Falls in the elderly (over 65) for GP practices

Scope

This clinical referral guideline covers the management of falls in adults over 65 in the community.

The Falls Clinic is staffed by Health Care of the Elderly Department; appointments take place at the LCC, Mount Gould Hospital. We provide a comprehensive assessment, investigation, treatment and advice for patients, over the age of 65, with the following presentation:

  • Patients presenting for medical attention as a result of a fall
  • Patients presenting with recurrent falls in the past year

The falls clinic assessment involves two appointments on separate days. The first appointment is with the clinical nurse specialist. The second appointment is with a senior clinician . It is possible to request a double slot, that is two appointments on the same afternoon (i.e. the patient would see the nurse and go straight on to see the doctor) If a 'double' is needed please advise on the referral letter and be aware there is a longer wait for 'doubles'. They are usually allocated to the very elderly, those with a long way to travel or who need ambulance transport.

Please refer to the community Geriatrician any patient who is unable to attend outpatient clinics.

Key referral criteria

For the following presentation:

  • Patients demonstrating abnormalities in gait and balance, or who need a home risk assessment can be referred to the Community Therapy Teams. These patients can then be referred on to the specialist Balance and Stability Team, if appropriate. Please see referral information below.

Out of scope

People younger than 55. People 55-64 maybe appropriate if no other contributing pathology.

Assessment

History

In elderly people who fall the following should be considered:
  • Accident and environmental hazards
  • Gait and balance disorders or weakness
  • Dizziness and vertigo consider referral to ENT
  • Confusion
  • Cardiovascular problems, e.g. orthostatic hypotension, carotid sinus hypersensitivity, vasovagal syncope
  • Postural hypotension
  • Visual disorder
  • Drug therapy – hypnotics, sedatives , diuretics, anti-hypertensives, psychoactive drugs (including anti-depressants), oxybutynin and tolterodine
  • Neurological disease, e.g. Parkinson's disease, stroke
  • Cognitive impairment
  • Increasing age
  • Foot problems, arthritis. Consider referral to MSK Physio , Podiatry or Orthotics
  • Alcohol

Examination

Clinical examination:

  • Pulse (rate and rhythm)
  • Respirations
  • Lying and standing blood pressure (Orthostatic hypotension is a fall in systolic BP of more than 20mmHg or to less than 90mmHg)
    • lie patient flat for 5 minutes (in silence) then take BP
    • stand patient then take blood pressure and repeat at 3 minutes
  • Assess for cardiac murmur
  • Mini mental test score - GPCOG (abbreviated)
  • Visual acuity, visual loss, confirm patient is having regular (yearly) eye tests
  • Sensory and motor neurological assessment:
    • Consider stroke/TIA, dementia, peripheral neuropathy, Parkinson's disease and other neurological conditions
  • Gait and balance examination:
    • assess gait - steadiness, broadbased, ataxic, shuffling, stamping
    • assess balance - patient safe mobilising with walking aids?, ability to walk and talk?, furniture walking?, able to stand unsupported?
  • Assess footwear

Investigations

Consider:

  • 12 lead ECG
  • Ambulatory cardiac monitor
  • 24hr BP recorder
  • Echocardiogram
  • Blood glucose
  • Full blood count, urea and electrolytes, thyroid function tests
  • Liver function
  • Bone profile
  • Vitamin B12
  • Folate

Management

  • Perform type 3 medication review with modification/withdrawal (see A guide to medication review).
  • Consider reducing or stopping culprit medication that may increase falls risk including:
    • vasodilators and anti-hypertensives
    • diuretics
    • sedatives and hypnotics
    • psycho active drugs (including anti-depressants)
    • drugs for urinary retention and incontinence e.g oxybutynin and tolterodine
  • If evidence of postural hypotension ensure good fluid intake
  • If gait or balance disorder refer direct to Community Therapy Teams (please see referral information below).
  • Provide alcohol reduction advice if pertinent

If unable to resolve in primary care, refer on as appropriate.

Referral

Referral criteria

Patients demonstrating abnormalities in gait and balance, or who need a home risk assessment can be referred to the Community Therapy Teams. These patients can then be referred on to the specialist Balance and Stability Team, if appropriate. Please see referral information below.

1. Community Therapy Teams referral forms.

2. Consultant Led Falls clinic * ( Falls clinic referral checklist)

Please also include the following information when referring to the Falls Clinic:

  • Referral details
  • History of fall(s)
  • Medication history including any recent changes
  • Previous Medical History

Investigations required:

  • 12 lead ECG - A baseline ECG helps diagnose conduction disturbances.
  • Lying and standing blood pressure (Orthostatic hypotension is a fall in systolic BP of more than 20mmHg or to less than 90mmHg)
    • 30% of falls in persons over 65 will have unrecognised syncope.
  • 10 point Abbreviated Mental Test Score or GPCOG
    • Evidence suggests a multidisciplinary approach to falls is not effective in the setting of significant cognitive impairment. Would a therapy review for walking aids or a domiciliary review from a community Geriatrician be more appropriate?
  • Height & Weight
    • Height and weight (not BMI) are needed to conduct a bone health review using the FRAX score. It is very helpful to have these provided to allow us to undertake other more specialist assessments during the clinic.
  • Blood tests within the last 6 months as outlined in investigations.

Please note that referrals, where these details have not been included, may be returned to the referrer for more information.

3. Please refer to the community Geriatrician any patient who is unable to attend outpatient clinics.

* The falls clinic assessment involves two appointments on separate days. The first appointment is with the clinical nurse specialist. The second appointment is with a senior clinician. It is possible to request a double slot, that is two appointments on the same afternoon (i.e. the patient would see the nurse and go straight on to see the doctor) If a 'double' is needed please advise on the referral letter and be aware there is a longer wait for 'doubles'. They are usually allocated to the very elderly, those with a long way to travel or who need ambulance transport.

Referral forms

Community Therapy Teams referral forms.

Falls clinic referral checklist

Orthotics referral form

Podiatry referral form

 

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