FMMC 17

Task 2

Nadia is an 80-year-old woman has come into your primary care clinic with
her daughter. The patient’s daughter is concerned about several falls her
mother has suffered in the last six months. The patient’s daughter states
that the problem is limited to the home, with about five falls in the last
month. There has been no definite pattern: one time she slipped on a rug
during the day; another time, she slipped on the threshold of her bathroom at
night. On another occasion, she fell to the ground after feeling lightheaded
when getting up from a chair. She has sustained only minor injuries with her
falls, but has been staying in her room more because of a fear of falling.
Nadia has a known history of congestive heart failure and coronary artery
disease, as well as insomnia. She takes furosemide, digoxin, aspirin, and
Trazodone, as needed, for sleep. On her physical exam, her sitting blood
pressure and pulse are 160/70 and
65. Standing, those values are 135/65 and 70. Cardiopulmonary exam is
unremarkable. Visual acuity in the right eye is 20/20, and 20/30 in the left.
Neurologic exam contains no focal abnormalities and good vibratory and
fine touch sensations in her lower extremities; a mental status exam shows
no significant findings. By applying Katz Activities of Daily Living Scale
(ADLs), she is fitted in the 2nd degree. The patient’s daughter is very
concerned and is wondering what you could do. She is very afraid of the
patient having a hip fracture the next time she falls.

Q.1- Identify at least 5 possible risk factors for falls in this

particular patient. Utilize appropriate open-ended questions to
ascertain details about fall history and fall risk factors?

❖ Possible risk factors for falls in this patient:

1. Environmental hazards: presence of irregular floor in the
homes , she slipped on a rug & slipped on the threshold of her
bathroom

1
2. Cardiac: Congestive heart failure & Hypertension.
3. Poly pharmacy: the patient is using four medications
4. Medication use: four medications are used simultaneously (Lasix,
digoxin, ASA, Trazodone)

5. Social status: the patient is living alone

6. Musculoskeletal: Limited mobility, impaired activity of daily livings
she can’t get out of her home
7. Psychological: anxiety of falling
8. Orthostatic blood pressure difference more than 20mmhg Postural
hypotension
9. Potential modifiable risk factors: decreased visual acuity
10. Non-modifiable: coronary heart disease, Age older than 80 years,
Female sex, History of falling

2
There are many risk factors for falls, some of which are
modifiable. The strongest modifiable risk factors are balance
impairment, gait impairment, muscle weakness, and medication
use.

Approximately 60% of falls are the result of multiple factors.

Open-ended questions to ascertain details about fall history and fall risk
factors?

- Tell me about the injuries you had in the past ?

To enumerate and evaluate injuries
- Where there any environmental hazards that may have precipitate it?
Evaluate the environment at the time of the fall

- Tell me about bone disease diagnosis you have had in the past?
Order energy X-ray absorptiometry for osteoporosis assessment

- What were the circumstances of the fall?

- Tell me about changes in medication you have?

Check for added or discontinued medication

- Tell me about vertigo or dizziness incidents ?

Check for ear disease or cardiovascular, neurological disease

- Tell me about your indoor or outdoor activities?

To assess for limited activity because of muscle skeletal disease

- What foot wear was worn at fall time?

Examine feet and footwear

- Was there any acute or subacute change in mental status precedes the
fall?
Examine neurologic and cognitive status, and if any signs present
continue CBC &
3
 chemistry panel & X ray & urine analysis.

- Do you use assessed device to help with walking?

- Is there is fear related to falling?

Examine muscle strength, gait and balance

- Are there any vision changing?

Evaluate visual acuity

- Where any restrains used?

- Have patient and family or (caregiver or stuff) receive fall
prevention education?
-
2- Describe the key components of a gait assessment?

A simple history is needed.

Ask the patient if can walk for a quarter of a mile or can go up for 10
steps

Basic Gait Cycle: The gait cycle is composed of 2 phases, with 7 components.

• Stance phase: body weight is shifted to a single limb as the contralateral

limb is in the swing phase and swings through. Subcomponents of this
include initial contact, loading response, mid stance, and terminal stance.
• Swing phase: the limb leaves the stance phase and enters the swing phase
as the contralateral limb enters the stance phase. This is composed of the
initial swing, mid swing, and terminal swing
• https://www.youtube.com/watch?v=wJqBeGe3ZEc

• Clinical Assessment Tools:

4
- Timed Get Up and Go Test One of the most commonly used tests of gait
and balance.

it begins by observing the patient rising from the chair to stand. The
patient walks at their usual pace 3 meters, turns around, walks back to
the chair and sits down.

Time of <20 seconds = independent for transfers and mobility; while

times of >30 seconds suggests increased risk for falls and
dependence.

5
- Qualitative assessment:
▪ Preliminary evaluation: To assess gait, begin with a general
neurologic test looking at cranial (including visual fields and
acuity), cerebellar (heel to shin, Rhomberg), and peripheral
nervous systems, paying additional attention to foot sensation,
proprioception (great toe position sense, 10g monofilament,
vibratory), and function. Look for musculoskeletal abnormalities
and deformities, particularly of the foot and lower extremities and
the spine.

▪ Standing and balance: Observe how the patient rises (need to use
arms to push off, or balance problems rising) and stands (with or
without support). Ask the patient to stand with eyes closed, and
to turn 360 degrees.

▪ Walking: Observe how the patient begins to walk (i.e. hesitancy or

multiple attempts), the step height for both feet, foot clearance
(looking for foot drop), step symmetry between right and left
sides, and the speed of the gait. Look for signs of path deviation
and need to use adaptive equipment to maintain a straight path.
Look at the posture and trunk for evidence of swaying, flexion,
arm swing, and stability. Assess tandem and heel walking gaits.

▪ Endurance: Observe the patient for signs of fatigue or for

comorbid problems that compromise walking.

6
Qualitative gait assessment
Direct qualitative and quantitative observation of gait to
determine stability is a quick and important assessment
component.

Qualitative aspects include evaluation of include:

• Step length (eg, heels do not clear toes of other foot)
• Step height (eg, heels do not clear floor)
• Hesitancy
• Sway

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 • Symmetry
• Continuity
• Path deviation

Gait speed
• Gait speed is also a helpful marker and correlates with risk
for recurrent falls and major osteoporotic fractures as well
as frailty and survival
• The recommended protocol is to time an individual while
walking a four- meter route with two administrations, one
as quickly as possible and one at a usual pace.
• The test can be done relatively simply by clinical support
staff and requires a four-meter walkway and a stop watch.
• Patients who take more than 13 seconds to walk 10
meters (0.8 meters per second) are more likely to have
recurrent falls.
• Patients whose gait speed exceeds 0.8 meters per second
are likely to live beyond the median life expectancy for age
and sex, whereas those below
0.8 meters per second are likely to have shorter survival.

Balance
• The ability to maintain a side-by-side, semi-tandem, and full-
tandem stance for 10 seconds
• Resistance to a nudge
• Stability during a 360-degree turn

In each of the balance tests, the examiner should be

positioned to stabilize the patient if the maneuver
precipitates a loss of balance. This can be accomplished by
standing close, face-to-face, and holding the patients hands
until the side-by-side, semi-tandem, or full-tandem stance
are observed (ie, letting go of the patient's hands) and
remaining vigilant in observing loss of balance. Similarly,
8
 resistance to a nudge should be tested with the examiner's
arm and hand positioned behind the patient's back so that if
the nudge precipitates loss of balance, the examiner can
stabilize the patient.

Muscle strength
Quadriceps strength can be assessed briefly by
observing an older person rising from a hard armless
chair without the use of his or her hands. Although other
muscle groups may be important to test, particularly
when there is neuropathy or neurologic disorders,

9
 quadriceps weakness is most closely associated with
falls and hip fractures.

The timed up and go test combines some features of

strength and gait. It is a timed test of the patient's ability
to rise from a standard armchair, walk 3 meters (10 feet),
turn, walk back, and sit down again.
Patients who take longer than 20 seconds to complete
the test should receive further evaluation.
However, this test does not provide insight into the
qualitative aspects of gait that also help the clinician
with diagnosis and treatment.
A systematic review and meta-analysis found that the
test's sensitivity was only 31 percent and the test had
limited ability to predict falls.

Q.3. Identify 5 evidenced-based interventions you could make for

this patient that would decrease her risk of future falls?

The USPSTF Recommendations:

Clinical Evidenc
e
recommendation
rating
Community-dwelling older persons at low to moderate B
risk of falls should participate in an exercise program
or physical therapy and take vitamin D3 supplements.
Exercise, particularly balance, strength, and gait A
training

10
Nursing home residents at risk of falls should receive B
a multifactorial risk assessment and intervention
tailored to their needs that are administered by a
multidisciplinary team.
Withdrawal or minimization of Trazadone and other B
medications
Management of foot problems and footwear B

Management of postural hypotension

Fall risk assessment and interventions in
older adults Screen for falls and/or fall risk:
Key questions:
• Fell in past year? If yes, ask: How many (6 FALLS)
• Times did you fall and were you injured?

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 • Feels unsteady when standing or walking?
• Worries about falling?

No to all key questions Low risk: individualized fall interventions:

Educate patient + Vitamin D with or without calcium + Refer
for strength and balance exercise

Yes to any key questions

• Evaluate gait, strength, and balance
• Recommended test: Timed Up and Go
• Optional: 30-Second Chair Stand and 4-Stage Balance tests

No gait, strength, or balance problems: Educate patient + Vitamin

D with or without calcium + Refer for strength and balance
exercise

Gait, strength, or balance problem:

1. ≥ 2 falls or 1 fall + Injury: Conduct multifactorial risk assessment
a. Review Stay Independent brochure
b. Falls history
c. Physical examination including:
Postural dizziness/postural hypotension, Medication
review, Cognitive screen, Feet and footwear, Use of
assistive devices, Visual acuity assessment
High risk: individualized fall interventions
Educate patient, Vitamin D with or without calcium, refer to
physical therapist to improve (gait, strength, and balance
Manage) and monitor hypotension, modify medications,
Address foot problems, optimize vision, Optimize home safety
Follow up with high-risk patients within 30 days: Review care
plan, Assess and encourage fall risk reduction behaviors,
Discuss and address barriers to adherence, Transition to
maintenance exercise program when the patient is ready

2. 1 fall + No Injury or 0 fall: Moderate risk: individualized fall

interventions Educate patient, Review and modify
medications, Vitamin D with or without calcium, refer to a
12
 physical therapist to (improve gait, strength, and balance or to
a community fall prevention program)Exercise:

Exercise is one of the most consistently positive interventions to

reduce the risk of falls and injurious falls.

An exercise program combining several

categories of exercise for muscle
strengthening and balance as a part of a multidisciplinary program
is suggested.

13
Tai chi which contains elements of strength and balance
training, was effective in several trials and systematic reviews.

The following types of exercise have been shown to be effective

in decreasing the risk of falls in randomized trials and systematic
reviews:
• Gait and balance training
• Strength training
• Movement (such as tai chi or dance)
• Aerobic

1. Medication modification

Clinicians should annually review the medications being taken by

their patients, looking for opportunities to de-prescribe medications
that carry greater fall risk, such as psychotropic medications
(benzodiazepines, other sedatives, antidepressants, and
antipsychotic medications).

To ask patient: Have any medications started or titrated recently -

Check for medication toxicity

Four medications are used simultaneously (Lasix, digoxin, ASA,

Trazodone) and may increase risk of fall

2. Vitamin D supplementation

Recommendations for supplementation with cholecalciferol

(vitamin D3) vary depending on the individual’s risk of having a low
level of vitamin D.

For community-dwelling older adults not known to have vitamin D

deficiency or insufficiency, a systematic review and trial sequential
analysis, as well as a USPSTF evidence review, concluded that
vitamin D supplementation has no benefit in falls prevention.
14
Vitamin D supplementation includes those with risk factors for low
vitamin D based on diet, sun exposure history, history of
malabsorption, or obesity, and those with slow gait speed (<0.8
m/second), difficulties rising from a chair, a slow Timed Up and Go
Test, or problems with balance.

3. Educate patient, family, care giver & or nurse about risk of

fall and prevention measures
4. Refer to physical therapist to improve (gait, strength, and balance
Manage)
5. Treatment of orthostatic hypotension
6. Address foot problems
7. Optimize vision
8. Optimize home safety
9. Follow up with high-risk patients within 30 days
10. Review care plan
11. Assess and encourage fall risk reduction behaviors
12. Discuss and address barriers to adherence,
13. Transition to maintenance exercise program when the patient is ready

Q.4- Functional ability and quality of life are critical outcomes in the
geriatric population. Interpret the results of her 2nd degree using
Katz Activities of (ADLs)?

Functional Ability

Functional status: a person's ability to perform tasks that are

required for living. There are two key divisions of functional

ability:
• Activities of daily living (ADL)
o Self-care activities that a person performs daily
Eating, dressing, bathing, transferring between the bed
15
 and a chair, using the toilet, controlling bladder and bowel
functions
• Instrumental activities of daily living (IADL).
o Activities that are needed to live independently
Doing housework, preparing meals, taking
medications properly, managing finances,
using a telephone

We can simply be observing older patients as they complete simple

tasks, such as unbuttoning and buttoning a shirt, picking up a pen
and writing a sentence, taking off and putting on shoes, and
climbing up and down from an examination table.

16
Two instruments for assessing ADL and IADL include the Katz ADL
scale and the Lawton IADL scale.

Deficits in ADL and IADL can signal the need for more in-depth
evaluation of the patient's socioenvironmental circumstances and
the need for additional assistance.

Physical Health

The geriatric assessment of all facets of a conventional medical

history, including main problem, current illness, past and current
medical problems, family and social history, demographic data, and
a review of systems.

Nutrition, vision, hearing, fecal and urinary continence, balance and

fall prevention, osteoporosis, and polypharmacy should be included
in the evaluation.

Katz Index of Independence in Activities of Daily Living

It is the most appropriate instrument to assess functional status as

a measurement of the client’s ability to perform activities of daily
living independently.

Used to detect problems in performing activities & to plan care accordingly

TOTAL POINTS 6 = High (independent) 0 = Low (very dependent)

A score of 6 indicates full function, 4 indicates moderate impairment, and

2 or less indicates severe functional impairment.

For our patient:

• By applying Katz Activities of Daily Living Scale (ADLs), she is fitted in
the 2nd degree.
She slipped on a rug during the day TRANSFERRIN 0
G
She slipped on the threshold of her bathroom at TRANSFERRIN 0
night G

17
 She fell to the ground after feeling lightheaded TRANSFERRIN 0
when getting G
up from a chair
BATHIN 1 DRESSIN 1 TOILETIN 1 CONTINENC 1 FEEDIN 1
G G G E G
Score: 5
In the above scenario no mentioned problems about bathing, dressing,
toileting, continence & feeding
Only she has problems during moving inside the house and she needs
assist until solving the present condition

18
Katz Index of Independence in Activities of Daily Living
ACTIVITIES (1
OR 0 POINTS) INDEPENDENCE (1 POINT)*
Bathing Bathes self completely oí
needs help in bathing only a
Points:
single paít of the body, such as
the back, genital aíea, oí
disabled extíemity
Díessing Gets clothes fíom closets and
díaweís, and puts on clothes
and outeí gaíments complete
Points:
with fasteneís; may need help
tying shoes
ľoileting Goes to toilet, gets on and
off, aííanges clothes, cleans
Points:
genital aíea without help
ľíansfeííing Moves in and out of bed oí
chaií unassisted; mechanical
Points:
tíansfeí aids aíe acceptable
Fecal and Exeícises complete self-contíol
uíinaíy oveí uíination and defecation
continence
Points:
Feeding Gets food fíom plate into
mouth without help;
Points:
píepaíation of food may be
19
DEPENDENCE (0 POINTS) †
Needs help with bathing
moíe than one paít of the
body, getting in oí out of the
bathtub oí showeí; íequiíes
total bathing
Needs help with díessing
self oí needs to be
completely díessed
Needs help tíansfeííing
to the toilet and cleaning
self, oí uses bedpan oí
commode
Needs help in moving fíom
bed to chaií oí íequiíes a
complete tíansfeí
Is paítially oí totally
incontinent of bowel oí
bladdeí
Needs paítial oí total
help with feeding oí
íequiíes paíenteíal
 done by anotheí peíson feeding

ľotal points‡:

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 Q.5- During the next three months you noticed that the falls problem
is becoming a common presentation to your practice. Construct a
proposal to your directorate manager to start a small project aiming
at “fall prevention in your community. The proposal will include the
following: -
• The epidemiology of falls in your country / city in
comparison with international figures, burden of falls as a
serious health problem in your community.
• Suggested steps to improve the services currently
covering the falls issue.
• Articulate the roles of multidisciplinary team members in
the assessment of patients and provision of multifactorial
treatment for falls at home and in the community.

Why fall prevention is important

- Falls can be devastating: they are leading cause of non fatal
injuries among adults
- Falls can be deadly: among older adults. Falls can lead to fatal
injuries. At least 25,000 die as a result of injuries
- Falls are preventable. People are living longer and falls will
increase unless we make a serious commitment to providing
effective fall prevention programs
-
Frequency of falls worldwide
• While approximately one in three older people falls each year,
this proportion varies depending on the country and the target
population studied.

For instance, a study of the South East Asia region found

that in China, 6%- 31% and in Japan 20% of older adults fell
each year. A study of Latin America found the proportion of
older adult who fell each year was 34% in Santiago, 29% in
Sao Paulo, and 24% in Havana.
21
 • In the developing world, however, there is a lack of data for
many regions. For instance, there is no epidemiological data
available for Africa, South Asia and the WHO Eastern
Mediterranean region.

Burden of falls as a serious health problem in your community

Fatal falls rate by age and sex group

22
Consequences of falls. Falls can result in fractures (64%), fear of
falling (44%) and hospital admissions (32%), and reduced quality of
life. Falls can also result in a post fall syndrome that includes
dependence (32%), loss of autonomy (14%), confusion (22%), and
immobilization (4%), depression (2%), and restrictions in daily
activities. Falls are often considered a contributing reason for
admission to a nursing home.

Hospital admission
Falls are common cause of hospital admissions for traumatic
injuries, accounting for 40% of hospitalization.
A Canadian survey analyzed fall related hospitalization data
between 1998/99 through 2002/03 found that approximately 85,000
Canadians age 65 and older had been admitted to a hospital due to
injuries related to falls. The average length of stay was
approximately 15-20 days for those 65-74 years of age, 13-15 days
for those 75-84 years, and 12-14 days for those 85 years and over.
The length of stay for a fall injury was consistently.
A Global Report on Falls Prevention Epidemiology of Falls longer
23
than the average length of stay for all causes combined for seniors
age 65 and older. Over the 1998/99 to 2002/03 period, the average
length of a hospital stay for fall related injuries among people age
65 and older declined.
Rates of fall-related hospitalizations increased with age for both
men and women [28]. The hospitalization rate among women
increased from 6 per 1000 population in the 65-74 age group to 46
per 1000 population among those age 85 and older. The rate for
men increased from 4 per 1000 in the 65-74 age group to 32 per
1000

24
in the 85 and older age group.

Immobility

Falls are a major cause of severe non-fatal injuries and are the
second leading cause of spinal cord and brain injury among older
adults. Approximately 30-50% of falls result in minor soft tissue
injuries. Overall, 20-30% of those who fall sustain moderate to
severe injuries that limit mobility and independence and may
result in death. Nearly 30% of older people experiences injuries to
the hip, thigh, knee, lower leg, ankle, or foot; 17% experience
injuries. Source to the wrist and hand, and 14% to the back and
spine. Approximately 50% of hip fractures lead to immobility.
Falls are the largest single cause of restricted activity among
older adults, accounting for 18% of restricted activity days,
increasing the probability of nursing home admission. Falls also
account for 12% of people bed-bound for life among those who fall
and are age 65 years and over.
Falls can cause fear of falling and reduce independence and quality of life.
Even falls that do not result in physical injuries can result in a
"post-fall syndrome" that is associated with a loss of confidence
and immobility.

Mortality

Falls account for 40% of all injury deaths. Men have a higher
mortality rate than women. A Canadian survey found the mortality
rate increased from 8.1 per 10,000
populations during 1997-99 to 9.4 per 10,000 populations during
2000-02. Falls can be an indirect cause of death if a person is
unable to get up from the floor and cannot call for a help. Lying on
the floor for more than 12 hours is associated with pressure sores,
dehydration, hypothermia, pneumonia, and ultimately with higher

25
 mortality. Approximately 20% of hip fractures lead to death within
6 months. The increasing fall death rate during the past decade is,
in part, a reflection of the increasing average age of the over-
population.

Planning for a Fall Prevention Program

Follow these important steps when planning your fall prevention program.

Determine your community’s needs

Before deciding what fall prevention program to implement, answer the
following questions to determine your community’s needs and identify
appropriate resources.
- What information or data do you have about the burden of falls in
your community? (Sources may include community hospitals,
emergency medical services, and local and/or state public health
departments.)
- How much support for starting a fall prevention program is there at
all levels of your organization— from the board and director, to the
staff, volunteers, and older adult

26
 clients?
- What are your organization’s current and future goals for providing
and resources services to older adults in your
community?
- What related programs or services are currently being offered
by your or other organizations in your area?
- What existing community resources could provide services to
address or support older adult fall prevention programs?
- What organizations or community champions would join in planning
to implement this program?

Make partnership and maintain it with the following organizations or

communities
- Hospitals and health care organizations
- Local and state government officials and offices
- Faith-based organizations
- Civic organizations
- Senior citizen groups
- Commercial establishments serving older adults
- Clubs that may have a large older adult membership (such as the
Veterans of Foreign Wars) • Universities or colleges that offer
academic programs or services for older adults

Selected web resources for developing partnerships eg.

- Partnership Self-Assessment Tool
www.depts.washington.edu/ccph/pdf_files/
project%20site%20final.pdf

Selecting an Evidence-Based Fall Prevention Program

Conclusion

Fall and fall related injuries are major public health challenges
that call for global attention. This problem will increase in
magnitude as the numbers of older adults increase in many

27
nations throughout the world. This report describes some
commonly reported fall risk factors from international studies.
These include demographic, biological and behavioral factors that
both alone and in interaction with each other, increase the risk of
falls. Epidemiological data show gender differences in the rates of
fall-related mortality and hip fracture, with considerably higher
death rates among men. Depending on the injury, falls can lead to
hospital admission, disability and functional limitations that
significantly decrease the quality of life for older people.
Preventive measure must be taken to reduce the burden of falls on
the individual, family and society. Additionally, there is a lack of
epidemiological data for many regions in the developing world.
Research is needed to identify prevention strategies that will be
effective in different cultural contexts.

28
Suggested steps to improve the services currently
covering the falls issue Falls Injury Prevention Policies:

Many procedures that have a potential to reduce the overall

burden of falls injury among older persons should be supported
and adapted and modified for use in developing countries.

Physicians can become advocates in petitioning Governments to

make injury prevention policy a priority on the agenda of health
issues. Existing resources to keep well informed of policy issues
and other initiatives could be used.

Increase in funding for injury prevention projects can be targeted.

Physicians can lead the medical community in promoting
prevention of and/or reducing falls related injury in older persons.
To do this, there is a need for inter- sectoral cooperation between
the medical and allied health professions.

Health care providers should work together to reduce falls injury.

The first point of contact is usually general practitioners.
Physicians should support the coordination and continuity of care
in all settings. Risk indicators should be included in a patient’s
medical records.

It’s believed that both formal and informal communication between

injury prevention groups is necessary. Stakeholders should be
involved in program development, implementation and evaluation.

Evidence-based strategies that improve the effectiveness and

efficiency of treatment and rehabilitation of falls injury and allow
for monitoring risk factors and implementation of interventions to
prevent or lessen fall injury need to be supported.

A systematic assessment of individual risk is desirable and a pro-

29
active, multi- factorial approach to injury prevention is essential.

Physicians should be encouraged to make their own decisions

about the appropriateness of fall screening tools and other
assessment procedures.

Commitment to exercise should be maintained throughout a

person’s life. However, it is critical for people to have an exercise
regimen in place by middle age. Older persons need to be
educated to increase their awareness of the beneficial effects of
targeted exercise. Older people should be encouraged to take up
physical interventions if it is safe to do so. A resistance to
exercising warrants investigation. Inclusion of injury prevention in
core medical curricula, and information on falls injury prevention
dissemination should be encouraged.

30
A long-term fall injury prevention strategy that incorporates risk
assessments, intervention strategies, health promotion, funding
issues and continuity of care is needed.

- The roles of multidisciplinary team members in the

assessment of patients and provision of multifactorial
treatment for falls at home and in the community

Following treatment for an injurious fall, older people should be

offered a multidisciplinary assessment to identify and address
future risk and individualized intervention aimed at promoting
independence and improving physical and psychological function.

31
There is weak evidence to support any single intervention directly
influencing the rate of falls.

Most evidence suggests that multifactorial interventions, which

target individual risk factors for falling, are far superior in reducing
the incidence of falls.

Therefore, the multidisciplinary team must work collaboratively to

identify individual risk factors that predispose their patients to
falling.

The multidisciplinary team includes the:

• Medical officer
• Physiotherapist
• Occupational therapist
• Nurse
• Pharmacist
• Podiatrist.

Medical officer
A patient presenting with a fall (particularly recurrent falls) should
receive careful medical screening because it could be the
symptom of an underlying pathology that may be responsive to
treatment. The patient’s medication regime should always be
reviewed with falls prevention in mind.

The physiotherapist
The physiotherapist can aid in problems of gait, balance and
posture, including assessment for suitable footwear and walking
aids.
Physiotherapists can teach patients different techniques to get
themselves up from the floor. If this is not realistic, patients can be
taught how to move while on the floor. Practical advice can be
given on how to summon help, such as pulling a telephone onto the
32
floor. Providing a lifeline pendant with instructions for its use will
be invaluable. Hypothermia may be avoided if the patient keeps a
blanket in each room which could be reached from floor level.

The occupational therapist

The occupational therapist can assess a patient’s suitability for
mechanical grab aids and other devices that will help maintain
independence while reducing the risk of falls.

Nurse

33
A home assessment can be vitally important to a patient who is at
risk from falling. Poorly fitted carpets, loose mats, dimly lit stairs
and lack of handrails are some common hazards in the home.

Pharmacist
Reinforcing the importance of taking the prescribed dose and
encouraging use of pill calendar boxes, to improve adherence and
overall compliance with drug therapy. Education about the adverse
reaction of the drugs.
Manage drug interaction and deal with poly-pharmacy in elder patient

Podiatrist
A podiatrist can help when gait problems are related to
conditions such as corns, bunions and overgrown toenails.

34