ofvestibular dysfunction and isgenerally described asasensationofspinning.198 Assess peripheral vestibular function using the Halmagyi head thrust test.200 Itonly has good sensitivity ifthe vestibular dysfunction issevereorcomplete.201 Use audiology testing toquantify the degree ofhearing loss. The auditory and vestibular systems are closely connected; therefore, auditory symptoms (hearing loss, tinnitus) commonly occur inconjunction with symptoms ofdizziness andvertigo.202 Ifclinically indicated, request computed tomography ormagnetic resonance imaging toidentify anacoustic neuroma orcentralpathology.191 Use the DixHallpike manoeuvre todiagnose BPPV. This test isincluded inadiagnostic protocol ingeneral practice for evaluating dizziness inolder people202 and isconsidered mandatory inall people with dizziness and vertigo after head trauma.203 BPPV should bestrongly considered aspart ofthe differential diagnosis inolder people who report symptoms ofdizziness orvertigo after afall that involved some degree ofheadtrauma.
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Use vestibular function tests toevaluate the integrity ofthe peripheral (inner ear) and central vestibular structures. These tests are available atsome specialised audiology clinics and may berecommended ifsymptomspersist.204 Refer the resident toaspecialist, such asan ear, nose and throat specialist oraneurologist,ifrequired.191
11.2.2 Choosing interventions toreduce symptomsofdizziness

The following strategies can beused inthe RACF setting totreat dizziness and balance problems caused byvestibular dysfunction. They can beused aspart ofamultifactorial falls prevention program toreduce the risk offalls relatedtodizziness.
PartC
Medicalmanagement
Based onclinical experience, treatment with antiemetics and vestibular suppression medication may berequired totreat the unpleasant associated symptoms ofnausea and vomiting. These medications should only beused for ashort time (one totwo weeks) because they adversely affect the process ofcentral compensation after acute vestibulardisease.204
Treating benign paroxysmal positionalvertigo

The literature describes arange ofoptions for treating BPPV,including: Brandt and Daroff exercises these can bedone regularlyathome205 the Epley manoeuvre involves taking the resident slowly through arange ofpositions that aim tomove the freely mobile otoconia back into the vestibule.206 Ameta-analysis showed that this manoeuvre ishighly successful for treatingBPPV.207 Older people with diagnosed BPPV respond aswell totreatment asthe general population; therefore, nospecial approaches are needed inthis group.207 However, itis important todiagnose and treat BPPV assoon aspossible, because treatment improves dizziness and general wellbeing.208 This isparticularly true inthe RACFsetting.
Vestibularrehabilitation
Vestibular rehabilitation (VR) isamultidisciplinary approach totreating stable vestibular dysfunction. The physiotherapy intervention component focuses onminimising apersons complaints ofdizziness and balance problems through aseries ofexercises, which are modified tosuit each person.192 The occupational therapy intervention component involves incorporating the movements required todo these exercises into daily activities,209 and the psychology input addresses the emotional impact ofvestibulardysfunction.210 The literature emphasises the following characteristicsofVR: VRis highly successful intreating stable vestibular problems inpeople ofallages.211 Starting VRearly isrecommended inthe community and hospital settings. Delayed initiation ofVR isasignicant factor inpredicting unsuccessful outcomes overtime.212 Age does not signicantly affect outcomes following aprogram ofVR inolder people who live inthe community,213 although cognitive impairment may influence ability tocomply with the exerciseprogram. Asupervised program ofVR can beprovided inRACFs toaddress safety and cognitive issues specific tothis setting. Successful outcomes have been demonstrated with supervised VRprovided once aweek,214 aswell asthree tove times perweek.215 VRcan improve measures ofbalance performance inpeople older than 65years who live inthe community.194,216 However, astudy ofpeople with multisensory dizziness showed that the prevalence offalls over a12-month period did not differ between those receiving VRand acontrolgroup.217 Regular training courses inVR are held across Australia, and increasing numbers ofphysiotherapists working inacute and subacute hospital systems are now trained toassess and manage dizziness. These physiotherapists can befound bycontacting the Australian Physiotherapy Association orthe Australian VestibularAssociation.
http://members.physiotherapy.asn.au http://www.dizzyday.com/avesta.html
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Casestudy
MrsP isan 87-year-old woman who lives inaresidential aged care facility. She requires help with personal care activities, such asshowering and dressing, and has had several recent falls. MrsP dislikes lying flat inbed and now sleeps with the head ofher bed elevated. She avoids rolling over and requires light assistance toget out ofbed inthe morning. Her visiting general practitioner requested that MrsP betested for benign paroxysmal positional vertigo (BPPV). DixHallpike testing identified this condition inher right inner ear. Following treatment using anEpley manoeuvre, MrsP reported that she feels more stable onher feet and uses only two pillows atnight. She has had nofurther falls since having her BPPVtreated.

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DixHallpike testing should not bedone onpeople with anunstable cardiac condition orahistory ofsevere neck disease,218 but can bemodied inolder people with othercomorbidities.219 Older people with symptoms ofdizziness should bemedically reviewed before starting arehabilitation program asoutlinedabove.
No economic evaluations were found that examined the cost effectiveness ofinterventions for dizziness inthe RACFsetting.
The following references maybeuseful: Herdman S(2007). Vestibular Rehabilitation (Contemporary Perspectives inRehabilitation) , FADavis Company,Philadelphia. Maarsingh OR, Dros J, van Weert HC, Schellevis FG, Bindels PJ and van der Horst HE(2009). Development ofadiagnostic protocol for dizziness inelderly patients ingeneral practice: aDelphi procedure. BMC Family Practice10:12. More information onnoncardiac dizziness and avideo demonstration ofthe DixHallpike manoeuvre can befound atthe ProFaNEwebsite: http://www.profane.eu.org/CAT
12 Medications
Recommendations
Assessment
Residents ofresidential aged care facilities should have their medications (prescribed and nonprescribed) reviewed atleast yearly byapharmacist after afall, orafter initiation orescalation indosage ofmedication, orif there ismultiple druguse.
Intervention
As part ofamultifactorial intervention,37 oras asingle intervention,32 residents taking psychoactive medication should have their medication reviewed byapharmacist and, where possible, discontinued gradually tominimise side effects and toreduce their risk offalling.(LevelII) Limit multiple drug use toreduce side effects and interactions.(LevelII-*) 37
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A number ofepidemiological studies have shown anassociation between medication use and falls inolder people.186,188,220,221 The risk offalls can beincreased bymedication interaction, unwanted side effects (such asdizziness) and even the desired effects ofmedications (such assedation). Itis important that staff ofresidential aged care facilities (RACFs) and the whole health care team recognise that pharmacological changes with ageing can lead topotentially avoidable events inolder people, including falls andfractures. Medication use inRACFs iscommonplace: 98% ofresidents take atleast one form ofmedication and 63% take four ormore medications.222 Astudy in51nursing homes inthe central Sydney health area found that 47% ofRACF residents took one ormore psychoactive drugs regularly, 11% took hypnotics regularly and 21% took antidepressantsregularly.223
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:113 The ageing process, aswell asdisease, can result inchanges inpharmacokinetics (the time course bywhich the body absorbs, distributes, metabolises and excretes drugs) and pharmacodynamics (the effect 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 inolderpeople: Central nervous system drugs, especially psychoactive medications (egbenzodiazepines), are associated with anincreased risk offalling while taking these drugs, compared with not taking them, ofbetween 1.25(25%) and1.9(90%).224 Benzodiazepine use isaconsistently reported risk factor for falls and fractures inolder people, both after anew prescription and over the long term. They affect cognition, gait andbalance.224 Antidepressants are associated with higher falls risk,225 inparticular specic serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants(TCAs).224 Antiepileptic drugs and drugs that lower blood pressure are weakly associated with anincreased riskoffalls.224 Some cardiovascular medications (diuretics, digoxin and type IQanti-arrhythmic drugs) are weakly associated with anincreased riskoffalls.226 Other types ofcardiac drugs, and analgesic agents, are not associated with anincreased riskoffalls.226 Taking more than one medication isassociated with anincreased risk offalls.186,220,224 This may bearesult ofadverse reactions toone ormore ofthe medications, detrimental drug interactions, increased comorbidity requiring multiple medications 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.220 For each drug, the potential falls risk modification should bebalanced against the benefit ofthedrug.
12.1.2 Evidence forinterventions

A medication review should beacore part ofthe assessment ofRACF residents 32,227 and should bedone regularly for those who have repeat prescriptions. The focus should beon appropriate prescribing that is, checking that medications are used safely and effectively, and that other forms oftreatment ormanagement are considered asalternatives, ifpossible (see the National Medicines Policy from the Australian Government Department ofHealth and Ageing the website isprovided inthe box containing additional information,below). Two published studies have looked atmedication review byapharmacist asasingle intervention inRACFs.32,228 Inone study, the rate offalls inthe intervention groups was lowered significantly compared with the control group (0.8falls per participant inthe intervention group, compared with 1.3falls per participant inthe control group; P<0.0001).32 Inasecond study looking specically atthe transition period between the hospital and RACF, apharmacist transition coordinator was found tobe effective interms ofquality ofprescribing, but was not effective inreducing falls. The study did not use falls asanendpoint.228
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Two other studies reviewed medications aspart ofamultifactorial falls intervention inresidential aged care.31,37 The use ofsuspect medications (including benzodiazepines, antidepressants, diuretics and neuroleptics) and multiple medication use were evaluated, and adjusted tominimise adverse effects. One ofthe studies found asignificant reduction inrecurrent fallers; 37 the other study found areduction infalls inpeople with aMini-Mental State Examination (MMSE) score ofgreater than 19 (see Chapter7 oncognitive impairment for moreinformation). A randomised controlled trial of93older people who lived inthe community looked atthe effectiveness ofdifferent falls prevention interventions the results ofwhich may beapplied with caution tothe RACF setting. The trial assessed the effectiveness ofgradually withdrawing psychoactive medication (compared with not withdrawing medication).229 After about 11weeks, the study group had asignificant reduction (66%) infalls compared with the control group. The preferred approach would therefore beto avoid prescribing psychoactive drugs ifclinically possible. However, due tothe small sample size, these results should beinterpreted with caution particularly because withdrawal from psychoactive drugs isdifcult. The trial did not report adverse effects from medicationwithdrawal.
12.2.1 Reviewingmedications
Medication review inRACFs shouldinclude: reviewing the residents medicationsonadmission227,230-232 reviewing medications annually, after afall, orafter initiation orescalation indosageofmedications230 using apharmacist toreduce the number ofmedications taken byresidents with dementia,32 delirium orachange inhealthstatus. Residential medication management reviews (RMMRs) are available toall permanent residents ofafacility inwhich residential care services are provided, asdefined inthe Aged Care Act 1997. AnRMMR involves collaboration between the residents general practitioner and apharmacist. AnRMMR reviews the residents medications, which are then discussed bythe pharmacist and the referring general practitioner. The key outcome ofthe process isanew orrevised medication management plan that isagreed between the general practitioner and the resident ortheir carer. For more details, see the Australian Government Department ofHealth and Ageingwebsite. Health care professionals and care staff can use the following checklist tohelp decide whether aresident requires amedication review from apharmacist ordoctor. Areview isneeded iftheresident: 230 istaking more than 12doses ofmedicationaday istaking one ormore psychoactivemedications istaking four ormore different typesofmedications has multiple medicalconditions issuspected ofnot adhering totheir medicationregime has symptoms that suggest anadverse medication reaction (eg confusion, dizziness, reducedbalance). New residents are entitled toan RMMR onadmission. Current residents can have anRMMR atthe request oftheir medical practitioner. For instance, anRMMR may beneeded because ofasignificant change inthe residents medical condition ormedicationregimen. The need for anew RMMR isindicatedby: discharge from anacute care facility inthe previous fourweeks signicant changes tothe medication regimen inthe past threemonths change inmedical conditions orabilities (including falls, cognition, physicalfunction) prescription ofmedication with anarrow therapeutic index orrequiring therapeuticmonitoring presentation ofsymptoms suggestive ofan adverse drugreaction subtherapeutic responsetotreatment suspected nonadherence orproblems with managing drug-related therapeuticdevices risk ofinability tocontinue managing own medications (eg due tochanges with dexterity, confusion orimpairedsight).
http://www.health.gov.au/internet/main/publishing.nsf/Content/health-epc-dmmrqa.htm
12 Medications
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The following interventions can beused aspart ofamultifactorial falls risk preventionprogram: Withdraw psychoactive medication gradually and under appropriate supervision toreduce the risk offalls signicantly.229 The National Prescribing Service has guidelines onwithdrawingbenzodiazepines. 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 uptheir risks andbenets.31 Alternatives todrugs that act onthe central nervous system (eg psychosocial treatments) tomanage sleep disorders, anxiety and depression should betried before pharmacological treatment. One study inan RACF found that group education and relaxation training can successfully reduce benzodiazepine use for sleepdisturbance.233 Ifcentrally acting medications such asbenzodiazepines are prescribed, increase surveillance and support mechanisms for residents during the first few weeks oftaking these drugs, because the risk offalling isgreatest during thisperiod.234 Limit multiple drug use toreduce side effects and interactions, and atendency towards proliferation ofmedicationuse.37 In addition, the following strategies help toensure quality use ofmedicines, and are good practice for minimisingfalls: Review medications aspart ofacomprehensive assessment ofaresidents riskoffalling. Prescribe the lowest effective dosage ofamedication specic tothesymptoms. Provide support and reassurance toresidents who are gradually stopping the use ofpsychoactivemedication(s). Ifthe resident needs totake medications known tobe implicated inincreasing the risk offalls, try tominimise the adverse effects (ie drowsiness, dizziness, confusion and gaitdisturbance). Provide the resident and their carer with explanations ofnewly prescribed medications or changes toprescriptions. Educate the whole multidisciplinary team, residents and their carers toimprove their awareness ofthe medications associated with anincreased riskoffalls. Document information when implementing, evaluating, intervening, reviewing, educating and making recommendations about medicationuse.
Casestudy
Mr Fis an80-year-old man whose behaviour had become unmanageable, with outbursts ofviolence towards staff and fellow residents ofhis residential aged care facility (RACF). His gait and posture had changed and hehad become notably drowsy. The nurse incharge athis RACF suspected that constipation could bethe main cause ofhis behavioural change. Aspart ofan evaluation, the nurse initiated aresidential medication management review. After pharmaceutical review, itwas found that recent medication changes had increased MrFs prescription ofhaloperidol (an antipsychotic drug) inresponse tohis behavioural change. Arevised medication management plan was agreed, which addressed MrFs constipation, and gradually reduced and then discontinued the haloperidol. Hewas prescribed vitamin Dand calcium toreduce fracture risk. RACF staff engaged MrFin awalking and group balance program tofurther reduce his riskoffalls.
http://www.nps.org.au/__data/assets/pdf_le/0004/16915/ppr04.pdf
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Neyens etal235 investigated the effectiveness ofamultifactorial intervention inpreventing falls inpsychogeriatric RACF residents. Intervention components included anticipating circumstances and precursors offalls, reviewing and modifying medication, providing individualised exercise programs and assessing the residents need for protective aids. Asignicantly lower incidence rate offalls was observed inthe interventiongroup. Zermansky etal32 included people with dementia intheir randomised controlled trial with residents ofcare homes. The intervention was aclinical medication review byapharmacist. Residents inthe intervention group experienced fewer falls than those who received usual care (0.8falls versus 1.3). Nearly 33% ofdrugs that were discontinued were central nervous system drugs, and close to60% ofmedications initiated were calciumorvitaminD.

Staff ofremote RACFs may need toseek further professional advice about managing medications. Thewebsites ofthe National Prescribing Service, specifically, the Therapeutic Advice and Information Service, maybeuseful.
A retrospective observational study examined the clinical and cost impact ofafalls-focused pharmaceutical intervention program.236 The study compared people who fell during aone-year period before the program was introduced with those who fell during the year after the program was introduced. The program was run inaUnited States rehabilitation facility and consisted ofaconsultant pharmacist making recommendations about monitoring and altering residents drug therapy. The authors reported that the intervention resulted ina47% reduction infalls, and estimated that the program would save US$7.74 per resident per day inavoided falls costs.236 The study did not include afull cost effectivenessanalysis. Some community interventions have been found tobe effective and cost effective; however, itis unclear whether the results are applicable tothe RACF setting (see Chapter12 inthe community guidelines for moreinformation).
http://www.nps.org.au/ http://www.nps.org.au/health_professionals/consult_a_drug_information_pharmacist
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Physician and pharmacist roles inassessment and evaluation procedures are governed bythe relevant professional practice standards andguidelines: Australian Pharmaceutical Formulary(APF) Pharmaceutical Society ofAustralia(PSA): http://www.psa.org.au The Society ofHospital Pharmacists ofAustralia(SHPA): http://www.shpa.org.au

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Useful resources forstaff

Australian Medicines Handbook, 10th edition (2009), produced byAustralian Health Consumers Forum and the Australasian Society ofClinical and Experimental Pharmacologists and Toxicologists (ASCEPT), the Pharmaceutical Society ofAustralia (PSA) and the Royal Australian College ofGeneral Practitioners(RACGP). Australian Medicines Handbook Drug Choice Companion: Aged Care, 2nd edition (2006); includes afalls preventionsection. Australian Pharmaceutical Advisory Council (APAC): http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-advisory-apac_mem.htm Australian Pharmaceutical Formulary and Handbook, 21st edition (2009), published bythe Pharmaceutical Society ofAustralia (PSA), includes guidelines and practice standards for medication managementreview: http://www.psa.org.au Medical Care ofOlder Persons inResidential Aged Care Facilities , 4th edition of (2006), published bythe Royal Australian College ofGeneral Practitioners, provides general practitioners and other health care professionals with advice onhow todeliver quality care inresidential aged carefacilities: http://www.racgp.org.au/guidelines/silverbook MIMS medicines database, which includes full and abbreviated information and overthecounter information Contact: CMPMedica Australia Phone 02 99027700 http://www.mims.com.au National Medicines Policy: http://www.health.gov.au/internet/main/publishing.nsf/Content/National+Medicines+Policy-1 National Prescribing Service (NPS); incorporates drug information service for healthprofessionals: http://www.nps.org.au The Therapeutic Advice and Information Service (TAIS) can becontactedon1300138677. National Strategy for Quality Use ofMedicines: http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdf-natstrateng-cnt.htm Pharmaceutical Health and Rational Use ofMedicines (PHARM) Committee: http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-advisory-apac-pharm Residential Medication Management Review(RMMR): http://www.health.gov.au/internet/main/publishing.nsf/Content/health-epc-dmmrqa.htm SHPA Committee ofSpeciality Practice inDrug Use Evaluation (2004). SHPA standards ofpractice for drug use evaluation inAustralian hospitals. Journal ofPharmacy Practice34(3):220223. Relevant state and territory drug informationcentres. Relevant state and territory pharmaceutical advisoryservices.
Useful resources forresidents

Adverse Medicine EventsLine Phone: 1300 134237 Consumer Medicine Information (CMI): http://www.health.gov.au/internet/main/Publishing.nsf/Content/nmp-consumers-cmi.htm National Prescribing Service (NPS), which incorporates drug information service onthe MedicinesLine Phone: 1300 888763 Pharmaceutical Society ofAustralia (PSA) self-care health information cards entitled Preventing Falls and Wise Use ofMedicines ; available from the PSA, local pharmacy orat http://www.psa.org.au Pharmacy Guild ofAustralia Phone: 02 6270 1888 Fax: 02 6270 1800 Email:guild.nat@guild.org.au http://www.guild.org.au/index.asp
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PartC
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13 Vision
Recommendations
Assessment
Arrange regular eye examinations (every two years) for residents inresidential aged care facilities toreduce the incidence ofvisual impairment, which isassociated with anincreased riskoffalls.
Intervention
Residents with visual impairment related tocataract should have cataract surgery assoon aspracticable.(LevelII-*) 237,238 Environmental assessment and modication should beundertaken for residents with severe visual impairments (visual acuity worse than 6/24).(LevelII-*) 239 When correcting other visual impairment (eg prescription ofnew glasses), explain tothe resident and their carers that extra care isneeded while the resident gets used tothe new visual information. Falls may increase asaresult ofvisual acuity correction.(LevelII-*) 240 Advise residents 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-*) 241
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. One trial, set inthe community, showed anincrease infalls asaresult ofvisual acuity assessment and correction. 240 However, correcting visual impairment may improve the health ofthe older person inother ways (egby increasing independence). Considerable research has linked falls with visual impairment inthe community setting, although notrials have reduced falls bycorrecting visual impairment, and these results may also apply tothe residential aged caresetting.
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Residents ofresidential aged care facilities (RACFs) often have more significant visual impairment than the general population.242,243 The leading causes ofvisual impairment for residents are cataracts (which are potentially reversible), followed byage-related macular degeneration (whichisirreversible).242,244 Much ofthe information inthis chapter isbased onresearch undertaken inthe community setting. Inmost cases, the findings and recommendations can beextrapolated tothe RACF setting; however, recommendations should befollowed withcaution.
13.1.1 Visual functions associated with increased fallsrisk

Studies have shown that reduced visual acuity isan important risk factor for falls inhigh-care RACFs.245 Inthe presence ofocular disease, reduced visual acuity isan independent risk factor for recurrent falls.246 Aretrospective study showed that the risk ofmultiple falls increases 2.6times ifvisual acuity isworse than 6/7.5.247 Similarly, aprospective study showed that visual acuity of6/15 orworse nearly doubles the risk ofhip fracture, and this risk isgreater with even lower visual acuitylevels.248 Some prospective studies show that other visual functions have also been associated with anincreased risk offalling. These visual functions include reduced contrast sensitivity,180,249 poor depth perception250,251 and reduced visual eldsize.247,252-255 Having avisual impairment may increase the relative falls risk byan average of2.7times inRACF residents.256 Some research inlow-care RACFs shows that residents who fall have reduced contrast sensitivity compared with residents who donotfall.250 A 2004 Cochrane review found that there were not enough data tomake recommendations about correcting visual impairment toprevent falls inany setting (community, hospital,RACFs).34 Despite this, considerable research inthe community setting has linked reduced vision with anincreased risk offalls orfractures. These findings may beapplicable tothe RACF setting and are highly relevant tothis high-risk group, given the groups higher rate ofvisual impairment and increased frailty. This section outlines interventions that can beconsidered good practice, despite alack ofdata ontheir effectiveness when usedinisolation.
13.1.2 Eye diseases associated with anincreased riskoffalling

Visual changes resulting from cataracts (see Figure13.2) are associated with postural instability257 and anincreased falls risk inolder people who live inthe community.258 People with glaucoma can present with arange ofloss ofperipheral visual fields (side vision) depending ondisease severity (see Figure13.3); this affects apersons postural stability259 and ability todetect obstacles and navigate through cluttered environments.253,260 Macular degeneration can cause loss ofcentral vision depending upon disease severity (see Figure13.4) and isassociated with impaired balance261 and increased riskoffalls.262 Figure13.1 shows normal vision,asacomparison.
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Source: Courtesy of 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
13 Vision
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13.2.1 Screeningvision
The following strategies may beused tomeasure vision problems inresidentsofRACFs: Ask the resident about their vision and record any visual complaints and history ofeye problems and eyedisease. Check for signs ofvisual deterioration. These can include the residents ability tosee detail inobjects, read (including avoiding reading) orwatch television; atendency tospill drinks; oratendency tobump intoobjects. Measure visual acuity orcontrast sensitivity using astandard eye chart (eg Snellen eye chart) orthe Melbourne Edge Test (MET), respectively (seeTable13.1). Check for signs ofvisual eld loss using aconfrontation test (see Table13.1) and refer the resident for afull automated perimetry test byan optometrist orophthalmologist ifany defects are found. Large, prospective studies found that prospective falls were mostly asaresult ofloss offield sensitivity, rather than loss ofvisual acuity and contrastsensitivity.252,253
Table13.1 Characteristics ofeye-screeningtests
Snellen eye chart (for testing visualacuity)

Description Standardised eye test ofvisual acuity. Comprises aseries ofsymbols (usually letters) inlines ofgradually decreasing sizes. Participant isasked toread the chart from adistance of6metres for standard charts (charts designed for shorter test distances are available; the examiner should check that they are using the correct working distance for the chart). Charts should also bewell lit and not obscured byglare orshadows. Visual acuity isstated asafraction, with 6being the numerator and the last line read the denominator (the larger the denominator the worse the visual acuity). Pocket versions ofSnellen charts are available for aclinical screen ofvisual acuity (these smaller charts can beused atashorter distance than the standard 6metres totest visualacuity). Time needed Criterion 5minutes A score of6/12 indicates visual impairment; however, this depends onthe age ofthe person (the cut-off score will decrease with increasingage).
Melbourne Edge Test (MET) (for testing contrastsensitivity) 263

Description The test presents 20 circular patches containing edges with reducing contrast. Correct identication ofthe orientation ofthe edges onthe patches provides ameasure ofcontrast sensitivity indecibel units, where dB=10log10contrast, where contrast denes the ratio ofluminance levels ofthe two halves ofthe circularpatch. Time needed Criterion 5minutes A score ofless than 18/24 indicates visual impairment; however, the results are agedependent.
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Confrontation Visual FieldTest264

Description Crude test ofvisual elds. Participant and examiner sit between 66cm and 1m apart atthe same height, with the examiners back towards ablank wall. Totest the right eye, the participant covers the left eye with the palm ofthe hand and stares atthe examiners nose. 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, What isthe total number ofngers Iam holding up? The procedure isrepeated for the lower half ofthe eld but changing the number ofngers extended ineach hand. The procedure isrepeated for the left eye. Ifthe participant incorrectly counts the number offingers inthe upper orlower field, itshould berepeated again and recorded. Ifthe participant moves fixation toview the peripheral targets, repeat the presentation. Results are recorded asnger counting elds Rand Lif the participant correctly reports the number offingers presented. For those who fail this screening, adiagram should bedrawn toindicate inwhich part ofthe eld the participant madeanerror. Time needed Criterion 4minutes If the participant incorrectly reports the number offingers held upfor either eye, they should bereferred for afull visual eldtest.
If more detailed visual assessment isneeded once the resident has been assessed using the crude visual screening methods described above, orif the resident scores poorly onthese tests, RACF staff should refer them toan optometrist, orthoptist orophthalmologist for afull visionassessment.
No studies have looked atvision intervention inRACFs. However, research inthe community setting about reducing falls risk through vision intervention may also beapplicable toRACFs. Interventions that could beused include thefollowing: Expedited cataract surgery: this isthe only evidence based intervention todate that iseffective for reducing both falls and fractures inolderpeople.237,238 Occupational therapy interventions: inpeople with severe visual impairments, 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; these include providing adequate lighting and contrast (eg painting white strips along the edges ofstairs and pathways).239,265 Three studies inRACFs included environmental modication aspart ofasuccessful multifactorial intervention program31,33,37 (see Chapter14 onenvironmental considerations for moreinformation). Detecting new visual problems: when anew visual problem isdetected, staff ofthe RACF should refer the resident toan eyespecialist112 ifthe resident has impaired visual acuity, wears spectacles that are scratched ordo not fit comfortably, orhas not had aneye examination inthe pastyear ifthere isno known reason for poorvision. Prescription ofoptimal spectacle correction with caution: make sure the residents 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.240 The authors speculated that large changes invisual correction may have increased the risk offalls, and that more time may beneeded toadapt toupdated prescriptions ornewglasses.
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Advice onthe most appropriate type ofspectacle correction : wearing bifocal ormultifocal spectacle lenses when walking outside the home and onstairs has been associated with atwofold increase inthe risk offalls inolder people who live inthe community.241 These results may also apply toresidents inan RACF setting. The health care team should advise residents with afalls history 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.257
Point ofinterest: mobilitytraining

Vision Australia specialises insafe mobility training for visually impairedpeople: http://www.visionaustralia.org.au
Casestudy
MrB isan 84-year-old gentleman who lives inaresidential aged care facility (RACF). Recently, hetripped and fell onastep. Hesaid that hedid not notice the step, and also reported that his vision seemed tobe growing fuzzier. Staff atthe RACF referred MrB toan optometrist tocheck hewas wearing the optimum spectacle correction for distance vision. The optometrist diagnosed that the cause ofMrBs vision loss was macular degeneration. Staff atthe RACF took measures toprovide asafe environment for MrB towalk around. Staff also checked that his room was properly lit atall times. MrB now has alight byhis bed and his walking frame isalways positioned bythe bedside atnight, because hetends toget upat night togo tothe toilet. MrB was also given instructions about mobilisation and encouraged tocall for help when hedid not feel confident towalk around, away from his room. Staff have made sure that MrBhas supervision when negotiatingsteps.
Where possible, residents with cognitive impairment should have their vision tested using standard testing procedures. Where this isnot possible, visual acuity can beassessed using the LandoltC orTumblingE chart neither ofwhich require letterrecognition. The LandoltC isastandardised 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 TumblingE chart issimilar, but uses the letter Ein differentorientations.

Health care professionals orcarers can contact Optometrists Association Australia intheir state orterritory for anup-to-date list ofoptometrists providing services inrural and remote areas. Tond alocal ophthalmologist, the residents general practitioner oroptometrist can provide areferral. Alternatively, contact the Royal Australian and New Zealand College ofOphthalmologists on+61296901001. The strategies outlined earlier inthis section should beimplemented before areferral toan ophthalmologistismade.

Where appropriate, visual acuity can bemeasured for Indigenous people using aculturally appropriate chart known asthe turtle chart,266 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.
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13.3.4 People with limitedmobility

Domiciliary visits byoptometrists orophthalmologists may benecessary for housebound older people. Contact Optometrists Association Australia inyour state orterritory toaccess acurrent list ofoptometrists willing toprovide suchservices.
No economic evaluations were identified that considered interventions specific tovision inthe RACF setting. Some community interventions have been found tobe effective and cost effective; however, itis unclear whether the results are applicable tothe RACF setting (see Chapter13 inthe community guidelines for moreinformation).
The following associations maybehelpful: Guide dogs associations inAustralia help people with visual impairment togain freedom and independence tomove safely and condently around the community and tofull theirpotential: http://www.guidedogsaustralia.com Macular Degeneration Foundation promotes awareness ofmacular degeneration and provides resources andinformation: http://www.mdfoundation.com.au Optometrists Association Australia Tel: 03 9668 8500 Fax: 03 9663 7478 Email:oaanat@optometrists.asn.au http://www.optometrists.asn.au (the website contains details for state and territorydivisions) Vision Australia provides services for people with low vision and blindness acrossAustralia: http://www.visionaustralia.org.au
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PartC
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14 Environmentalconsiderations
Recommendations
Assessment
Residents considered tobe atahigher risk offalling should beassessed byan occupational therapist and physiotherapist for specic environmental orequipment needs and training tomaximisesafety.
Intervention
Environmental review and modication should beconsidered aspart ofamultifactorial approach inafalls prevention program.(LevelI) 7
Good practicepoints
Residential aged care facility staff should discuss with residents their preferred arrangement for personal belongings and furniture. They should also determine the residents preferred sleepingarrangements. Make sure residents 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, and consider combining them with occupational health and safetyaudits.
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Rates offalls vary between residential aged care facilities (RACFs), indicating that environmental factors influence the riskoffalls.2 Environmental review and modification refers tochecking the RACF for hazards that might cause residents tofall, and then modifying orrearranging the environment toremove orminimise these hazards. For example, this could include removing clutter, improving lighting, supplying and repairing assistive devices, and installinghandrails. A Cochrane review looked atthe effectiveness ofdifferent interventions for preventing falls inresidents ofRACFs.7 The review found that multifactorial interventions that target several different risk factors (egfalls prevention programs that include environmental modication inasuite ofinterventions) may help toprevent falls inresidential care settings.2,7 Multifactorial approaches could include exercise, medication review, vision assessment and anumber ofother interventions. However, there are not enough data tosee what effect environmental modification, onits own, has onreducing falls inthese settings mainly because individual trials either did not look atthe effectiveness ofthese interventions inisolation orbecause the trials were ofalowquality. Based onthis Cochrane review, environmental review and modification should beconsidered aspart ofamultifactorial approach inafalls prevention program. However, itmust beremembered that, when used ontheir own, environmental modification strategies may ormay not make adifference tothe incidenceoffalls. Different environmental factors may berelevant tospecific higher risk populations, such asnonambulatory people, and people with cognitive impairment, incontinence and gait disturbance (see below for more information).2 Rapp etal267 evaluated subgroups ofnursing home residents from anearlier randomised controlled trial33 and found that the intervention (which included staff and resident education, environmental modification, progressive balance and resistance training, and hip protectors) was effective for people with cognitive impairment, ahistory offalls, urinary incontinence and those who reported adepressedmood.
Point ofinterest: using low beds toreduce risk ofinjury fromfalls

As well asminimising the use ofbed rails, some Australian health care professionals have identified the use ofhigh/low beds (beds able tobe lowered close tofloor level), low/low beds (beds able tobe lowered tofloor level), bean bag chairs and the occasional practice ofpeople sleeping onmattresses onthe floor asways ofreducing the injury risk ofolder people who fall out ofbedfrequently.
14.2.1 Assessing the resident intheirenvironment
An environmental assessment should bedone byahealth professional (egan occupational therapist) with experience and training inevaluating people and their environment.34 Anoccupational therapist can evaluate residents todetermine their capacity toplan and perform activities ofdaily living and tomeet the functional demands oftheenvironment.268 Where anoccupational therapist receives areferral from another member ofthe health care team and isasked toreview aresident because ofafall orrisk offalls, the occupational therapist should dothefollowing: Conduct aninitial evaluation and identify the range ofenvironments inwhich the person lives, chart their daily schedule orroutine and identify relevant activities ofdaily living (ADL) forassessment. Assess the persons impairment bycheckingtheir physical resources (strength, range ofmotion, coordination, sensation,balance) perceptual orcognitivefunction general mobility (bed, wheelchairambulation).
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Conduct aperformance evaluation using anADL checklist orstandardised ADL evaluation. While many ofthese exist, assessments that focus onfunctional performance and safety inADL concurrently are recommended. ADL assessments shouldinclude268,269 mobility: movement inbed, wheelchair mobility and transfers; indoor and outdoor ambulation with equipment and use oftransportation (whereappropriate) self-care activities: dressing, feeding, toileting, bathing andgrooming management ofenvironmental devices: use oflight switches and call bells; ability toopen windows, reach into cupboards and access personalitems communication: ability tosummon help and communicateneeds. The assessment should include observing the person within their environment, including their use ofequipment. Also, the assessment should bedone atthe same time ofday and inthe same location that the person normally does these tasks,269 and with the same walking aids and devices that they would usuallyuse. When evaluating the persons performance inADL, the occupational therapist shouldobserve: methods the person isusing orattempting touse toaccomplish thetask safety factors (use ofequipment safety features,etc) easeofmobility limitations imposed bythe environment (eg disparity intransfer surfaces, inappropriate position ofgrabrails) suitability ofexisting assistivedevices. At the end ofthe evaluation, the occupational therapist should provide asummaryidentifying: additional safety equipmentrequired assistive devices required and recommendations fortheir use rearrangementoffurniture environmental modicationsrequired training requirements ofthe resident insafe transfer technique and equipmentuse. Equipment oralterations should benoted interms ofsize, specification and cost. Recommendations should bereviewed with the person and the relevant staff ofthefacility.
14.2.2 Designing multifactorial interventions that include environmentalmodications

Several good-quality trials have demonstrated that amultifactorial approach that also addresses the environmental and cultural setting ofthe institution can prevent falls for nursing home residents.33,267,270 For example, one randomised controlled trial with asample of439residents reduced falls by40% (incident rate ration = 0.6, 95%CI 0.50 to0.73).270 The intervention consisted ofastaff training program that included environmental modification (eg removing furniture that posed arisk and keeping floors dry); exercises toimprove muscle strength, balance, gait and transfers; repair and provision ofmobility aids, equipment and fitted footwear; medication review; hip protectors for residents with the highest falls risk; and staff team support and reportingsystems. Effective multifactorial interventions should incorporate environmental modications suchas: 2 ensuring chairs and beds are atthe correct height (ie when the residents feet are flat onthe ground, their hips are slightly higher than theirknees) assessinglighting installing nonslip flooring inwetareas routinely cleaning upwetfloors installing additional rails inbathrooms andcorridors reducing clutter inresidentsrooms providing and repairing walkingaids replacing orrepairing unsafefootwear removing loosecarpets providing individualseating promoting wheelchairsafety providing bed stabilisers, and bedside commodesatnight moving residents athigh risk offalling closer tothe nursingstation using electronic warning devices and avoiding useofrestraints.
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Little research has looked atfloor surfaces, but one small observational study has shown that wooden floors covered bycarpet were associated with the lowest number offractures when comparing carpeted, uncarpeted, wooden and concrete floors.271 Therefore, carpeting high-traffic areas might beauseful component ofamultifactorial intervention strategy,2 although itshould beremembered that carpeting will not reduce the risk orincidence offalls, but may help tominimiseinjuries.
14.2.3 Conducting environmentalreviews

Regular environmental reviews should bedone with the following pointsinmind: Make modications based onthe ndings oftheaudit. Prioritise audits byconsidering the followingenvironments high-risk environments (bedrooms, dining rooms, bathrooms andtoilets) environments identified through incident monitoring, hazard identification ornear-missreporting environments identied through environmental checklists (Appendix5 contains ageneral environmental checklist that may beuseful when auditing theenvironment). Include external environments inenvironmentalreviewing.272 Consider how environmental reviews may t inwith existing workplace health and safetyaudits. Involve arange ofdisciplines inenvironmental reviews and interventions, including health professionals, workplace health and safety personnel, infection-control personnel,272 staff working inthat particular environment, specialists ingeriatric assessment orergonomics, technical advisers and residents carers, whereappropriate. Ensure amechanism isin place for reporting environmentalhazards. When considering environmental change, RACF staff should explore arange ofproducts, equipment and innovative solutions. Keep inmind that changing aresidents environment could have anegative impact. For example, reorganising furniture may becontraindicated for residents who are visually impaired orthose withdementia. Appendix6 contains useful information onmodifying flooring, lighting, bathrooms and toilets, hallways, stairways and steps, furniture, beds, chairs, alert orcall systems and externalenvironments.
14.2.4 Orientating newresidents

Many falls occur inapersons rst few days inanew setting.273 Therefore, staff inRACFs should help residents tobecome familiar with new environments and teach them touse equipment.274 This orientation could include teaching the resident tomobilise and transfer safely between furniture orequipment that they are unfamiliarwith.231,275
14.2.5 Incorporating capital works planning anddesign

When building orrenovating RACFs, the following issues shouldbeconsidered: Safety and practicality are just asimportantasaesthetics. Facilities should conform tolegislated safetyrequirements.272,276 Adesign that allows observation orsurveillance ofresidents isimportant forsafety.272 Lighting and handrails atsteps and stairs should beused, and stairs should bedesigned toallow safedescent.276 Slip-resistant flooring should beinstalled inall wetareas.276
14.2.6 Providing storage andequipment

The risk offalls needs tobe considered when new equipment isacquired, orwhen existing equipment arrangements are being designed ormodified (egwalking aids, new seating, shower chairs).272,276 Health professionals and RACF staff should beinvolved indecisions about buyingequipment. Clutter should bereduced byproviding adequate storage space for equipment,272 and equipment should beaudited atleastmonthly.113
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14.2.7 Review andmonitoring

Environmental strategies are likely tobe incorporated inconjunction with other interventions toreduce falls. 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 inRACFs regularly (particularly high-risk environments such asbedrooms, bathrooms, dining rooms, etc). Afloor plan ofthe RACF isauseful tool for mapping fall locations and for showing the number offalls and near misses inparticular environmental hot spots. Mapping falls before and after environmental modication can provide feedback onthe effectiveness ofthe environmentaladjustments.
Casestudy
MrG has Parkinsons disease. Recently, staff noticed that hefinds ithard torise from the lounge chair inhis room atthe residential aged care facility. Nursing staff advised his general practitioner, who undertook amedical review, and therapy staff assessed his transfers and activities ofdaily living. His chair height was adjusted and awedge cushion supplied (for use inboth lounge and dining rooms), assistive bed equipment was provided for bed transfers, and support staff were instructed inhow tobest help him with transfers given his condition. MrG now attends regular group sessions with the physiotherapist aimed atbalance and strength training. Asaresult ofthis process, MrG isnow safer inhis activities ofdaily living and has alower riskoffalling.
The physical environment takes ongreater significance for people with diminished physical, sensory orcognitive capacity.274 The unique characteristics ofpeople who are cognitively impaired may adversely affect their interaction with the environment. Aswell asreviewing the environmental factors noted inAppendix5, staff ofRACFs should make sure that residents who are agitated orwho show behavioural disturbances are observed ormonitoredadequately. Specic environmental changes can help residents with cognitive impairment tobe more comfortable and independent, and can reduce confusion and the risk offalls. For example, consider positioning the resident close tonursing staff, using bed orchair alarms, orusing electronic surveillance systems.277 Colour-coded rooms indedicated dementia units have been used insome Australian RACFs tohelp cognitively impaired residents know which room istheirs. Other things that may helpinclude: using calming colour schemes toreduceagitation2 making sure the RACF setting supports and promotes improved continence (ie toilet close by, easy tofind and clearlymarked) 274 providing apredictable, consistentenvironment using suitable and stable furniture without sharpedges232 providing adequate lighting toensure clear vision and toprevent castingshadows.232 Specic recommendations for dementia care and the built environment are available and suggest that home-like surroundings may beassociated with less agitation and disruptive behaviour for people with dementia.278 This may prevent falls, but further research isneeded totest specific environmental modications and effect onoutcomes includingfalls.

Many ofthe environmental strategies suggest multidisciplinary involvement, which may not bereadily available inrural and remote settings. Videoconferencing, teleconferencing and interagency collaboration maybebenecial. In facilities where only avisiting occupational therapist isavailable, itwould beuseful toaudit the environment (see Appendix5) and the equipment (see Appendix6) and totake corrective action before the therapists visit. This would help toidentify key areas requiring specialistadvice.
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14.3.3 Nonambulatorypeople
Falls occurring innonambulatory people are more likely toinvolve equipment and tooccur while seated orduring transfers.279 Therefore, interventions toreduce the risk offalls for these people should consider transfer and equipmentsafety.
14.3.4 People whowander

RACFs need toinclude safe walking areas, and staff should provide opportunities for residents who wander.113,272 This will require assessing both internal and external areas, with due consideration toflooring, lighting andseating. A simulated community environment inan enclosed and safe area that incorporates awalking track with abench and bus stop sign can beuseful for helping people who wander. For asafe, simulated communityenvironment: ensure exits aresecure280 avoid extremes ofstimulation (noise, activity, lighting) and monitor the impact ofthese onapersons behaviour, confusion andagitation2 mark appropriate doors (eg toilet, bathroom) with both letters andpictures275 have familiar pictures toprovide cues tothe residents ownroom.277
Some environmental modication interventions have been effective and cost effective inthe community setting; however, itis unclear whether the results are applicable tothe RACF setting (see Chapter14 inthe community guidelines for moreinformation).
The following associations and organisations maybehelpful: Alzheimers Australia (2004). Dementia Care and the Built Environment: Position Paper 3, Australian Government,Canberra: http://www.alzheimers.org.au/upload/Design.pdf Home Modication Information Clearinghouse collects and distributes information onhome maintenance and modifications, and has anumber ofuseful environmental reviews: http://www.homemods.info 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 OT AUSTRALIA Ph: 03 9415 2900 Fax: 03 9416 1421 Email:info@ausot.com.au http://www.ausot.com.au
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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 onresidents privacy.(LevelIII-2-*) 38 Falls risk alert cards and symbols can beused toflag high-risk residents aspart ofamultifactorial falls prevention program, aslong asappropriate interventions are used asfollow-up.(LevelII-*) 185 Falls alerts used ontheir own are ineffective.(LevelII) 35 Consider using avolunteer sitter program for people who have ahigh risk offalling, and dene the volunteer roles clearly.(LevelIV-*) 281,282 Residents with dementia should beobserved more frequently for their risk offalling, because severe cognitive impairment ispredictive oflying onthe floor for along time after afall.(LevelIII-2-*) 38
Note: most falls inresidential aged care facilities are unwitnessed.23 Therefore, asis done inthe hospital setting, the key toreducing falls isto improve surveillance, particularly for residents with ahigh riskoffalling.38
Good practicepoints
Individual observation and surveillance arelikely toprevent falls. Many falls happen inthe immediate bed orbedside area, orare associated with restlessness, agitation, attempts totransfer and stand, lack ofawareness orwandering inpeople withdementia. Residents who have ahigh risk offalling should beindentied and checkedregularly. A staff member should stay with at-risk residents while they are inthebathroom. Although many residents are frail, not all are atahigh risk offalling; therefore, surveillance interventions can betargeted tothose residents who have the highestrisk. A range ofalarm systems and alert devices are commercially available, including motion sensors, video surveillance and pressure sensors. They should betested for suitability before purchase, and appropriate training and response mechanisms should beoffered tostaff. Suppliers ofthese devices should belocated ifafacility isconsidering this intervention. However, there isno evidence that their use inresidential aged care facilities reduces falls orimprovessafety.
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Many falls that occur inresidential aged care facilities (RACFs) are unwitnessed.23 AnAustralian report onfalls leading tohospitalisation showed that one-fifth (21.8%) ofthese falls occurred inRACFs in200506.283 Arange ofapproaches have been reported for identifying when aperson athigh risk offalling isgetting out ofabed orchair unsupervised (particularly for people with cognitive impairment). These approaches, which have been investigated inthe hospital setting but may beuseful inthe RACF setting,include:
locating the resident inan area ofhigher visibility (eg nearthe nursing station orusing videosurveillance) 21 flagging those athigh risk (eg use offalls risk alert cardsorsymbols) 35,185 making frequent, systematicobservations284 using sitterprograms21,281,282 using alarm systems and alertdevices.2,285 Observational studies have looked attechnologies for detecting falls, such asinfrared movement detectors, fall alarms (which sound when the resident isalready onthe floor), bed and chair alarms, and movement alarms; however, the studies were generally ofpoor quality. Asystematic review concluded that there are not enough trials inhospitals and care homes that investigate specific interventions, suchasalarms.27 The use ofsurveillance can have ethical and legal considerations (iedeprivation ofliberty, mental capacity and infringement ofautonomy). Care must betaken that surveillance does not infringe onthe residents autonomy ordignity. RACFs must have clear policies and procedures inplace for using surveillance. See also Chapter16 onthe use ofrestraints and associated ethical and legalconsiderations.
While many residents ofRACFs are frail, not all have ahigh risk offalling because oftheir relatively immobile state. Therefore, the burden ofcare can beeased bytargeting surveillance interventions tothose who have the highest riskoffalling. The following general principles ofobservation and surveillance inRACFs are based ongood practice inthe hospital setting. They may also beconsidered good practice inthe RACF setting despite alack ofRACFspecific trials. However, the circumstances ofan older person being admitted toan acute orrehabilitation hospital mean their risk profile differs markedly from that ofthe resident inastable state inan RACF. Strategies are not necessarilytransferable. The choice ofsurveillance and observation approaches will depend onacombination ofthe ndings from the assessment ofeach resident, clinical reasoning, and access toresources and technology. More than one surveillance and observation approach should beused, thereby avoiding dependence onone specicapproach. An important strategy toconsider for improving surveillance isto review staff practices, such astiming oftea and lunch breaks, toensure adequate supervision isavailable when required. Also, personal choice for the frequency ofshowers orpersonal hygiene needs tobe considered onan individual basis and balanced against existing routines inthefacility. Where possible, allocate high-visibility beds orrooms (such asnear nursing stations) tothose residents who require more attention and supervision, including residents who have ahigh riskoffalling.
15.2.1 Flagging
Residents who have ahigh risk offalling should beinformed oftheir risk. Inan RACF, the residents risk offalling should beidentified (flagged) insuch away that considers their privacy, yet isrecognised easily bystaff and the residents 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) 35 signs, pictures orgraphics onor near thebedhead.35,185
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Flagging reminds staff that aresident has ahigh risk offalling, and should trigger interventions that may prevent afall. These interventions must beavailable orthe flagging may not bebeneficial. Flagging may also improve aresidents own awareness oftheir potential tofall.232 Arandomised controlled trial conducted in14RACFs inNew Zealand used alogo and coloured dots toflag falls risk.35 The logo was aflower with afalling leaf and was displayed onawall inthe residents room. Each coloured dot indicated aparticular falls risk and had acorresponding strategy for staff tofollow tominimise that falls risk. This intervention was low intensity and aimed toraise staff awareness. However, itwas associated with increased falls inthe intervention group, compared with baseline, emphasising the importance ofincorporating appropriate interventions with the logo oralert, rather than using the alert asasoleintervention. A multifactorial trial inthree Australian subacute hospital wards included arisks alert card bythe bedside.185 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 the use ofhip protectors. The incidence offalls inthe intervention group was reduced compared with the controlgroup.
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 ahigh 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 residents, 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 atleast half-hourly and offered assistance; this may also apply tothe RACF setting.284 Astaff member should remain with the high-risk resident while inthebathroom.284 If appropriate, RACF staff should notify carers, family orfriends ofthe residents risk offalling and their need for close monitoring. Encourage them tospend time sitting with the person, particularly inwaking hours, and tonotify staff ifthe resident requiresassistance. If anearby resident consents toinformally observe the resident atrisk offalling, they may report tostaff ifthat resident needshelp.
15.2.3 Sitterprograms
Some RACFs have introduced sitter programs.286 These programs use volunteers, families orpaid staff tosit with residents who have ahigh risk offalling. The sitters are rostered tospend between two and eight hours atatime with aresident. The role ofthe sitter isto provide company for the resident and tonotify the appropriate staff when the resident wishes toundertake anactivity where they may beat risk offalling (such astransferring ormobilising). This may beaviable strategy incertain settings, inan effort toprevent falls for selected residents. Using sitters requires planning, resources, education, investment (particularly for paid people) and ongoingcoordination. An observational study inAustralian hospitals found that alimitation ofvolunteer sitters isthat they are typically only available inbusiness hours.281 Afeasibility study run inAustralian hospitals found that providing 24/7 surveillance coverage byvolunteers would require anadditional 15volunteers aweek.282 Both studies found some tensions between volunteers and nursing staff, arising from lack ofclarity about the volunteers role ornurses feeling that volunteers were demanding their time. However, because these studies were conducted inthe hospital setting, itis unclear whether similar situations would occur inthe RACFsetting.
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15.2.4 Responsesystems
Response systems are usually aform ofmonitor, incorporating analarm that sounds when aperson moves. Anumber ofresponse systems are commercially available. Aprospective cohort study investigated the use ofalarms byresidents 90years and older, living either intheir own home orin anRACF.287 All residents had acall alarm installed intheir room. However, failure touse the alarm was extremely common among residents who had afall when alone: 62 out of66residents (94%) who had afall when alone did not use the alarm. Insome systems, analarm isactivated byapressure sensor when aperson starts tomove from abedorchair. A randomised controlled trial ofresidents ofageriatric evaluation and treatment unit did not nd any statistically signicant difference between anintervention group who received abed alarm system and acontrol group who did not.288 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 RACFsetting. Another type ofalarm isacredit cardsized patch containing areceiver, which isworn onthe body.285 Ideally, the patch isworn directly onthe thigh. However, for people with compromised skin integrity, the patch can beplaced onclothing (although this limits its usefulness towhen clothing isworn). The alarm can beintegrated with existing nurse-call systems and isactivated when the wearers leg moves toaweight-bearing position. Across-over study investigated the effectiveness ofthis type ofalarm.285 However, the study had many limitations: the observation time was only one week, and itwas not clear what other falls prevention interventions the participants were also using. The study was conducted bythe company that produced the device, suggesting that independent studies are needed toverify findings. The possible advantages ofabody-worn device appear tobe its small size and nonobtrusiveness, and that itcan beintegrated with existing nurse-callsystems. In other alarm systems, analarm sounds when any part ofapersons body moves within aspace monitored bythe alarm. Yet another style ofalarm activates when aperson falls but does not get up. Response systems require capital investment and rely onathird party (egRACF staff orthe residents carer) torespond when the alarm sounds. The issues ofwho responds and how, and what impact this has onward practice including that itmay take away from other areas ofcare need tobe considered before any systemisimplemented. Alarms may pose risk management problems for RACFs 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.287 Care should betaken that alarms donot infringe onautonomy. The lack ofclear research results (probably due tothe difficulties inresearching this area), and the ethical and legal considerations ofmonitoring people should beconsidered when making decisions. There isno evidence tosupport the use ofalarms inpreventingfalls.

Evaluation ofthe effectiveness ofsurveillance and observation systems will depend onthe range and mix ofsystems that are used. Indicators ofthe acceptance ofsurveillance and observation systems mayinclude: 281,282 frequency ofuse ofobservation and surveillancemethods satisfaction ofstaff, residents, and their family, carers orfriends with observation and surveillancemethods. 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.
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Casestudy
MissD isamobile 90-year-old resident ofaresidential aged care facility. She has dementia and has been falling frequently inthe past month. All staff including medical, allied health, nursing, administration, food services and operational staff are aware ofMissDs high fall risk because ofagreen sticker onher bedhead and her walking aid. This isan ongoing reminder that MissD should walk with supervision atall times. Toavoid confusing and disorientating MissD, staff agree not tomove her toaroom ofhigher visibility, but each hour, night and day, they check onher. IfMissD isawake, she isoffered assistance. Family, carers and friends know ofMissDs high risk offalling and are encouraged tospend time with her. Recognising the importance ofmaintaining her mobility, staff donot discourage her from being mobile. Analarm device isused when she isin bed. All staff are aware ofthe need torespond promptly when the alarmisactivated.
Surveillance and observation approaches are particularly useful for older people who forget ordo not realise their limitations. Improved surveillance and observation may offer apreferable alternative injury minimisation strategy tothe useofrestraints.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.
No economic evaluations were identied that specically considered interventions for individual surveillance inthe RACF setting. Some interventions have been conducted inahospital environment; however, itis unclear whether the results are applicable tothe RACF setting (see Chapter15 inthe hospital guidelines for moreinformation).
Successful observation practices inthe hospital setting have targeted changes innursing practice. Nurses are able toobserve patients for greater periods oftime 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.38 The Australian Resource Centre for Health Care Innovation 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
Recommendation
Assessment
Causes ofagitation, wandering orother behaviours should beinvestigated, and reversible causes ofthese behaviours (eg delirium) should betreated before the use ofrestraintisconsidered.
Note: physical restraints should beconsidered the last option for residents who are atrisk offalling289 because there isno evidence that their use reduces incidents offalls orserious injuries inolder people.290-293 However, there isevidence that they can cause death, injury orinfringementofautonomy.294,295
Good practicepoints
The focus ofcaring for residents with behavioural issues should beon responding tothe residents behaviour and understanding its cause, rather than attempting tocontrolit. All alternatives torestraints should beconsidered, discussed with family and carers, and trialled for residents with cognitive impairment, includingdelirium. If all alternatives are exhausted, the rationale for using restraint must bedocumented and ananticipated duration agreed onby the health care team, inconsultation with family and carers, and reviewedregularly. If drugs are used specifically torestrain aresident, the minimal dose should beused and the resident reviewed and monitored toensure their safety. Importantly, chemical restraint must not beasubstitute for alternative methods ofrestraint outlined inthischapter.
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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 orstroke 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 but, inmost situations, this isregarded asan inappropriate form ofrestraint. However, when aresidents behaviour isdisturbed and their risk offalling isincreased, there may beacase for chemical restraint. Bed rails are also sometimes used asatypeofrestraint. Physical restraint ofpeople during admission toresidential aged care facilities (RACFs) was common practice for many years.291 The prevention offalls iscited asthe most common reason for the use ofphysical restraints.296 Studies have shown that some health care workers believe that restraining people will prevent afall; 289 however, evidence suggests that restraints may have the opposite effect and that people who are restrained are more likely tofall.232,296 Insome instances, reducing the use ofrestraints may actually decrease the riskoffalling.297 An observational study from Finland recorded the use ofpsychoactive medications and other drugs aschemical restraints inlong-term care. They found that, out of154participants, 33% received three ormore psychoactive medications regularly, and 24% received two ormore benzodiazepine derivatives orrelated drugs regularly. The authors concluded that psychoactive medications were used aschemical restraints inthese long-term carewards.298 If used, restraints should bethe last option considered.299 Asystematic review ofphysical restraint use and injuries found anassociation between restraint use and increased risk ofinjury anddeath.291 If drugs are used specifically torestrain aresident, the minimal dose should beused and the resident reviewed 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
RACFs should aim tobe restraint free. All RACFs 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 (egdelirium) should betreated before the use ofrestraint isconsidered.4,300 Restraints should not beused atall for residents who can walk safely and who wander ordisturb other residents.232 Wandering behaviour warrants urgent exploration ofother management strategies, including behavioural and environmental alternatives torestraint use. These alternatives mayinclude: 299 using strategies toincrease observationorsurveillance providingcompanionship providing physical and diversionaryactivity meeting the residents physical and comfort needs, especially toileting (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. Staff ofRACFs should have appropriate and adequate education about alternatives torestraints. Education can reduce the perceived need touse restraints, aswell asminimise the risk ofinjury when they areused.289
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16.2.2 Usingrestraints
When the residents 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: 289 prevent orminimise harm totheresident prevent harmtoothers optimise the residents healthstatus. The health care team must also take into account the rights and wishes ofthe resident, their carer(s) and family.4 Any decision touse restraints should bemade bydiscussing their use and possible alternatives with the resident, their carer(s) 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 beasubstitute for supervision, inadequate staffing orlack ofequipment,280,299 and they should not beapplied without the support ofawritten order.299 The minimum standard ofdocumentation for restraint use shouldinclude: 289,301 date and timeofapplication the name ofthe person ordering therestraint authorisation from the medicalofcer evidence ofregularreview typeofrestraint reasons for therestraint alternatives considered andtrialled information about discussion with the resident, carers orsubstitute decisionmakers any restrictions onthe circumstances inwhich the restraint maybeapplied the intervals atwhich the resident mustbeobserved any special measures necessary toensure the residents proper treatment while the restraintisapplied the duration oftherestraint.

Every RACF should have arestraint policy that isreviewed regularly. Staff should also beassessed ontheir knowledge and skill inusing alternatives torestraints, aswell astheir knowledge ofthe RACFs restraint policy. Trends inthe use ofrestraints should also bemonitored; for example, why arestraint isused, for how long and what alternatives were considered.299 Arestraint-use form may beuseful for thispurpose.
Casestudy
MrsS isa90-year-old woman who lives inaresidential aged care facility. She has dementia and walks with supervision. Her family requested that the staff raise the bed rails when she isin bed, because they were concerned she would get upwithout assistance and could fall. The staff discussed with MrsSs family the potential for injury ifshe manages toclimb over raised bed rails. They informed the family oftheir restraint reduction policy, which particularly targets the reduced use ofbed railsorbedsides. Staff repeated afalls risk assessment and developed amanagement plan aiming toreduce MrsSs risk offalling. They addressed the identified risk factors for falling, including amedication review and reduction inpsychoactive medication, and asupervised balance and strengthening exercise program with the physiotherapist. Staff also issued MrsS with hip protectors, lowered the bed toits lowest height when Mrs Sis inbed, placed one side ofthe bed against the wall and ensured everything she needed was within her reach. Despite their efforts, the family remained insistent that the bed rails beraised. Staff will continue towork with the family and trial alternative options, and have requested acase conference with the family and the general practitioner inafew weeks toreview the currentstrategies.
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For residents with cognitive impairment who cannot stand ormobilise safely ontheir own, restraints should only beused after their falls risk has been evaluated and alternatives torestraint have been considered. Ifrestraints are applied, they should beused only for limited periods andreviewed regularly. The use ofphysical restraints has been associated with delirium and therefore their use should bekept toaminimum.300 See Chapter7 for more informationondelirium.
No economic evaluations were found that examined the cost effectiveness ofrestraints inthe RACFsetting.
Below are some useful guidelines, policy statements and tools for the use ofrestraints andalternatives: Decision-Making Tool: Responding toIssues ofRestraint inAged Care, Australian Government Department ofHealth and Ageing. This isacomprehensive resource that includes useful tools and flowcharts: http://www.health.gov.au/internet/main/publishing.nsf/Content/ ageing-decision-restraint.htm Guidelines for the Use ofRestraint asaNursing Intervention, Nursing Board ofTasmania: http://www.nursingboardtas.org.au/domino/nbt/nbtonline.nsf/$LookupDocName/publications (and click onStandards for the Use ofRestraints for Nurses and Midwives2008 ). Restraint inthe Care ofOlder People 2001, Australian Medical Association Policy Statement: http://www.ama.com.au/node/1293
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PartD
Minimising injuries fromfalls
PartD Minimising injuries fromfalls

17 Hipprotectors
Recommendations
Assessment
When assessing aresidents need for hip protectors inaresidential aged care facility (RACF), staff should consider the residents recent falls history, age, mobility and steadiness ofgait, disability status, and whether they have osteoporosis oralow body massindex. Assessing the residents cognition and independence indaily living skills (eg dexterity indressing) may also help determine whether they will beable touse hipprotectors.
Intervention
Use hip protectors toreduce the risk offractures for frail, older people ininstitutional care.(LevelI) 302 Hip protectors must beworn correctly for any protective effect, and the residential care facility should educate and train staff inthe correct application and care ofhip protectors.(LevelII) 303 When using hip protectors aspart ofafalls prevention strategy, RACF staff should check regularly that the resident iswearing their protectors, that the hip protectors are inthe correct position, and that they are comfortable and the resident can put them oneasily.(LevelI) 302
Good practicepoint
Hip protectors are apersonal garment and should not beshared amongpeople.
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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.302 Hip fractures occur inapproximately 1.65% offalls,31,304,305 are one ofthe more severe injuries associated with afall, and usually require surgery and lengthy rehabilitation. 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 ordisperse forces onthe hip ifaperson falls onto their hip area. 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

There issome evidence that, when worn correctly, hip protectors may prevent hip fractures inresidents inresidential aged care facilities (RACFs), although more recent research indicates that their benefits may beless than originally thought.302 Hip protectors can therefore beused aspart ofamultifactorial falls and injury prevention intervention inRACFs, although they will not prevent falls orprotect other parts ofthebody.306 When the results from studies ofhip protector use asastand-alone intervention for preventing hip fractures were pooled inthe 2009 Cochrane review,302 the overall effect of11cluster and individually randomised controlled trials (RCTs) was a23% reduction inincidence (risk ratio = 0.77, 95%CI 0.62 to0.97). The review authors concluded that there was evidence ofmarginally signicant effectiveness ofhip protectors for preventing hip fracture inthe RACF setting. However, more attention needs tobe paid totheir acceptance and adherence inthis setting, and further investigation into alternative fracture prevention strategies inhigh-risk groups shouldbeencouraged. A large RCT performed inFinland in2000 307 investigated the effect ofhip protector use infrail but ambulatory people. The intervention resulted ina60% reduction inthe risk offracture. However, because 31% ofeligible people inthis study refused towear the hip protectors, itis not clear whether the results can begeneralised tothe widerpopulation. The issue ofadherence was addressed inastudy byMeyer in2003,303 where hip protectors were provided to459people and compared with 483controls. Before implementing the intervention, staff and residents were provided with astructured education session, which included information about the risk ofhip fracture, prevention strategies and the effectiveness ofhip protectors. The results showed that residents wore hip protectors during 54% ofall falls inthe intervention group, compared with 8% offalls inthe control group, and there was a40% reduction inthe relative risk ofhip fracture inthe interventiongroup. A study byJensen etal in200231 included the use ofhip protectors aspart ofamultiple intervention inthe RACF setting. Residents atincreased risk ofhip fracture were offered hip protectors, and 72% initially agreed towear them. Results showed areduction inthe number ofhip fractures inthe intervention group overall; however, adherence with hip protector use was not reported, and the use ofco-interventions aimed atreducing the risk offalls make itdifcult todetermine the effectiveness ofhip protectorsalone. Similarly, alarge, multiple intervention program run inGermany33 provided hip protectors toresidents who were able tostand. The authors reported nosignicant difference inhip fracture rates between the intervention and control groups; however, nohip fractures occurred while the residents were wearing the hip protectors properly. Issues identied with this study included poor resident adherence tousing the hip protectors and lack ofRACF staff support with their use andprovision.
17.1.2 Types ofhipprotectors

There are three types ofhipprotectors: Soft hip protectors (typeA) are available inavariety ofdesigns. Their common feature isthat they are made from asoft material, rather than arigid plasticshell. Hard hip protectors (typeB) 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 (typeC) are stuck directly tothe skin ofthe wearer. Few studies use this type ofhip protectorintrials.
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As ageneral observation, typeA ispreferred infacilities, because typeB presents laundering difficulties. The key factor for success appears tobe the commitment ofstaff toresident care and quality improvement, particularly when this issupported bysenior staff. Acceptance ofhip protector use was also higher inpeople inlonger term care. Features oflong-term care include residents with less acute conditions, greater staff familiarity with the resident and aslower rate ofpopulation turnover. Adherence ofboth the resident and staff tohip protector use isan issue inall environments, and islower inwarmer climates (seeSection17.3.3).
PartD
17.1.3 How hip protectorswork

Hip protectors work byabsorbing ordispersing the energy created byafall away from the hip joint sothat the soft tissues and muscles ofthe surrounding thigh absorb the energy. The hard plastic hip protectors 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,308 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.305 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 6000newtons. The most effective padding system can reduce this toapproximately 2000newtons inalaboratorytest.309 It isnot necessary towear ahip protector over ahip that has been surgically repaired with internal xation orhip replacement, because the neck ofthe femur has either been replaced orreinforced (hemiarthroplasty, pin and plate, etc).310 Equally, ithas not been demonstrated tobe harmful todoso. An RCT ofhip protectors noted adverse effects in5% ofpeople.311 Bruises may occur ifthe person falls onto the hip protector. Also, skin infections and pressure ulcers (bedsores) can develop under oraround the area where ahip protectorisworn. For frail older people, hip protectors can cause difficulties with toileting.302 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 Chapter8 oncontinence for more information). Also, ifdexterity isan issue for the resident, wearing hip protectors can increase their falls risk, because the resident must manage another garment during dressing and undressing, particularly inthetoilet.
17.1.4 Adherence with use ofhipprotectors

A disadvantage ofhip protectors isalow level ofadherence because ofdiscomfort, practicality,312 the extra effort needed toput them onor urinary incontinence.313-316 Insome settings, cost might also beabarrier tohip protectoruse.317 Adherence with the use ofhip protectors iscrucial totheir effectiveness.318 Inthe rst reported randomised trial ofhip protectors, only 24% ofasubgroup ofparticipants wore hip protectors when they fell.316 This trial was included ina2005 Cochrane review ofhip protectors, and the other trials included also reported low adherence rates, which may have influenced theoutcome.302 To help older people tokeep wearing their hip protectors, the older persons 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.319 Inmany cases, adherence ismost affected bythe older persons motivation towear the hip protectors, 319 and bythe type ofhip protector (eg hard, soft).302 Inother cases, wearing ahip protector may beavisual reminder ofthe consequences offalling, and cause the older person ortheir carer tomodify their behaviour tominimiserisk.302 The attitudes ofstaff inRACFs may also have asubstantial effect onwhether aresident wears hipprotectors.319
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Queensland Health developed aset ofbest practice guidelines for RACFs, which included the following feedback from focus groups and health professionals onwhy protector pads were difcult tointroduce asstandardpractice: 232 They caused skin rashes and increasedperspiration. They were uncomfortable tosleep inand had the potential tocause pressuresores. They were difficult towash, particularly for people withincontinence. Replacing them wascostly. There were infection-controlissues. Some residents removed orrefused towearthem. They were considered too big orbulky, particularly with incontinence pads, catheters anddressings. They move and can becomeuncomfortable. There was not enough information about how totthem. Some staff did not always support residents touse them, orwere sceptical about theirefficacy. There were problems with price, style and comfort for the wearer, including imageperception.
Point ofinterest: Cochrane review ofhip protector use andadherence

The 2005 Cochrane Collaboration review302 contains tables that summarise the randomised trials ofhip protectors (see http://www.thecochranelibrary.org and search for hipprotectors).
Point ofinterest: using helmets and limbprotectors

When these guidelines were being developed, anational consultation process revealed that astrategy insome residential aged care facilities for residents who often fell was the use ofhelmets and limb protectors tominimise the risk ofinjuries tothe head and limbs. While this approach appears tohave potential toreduce injury from falls, todate there has been noresearch evaluating the effectiveness ofthese protectivedevices.
Because ofthe diversity ofolder people, service settings and climates, residents should beoffered achoice oftypes and sizes ofhip protectors. Soft, energy-absorbing protectors are often reported tobe more comfortable for wearing inbed. Achoice ofunderwear styles and materials means that problems with hot weather, discomfort and appearance canbeaddressed.
17.2.1 Assessing the need for hipprotectors

When assessing aresidents need for hip protectors, RACF staff should consider the residents recent history offalls, age, mobility, whether they have adisability, whether they are unsteady ontheir feet and whether they have osteoporosis. Assessing the residents cognition and independence indaily living skills (egdexterity indressing) may also help determine whether the resident will beable touse hip protectors. RACF staff can use afalls risk assessment tool (see Chapter5) tohelp decide whether someone has ahigh risk offalling and therefore beconsidered for the use ofhipprotectors.
17.2.2 Using hip protectorsatnight

There isarisk offalling and breaking the hip during the evening and night. Ifthe risk issufcient tojustify the use ofhip protectors, and the resident gets out ofbed togo tothe toilet atnight, the use ofhip protectors atnight should beconsidered. The soft protectors (typeA) are relatively comfortable when positioned correctly and can beworn more easily inbed, because they are less obtrusive than the hard shell protectors(typeB).232
17.2.3 Cost ofhipprotectors

The cost ofhip protectors appears tobe afactor influencing uptake. 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 Section17.4 oneconomicanalyses).
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17.2.4 Training inhip protectoruse

Fitting and managing hip protectors are often the responsibilities ofaparticular member ofthe health team. Nurses and personal care attendants are inakey position toencourage adherence with hip protector use, because they help frail residents with dressing, bathing and toileting. Nurses and personal care attendants should begiven education and support indeveloping strategies toencourage adherence with, and correct application of, hipprotectors. Two studies have assessed the benets oftraining staff inthe correct application and reason for use of hip protectors, and the importance ofsupporting and encouraging residents touse hip protectors.33,303 One ofthese studies found that training the individual wearer may also improve adherence byaddressing any barriers that the person sees towearing hip protectors, and providing them with precise instructions and demonstration onhow towearthem.303 Before the resident starts wearing hip protectors, RACF staff should discuss arrangements for cleaning the protectors. Washing indomestic washing machines and dryers isfeasible, but some hip protectors will not withstand commercial laundering. While self-adhesive hip protectors may beappealing insome instances (ie they can beworn with the residents own undergarments), itis unclear whether they can beused safely inthe longterm.

Currently, the design and production ofhip protectors isunregulated and there are nonational orinternational testing procedures for theireffectiveness.302 A standard denition ofadherence with use ofhip protectors should beused when reviewing and monitoring their use.320 The most easily measured marker ofadherence isthe number ofprotected falls, which isthe proportion offalls inwhich ahip protectorisworn.
Casestudy
Recently, MrsJ was admitted toaresidential aged care facility (RACF). Onadmission, her falls risk assessment indicated she had amoderate risk offalling. RACF staff implemented several falls prevention strategies, including recommending safer footwear and referring MrsJ tothe physiotherapist for anexercise program. Staff reviewed MrsJs medical history (from her general practitioner) and noted that she had ahistory ofosteoporosis, and had fractured awrist inafall 12months earlier. RACF staff discussed hip protectors with MrsJ, highlighting how they appear towork inreducing forces onthe hip inthe case ofafall. They also showed her examples ofthe different types ofhip protectors. MrsJ discussed buying hip protectors with her family, who bought them for her. Staff members used achecklist torecord her adherence with hip protector use each day. MrsJ feels more condent walking around the RACF when wearing the hip protectors, and even wears them atnight, asshe usually needs toget upto the toilet once ortwiceanight.
People with cognitive impairment have ahigher prevalence offalls and fractures 321 and should beconsidered for hip protector use. People with cognitive impairment will often need help touse hip protectors both initially and inthe long term. Hip protectors may need tobe used with anadditional risk management strategy for people known tohave balance difculties 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 the 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.
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A number oftrial-based and modelled economic evaluations ofhip protectors inaresidential care setting have been conducted. These analyses primarily rely ontrial-based efcacy and adherence data. Results should therefore beinterpreted with some caution, asthese estimates may besomewhat optimistic, compared tothe levels ofefcacy and adherence achievable inusual clinicalpractice. Two economic evaluations 317,319 were conducted alongside RCTs ofhip protectors. Van Schoor etal319 found that there was nosignicant difference inthe number ofhip fractures inthe intervention and control groups ofan RCT ofhip protectors inafrail, institutionalised older population. The average total costs (in 2001) over a12-month period (including hip fracture and rehabilitation and intervention costs) were 913 (95%CI 643 to1353) inthe hip protector group, and 502 (95%CI 284 to803) inthe control group. Unlike many modelled analyses, hip protector use was not associated with lower costs. Incontrast, Meyer etal317 found that that there were signicantly fewer fractures inthe hip protector group (21fractures versus 42fractures) inan RCT ofGerman nursing home residents aged 70years orover who had ahigh risk offalling. The hip protector group was associated with slightly higher mean total costs (in 2000US$, US$634 versus US$583), and the incremental cost effectiveness ratio (ICER) was US$1234 per hip fracture avoided. The ICER was sensitive tocosts ofthe education programs, the time horizon ofthe analysis and the need for extra nursingcare. Two Canadian analyses modelled costs (in CA$) and health outcomes (quality-adjusted life years, QALYs) ofhip protector use innursing home residents.322,323 Waldegger etal323 modelled one year ofhip protector use inwomen aged 82years with aprevious hip fracture, with QALYs measured over alifetime. Inthe primary analysis (82-year-old females with previous hip fracture), the authors reported hip protector use was both less costly and more effective than nohip protector use. However, cost effectiveness was particularly sensitive tostarting age, history ofprevious fracture and adherence with hip protector use, and ranged from CA$6600 per QALY gained toCA$14200 per QALY gained, depending onthese variables. Singh etal322 conducted amodelled analysis ofhip protectors compared with vitaminD and calcium, orwith notreatment, inCanadian nursing home residents with amean age of85years. The authors reported that hip protector use resulted inlower costs (in 2001CA$), fewer hip fractures and higher QALYs, compared with both notreatment and with calcium and vitaminD supplementation. However, results were sensitive tothe relative risk offracture, the price ofhip protectors and the extent ofadditional nursing requirements, and ICERs ranged upto CA$28326 per QALY gained depending onthesevariables. A USmodelled analysis 324 reported, over an18-month timeframe, anICER ofUS$4720 per hip fracture prevented (in 2000US$), which ranged from US$85 toUS$49345 per hip fracture prevented, depending oncosts and efcacy. The primary analysis considering QALYs reported anaverage cost saving ofUS$300 and again of0.01QALYs. The ICER increased tobetween US$15700 and US$30600 per QALY gained, when the price ofhip protectors increased. Asimple modelled analysis inthe United Kingdom325 directly applied RCT efcacy data tohip fracture incidence and admission rates from institutional care. The cost per fracture prevented (in 1998GB) ranged from 678000 inmen aged 5059years, to9309 inwomen aged7579years. In addition, two cost analyses estimated the costs ofhip protector use and potential cost offsets from hip fractures averted innursing homes.326,327 Cost effectiveness ratios were not calculated. ACanadian analysis 327 considered costs over aone-year period (in 2003CA$), and estimated that provision ofhip protectors toall Ontario nursing home residents older than 65years may result incost savings ofCA$6million inone year. The costs associated with this strategy ranged from costing anextra $26.4million tosaving $39.7million. These results are based onhip protectors resulting ina60% reduction inhip fracture risk, and adherence estimates from clinical trials that may not beachievable inusual clinical practice. AUnited States analysis 326 estimated lifetime potential cost savings toMedicare (in 2002US$) from providing hip protectors topermanent nursing home residents aged 65years orolder, without aprevious hip fracture. Three pairs ofhip protectors replaced annually would lead toan 8.5% lifetime absolute risk reduction ofhip fracture, with net lifetime savings ofUS$223 per person. However, the extent ofany savings depended onthe persons starting age and sex. Hip protectors did not reduce costs inwomen who started wearing them at65years ofage, nor inmen who started wearing them at70yearsofage.
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In summary, these data suggest that the use ofhip protectors inaresidential care setting may offer reasonable value for money, depending onstarting age, previous history offracture and cost ofhip protectors. However, these results should beinterpreted with some caution, because analyses rely ontrialbased efficacy and adherence data that may besomewhat optimistic, compared with the levels ofefficacy and adherence that are achievable inclinicalpractice.
The following resources provide additionalinformation: Appendix7 contains achecklist ofissues toconsider before using hipprotectors.310 Appendix8 isasample hip protector careplan. Appendix9 isasample hip protector observationrecord. The description ofthe educational program used inthe study ofMeyer and colleagues 303 provides aguide tohip protector implementation inresidential aged care facilities(Appendix10). Cochrane Collaboration website The CochraneLibrary: http://www.thecochranelibrary.org and search for hipprotectors.
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18 Vitamin Dand calciumsupplementation

Recommendation
Intervention
VitaminD and calcium supplementation should berecommended asan intervention strategy toprevent falls inresidents ofresidential aged care facilities.(LevelI) 7
Good practicepoint
Assess whether residents are receiving adequate sunlight for vitaminDproduction.
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Low vitaminD levels have been associated with reduced bone mineral density, high bone turnover and increased risk ofhip fracture.328 Furthermore, vitaminD may prevent falls byimproving muscle strength and psychomotor performance, independent ofany other role inmaintaining bone mineraldensity.329,330
Point ofinterest: How vitaminD reduces the riskoffalling

The active vitaminD metabolite (25-hydroxyvitaminD) binds toahighly specic nuclear receptor inmuscle tissue. This improves muscle function, which may bethe reason why vitaminD reduces the risk offalling.329 Furthermore, vitaminD deficiency has also been associated with osteoporosis, urinary incontinence, cognitive decline and maculardegeneration.331 VitaminD levels are measured byblood serum 25-hydroxyvitaminD (25(OH)D) levels. Previously recommended levels of25(OH)D considered indicative ofadequate vitaminD stores may betoo low.328,332 The incidence ofdeciency ofvitaminD (25(OH)D levels less than 25nmol/L) inAustralia has been reported as2286% inresidential aged care, 67% ofgeriatric hospital admissions and 61% ofpeople experiencing hip fractures.328 Another study found that inAustralia, 86% ofwomen and 68% ofmen inresidential aged care facilities (RACFs) have vitaminD deficiency and virtually all the remainder have alevel inthe lower half ofthe referencerange.333 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.328 VitaminD deciency issignicantly more common among people with dementia and people from culturally and linguistically diversegroups.334 Nutrition management isan important element ofgood aged care practice, and can play animportant role insome aspects offalls prevention, directly and indirectly (eggood nutrition isrequired togain optimal effect froman exercise program). Other than vitaminD and calcium supplementation (and related 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. However, Appendix11 provides achart for monitoring food and fluid intake, and Appendix12 provides food guidelines for calcium intake for preventing falls inolderpeople. Intervention approaches toimproving the levels ofvitaminD inresidents and older people have used arange ofoptions with varying success levels, including vitaminD supplementation alone, vitamin Dsupplementation together with calcium supplementation, and exposure tosunlight. These are explained inthe followingsections.

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18.1.1 VitaminD supplementationalone

A meta-analysis found that vitaminD supplementation appears toreduce the risk offalls among ambulatory orinstitutionalised older people with stable health bymore than 20%.329 Although not looking atthe same outcome, anearlier Cochrane review ofvitaminD for preventing fractures associated with osteoporosis reported uncertainty about the efcacy ofregimens.335 Inthis review, vitaminD without any calcium co-supplementation was not associated with areduced risk ofhip fracture orother nonvertebralfractures.334-336
18.1.2 VitaminD combined with calciumsupplementation

A high-quality systematic review (a Cochrane review) looked atinterventions including vitaminD supplementation for preventing falls inthe hospital and RACF settings.7 The review included five trials, two ofwhich were similar enough for the data tobe pooled. The pooled results showed that vitaminD with calcium appeared tobe effective for preventing falls inlong-term residents ofRACFs, and that the benefits ofsupplementation were more certain inpeople who had low serumvitaminD. A study ofthe alfacalcidol form ofvitaminD supplementation innonvitaminD-decient older people inthe community supports the hypothesis that treatment with vitaminD (or its analogues) requires aminimum daily calcium intake ofmore than 500mg/day toproduce clinically signicant results.332 The Australian recommended daily intake (RDI) for calcium inolder people is800mg for men and 1000mg for women.337 However, this level may betoo low, with other sources recommending daily intake of1500mg for both men andwomen.338
Calcium supplementation should beapproached with caution inwomen older than 70years ofage. Alarge trial ofcalcium supplementation of1000mg/day found anexcess ofcardiovascular events inthe interventiongroup.339,340 The Nottingham Neck ofFemur study (which was not included inthe Cochrane review discussed above) concluded that vitaminD administered orally orinjected increases bone mineral density and decreases falls, and that calcium co-supplementation mayhelp.341
18.1.3 VitaminD andsunlight

The main source ofvitaminD isfrom sunlight.337 Evidence suggests that sourcing vitaminD from dietary intake alone isnot sufcient.328 Compounding this fact isthat nutrient intake inresidential care isoftenlimited.342 Sun exposure may not work ifthe skin ofolder people does not convert cholesterol precursors tovitaminD efficiently. Additionally, sun exposure recommendations are difficult toimplement infrailer people, particularly inRACFs. Inthe absence ofroutine fortification offood, either sunlight exposure, the regular consumption ofoily sh orvitaminD supplementation are the mainstay approaches toensuring adequate levels ofcalcitriol(1,25(OH)2D3). The Geelong Osteoporosis Study found that inwinter there was reduced serum vitaminD, increased bone resorption and anincrease inthe proportion offalls resulting infracture.343 The role ofvitaminD supplementation during the Australian winter has yet tobeinvestigated.
Point ofinterest: vitamin Dandlatitude

Little vitaminD isproduced beyond latitudes ofabout 35 (ie Victoria and Tasmania) inwinter, especially inolder people. This isbecause ofan increase inthe zenith angle ofthe sun (angle between directly overhead and aline through the sun), resulting inmore photons being absorbed bythe stratospheric ozonelayer.344
18.1.4 Toxicity anddose

Toxicity tovitaminD cannot becaused byprolonged sun exposure; however, itcan occur from supplementation with vitaminD.337 Hypercalcaemia may occur ifvitaminD isgiven, particularly inthe form ofthe vitaminD analogues.335 However, toxicity with cholecalciferol (vitaminD3) upto 10000IU daily israre and occurs predominantly ifdietary ororal calcium supplements are high, orif granulomatous disorders are present. There isno RDI for vitaminD, although trials that show benefit from vitaminD have used aminimum of800IU daily. The United States Institute ofMedicines Food and Nutrition Board proposes adaily intake of600IU vitaminD inpeople over 71years ofage.328 InAustralia, aminimum daily dose of400IU isrecommended, with higher doses required for people with vitaminD levels lower than 50nmol/L.345 InNew Zealand, apreparation of50000IU ofvitaminD isavailable, and current recommendations are for one tablet monthly. Recommended daily doses inRACFs tend tobe higher, given the limited exposuretosunlight.328,346,347
18.2.1 Assess adequacyofvitaminD
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, they canuse: food preferencerecords food and fluid intake records (seeAppendix11) 25(OH)D bloodlevels.
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18.2.2 Ensure minimum sun exposure toprevent vitaminDdeciency

Osteoporosis Australia (in association with the Cancer Council Australia) recommends that for most older Australians, vitaminD deficiency can beprevented by515minutes exposure ofthe face and upper limbs tosunlight, four tosix times per week although deliberate exposure tosunlight between 10am and3pm inthe summer months for more than 15minutes isnotadvised. If this modest sunlight exposure isnot possible, then avitaminD supplement ofat least 800IU/day isrecommended.
18.2.3 Consider vitaminD and calciumsupplementation

Health care professionals should consider the high possibility ofvitaminD deciency inpeople living inRACFs and supplement without doing routine blood tests. Ifthere isuncertainty, 25(OH)D can bemeasured using abloodtest. For confirmed cases ofvitaminD deficiency, supplementation with 30005000IU/day for atleast one month isrequired toreplenish body stores (one 50000IU tablet daily for three days and then one tablet monthly). Increased availability oflarger dose preparations ofcholecalciferol (vitaminD3) would beauseful therapy inthe case ofseveredeciencies. For most older people inlong-term care inAustralia, itis appropriate tosupplement with 1000IU vitaminD without measuring 25(OH)D vitaminD blood levels. This isbased onthe prevalence ofdeficiency, the low risk and the benet shown when doing itin this untargeted way for hip fractureprevention.328,346,347 However, use calcium supplementation with caution inwomen older than 70years ofage, due tothe possible association with cardiovascular events.339,340 Dietary calcium should beencouraged ifat all possible and amaximum supplementation dose of500mg/day considered ifdaily dietary intake does not reach1000mg.
18.2.4 Encourage residents toinclude foods high incalcium intheirdiet

The food guidelines inAppendix12, which outline calcium and vitamin dietary suggestions and hints,348 are useful for encouraging residents toinclude more calcium intheir diet. Referral toadietician may beappropriate ifaresident 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).
18.2.5 Discourage residents from consuming foods that prevent calciumabsorption

Oral calcium intake needs tomeet the RDI. Toachieve this, discourage residents from consuming too many foodstuffs that lower orprevent calcium absorption (eg caffeine, soft drinks containing phosphoric acid). Instead, encourage them toinclude foods high incalcium intheirdiet. Analysis offood intake records ordiet history should show adaily intake ofcalcium of800mg for men and 1000mg forwomen.348
Casestudy
MrsQ lives inanursing home and has been falling frequently. Staff report that she has difculty getting out ofachair and has notable proximal muscle weakness (a clinical manifestation ofvitaminD deficiency). She eats anutritionally balanced diet, including regular consumption ofmilk. She does not gooutside but does catch some rays inthe sunroom, which has large glass windows. Unfortunately, glass absorbs nearly all ultraviolet Bphotons, which are required for vitaminD production. Blood tests confirmed vitaminD deficiency, which was corrected with oral supplementation. Other interventions were also included aspart ofatargeted multifactorial falls prevention program inresponse tothe falls riskassessment.
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Cognitive impairment can beassociated with nutritional deficiencies, including areduced calcium and vitaminD intake inthe diet. RACF staff should monitor residents oral intake closely, and refer them toadietician ifintake isreduced. Oral calcium and vitaminD supplementation is frequently required tomaintain levels ofboth calcium and vitaminD inthispopulation.
PartD

Increased skin pigment reduces the amount ofvitaminD production after sun exposure, sodark-skinned people are more susceptible toreduced vitaminD levels. People who are heavily clothed and veiled for religious orcultural reasons are also atincreased risk ofreduced vitaminDlevels.
A number ofvitaminD and calcium-based compounds are publicly funded via the Pharmaceutical Benets Scheme. See Chapter19 onosteoporosis management for moreinformation.
The following publications provide useful information ondietary intake ofvitaminD andcalcium: Dietary Guidelines for all Australians, National Health and Medical Research Council(2003): http://www.nhmrc.gov.au/publications/synopses/dietsyn.htm Nowson CA, Diamond TH, Pasco JA, Mason RS, Sambrook PNand Eisman JA(2004). Vitamin Din Australia: issues and recommendations. Australian Family Physician33(3):133138. http://www.osteoporosis.org.au/les/research/vitamind_nowson_2004.pdf Recommendations from the Vitamin Dand Calcium Forum. Medicine Today6(12):4350. http://www.osteoporosis.org.au/les/research/Vitdforum_OA_2005.pdf Vitamin Dand adult bone health inAustralia and New Zealand: aposition statement, Working Group ofthe Australian and New Zealand Bone and Mineral Society, Endocrine Society ofAustralia and Osteoporosis Australia. Medical Journal ofAustralia182:281285. 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
Residents with ahistory ofrecurrent falls should beconsidered for abone health check. Also, residents who sustain aminimal-trauma fracture should beassessed for their riskoffalls.
Intervention
Residents with diagnosed osteoporosis orahistory oflow-trauma fracture should beoffered treatment for which there isevidence ofbenet.(LevelI) 349 Residential aged care facilities should establish protocols toincrease the rate ofosteoporosis treatment inresidents who have sustained their rst osteoporotic fracture.(LevelIV) 350
Good practicepoints
Strengthening and protecting bones will reduce the risk ofinjuriousfalls. In the case of recurrent fallers and those sustaining low-trauma fractures, health care professionals and care staff should consider strategies for optimising function, minimising along lie onthe floor, protecting bones, improving environmental safety andprescribingvitaminD. When using osteoporosis treatments, residents 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.351 Bone mineral density isan important measure inpredicting fractures inboth men and women, while quadricep strength and postural sway are ofsimilar importance inpredicting fractures.352 Notherapy islikely tonormalise bone mineral density, but small improvements can reduce fracturerisk.353
With this inmind, interventions that reduce falls risk may prevent fractures, even ifbone density isnot altered. This isof particular relevance tothe very old, inwhom low bone density places them atparticular risk, and for whom 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.354 A30% loss ofanterior vertebral height issufficient todiagnose osteoporosis for the Pharmaceutical Benets Scheme(PBS). Osteoporosis isdiagnosed byhaving abone mineral density test. The most reliable and accurate test ofthe several methods available isthe DXA (dual energy X-ray absorptiometry), which iswidely available inAustralia. All bone mineral density tests measure the amount ofmineral inaspecic area ofbone. The DXA test will give results asthe following twoscores: 354 Tscore, which compares bone density with that ofan average young adult ofthe same sex. ATscore ofzero means bones are the same density asthe average younger population and notreatment isnecessary. ATscore above one means bones are denser than the average younger population, and aTscore below zero means 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. Zscore, which compares bone density with the average from the persons age group and sex. Ifthe Zscore iszero, bones are average for their age and sex. Below zero indicates bones are below average density, and above zero indicates bones are above average density for age. AZscore below 2 means bone isbeing lost more rapidly than matched peers, sotreatment needs tobe monitored carefully. AZscore below 2 may also indicate that anunderlying disease isresponsible for theosteoporosis. Health care professionals and care staff inresidential aged care facilities (RACFs) should bevigilant indetecting anyone who has obvious manifestations ofosteoporosis (eg thoracic kyphosis, low-trauma fracture). Also, residents with multiple risk factors for osteoporosis can bedetected opportunistically byroutine screening inRACFs (eg residents onlong-termsteroids).
19.1.3 Interventions for falls and falls-related injuries relevanttoosteoporosis

A previous fracture isone ofthe strongest risk factors for future fracture.350 However, studies suggest that many people who sustain fractures are not checked ortreated for osteoporosis, orare not treated adequately toreduce future fracture risk, even when adiagnosis ofosteoporosis has beenmade.355,356 Despite this, several effective drug treatments are now available. Ameta-analysis and various randomised controlled trials (RCTs) have shown benecial effects oforal orintravenous bisphosphonates inpostmenopausal women who have low bone density; 349,357 asystematic review has shown the benets ofselective oestrogen receptor modulators inpostmenopausal women with osteoporosis; 358 and anRCT has shown the benets ofstrontium ranelate for preventing osteoporosis inpostmenopausal women.359 These drugs are now considered the rst-line treatments forosteoporosis. As most ofthe RCTs ofantiresorptive agents have used concomitant calcium and vitaminD (see Chapter18), itis appropriate toensure vitaminD deficiency iscorrected and toadd alow-dose calcium supplement tothese therapies when dietary calcium intakeissuboptimal.
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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.354,357 Currently, four bisphosphonates are available onthe PBS totreat osteoporosis. The following three medications are available for men and postmenopausal women with anosteoporoticfracture: 354 alendronate (Fosamax, Fosamax Plus, Alendro), which increases bone density and reduces the frequency offractures atthe hip andspine 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 low bonedensity357 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 bisphosphonate medication isalso available forosteoporosis: etidronate (Didrocal), which increases bone density and reduces risk offractures inthe spine, but not thehip.349,354,357,360 An association between bisphosphonate use and arare dental condition termed osteonecrosis ofthe jaw has been reported.357 Osteoporosis Australia recommends that the small risk ofthis condition needs tobe considered against the signicantly 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.361 Alendronate and risedronate have been associated with adverse gastrointestinal effects (egdyspepsia, abdominal pain, oesophageal ulceration).357 Therefore, residents who have reflux oesophagitis orhiatus hernia should bescreened before use.362 However, most studies have shown that the overall risk ofadverse gastrointestinal events associated with risedronate oralendronate use islow, although there are asmall number ofstudies that report the opposite.363 There isalso evidence that risedronate isless risky than alendronate.364 The potential for experiencing gastrointestinal side effects from either drug islowered when the dosing isdecreased toonce perweek.364
Selective oestrogen receptormodulators

Selective oestrogen receptor modulators (SERMs) are aspecial class ofdrug with many features similar tooestrogen 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.349,354,360 However, SERMs have also been associated with anincreased risk ofvenousthromboembolism.365
Strontiumranelate
In RCTs, strontium ranelate has reduced the risk ofboth vertebral and peripheral fractures.359 Strontium ranelate isthe only anti-osteoporotic agent that both increases bone formation markers and reduces bone resorption markers, resulting inarebalance ofbone turnover infavour ofboneformation.
19.1.4 Osteoporosis inresidential agedcare

There isevidence ofundertreatment ofosteoporosis inresidents inRACFs. For example, inone study, 37% offemale RACF residents were known tohave previous osteoporotic fractures; however, calcium supplementation was prescribed inonly 14% ofresidents and specific anti-osteoporosis therapy was prescribed inonly 3%ofresidents.356 Older people are more likely tohave several risk factors for fractures, including previous fractures.353 Inthese frail, older people, osteoporosis treatments must take account ofthe likelihood ofcomorbidity andthe use ofmultiple othermedications.
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Screening for osteoporosis isimportant for minimising falls-related injuries. Itis important torecognise that people sustaining low-trauma fractures after the age of60years probably have osteoporosis and anincreased risk ofsubsequent fracture.362,366 Health care professionals and care staff should consider bone densitometry and specific anti-osteoporosis therapy for people inthis group. Also, older people 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 prescribing vitaminD.367,368 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 intheir spine orhip.357 Consider using bisphosphonates, strontium orraloxifene toreduce the risk ofvertebral fractures and toincrease bone density inolder men atrisk ofosteoporosis (ie those with alow body mass index). Bisphosphonates work best inpeople with adequate vitaminD and calcium levels, and should thereforebeco-prescribed. RACFs should establish protocols toincrease the rate ofosteoporosis treatment inresidents who have sustained their rst osteoporoticfracture.350

A good-practice clinical indicator among residential care populations may beto review medication charts tosee whether residents have been prescribed vitaminD supplements, and toadjust for the number ofresidents who gooutside regularly and for the geographical latitude ofthe facility. Also, check whether residents sustaining fractures are screened for osteoporosis. Finally, compare the residents fracture rate with that ofpeople being treated for osteoporosis, checking first that they are ofacomparable age, falls risk, sex,etc.
Casestudy
MrsN isan 85-year-old lady who lives inaresidential aged care facility. She has ahistory offalling, and recently fell and fractured her hip. She thinks she has afamily history ofosteoporosis, and was treated for osteoporosis inhospital. Onreturn toher aged care facility, Mrs Nwas treated byaphysiotherapist using agraduated exercise program, beginning atalow intensity, with agoal ofsafe ambulation with the use ofaframe. MrsN wasprescribed vitaminD and calcium supplementation and wastaught about the use and availability ofhipprotectors.
Some residents with cognitive impairment need tobe supervised inthe correct and safe manner oftaking oral bisphosphonates. This isbecause there are restrictions onlying down oreating after taking thesemedications.
A number ofantiresorptive agents (such asbisphosphonates and strontium) and vitaminD analogues (alone orin combination with antiresportive agents) are available onthe Australian PBS for treatment ofosteoporosis (prevention offracture) inspecific populations. The safety, effectiveness and costeffectiveness ofthese agents have been reviewed bythe Pharmaceutical Benefits Advisory Committee, and the fact that they are subsidised bythe PBS indicates that they offer acceptable value for money inthe Australian context, for specificpopulations. Table19.1 provides specic PBS subsidy details for various agents affecting bone mineral density (current at27August2009).
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Table19.1 Pharmaceutical Benets Scheme details for osteoporosisdrugs
Drug
Alendronate Alendronate + cholecalciferol Risedronate Risedronate + calcium carbonate Risedronate + calcium carbonate + cholecalciferol Calcitriol Etidronate + calcium carbonate Raloxifene Strontium ranelate
Subsidisedindications
Treatment asthe sole PBS-subsidised antiresorptive agent for osteoporosis inapatient aged 70 years orolder with abone mineral density T-score of3.0 orless. Treatment asthe sole PBS-subsidised antiresorptive agent for established osteoporosis inpatients with fracture due tominimaltrauma.
Treatment for established osteoporosis inpatients with fracture due tominimaltrauma. Treatment asthe sole PBS-subsidised antiresorptive agent 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 of3.0 orless. Treatment asthe sole PBS-subsidised antiresorptive agent for established postmenopausal osteoporosis inpatients with fracture due tominimaltrauma.
Teriparatide
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 12months continuous therapy with anantiresorptive agent atadequatedoses. 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).
Zoledronic acid
PBS = Pharmaceutical BenetsScheme 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 (NICE), 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 specic diseases andconditions: http://www.nice.org.uk Osteoporosis Australia isanational organisation that aims toreduce fractures and improve bone health inthe community. They provide information kits onfalls and fractures. Ph: 02 9518 8140 Fax: 02 9518 6306 Toll free: 1800 242141 http://www.osteoporosis.org.au/html/index.php
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PartE Respondingtofalls
20 Post-fallmanagement
Recommendation
Assessment
Staff ofresidential aged care facilities should complete apost-fall assessment for every resident whofalls.
Good practicepoints
Residential aged care facility (RACF) staff should report and document allfalls. It isbetter toask aresident whether they remember the sensation offalling rather than whether they think that they blacked out, because many older people who have syncope are unsure whether they blackedout. RACF staff should follow the facilitys post-fall protocol orguideline for managing residents immediately afterafall. After the immediate follow-upof afall, review the fall. This should include trying todetermine how and why afall may have occurred, and implementing actions toreduce the risk ofanotherfall. An in-depth analysis ofthe fall event (eg aroot-cause analysis) isrequired ifthere has been aserious injury following afall, orif there has been adeath fromafall.
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Staff ofresidential aged care facilities (RACFs) must take all falls seriously. Falls may bethe first and main indication ofanother underlying and treatable problem inaresident.280 Older people who fall are also more likely tofall again.369 All RACF staff should beaware ofwhat constitutes afall (see Section1.3.1 for adefinition), what todo when aperson falls, and what follow-upis necessary (including completing anincidentform). Post-fall assessments have been part ofmultifactorial interventions successful inreducing falls.256 Arandomised controlled trial of439residents ofRACFs inSweden included post-fall assessments and meetings inan 11-week multifactorial falls prevention program. The program also included staff education, environmental modification, medication review, exercise programs, supplying and repairing aids, and providing free hip protectors, and was compared with usual care.256 Post-fall assessment involved followupfrom anurse onthe day ofthe fall, and follow-upfrom aphysiotherapist within three days. Ateam ofaphysician, nurse and physiotherapist (and other staff, asneeded) met weekly todiscuss falls and identify possible causes. Physical restraints were not suggested for any residents who fell. At34-week follow-up, 82 residents (44%) inthe intervention group fell compared with 109residents (56%) inthe control group. The authors concluded that amultifactorial falls prevention program targeting residents, staff and the environment reduced falls and femoralfractures. Another randomised controlled trial collected falls information and used this feedback toimprove the multifactorial falls prevention intervention.33 The trial, which was run insix RACFs inGermany and involved 981residents, included falls education for staff and residents, advice onenvironmental modification, progressive balance and resistance training, and hip protectors. Staff received training infalls prevention atthe start ofthe trial, and then monthly feedback onfallers, rates offalls and severe injuries over 12months. There was asignificant decrease inthe number offalls and fallers inthe study group, although the trial was too underpowered toshow adifference inhip ornonhipfractures. The remainder ofthis chapter describes the responsibilities ofRACF staff during and following afallbyaresident.
20.2 Respondingtoincidents
RACF staff should review every fall 280 and complete afalls report, including recommendations for the immediate and longer term carerequired.4 The circumstances surrounding afall are ofcritical importance. However, this information isoften difficult toobtain and may need tobe sourced from people other than the residents themselves, including staff, visitors and other residents. This may beparticularly important ifthe resident, when questioned directly, does not recall the circumstances ofthe fall orhitting theground. RACFs should have their own falls incident policy, orfollow aclinical practice guideline for preventing and responding tofalls. Staff should bemade aware of, and have access to, these policies orguidelines. The following checklist for RACF staff isaguide towhat should beincluded inafalls incidentpolicy.
Checklist for managing the resident immediately afterafall

Offer basic life support and providereassurance
Check for ongoingdanger. Check whether the resident isresponsive (eg responds toverbal orphysicalstimulus). Check the residents airways, breathing andcirculation. Reassure and comfort theresident.232,280
Take baselinemeasurements
Conduct apreliminary assessment that includes taking baseline measurements ofpulse, blood pressure, respiratory rate, oxygen saturation and blood sugar levels. Ifthe resident has hit their head, orif their fall was unwitnessed, record neurological observations (eg using the Glasgow Coma Scale).280 The RACFs incident policy should guide the staff member according totheir level oftraining, including helping them toknow when tocall forassistance.
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Check forinjuries
Check for signs ofinjury, including abrasion, contusion, laceration, fracture and headinjury.232,275,280
Move theresident
Assess whether itis safe tomove the resident from their position, and identify any special considerations inmoving them. Staff members should use alifting device instead oftrying tolift the resident ontheir own. Follow the RACFs policy orguidelineonlifting.
PartE
Monitor theresident
Observe residents who have fallen and who are taking anticoagulants orantiplatelets (blood-thinning medications) carefully, because they have anincreased risk ofbleeding and intracranial haemorrhage. Residents with ahistory ofalcohol abuse may bemore prone tobleeding. Contact the medical ofcer and provide relevantdetails. Ensure ongoing monitoring ofthe resident, because some injuries may not beapparent atthe time ofthe fall.4,232 Make sure RACF staff know the type, frequency and duration ofthe observations that arerequired.
Respondingtofalls
Report thefall
Report all falls toamedical officer, even ifinjuries are not apparent.232,275,280 The medical officer should assess and treat any injury, assess the conditions that may have caused the fall, and put any appropriate interventions inplace. Staff may need tocall for anambulance totransfer the resident tohospital. Inthis case, transfer information should beprovided, including details ofthe fallevent. Document all details inthe persons medical record, including their appearance orresponse, evidence ofinjury, location ofthe fall, notification oftheir medical provider and actionstaken.232,275,280 Complete anincident reporting form for all falls,4,275,280,299 regardless ofwhere the fall occurred orwhether the person wasinjured. Note any details ofthe fall when reporting the incident, including any recollections ofthe resident.275,280 Ataminimum, this should include the location and time ofthe fall, what the resident 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 resident has fallen and has anincreased risk offallingagain.275 At the earliest opportunity, notify the person nominated tobe contacted incase ofanemergency.275,280 Discuss with the resident and their family the circumstances ofthe fall, its consequences and actions planned toreduce their risk offallingagain.232 Assume that once aresident has fallen, they automatically have ahigh risk offalling again until they have beenassessed.232 Follow local guidelines for identifying residents asbeing atincreased riskoffalling.
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20.2.1 Post-fallfollow-up
After the fall, determine how and why the fall may have occurred, toreduce the risk ofanother fall. Thefollowing steps are aguide towhat should beincluded inan RACFs falls policy orpracticeguidelines: Investigate the cause ofthe fall, including assessing fordelirium. Complete afalls risk assessment onthe resident following afall (see Chapter5), because new risk factors maybepresent.4,232,275 Review the implementation ofexisting falls prevention strategies, including standard falls prevention strategies for theresident.4,232,275 Implement atargeted, individualised plan for daily care, based onareassessment from afalls risk assessment tool. Implement multifactorial interventions asappropriate. These may include, but arenot limited to, gait, balance and exercise programs, footwear review, medication review, hypotension management, environmental hazard modification and cardiovascular disorder treatment.370 This will often involve referral toother members ofthe health care team (eg general practitioner, physiotherapist, podiatrist,dietician). Encourage the resident toresume their normal level ofactivity, because many older people are apprehensive after afall and the fear offalling isastrong predictor offuturefalls.371 Consider the use ofinjury-prevention interventions, such asvitaminD and calcium supplementation, andthe use ofhip protectors (see Chapters17 and18).4,232,275 Consider investigations for osteoporosis inthe presence oflow-traumafractures. Ensure effective communication ofassessment and management recommendations to everyone involved.4,232,275
20.2.2 Analysing thefall

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

Accurate reporting offalls will only occur inaculture that isfair and just that is, ano blame culture. Staff often feel anxious when having tocomplete anincident form and can associate the incident with feelings ofguilt and blame. For accurate reporting offalls, the leaders inthe facility must promote incident reporting asapart ofthe quality improvement process, rather than apunitive tool toidentify potential staff negligence.372 This requires afair and just culture for achieving safe and high-qualitycare. 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.280 Feedback should also beprovided tostaff regularly (eg monthly) sothat local trends can beidentified and addressed aspart ofthe routine, continuous quality-improvementplan. Any data collected should beused toinform changes inRACF practice aimed atreducing resident falls rates. This requires analysing collected data regularly, monitoring trends, comparing falls data with that from other RACFs and making changes tousual care basedonfindings.
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20.3.1 Minimum dataset for reporting and recordingfalls

A minimum dataset about all falls within anRACF should becollected for reporting and reviewing, and toimprove the safety and quality ofcare tothe resident. Items tobe included inaminimum dataset should bedetermined byeach facility ororganisation. Examples ofsome items that could beincludedare: type offall (eg slip, trip, bumping into orfalling onan object),4 and activity attime ofthe fall (egattempting tostand,walking) whether the resident depends onaidsorstaff relevant information about clothing, footwear, eyewear and mobility aids used atthe time ofthefall4 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, clutter4 ) orstafnglevels status following the fall (eg baseline observations,injuries) interventions tobe implemented following the fall, and medical treatmentrequired the residents perception ofthe fall, including description ofany preceding sensations orsymptoms 4 andwhat they consider could have prevented thefall any witnesses tothefall any othercomments. This information should becompleted whenever afall ornear miss occurs inan RACF. Ageneric incident form may already bein use; however, RACFs may need todevelop afalls-specific incident form tofocus onthe details required tomonitor falls incidences and management plans. Any ofthis information not being collected can becaptured byincorporating itinto existing incidentreports. To achieve the most accurate information about the incident, the description ofthe fall should also allow for free text. There should beroom onthe incident form for additional comments tobe made. Staff should beencouraged tocomplete all sections ofthe incident report tominimise missing information when the fall isbeingreviewed.
20.4 Comprehensive assessmentoffalls

People who fall repeatedly and people who are prone toinjurious falls require acomprehensive and detailed assessment, inaddition totheir falls risk assessment.370 When RACF staff believe that amore detailed assessment isnecessary, they should discuss itwith the residents general practitioner and, ifappropriate, arrange for areferral toaspecialist (eg geriatrician) orto afallsclinic.
20.5 Loss ofcondence afterafall

A common but often overlooked consequence ofafall isaloss ofconfidence inwalking orfear offalling, 373 which can occur even inthe absence ofany injury. Inthe period after afall, RACF staff should observe the resident tonote any change intheir usual activity that might indicate the presence of, orincrease in, fear offalling. Discussion with the resident about any concerns about falling might also bean opportunity toidentify itspresence. Common approaches toimproving loss ofconfidence orfear offalling inRACF settings include participation inabalance and mobility training exercise program, and other falls prevention activities, including the use ofhipprotectors.374
The following information sheetisuseful: General Practice inResidential Aged Care: Clinical Information Sheet. Falls Management and Prevention, North West Melbourne Division ofGeneralPractice: http://nwmdgp.org.au/pages/after_hours/GPRAC-CIS-06.html
133
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 residents infallsprevention Ms MegHeaslop Ms MegHeaslop Dr ConstanceVogler Mr GrahamBedford Assoc Prof StephenLord Dr ConstanceVogler
Part B Standard falls preventionstrategies

Falls preventioninterventions Falls risk screening and assessment Ms MegHeaslop Dr Kim Delbaere Dr ConstanceVogler Prof KeithHill
Part C Management strategies for common falls riskfactors

Balance and mobility limitations Cognitive impairment Continence Feet and footwear Syncope Dizziness and vertigo Medications Vision Dr Cathie Sherrington Dr Kim Delbaere Dr Kim Delbaere Dr Kim Delbaere Dr Janet Salisbury Dr Kate Murray Assoc Prof Jacqueline Close Assoc Prof Stephen Lord Assoc Prof Jacqueline Close Dr Kim Delbaere Environmental considerations Individual surveillance and observation Restraints Ms Meg Heaslop Ms Jacinda Wilson Ms Meg Heaslop 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
Appendix 1
137
Chapter
Part D Minimising injuries fromfalls
Hip protectors Vitamin Dand calcium supplementation
Author(s)
Reviewer
Ms Meg Heaslop Assoc Prof Jacqueline Close Ms Meg Heaslop
Prof IanCameron Prof TerryDiamond
Appendices
Osteoporosis management
Assoc Prof Stephen Lord Ms Meg Heaslop
Dr PeterEbling
Part E Respondingtofalls
Post-fall management Ms Meg Heaslop Assoc Prof MichaelDorevitch
Guideline
Community Residential aged carefacility Hospital
Australianreviewer
Dr NancyePeel Ms MandyHarden Assoc Prof JacquelineClose
Internationalreviewer
Assoc Prof ClareRobertson Assoc Prof NgaireKerse Prof DavidOliver
Additionalwork
Economicevaluations Editors Dr KirstenHoward Ms MegHeaslop, Biotext PtyLtd Dr JanetSalisbury, Biotext PtyLtd Design True Characters PtyLtd
Contributors
Name
Mr Graham Bedford Prof Ian Cameron
Position
Policy Team Manager, Australian Commission onSafety andQuality inHealthCare Professor ofRehabilitation Medicine, The University ofSydney; and Head, Rehabilitation Studies Unit, TheUniversityofSydney Associate Professor, Convener ofBachelor ofPhysiotherapy Program, School ofHealth Sciences, TheUniversityofNewcastle 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; and Honorary Senior Fellow, Prince ofWales Medical Research Institute, TheUniversity ofNew SouthWales Postdoctoral researcher, Prince ofWales Medical Research Institute, The University ofNew SouthWales Senior Endocrinologist, StGeorge Hospital; and Associate Professor inEndocrinology, The University ofNew SouthWales
Assoc Prof Pauline Chiarelli
Assoc Prof Lindy Clemson Assoc Prof Jacqueline Close
Dr Kim Delbaere Prof Terry Diamond
138
Name
Assoc Prof Michael Dorevitch Dr Peter Ebeling
Position
Senior Geriatrician, AustinHealth Professor ofMedicine, Department ofMedicine (RMH/WH), The University ofMelbourne; and Head, Endocrinology, WesternHealth Associate Professor ofMedicine, Monash University; and Consultant Geriatrician, Cabrini MedicalCentre CNC Aged Care Education/Community Aged Care Services, Hunter New England Area HealthServices Professor ofAllied Health, La Trobe University and Northern Health; and Senior Researcher, Preventive and Public Health Division, National Ageing ResearchInstitute Senior Lecturer, Health Economics, School ofPublic Health, The UniversityofSydney Leader, New South Wales Falls Prevention Program, Clinical ExcellenceCommission Associate Professor, General Practice and Primary Health Care, School ofPopulation Health, Faculty ofMedical and Health Sciences, The UniversityofAuckland Principal Research Fellow, Prince ofWales Medical Research Institute, The University ofNew SouthWales National Health and Medical Research Council Research Fellow; and Director, Musculoskeletal Research Centre, Faculty ofHealth Sciences, LaTrobeUniversity Principal, Dizzy DayClinics Consultant Physician and Clinical Director, Royal Berkshire Hospital, United Kingdom; and Visiting Professor ofMedicine for Older People, School ofCommunity and Health Sciences, City University,London Research Fellow, Academic Unit inGeriatric Medicine, School ofMedicine, 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, The UniversityofSydney Research Officer, Prince ofWales Medical Research Institute, The University ofNew SouthWales Clinical Senior Lecturer, Medicine, Northern Clinical School, The University ofSydney; and Staff Specialist Geriatrician, Royal North ShoreHospital Professor, School ofOptometry and Institute ofHealth and Biomedical Innovation, Queensland UniversityofTechnology
Appendices
Assoc Prof David Fonda Ms Mandy Harden Prof Keith Hill
Dr Kirsten Howard Ms Lorraine Lovitt Assoc Prof Ngaire Kerse
Assoc Prof Stephen Lord Assoc Prof Hylton Menz
Dr Kate Murray Prof David Oliver
Dr Nancye Peel Assoc Prof Clare Robertson
Dr Jeffrey Rowland Dr Cathy Sherrington
Dr Anne Tiedemann Dr Constance Vogler
Prof Joanne Wood
Appendix 1
139
Appendices
Appendix 2
Falls risk screening and assessmenttools
Appendices
A2.1 Peninsula Health FRAT (screeningcomponent)

The Peninsula Health Falls Risk Assessment Tool (FRAT) has several parts, and ispart 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. Itwas developed through funding from the Department ofHumanServices.
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
141
Appendices
Appendix 3
Rowland Universal Dementia Assessment Scale(RUDAS)105
Appendices
RUDAS
Rowland Universal Dementia Assessment Scale: A Multicultural Mini-Mental State Examination. (Storey, Rowland, Basic, Conforti & Dickson, 2002) Date: / / Name: Patient Name:
Item
Memory
Max Score
1. (Instructions) I want you to imagine that we are going shopping. Here is a list of grocery items. I would like you to remember the following items which we need to get from the shop. When we get to the shop in about 5 mins. time I will ask you what it is that we have to buy. You must remember the list for me. Tea, Cooking Oil, Eggs, Soap Please repeat this list for me. (Ask person to repeat the list 3 times). (If person did not repeat all four words, repeat the list until the person has learned them and can repeat them, or, up to a maximum of ve times.)
Visuospatial Orientation
2. I am going to ask you to identify/show me different parts of the body. (Correct = 1) . Once the person correctly answers 5 parts of this question, do not continue as the maximum score is 5. (1) show me your right foot (2) show me your left hand (3) with your right hand touch your left shoulder (4) with your left hand touch your right ear (5) which is (indicate/point to) my left knee (6) which is (indicate/point to) my right elbow (7) with your right hand indicate/point to my left eye (8) with your left hand indicate/point to my left foot
Praxis
1 1 1 1 1 1 1 1
/5
3. I am going to show you an action/exercise with my hands. I want you to watch me and copy what I do. Copy me when I do this (One hand in st, the other palm down on table alternate simultaneously.) Now do it with me: Now I would like you to keep doing this action at this pace until I tell you to stop approximately 10 seconds. (Demonstrate at moderate walking pace). Score as: Normal = 2 (very few if any errors; self-corrected, progressively better; good maintenance; only very slight lack of synchrony between hands) Partially Adequate = 1 (noticeable errors with some attempt to self-correct; some attempt at maintenance; poorsynchrony) Failed = 0 (cannot do the task; no maintenance; no attempt whatsoever)
Visuoconstructional Drawing
/2
4. Please draw this picture exactly as it looks to you (Show cube on back of page). Score as: (Yes = 1) (1) Has person drawn a picture based on a square? (2) Do all internal lines appear in persons drawing? (3) Do all external lines appear in persons drawing? 1 1 1 (2) (3) /3
Appendix 3
143
Appendices
Item
Judgment
Max Score
5. You are standing on the side of a busy street. There is no pedestrian crossing and no trafc lights. Tell me what you would do to get across to the other side of the road safely. (If person gives incomplete response that does not address both parts of answer, use prompt: Is there anything else you would do?) Record exactly what patient says and circle all parts of response which were prompted. Score as: Did person indicate that they would look for traffic? (YES = 2;YES PROMPTED = 1; NO = 0) Did person make any additional safety proposals? (YES = 2;YES PROMPTED = 1; NO = 0)
Memory Recall
2 2
/4
1. (Recall) We have just arrived at the shop. Can you remember the list of groceries we need to buy? (Prompt: If person cannot recall any of the list, say The rst one was tea. (Score 2 points each for any item recalled which was not prompted use only tea as a prompt.) Tea Cooking Oil Eggs Soap
Language
2 2 2 2 /8
6. I am going to time you for one minute. In that one minute, I would like you to tell me the names of as many different animals as you can. Well see how many different animals you can name in one minute. (Repeat instructions if necessary). Maximum score for this item is 8. If person names 8 new animals in less than one minute there is no need to continue. 1. 2. 3. 4.
TOTAL SCORE =
5. 6. 7. 8. /8
/30
144
Appendix 4
Safe shoechecklist232
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 on thefoot. A straight-through sole is also recommended. Have a broad heel with good ground contact. Have a rm 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 nd 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. Have 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.
Appendix 4
145
Appendices
Appendix 5
Environmentalchecklist280
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 afx 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?
Appendix 5
147
Client location:
Floor surfaces
Bed/room No:
Please
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
Appendices
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 rm 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 non-slip 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 rm 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 non-slip edging in contrasting colour? Is there enough room for two people with frames/wheelchairs to pass each other safely?
Lifts Please
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?
148
Client location:
External areas
Bed/room No:
Please
appropriate box
Yes
No
N/A
Are pathways even and with a non-slip surface? Are pathways clear of weeds, moss and leaves? Are steps marked with a contrasting colour and non-slip surface? Are there handrails beside external steps and pathways? Are there any overhanging trees, branches and shrubs? Are sensor lights installed? Are there sufcient numbers of outdoor seats for regular rests?
Security of environment Please
Appendices
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 5
149
Appendices
Appendix 6
Equipment safetychecklist275
Appendices
Reproduced with permission from VANational Centre for Patient Safety 2004 Falls Toolkit, page43.
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 rmly when applied Height adjusts easily (if applicable) Sturdy, attached properly Wheels rmly locked Positioned on wall-side of bed
IV poles/stand
Pole Wheels Stand
Raises/lowers easily Roll easily and turn freely, do not stick Stable, does not tip easily (should be five-point base)
Appendix 6
151
Appendices
Equipment safety checklist:

Footstools
Please
Legs
Rubber skid protectors on all feet Steadydoes not rock
Top
Call bells/lights
Non-skid surface
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 rmly 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: / /
152
Appendix 7
Checklist ofissues toconsider before using hipprotectors313
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 t 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 adherence? When should the hip protectors be replaced? Has education been provided to care staff?
Appendix 7
153
Appendices
Appendix 8
Hipprotector care plan232
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: / / Afx ID label
Identied/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 who already wear stretch pants for incontinence pads, a second pair of stretch pants may be needed and worn over the rst 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 t 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
Appendix 8
155
Appendices
Appendix 9
Hipprotector observation record232
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): Afx ID label
Date
Time applied
Time removed
Hours in use
Comment
Initials
Appendix 9
157
Appendices
Appendix 10
Hip protector educationplan303
Appendices
The following information is taken from Meyer G, Warnke A, Bender R and 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.
Appendix 10
159
Appendices
Appendix 11
Food and uid intakechart
Reproduced with permission ofToowoomba Health Services District, QueenslandHealth.
Appendices
Food and uid intake chart

Please afx client identication 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 uid 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 uid type and volume)
None None None None None None None
All All All All All All All
Appendix 11
161
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 uid type and volume)
Supper
None None None None None None None
All All All All All All All
Food Drink Other (specify uid 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).
162
Appendix 12
Food guidelines for calcium intake for preventing falls inolderpeople348
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.
163
Appendices
Glossary
Appendices
Cognitive impairment Cognitively intact Comorbidity Consumer Delirium Dementia Extrinsic factors Facility Fall
Impairment inone ormore domains ofnormal brain function (egmemory, 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 denition: 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 ofthese guidelines, Preventing Falls and Harm From Falls inOlder People: Best Practice Guidelines for Australian Residential Aged Care Facilities2009. A more detailed and systematic process than afalls risk screen and isused toidentify apersons risk factors forfalling. The minimum process for identifying older people atgreatest risk offalling. Itis also anefficient process, because fewer than ve 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 cost effectiveness ratio (ICER)
165
Injurious fall
These guidelines use the Prevention ofFalls Network Europe (ProFaNE) panel definition ofan injurious fall. They consider that the only injuries that could beconrmed accurately using current data sources were peripheral fractures (defined asany fracture ofthe limb girdles and ofthe limbs). Head injuries, maxillofacial injuries, abdominal, soft tissue and other injuries are not included inthe recommendation for acore dataset. 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
A therapeutic procedure ortreatment strategy designed tocure, alleviate orimprove acertaincondition. Factors that relate toapersons behaviourorcondition.
A measure ofthe gain inhealth outcomes fromanintervention. Life-years saved orlife-years generated (LYS) Multifactorial interventions Multiple interventions Older person orolder people Patient Pharmacodynamics Pharmacokinetics Psychoactive medication Quality-adjusted life year (QALY) Resident Residential aged care facility (RACF) Root-cause analysis (RCA) Single interventions Syncope Vision Visual acuity Where people receive multiple interventions, but the combination ofthese interventions istailored tothe individual, based onan individualassessment. Where everyone receives the same, fixed combinationofinterventions. These 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 chemical breakdown. 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. These guidelines use resident wherever possible, infavour ofpatient, older person orolder people. The term 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 nedetail. A measure ofthe ability ofthe eye tosee ne detail when the best spectacle orcontact lens prescription isworn. Visual acuity (VA) = d/D (written asafraction) where: d=the viewing distance (usually 6metres), and D=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 asthe standard for goodvision.
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Preventing Falls and Harm From Falls in Older People

Statement fromthe chiefexecutive

iii xiii xv xvii xix

Part BStandard falls preventionstrategies

Part CManagement strategies for common falls riskfactors

Preventing Falls and Harm From Falls inOlderPeople

10.1.2 Orthostatic hypotension (posturalhypotension) 64

Preventing Falls and Harm From Falls inOlderPeople

90 90 90 91 91 91 91 92 92 92 93 94 94 94 95 95 96 96 97 97 97 97 99 100 100 100 101 101 102 102 102

Part DMinimising injuries fromfalls

Preventing Falls and Harm From Falls inOlderPeople

Table6.2 Table7.1 Table13.1 Table19.1

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

Management strategies for common falls riskfactors

Preventing Falls and Harm From Falls inOlderPeople

Summary ofrecommendations and goodpracticepoints

Preventing Falls and Harm From Falls inOlderPeople

Summary ofrecommendations and goodpracticepoints

Preventing Falls and Harm From Falls inOlderPeople

Individual observation andsurveillance

Summary ofrecommendations and goodpracticepoints

Minimising injuries from falls

Preventing Falls and Harm From Falls inOlderPeople

Vitamin Dand 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 Specic toAustralian residential aged carefacilities

1.2.3 Relevant toall residential aged care facilitystaff

1.3.2 Denition ofan injuriousfall

1.3.3 Denition 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

1.6 Governance ofthe review ofthe Australian FallsGuidelines

1.7 How touse theguidelines

Preventing Falls and Harm From Falls inOlderPeople

Review and monitor

Implement targeted, individualised falls and falls 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

Table2.1 Risk factors for falling inresidential aged carefacilities

Intrinsic risk factors

2 Falls and falls injuriesinAustralia

1.1 About theguidelines

1.2 Scope oftheguidelines

1.2.2 Specic toAustralian residential aged carefacilities

1.2.3 Relevant toall residential aged care facilitystaff

1.3.2 Denition ofan injuriousfall

1.3.3 Denition ofassessment and riskassessment

1.4 Development oftheguidelines

1.6 Governance ofthe review ofthe Australian FallsGuidelines

1.7 How touse theguidelines

Figure 1.1 Using the guidelines toprevent fallsinAustralia

1.7.2 How the guidelines arepresented

2.2 Fall rates inolderpeople

2.5 Economic considerations infalls preventionprograms

2.7 Risk factors forfalling

3 Involving residents infallsprevention

4.1 Background andevidence

4.2 Choosing falls preventioninterventions

4.3.2 Rural and remotesettings

4.3.3 Indigenous and culturally and linguistically diversegroups

5.1 Background andevidence

5.1.1 Falls riskscreening

5.1.2 Falls riskassessment

5.2.2 Falls riskassessment

5.3.2 Rural and remotesettings

5.3.3 Indigenous and culturally and linguistically diversegroups

5.3.4 People with limitedmobility

6.1 Background andevidence