When treating the frail elderly, it is always sad to see their quality of life diminish due to a fall. Particularly when that fall could have been prevented. In this blog post, we take a look at bone health and falls prevention, with reference to NICE guidance. For an in-depth look at Frail Elderly: Bone Health and Falls Prevention, head to our Training for Pharmacists page to sign up to a webinar in your area.
Bone health
Older people with frailty, reduced mobility and multiple co-morbidities are susceptible to problems with bone health. There is a particular focus on patients with mobility and balance issues such as Parkinson’s disease, frequent falls, osteoporosis, previous fractures and vitamin D deficiency.
There is no national guidance on treating vitamin D deficiency. However, the Royal Osteoporosis Society provide guidance on vitamin D doses for deficiency and insufficiency for bone health. NICE Guideline PH56 recommends Vitamin D Prophylaxis for certain groups within the population. Most care home residents get at least 400 IU of vitamin D per day. During the Covid pandemic, the Department of Health provided free vitamin D drops to all care homes. Local CCGs may offer additional guidance on vitamin D treatment and prophylaxis.
Electronic Frailty Index and falls prevention
The Electronic Frailty Index (EFI) helps to identify individuals who are more likely to fall. This includes individuals aged 65 years and over living with moderate or severe frailty. Other factors include tight blood glucose control that is not necessarily needed. People with severe frailty need to have higher targets if they are type 2 diabetics. Multiple blood pressure medications can also cause problems, because orthostatic hypotension can be implicated in falls.
Medications that can be a factor in multiple falls include:
- Antihypertensives
- Beta blockers
- Diuretics
- Antidepressants
- Antipsychotics
- Anti-epileptics
- Sedating antihistamines
- Anticholinergics for bladder spasm
- Medicines with anticholinergic side effects such as TCAs
NICE falls prevention pathway
The NICE fall prevention pathway is a useful tool that brings all the advice on falls prevention together in a flowchart. The flowchart itself takes this format:
Assessment and interventions
Within the fall prevention pathway, NICE refer to their assessment and interventions guidance. Of note is the necessity to ensure that the individual’s environment is assessed to identify and address factors that could impact their risk of falling. These include:
- Flooring
- Lighting
- Furniture and fittings such as hand holds
When patients are in hospital, a multifactorial assessment and intervention should be considered. Identify the patient’s risk factors for falling that can be treated, improved or managed during the course of their expected hospital stay. These may include:
- Cognitive impairment
- Continence problems
- Falls history including causes and consequences such as injury and fear of falling
- Unsuitable footwear
- Health problems that increase their fall risk
- Medication
- Problems with posture, balance or mobility
- Syncope syndrome
- Being visually impaired
Any intervention must address the risk factors that make the patient more likely to fall in hospital. You also need take into account the possibility of treating, managing or improving those risk factors while the patient is in hospital. Interventions that are not tailored to the individual patient’s risk factors should not be offered.
Falls prevention and multifactorial risk assessment
A multifactorial risk assessment should be carried out when an older person:
- Reports recurrent falls
- Needs medical attention due to a fall
- Has abnormal balance or gait
This will usually be done by the specialist fall service. In any event, it will be performed by a healthcare professional with appropriate skills and experience. Where appropriate, a multifactorial intervention programme will be considered. Common components of such a programme include:
- Balance and strength training
- Assessment of home hazards and intervention to remove them
- Assessment and referral of the patient’s vision
- Review of the patient’s medications with withdrawal or modification considered where appropriate
Education and information for patients at risk of falling
People who are identified as at risk of falling should be given the following information verbally and in writing, along with their carers:
- Information on measures to take to avoid further falls
- Help to stay motivated when referred for prevention strategies including strength, balance and exercise components
- The fact that some falls are preventable
- The benefits of falls risk modification, both psychological and physical
- Where to find additional assistance and advice
- What to do if they fall, such as how to get help
It is useful to point them in the direction of the NICE guidance for the public on risk and prevention of falls in older people.
