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Introduction

The risk of falls increases significantly with age, and is one of the leading causes of morbidity and mortality in older Australians(1, 4).

Falls prevention in the older generation is a priority for health services, with previous trials showing that targeting multiple risk factors related to falls can reduce the risk of falls in patients(6, 3).

Common drugs that may contribute to falls include:

  • cardiac drugs (e.g. antiarrhythmias, beta-blockers)
  • urological drugs (e.g. oxybutynin)
  • neuropsychiatric drugs (e.g. parkinson's drugs, antipsychotics, tricyclic antidepressants)(9)

Patients who have fallen and been on the floor for over an hour are at a higher risk of complications, such as pneumonia, pressure areas, rhabdomyolysis, dehydration and hypothermia(9).

Patients who report unexplained falls or episodes of collapse should be assessed for the underlying cause(3).

Any fall that happens in our care must be reported as per the Clinical Incident Management policy.
Risk Assessment
Factors that increase the risk of falls can be classified as intrinsic (related to the patient) or extrinsic (related to the environment)(5). Assess your patient for the following risk factors to assess their falls risk. Patients should be considered high falls risk if they meet 3 or more criteria(3,9).

Intrinsic:

  • Previous falls
  • Postural instability, muscle weakness
  • Cognitive impairment, delirium, disturbed behaviour
  • Urinary frequency, incontinence
  • Postural hypotension
  • Medications (eg. psychoactive medications)
  • Visual impairment
  • Low body mass index
  • Age over 80

Extrinsic:

  • Hospitalisation for 19 days or more
  • Environmental risk factors (e.g. poor lighting, slippery surfaces)
  • obsacles
  • Inappropriate or unsafe walking aids
  • Unsafe or absent equipment such as handrails
  • Loose fitting footwear and clothing
  • Time of day
Egress from the ambulance is a high risk for falls(2). Careful instruction should be given to any patient exiting the ambulance, ensuring they have been advised of the hand rails.
Assessment
FRAT Score

The Falls Risk Assessment Tool (FRAT) is a validated tool, and should be performed on any patient than has fallen or considered at risk of falls(3)

Allocate the appropriate FRAT score (0-5) by determining the value and score associated with each of the five variables(14).

Assessment CriteriaValueScore
Fall History
Has the patient had a fall within the last 12 months?Yes1
No0
Medications
Does the patient take four or more prescribed medications per day?Yes1
No0
Medical History
Does the patient have a diagnosis of Stroke or Parkinson's disease?Yes1
No0
Stability
Does the patient report any problems with their balance?Yes1
No0
Core Strength
Does the patient need to use their arms to stand from a chair of knee height?Yes1
No0

Automatic High Risk Status(14, 15).:

  • Recent change in functional status and / or medications affecting safe mobility (or anticipated)
  • Dizziness / postural hypotension

Scoring

The total score is used to predict the patient's falls risk:

Score of 3 – 5 High falls risk
Score of 0 – 2 Low falls risk

The FRAT score should be documented on the ePCR and handed over to the recieving clinical staff(14).

Management
  • Use aids where possible
  • Ensure the patient has appropriate footwear on
  • Be cautious using walking aids in patients with delirium or cognitive impairment
  • Ensure good lighting and patient is using any visual aids (e.g. glasses) required
  • Make sure the patient's personal belongings and equipment are easy and safe for them to access wherever possible
  • Check all aspects of the environment and modify as necessary to reduce the risk of falls (eg. furniture, floor surfaces, clutter and spills)
  • Highlight to triage staff that the patient is a falls risk and document on ePCR
Additional Information
  • The grasp reflex is the involuntary flexion-adduction movement that can reemerge in aging patients(8,9). When an older patient won’t release an object, it’s due to a primitive reflex out of fear of falling rather than an adverse behaviour(10). Clinicians should be aware of this risk, and work to avoid situations that may trigger this reflex (e.g. hand holding)(10). Rather than attempting to force the patient’s grip open, it may be released by gently stroking the back of the hand(11).
  • Clinicians have a responsibility to have open conversations about falls prevention with people who have fallen or are at risk of falling(9). Evidence suggests that engaging in conversations focused on health prevention wherever possible can potentially have a significant impact on the health if the population(9, 12). Officers should aim to empower at risk individuals to be proactive about falls prevention and encourage patients to speak with their healthcare practitioner(13).

References

Australian Commission on Safety and Quality in Healthcare (2012). Standard 10, preventing falls and harm from falls. https://www.safetyandquality.gov.au/sites/default/files/migrated/Standard10_Oct_2012_WEB.pdf

St John WA (2019). Safety performance. https://stjohnwa.sharepoint.com/sites/connect-Safety/Shared%20Documents/Safety-Performance-2018-2019_30365.pdf

Australian Commission on Safety and Quality in Healthcare (2009). Preventing falls and harm from falls in older people. https://www.safetyandquality.gov.au/sites/default/files/migrated/Guidelines-HOSP1.pdf

Karlsson, M. K., Magnusson, H., von Schewelov, T., & Rosengren, B. E. (2013). Prevention of falls in the elderly—a review. Osteoporosis International, 24(3), 747-762. https://doi.org/10.1007/s00198-012-2256-7

Infinger, A., Dowbiggin, P., Seymour, R., Wally, M., Karunakar, M., Caprio, A., Patt, J., & Studnek, J. R. (2020). Development of a content valid and reliable prehospital environmental falls risk assessment tool for older adults. Prehospital Emergency Care, 24(3), 349-354. https://doi.org/10.1080/10903127.2019.1634777

Halter, M., Vernon, S., Snooks, H., Porter, A., Close, J., Moore, F., & Porsz, S. (2011). Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: A qualitative study. Emergency Medicine Journal : EMJ, 28(1), 44-50. https://doi.org/10.1136/emj.2009.079566

St John WA (2021). Policy: Clinical Incident Management. https://stjohnwa.sharepoint.com/sites/connect-clinical-governance/SiteAssets/SitePages/connect-clinical-governance/2021-Clinical-Incident-Management-Policy.pdf

Falkson, S. (2021). Grasp reflex. https://www.statpearls.com/ArticleLibrary/viewarticle/22413

Brown, S. N., Kumar, D. S., James, C., & Mark, J. (Eds.). (2019). JRCALC clinical guidelines 2019. Class Professional. 

Queensland Ambulance Service (2021). The older patient. https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_The%20older%20patient.pdf

Watanabe D, Matsunobe I, Okuma Y, et al. (2019). Releasing forced grasp reflex by use of concomitant imitation behaviour during rehabilitation of a stroke patient. BMJ Case Reports CP 2019;12:e228304.

Health Education England (2021). Make every contact count. http://www.makingeverycontactcount.com/ 

Department of Health WA (2014). Falls Prevention Model of Care. https://ww2.health.wa.gov.au/~/media/Files/Corporate/general-documents/falls/PDF/Falls_Model_of_Care.pdf

Queensland Ambulance Service (2021). Falls Risk Assessment Tool. https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_FRAT.pdf 

Department of Health Victoria (2009). Falls Risk Assessment Tool.

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