Falls & Balance

Overview

Please consider the CKS guidelines for Falls - risk assessment (2019) which has advice about the assessment of patients aged over 65 in primary care to identify those at risk of falls.

Patients who have fallen and/or are at increased risk of falls should have baseline tests in primary care and any underlying causes addressed. Community nursing teams have all been trained to undertake falls assessments and can provide advice and support.

For patients with more complex reasons for falls who need support of a multi-disciplinary team then a referral to the Community Specialist Falls Service may be appropriate.

There are no specific secondary care clinics for patients who fall. Referrals should be made to specific specialist clinics where appropriate - see Referral options section below.

For patients with falls due to a more acute cause please see the Red Flag section below.

Assessment

History

Take a good history of the circumstances around a fall from the patient and witnesses if possible. Try to identify any history of dizziness, syncope or palpitations prior to the fall or if there are any other risk factors for further falls.

Assess lifestyle factors such as alcohol, obesity, poor nutrition or fluid intake.

Physical examination

• Pulse - rate and rhythm
• Blood pressure - including lying and standing BP 
• Any new neurological impairment
• Signs of infection
• Any cardiac abnormalities
• Cognitive impairment
• Observe gait.

Review Meds

• Anticoagulants (DOAC or warfarin) - Review ORBIT score to assess risk of bleeding.
• Sedative drugs - anticholinergics, antipsychotics, tricyclic antidepressants

Investigations

• Blood tests - FBC, U&E, TSH, B12/folate, LFTs, Calcium, HbA1c.
• MSU - if urinary symptoms 
• ECG or rhythm analysis (Alivecor) - particularly if dizziness, syncope, palpitations prior to fall.

Consider multifactorial risk factors for falls

• Vision – check the patient has had a recent eye test
• Footwear – check appropriate and that shoes fit well
• Continence – fluid intake, overactive bladder.
• Cognitive function – assessment for dementia or delerium.

Orthostatic hypotension (OH) is diagnosed when:

• there are no features suggesting an alternative diagnosis and the history is typical
  and
• Lying and standing blood pressure changes with repeated measurements while standing for 3 minutes. Classical OH is defined as a decrease in systolic BP ≥20 mmHg and in diastolic BP ≥10 mmHg within 3 mins of standing.

If orthostatic hypotension is confirmed, consider likely causes, including drug therapy (eg: Alpha and Beta blockers, ACE inhibitors, ARBS, Calcium channel blockers, Diuretics, Nitrates, Hydralazine, Diuretics, Antidepressants and alcohol) and manage appropriately. Consider referring on for trial of fludrocortisone.

Bone Health

Patients who fall should have an assessment of bone health due to risk for fragility fracture (e.g FRAX score).  Ensure adequate vitamin D intake and consider treatment with bisphosphonates. See Osteoporosis page.

Red Flags

Identify conditions that might require urgent admission to A&E, secondary care, or other urgent care setting, including:

• if an older person could walk before a fall and is now unable to walk, they require prompt assessment for injury or acute illness
• loss of consciousness
• swellings and tenderness
• fractures, including hip
• neurological conditions, eg stroke 
• cardiovascular conditions:
  • arrhythmia
  • heart attack
  • syncope

Referral options

Most patients who have had a fall or are at risk of falls can be managed in the community. District nursing teams undertake falls risk assessment as part of their routine work and can provide support and advice to patients.

In addition the following options are also available for appropriate patients:

Community and Self Care

Strength and Balance Classes

Patients who are unsteady when moving around, are worried about falling, or are less mobile than they would like to be, can be referred to strength and balance classes run by local councils. See Services section below for details of classes available in your area.

These classes are only delivered in the venues specified and no remote or digital option is currently available.

Fall-Proof

Please also see Fall-Proof website - a community based approach to Falls Prevention (run by Wesport charity across BNSSG and BANES) which includes booklets and videos on strength and balance and details of classes running locally.

Specialist Falls Service (Sirona)

Please note that this service has limited capacity and should only be used when a patient continues to recurrently fall despite initial management in the community and where a multi-disciplinary approach for complex falls is required. This team of nurses, physiotherapists, occupational therapists and rehabilitation support workers can undertake more detailed falls assessment - please see Services section below for further details.

Patients who have had a fall should initially have assessment in primary care (see above) and a community falls risk assessment (district nurse or community physio). If a falls risk assessment has already been completed in the last 12 months then any outcomes or changes should be reviewed first. 

Referrals should be made using the Specialist Falls Clinic referral proforma embedded in EMIS and sent via email - please see details on pre-referral requirements in Services section below.

Referrals can also be made directly from secondary care.

Secondary Care Specific Condition Referrals

There are no longer specific Falls Clinics in secondary care. However, patients with suspected underlying medical conditions as the primary cause of falls should be considered for referral as appropriate. For example:

• Syncope/Transient loss of consciousness where cardiac cause is suspected - consider cardiology referral - see Syncope and TLOC page.
• Arrythmia - consider cardiology referral - see Arrhythmia page.
• Parkinson's disease/ movement disorder - consider care of the elderly referral - see Movement Disorders page.
• Cognitive disorders - consider cognitive assessment -  see Dementia - assessment and referral page.
• Dizziness/vertigo with suspected ENT cause and age <75 - consider ENT referral - see Dizziness and Vertigo page
• History of stroke - see the Stroke page for advice on community stroke services.

Geriatric Medicine and RACOP clinics

Geriatric medicine clinics are available at UHBW (RAS) and NBT via eRS for patients who cannot be managed in the community and do not meet criteria for other specific secondary care services as above. 

RACOP clinics at UHBW and NBT should not be routinely used for patients who fall unless there are other concerns that need their input.

Services

• Strength & Balance classes : Bristol City Council

• Staying Steady : Age UK Somerset

• South Glos - Active Ageing

• Specialist Falls Service

• UHBW - Geriatric Medicine

• Falls Service : NBT

• Everyone Active and ReACT - Bristol

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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