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

Consider:

• 12 lead ECG
• Ambulatory cardiac monitor
• 24hr BP recorder
• Echocardiogram
• Blood glucose, HbA1c
• Full blood count, urea and electrolytes, thyroid function tests
• Liver function
• Bone profile
• Vitamin B12
• Folate
• Iron studies
• Vitamin D

• Perform type 3 medication review with modification/withdrawal (Falls/decision-tree).
• 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 criteria

Patients demonstrating abnormalities in gait and balance, or who need a home risk assessment can be referred to the Community Therapy Teams. Please see referral information below. Consider a referral to FaME (Falls Management Exercise) group programme OR
The Falls Prevention Team Physiotherapists (Plymouth only) based on criteria met (please see referral form below).

1.Community Therapy Teams - Please see the referral forms section below.

• Plymouth Community therapy referrals
  
• Plymouth Falls prevention team - Please see referral form and guidance below.
  
  • Ivybridge
    
  • Tavistock
    
  • North & East Cornwall
    

2. Falls MDT clinic

Please 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
• Clinical Frailty Score (CSF)

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.

The first appointment is the Falls MDT clinic where the comprehensive assessment is performed by a Falls Specialist Nurse, Consultant therapist and a Clinical Director of Pharmacy for Livewell. This is a one stop clinic and patients should expect to spend 3-4 hours in clinic.

The second appointment is with a senior clinician, if after discussion at the MDT it felt that the patient requires review by a Geriatrician.

For any patients who are unable to attend outpatient clinics, please refer to the Community Geriatricians.

Referral forms

Community Therapy Teams referral forms.

• Plymouth Community Therapy referral form
• Ivybridge/Yealm Intermediate Care and Community Therapy Team referral form
• Tavistock Community Rehabilitation team referral form
• North & East Cornwall locality referral form

Falls clinic referral checklist

Orthotics referral form

Podiatry referral form

GP information

Patients with the high risk of falls (Age and Ageing 2022))

World guidelines for falls prevention and management for older adults: a global initiative (Age and Ageing 2022)

NICE Guidance on Falls

• Falls in older people Quality standard 86
• Falls in older people assessing risk & prevention clinical guide 161

Royal Osteoporosis Society (formerly national osteoporosis society)

Syncope & falls in the elderly

General practitioner assessment of cognition (GPCOG)

Guide to medication review

Patient information

Age UK - Avoiding a fall | Elderly fall prevention

Prevention of falls in the elderly - Patient.co.uk

Royal Osteoporosis Society (formerly national osteoporosis society)

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: July 2019

Updated: May 2023