12. CGA in Primary Care Settings: Patients at risk of falls and fractures

Who should receive a multifactorial risk assessment for falls?

The following patients should receive a multifactorial risk assessment:

• Two or more falls in the past 12 months.
• Presentation for medical attention with a fall.
• Difficulty with walking or balance.

What should be covered in a mulitfactorial risk assessment and management plan?

As part of a multifactorial assessment, perform the following assessment and management plan:

1) Enquire about a history of falls (this needs to be thorough to establish the circumstances of the fall).

How did you fall? What exactly happened?

How many falls have you had in the past year? This helps to differentiate someone with a one-off fall, from someone at risk of recurrent falls. If someone has started falling recently, or more frequently recently, it is often due to acute illness which must be evaluated appropriately.

Describe them: can you remember what you were doing at the time? What exactly happened? Where did you fall? (This helps with early identification of environmental risk factors).

Have you ever blacked out or “just gone down” without warning? Beware the patient who says “I must have tripped.” Do they actually remember tripping? Older people with or without cognitive impairment may try and be helpful by saying this but you should assess their risk factors. Also, many patients will not remember that they lost consciousness and if history from the patient seems unclear, try to obtain collateral history. Some people find it helpful to be asked - do you remember actually falling?

Consider the possibility of syncope or near syncope causing falls that are unexplained. Ask about prodromal symptoms like palpitations, as well as about possible precipitants like head turning, coughing, eating, micturition/straining. Consider seizures if these episodes happen in a lying or sitting position.

Do you get dizzy if you stand up quickly? Do you get light-headed? Do you ever feel the room spinning round? Do you feel unsteady or unbalanced? Conditions such as orthostatic hypotension or those causing vertigo may contribute to falls.

Do you have to rush to get to the toilet? Older people with overactive bladder or urinary incontinence will rush to go to the toilet, placing them at increased risk of falls. It is important to differentiate acute urinary symptoms consistent with a urinary tract infection from chronic urinary symptoms. 

2) Consider the impact of co-morbidities

Patients with falls may have multiple co-morbidities for which they receive treatment e.g. they may be on antihypertensives or anticoagulants to reduce their risk of vascular events. These may increase the risk of falling or fall-related injuries and a pragmatic approach should be adopted in these circumstances, taking into account the magnitude of benefit of current or intended treatment, the magnitude of harm and the patient's preferences and goals. Recent NICE and American Geriatrics Society guidelines for multimorbidity may provide a helpful framework for dealing with this situation. 

3) Review medications 

Medication review which includes looking at timing of meds, compliance and  reduction and withdrawal should be considered for older people with falls, especially if they are frail with multimorbidity.

The best evidence for reducing rate of falls comes from gradual withdrawal of psychotropic medications (antipsychotics, antidepressants, sedatives). However, when an older person presents with a fall, a thorough medication review should be undertaken, and withdrawal or dose reduction of medications should be considered. Particular attention should be paid to antihypertensive medications, especially if there is a history of postural dizziness or postural hypotension. Frail older people should have individualised targets for blood pressure control taking into account co-morbidities, side-effects and patient preferences.

There is often concern about an increased risk of subdural haemorrhage with the use of anticoagulants in patients who fall, although this may be over-estimated.

4) Perform an examination focusing on:

• Vision
• Heart rhythm and rate
• Muscle strength
• Other neurological impairment
• Knee exam
• Peripheral sensation
• Feet/footwear.

Vision assessment and referral is recommended as part of a multifactorial intervention to reduce risk of falls but it is unclear whether this is an essential component. Guidelines recommend use of a Snellen chart to assess visual acuity and further assessment for those with a visual acuity of 6/12 or less.

A baseline cognitive assessment is recommended as it may raise awareness that the rest of the falls history is unreliable as well as helpful in identifying patients unable to consent to, or comply with any recommendations that may result from CGA.

A routine ECG should be performed. If falls are unexplained or may be consistent with syncope e.g. "I just go down, doctor" then consider the possibility of cardioinhibitory carotid sinus hypersensitivity or  arrhythmia that may require further assessment. Arrhythmia should particularly be suspected if the resting ECG is abnormal, as follows:

• Bifascicular block
• Trifascicular block
• Prolonged QRS
• Second degree heart block
• Sinus bradycardia <50pbm or sinus pause >3 seconds
• Long or short QT interval
• Non-sustained VT
• Ventricular ectopics
• Q waves suggesting myocardial ischaemia.

A neurological examination should be performed testing muscle strength and searching for neurological abnormalities that may predispose to falls e.g. stroke or Parkinson's disease. Patients should be referred for balance and strength training exercises by appropriately trained professionals. Older people living in the community with a history of recurrent falls and/or a balance and gait deficit are mostly likely to benefit from strength and balance training.

Muscle strength could be reduced due to recent weight loss or drugs (e.g. steroids).

Knees should be examined for deformities such as osteoarthritis or fixed flexion which may contribute to gait instability.

Peripheral sensation should be assessed. Patients with peripheral neuropathy may be unaware of foot position and have impaired balance.

Feet should be examined for bunions, deformities, ulcers or deformed nails. Footwear that fits poorly, has worn heels, high heels or is not laced or buckled is associated with a higher rate of falling.

5) Perform a lying and standing blood pressure

Orthostatic hypotension can be tested by asking the patient to lie down for 5 minutes; blood pressure can then be checked supine, immediately on standing, and again at 1 minute and 3 minutes. It is usually defined by a fall in systolic blood pressure of at least 20mm Hg or in diastolic blood pressure of at least 10 mm Hg.

Patients who become bedbound for long periods of time may become deconditioned, and may develop orthostatic intolerance such that they feel tired or dizzy when sitting out. This can be confirmed by comparing supine blood pressure to when patients are sat out and  symptomatic. Treatment involves gradually increasing periods of sitting upright in conjunction with other usual measures. 

Postprandial hypotension can occur due to splanchnic vasodilatation after eating. This may be minimised by having smaller meals with lower carbohydrate content, avoiding excess alcohol and standing slowly after eating.

If orthostatic hypotension is present then strategies for treatment include:

• Medication reduction and withdrawal e.g. antihypertensives, alpha blockers, antidepressants.
• Maintaining adequate salt and water intake.  Patients with symptomatic postural dizziness should be advised to drink at least one litre of fluid before midday, and up to 2 litres in a day. They should be advised to take adequate salt in their diet (up to 10g/day). Often when dealing with frail older people, advice that seemed sensible in healthy middle age is reversed in later life when other problems such as falls arise.
• If conservative measures are inadequate, then a trial of fludrocortisone at doses between 50-300 micrograms daily can be instituted. This is a synthetic mineralocorticoid that causes salt and water retention. Patients should be monitored for supine hypertension, signs of fluid overload and electrolyte abnormalities. 

6) Perform a "Get up and Go Test"

This is performed by asking the patient to rise from a standard armchair, walk a fixed distance across the room, turn around walk back to the chair, and sit down. Whilst the test can be scored from 0-5, or timed over a distance of 3 metres, in primary care it is best used as a way to evaluate gait and balance.  In particular observe:

• Sitting balance
• Ability to move from sitting to standing position, including symptoms of postural dizziness
• Pace of walking
• Obvious gait abnormalities e.g. stroke disease, Parkinsonism, foot drop
• Ability to turn steadily.

The patient's usual walking aid should be used during this test.

7) Assessment of home hazards by a trained professional, usually an occupational therapist

This may identify hazards that need to be addressed such as loose carpets, seats that are too low or dim lighting, or safety devices that need to be installed such as handrails or grabrails.

Calcium and vitamin D supplementation has been shown to reduce fracture rates in older people in long term care facilities or sheltered accommodation but currently is not recommended for routine use.

Patients who fall are at higher risk of fractures and should have their bone health and fracture risk assessed in accordance with NICE guidance using a tool such as FRAX. Bear in mind that FRAX may underestimate the short term risk of fractures in people over the age of 80.