Falls clinical Guidance

(PRESENTED BY

NAME:

INSTITUTION:

DISCIPLINE:

TUTOR:

INTRODUCTION

This guideline is meant for health care professionals and
other clinical practitioners.

Entails summary of fall assessment and screening, especially
with regard to the elderly.

Specific details include focused history, functional
assessment, physical and environmental assessment

Recommendations for elderly in various care settings also
integral

Guideline seeks to address falls and related issues,
recommends preventive measures (American Geriatrics
Society, British Geriatrics Society, & American Academy of
Orthopedic Surgeons Panel on Falls Prevention, 2008).

Practice problem is prevention of falls among the elderly

Significant to nursing as falls affect significant portion of
population under health care

Problem tackled by American Geri-atrics Society/British
Geriatrics Society Clinical Practice Guideline for Prevention of
Falls in Older Persons (2010)

DEVELOPMENT AND CREDIBILITY

Developed by Panel on Prevention of Falls in Older Persons,
American Geriatrics Society and British Geriatrics Society.

Development of update began by convening panel of new
members and others from previous panels.

Based on analyses and evidence available since adoption of
an earlier guideline in 2001.

Panel members professionals in nursing and other medical
fields to ensure credibility.

Relied on experience of panel members and borrowed from
related publications.

LITERATURE SEARCH

Literature search included:

Meta-analyses

Systematic literature reviews

Randomized control trials (RCTs)

Controlled before-and-after studies

Cohort studies(2001-2008)

Panel reviewed RCTs (of 2008-2009) and concluded
additional evidence did not alter ranking of available
evidence, or guideline recommendations (National
Osteoporosis Society (Great Britain), 2008).

Multifactorial interventions negative RCTs involved risk factor
assessment

Assessment involved referral with no direct intervention.

Interventions were instituted.

Research databases included:

Medline

PubMed

Cochrane Central Register of Controlled Trials

Health Technology Assessment/Centre for Reviews and
Dissemination

Database of Abstracts of Reviews of Effectiveness

Interventions centered on bone health and topics of restraints,
syncope, bone protection and inpatient hospital-based fall
prevention were not included in evidence review or guideline.

Quality of Research

Panel members completed disclosure form at the start of
guideline process.

Form was shared with entire panel in its initial sessions to
ensure research would not be compromised.

Conflicts of interest were resolved by ensuring the various
processes were peer reviewed.

Where outcome data was insufficient to allow evidence based
recommendation, recommendations were based on
consensus (American Medical Directors Association,2008).

Consensus followed intensive discussion.

BEST EVIDENCE

Standardized format used to analyze literature and grade
evidence for guideline.

Format based on evidence rating system employed by U.S
Preventive Services Task Force (American Medical Directors
Association, 2008).

Evidence prompting recommendation informed by factual
and perceived sufficiency .

Best evidence determined by magnitude of benefit for each
intervention (Perry & Potter, 2012)

Ratings of A,B,C,D assigned to each recommendation.

Recommendation strength/grading

Rating

Recommendation

A

Strong recommendation for intervention to be provided to eligible patients

B

Recommendation that intervention should be provided to eligible patients

C

No recommendation for or against routine provision of intervention

D

Panel recommends against routine provision of intervention to
asymptomatic patients

Best Practice

Initiation of multifactorial/multicomponent interventions to
address identified risks, prevent falls.

Two methods tested in clinical trials:

Multicomponent intervention-set of interventions offered to
all program participants, addresses more than one category.

Multifactorial intervention-only adjusted subset of
interventions offered to participants in a program.

Interventions are offered after identification of risk factors
through fall risk factor assessment (New South Wales, 2011).

….continued

Multicomponent/multifactorial studies revealed great
heterogeneity of designs; panel prompted to include trials
regardless of dimensions.

Components of multicomponent and customized
multifactorial interventions:

exercise/physical activity

medical assessment and management

medication adjustment

environmental modification

education

Research articles summary

Research mainly employed:

Meta-analyses

Clinical trials

Quasi-experimental studies

Integrative reviews of related research

…continued

Brown AP. Reducing falls in elderly people: A review of exercise
interventions. Physiother Theory Pract 1999

Range of exercise types investigated include: balance
exercises, strength training, flexibility, tai chi, and
cardiovascular/endurance/fitness training

Exercise programs associated with fewer falls (Brown, 1999)

Should be initiated with caution as other studies show
exercise increases rate of falls in persons with mobility
problems.

Trials involving balance training showed fall reduction
alongside benefits in balance and gait, reduced fear of falling
too

Fits in level VI of evidence table

Hornbrook MC, Stevens VJ, Wingfield DJ et al. Preventing falls
among com-munity-dwelling older persons: Results from a
randomized trial. Gerontologist 1994

Use of psychotropic medication as single intervention reduces
fall rate

Assessment and adjustment or discontinuation of medication
regimens effectively reduces fall rates

Strong evidence supporting withdrawal of psychotropic
medication (Hornbrook et al, 1994)

Evidence falls to level III of evidence table

Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the
prevention of falls in older adults: Systematic review and
meta-analysis of randomized clinical trials. BMJ 2004

Investigated effectiveness of customized multicomponent
intervention after multifactorial clinical assessment

Interventions were: medical assessment, physiotherapy,
optical correction, foot care, occupational therapy

No difference found between intervention and fall risk control
group

Foot problems ,cognitive impairment , dementia e.t.c increase
risk fall (Chang et al, 2004)

Evidence fits to level I of evidence hierarchy.

Broe KE, Chen TC, Weinberg J et al. A higher dose of vitamin D
reduces the risk of falls in nursing home residents: A randomized,
multiple-dose study. J Am Geriatr Soc 2007

Vitamin D supplements used as single interventions

Meta-analyses and RCTs studies support use of vitamin D3
and calcium (combination) supplementation as intervention

Intervention reduces fracture rates, hence fall rates in older
people (Broe et al, 2007).

Evidence falls to level I of evidence table

Rucker D, Rowe BH, Johnson JA et al. Educational intervention to
reduce falls and fear of falling in patients after fragility fracture:
Results of a controlled pilot study. Prev Med 2006

Studied education as a multicomponent intervention program

Program included drug review, staff education, environmental
adjustment, exercises, aids, problem-solving conferences

Education and information do not reduce falls when used as
single interventions.

Education should not be used as a single intervention to reduced
falls in older persons (Rucker et al, 2006).

Evidence fits in level VI of evidence hierarchy

Healey F, Monro A, Cockram A et al. Using targeted risk factor
reduction to prevent falls in older in-patients: A randomized
controlled trial. Age Ageing 2004

One RCT was used as a cognitive-behavioral fall prevention
program.

‘stepping on’ (RCT) was part of a multicomponent fall
reduction program

Falls were relatively lower in the intervention group (Healey
et al, 2004).

Evidence falls to level II of evidence hierarchy

APPLICATION(TO PRACTICAL SETTING)

Numerous practices for implementation based on
recommendation of guideline

Examples:

Medication review: prescribed and over-the counter medications
to be reviewed. Likely to be opposed by chemist/pharmacy
owners and private practitioners, likely to be supported by
government.

Exercise: Inclusion of regular exercise in programs of older
people should be considered. Likely to be supported by
government and healthcare providers. Opposition expected
from the ‘patients’/older people themselves who think they
are too old to exercise

Decision to change practice likely to be made by government
through its health docket.

PLANNING FOR CHANGE

Best practice is the Initiation of
multifactorial/multicomponent interventions
to address identified risks, prevent falls

Should be implemented by all stakeholders
including government and private health care
providers

Citizens also have obligation to do what
would help reduce falls

Action should be taken not only when falls
have occurred but before i.e. prevent them

Implementation of best practice would involve
cost factors like:

Cooperation from target niche of population

Funding

Qualified and competent medical personnel

Reliable research methods that would
accurately determine risk factors.

A unified approach that would ensure all work
towards one objective

Guideline Recommendation(s)

Periodical multifactorial risk assessment by clinicians with
appropriate training skills.

Such should focus on :

fall history

medication review

history of relevant risk factors

physical examination

functional assessment

environmental assessment

OUTCOMES

More budgeting for the health docket, specifically channeled
to nursing

A more enlightened population

Need for more health experts to specialize in fall-related
initiatives

Need for more counseling and various forms of therapy

Improved quality of life if best practice is implemented
(American Medical Directors Association, 2008).

Fall reduction and longer life in cases where falls would result
to death

SUMMARY

Need to reduce falls identified

Guideline developed by Panel on Prevention of Falls in Older
Persons, American Geriatrics Society and British Geriatrics
Society.

Employs and recommends various strategies for interventions
for fall reduction

Recommendations mainly based on scientific research

Best practice identified as Initiation of
multifactorial/multicomponent interventions to address
identified risks, prevent falls

REFLECTION

Developing the evidence-based presentation
was indeed one of the best academic
experiences in along time. More insight on
clinical practice as regards falls has been
gained. Moreover, it was fun developing the
slides with PowerPoint. It has been a rich
experience.

References

American Geriatrics Society., & British Geriatrics Society., & American
Academy of Orthopaedic Surgeons Panel on Falls Prevention. (2001).
Guideline for the prevention of falls in older persons. New York.

American Medical Directors Association. (2008). Falls and fall risk.
Columbia, MD: American Medical Directors Association.

Broe KE, Chen TC, Weinberg J et al. A higher dose of vitamin d reduces
the risk of falls in nursing home residents: A randomized, multiple-dose
study. J Am Geriatr Soc 2007;55:234–239

Brown AP. Reducing falls in elderly people: A review of exercise
interventions. Physiother Theory Pract 1999;15:59–68

Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the
prevention of falls in older adults: Systematic review and meta-analysis of
randomized clin-ical trials. BMJ 2004;328:680–683.

Healey F, Monro A, Cockram A et al. Using targeted risk factor reduction
to prevent falls in older in-patients: A randomized controlled trial. Age
Ageing 2004;33:390–395.

Hornbrook MC, Stevens VJ, Wingfield DJ et al. Preventing
falls among com-munity-dwelling older persons: Results from
a randomized trial. Gerontologist 1994;34:16–23.

National Osteoporosis Society (Great Britain). (2008).
Accidents, falls, fractures, and osteoporosis: A strategy for
primary care groups and loyal health groups. Radstock, Bath:
National Osteoporosis Society.

New South Wales. (2011).Prevention of Falls and Harm from
Falls Among Older People: 2011-2015. Norm Sydney, N.S.W:
NSW Dept. Of Health, 2011. Print.

Perry, A.G, & Potter, P.A.(2012). Nursing Interventions and
clinical skills. St. Louis, Mo: Mosby.

Rucker D, Rowe BH, Johnson JA et al. Educational
intervention to reduce falls and fear of falling in patients after
fragility fracture: Results of a controlled pilot study. Prev Med
2006;42:316–319

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