2010年AGSBGS老年人跌倒预防临床实践指南概要
SPECIAL ARTICLE
Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention
of Falls in Older Persons
Developed by the Panel on Prevention of Falls in Older Persons,American Geriatrics Society and British Geriatrics Society
The following article is a summary of the American Geri-atrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons(2010). This article provides additional discussion of the guideline process and the differences between the current guideline and the2001version and includes the guidelines’recom-mendations,algorithm,and acknowledgments.The com-plete guideline is published on the American Geriatrics Society’s Web site(https://www.wendangku.net/doc/0a3812342.html,/health_ care_professionals/clinical_practice/clinical_guidelines_recom mendations/2010/).J Am Geriatr Soc59:148–157,2011. T he risk of falling and sustaining an injury as the result of a fall increases with age.1,2Falls are not only asso-ciated with morbidity and mortality in the older popula-tion,but are also linked to poorer overall functioning and early admission to long-term care facilities.3–5For older community residents,effective fall prevention has the po-tential to reduce serious fall-related injuries,emergency de-partment visits,hospitalizations,nursing home placements, and functional decline.Reducing fall risk in older individ-uals is therefore an important public health objective.6 The Guideline for the Prevention of Falls in Older Persons was published in May2001.7The present publi-cation updates the earlier guideline by evaluating evidence and analyses that have become available since2001and by providing revised recommendations based on these evaluations.
The development of this guideline update began by convening a panel comprising members from the previous panels and new members with substantial knowledge,experience,and publications in fall prevention and care of older patients.Panel members included experts in physical therapy,pharmacy,orthopedics,emergency medicine,oc-cupational therapy,nursing,home care,and geriatric clin-ical practice.The literature search included meta-analyses, systematic literature reviews,randomized controlled trials (RCTs),controlled before-and-after studies,and cohort studies published between May2001and April2008.(The panel reviewed the RCTs published between April2008and July2009and concluded that the additional evidence did not change the ranking of the evidence or the guideline recommendations.The negative RCTs of multifactorial in-terventions all involved risk factor assessment with referral without direct intervention or ensuring that the interven-tions were instituted.)
In addition to Medline and PubMed,the following da-tabases were searched:Database of Abstracts of Reviews of Effectiveness,Centre for Reviews and Dissemination/ Health Technology Assessment,and the Cochrane Central Register of Controlled Trials.Interventions aimed at bone health(e.g.,medications for osteoporosis)and the topics of syncope,restraints,bone protection(e.g.,hip protectors), and inpatient hospital-based fall prevention,although im-portant to fall and injury prevention,were not included in the evidence review or guideline.
Each expert panel member completed a disclosure form at the beginning of the guideline process that was shared with the entire expert panel at the start of its two expert panel meetings.Con?icts of interest in this guideline have been resolved by having the guideline independently peer reviewed and then edited by the Expert Panel Chair,who had no con?ict of interest with the medications being dis-cussed.Expert panel members who disclosed af?liations or ?nancial interests with commercial interests involved with the products or services referred to in the guideline are listed under the disclosures section of this article.
CLINICAL ALGORITHM
The clinical algorithm describes the systematic process of decision-making and intervention that should occur in
Address correspondence to Marianna Drootin,American Geriatrics Society, 350Fifth Avenue,Suite801,New York,NY10118.E-mail:mracz@amer https://www.wendangku.net/doc/0a3812342.html,
DOI:10.1111/j.1532-5415.2010.03234.x
Professional Education,American Geriatrics Society,New York,New York.
JAGS59:148–157,2011
r2011,Copyright the Authors
the management of older persons who present in a clinical setting with recurrent falls or dif?culty walking or in the emergency department after an acute fall.For some interventions,outcome data were insuf?cient to allow evidence-based recommendations to be made,or the exist-ing literature was ambiguous or con?icting.In these cases, the panel made recommendations based on consensus after intensive discussion.
Grading the Strength of Recommendations
A standardized format based on an evidence rating system used by the U.S.Preventative Services Task Force was used to critically analyze the literature and grade the evidence for this document.8
Based on overall quality of evidence and magnitude of bene?t for each intervention,the committee assigned a rating of A,B,C,or D to each recommendation(A5a strong recommendation that physicians provide the inter-vention to eligible patients,B5a recommendation that cli-nicians provide this intervention to eligible patients, C5that no recommendation for or against the routine provision of the intervention can be made,and D5that the panel recommends against routinely providing the inter-vention to asymptomatic patients).If evidence was insuf?-cient to come to a decision for or against the intervention, the panel assigned a rating of I.
Changes Since the2001Guidelines
Assessments
The2010guidelines,although recommending a multifac-torial fall risk assessment for all older adults who present with a fall or who have gait and balance problems,also calls for a multifactorial falls risk assessment for individuals who simply report dif?culties with gait or balance.A falls risk assessment is not considered necessary for older persons reporting only a single fall without reported or demon-strated dif?culty or unsteadiness.
The history of fall circumstances is more speci?c in the 2010guidelines,including questions about frequency of falling,symptoms at time of fall,and injuries from fall.
New speci?c recommendations for assessment include examination of the feet and footwear,functional assessment (assessment of activity of daily living skills,including use of adaptive equipment and mobility aids,as appropriate);as-sessment of the individual’s perceived functional ability and fear related to falling;and environmental assessment,in-cluding home safety.
Interventions
New recommendations specify that direct interventions ad-justed for the identi?ed risk factors,performed by the health professionals who performed the assessment or other healthcare professionals referred by them must follow the multifactorial fall risk assessment.
All multifactorial interventions for community-resid-ing older people should have an exercise component.Ex-ercise recommendations in the2010guidelines specify programs that include balance,gait,and strength training, such as tai chi or physical therapy,in group programs or as individual programs at home.The2001guidelines were unable to recommend tai chi,because inadequate data were available at that time.Endurance and?exibility training are supported but not as sole components of a program.Cur-rent data support exercise programs only for community-dwelling older persons,in contrast to the earlier guidelines, which recommended long-term exercise and balance train-ing for all older people who have had recurrent falls.
A healthcare professional should perform environmen-tal adaptation or modi?cation,not only environmental as-sessment,as part of a multifactorial fall risk assessment and intervention for all older persons who have fallen or who have risk factors for falls.The intervention should include mitigation of fall risk factors identi?ed in the home and evaluation and interventions to promote safe performance of daily activities.
Cataract surgery on the?rst eye should be expedited in older persons in which the surgery is indicated;however,the new guidelines recommend against vision assessment or in-tervention as an individual approach outside of a multifac-torial assessment and intervention strategy.
Medication reduction or withdrawal is stressed for all older people,not only for those taking four or more med-ications,as in the earlier guidelines.
Assessment and treatment of postural hypotension should be included as part of a multifactorial intervention approach.
Dual-chamber cardiac pacing should be considered for older persons with cardioinhibitory carotid sinus hypersen-sitivity who experience unexplained recurrent falls.
Vitamin D(800IU)is recommended as a daily supple-ment for all older adults at risk of falls.Vitamin D is also recommended for all older adults with known vitamin D de?ciency and should be considered for those suspected of having vitamin D de?ciency.There is strong evidence for vitamin D supplementation(800IU/d)in patients residing in long-term care who have known vitamin D de?ciency; vitamin D supplementation should also be considered for those with problems of gait or balance or who are otherwise at risk for falls residing in long-term care.
No speci?c recommendations are made for or against assistive devices,alarms,or hip protectors.
For older persons with cognitive impairment,there is insuf?cient evidence for supporting any recommendations to reduce fall risk.
SCREENING AND ASSESSMENT
Further explanation of the basis of the clinical algorithm is provided below(Figure1).
Annotation A:Older Adult Encounters with Health-care Provider.This guideline algorithm is to be used in the clinical setting for assessment and intervention to reduce falls in community-residing older persons( 65).The guide-line algorithm is not intended to address fall injuries per se or falls that occur in the hospital.
Annotation B:Screen for Falls or Risk for Falling.The screening for falls and risk for falling is aimed at preventing or reducing fall risk.Any positive answer to the screening questions puts the person screened in a high-risk group that warrants further evaluation.All older adults who are under the care of a health professional(or their caregivers)should be asked at least once a year about falls,frequency of fall-ing,and dif?culties in gait or balance.
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Annotation C :Screen Positive for Falls or Risk for Falling .Persons at higher risk of falling,identi?ed by screening,should be assessed for known risk factors.A multifactorial fall risk assessment should be performed for community-dwelling older persons who report recurrent ( 2)falls,report dif?culties with gait or balance,or seek medical attention or present to the emergency department because of a fall.
Annotation D :Report of a Single Fall in the Past 12Months .A (?rst)single fall may indicate dif?culties or un-steadiness in walking or standing.In older individuals,a fall may be a sign of problems in gait or balance that was not present in the past.
Annotation E :Evaluation of Gait and Balance .Gait and balance de?cits should be evaluated in older individuals reporting a single fall as a screen for identifying individuals who may bene?t from a multifactorial fall risk assessment.For persons who screen positive for falls or fall risk,eval-uation of balance and gait should be part of the multifac-torial fall risk assessment.Frequently used tests of gait
or
Figure 1.Algorithm and annotations.
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balance include the Get Up and Go Test;9Timed Up and Go Test,10the Berg Balance Scale,11and the Performance-Oriented Mobility Assessment.5,12
Annotation F:Determination of Multifactorial Fall Risk.A multifactorial fall risk assessment can reveal the factors that put an older adult at risk of falling and can help identify the most appropriate interventions.A multifacto-rial fall risk assessment followed by intervention to modify any identi?ed risks is a highly effective strategy to reduce falls and the risk of falling in older persons. INTERVENTIONS
Initiation of Multifactorial or Multicomponent Interventions to Address Identi?ed Risk(s)and
Prevent Falls
Two methods for reducing multiple risk factors have been tested in clinical trials.The?rst method,termed‘‘multi-component intervention’’in this guideline,refers to a set of interventions offered to all participants in a program that addresses more than one intervention category.This method has been used most often in long-term care set-tings.In the second method,called‘‘multifactorial inter-vention,’’participants are offered only the adjusted subset of interventions that target the risk factors that have been identi?ed through a fall risk factor assessment.This tar-geted or customized approach has been implemented pri-marily in community-dwelling older persons.13Because of the great heterogeneity among the designs of the multifac-torial and multicomponent studies,the panel chose to in-clude trials with multifactorial or multicomponent approaches regardless of dimensions.
Most of the components included in multicomponent or customized multifactorial interventions can be described under the broad headings of exercise and physical activity, medical assessment and management,medication adjust-ment,environmental modi?cation,and education.A sig-ni?cant body of evidence,including two meta-analyses, supported the multifactorial or multicomponent approach to interventions designed to prevent falls in older per-sons.14–35Risk factor assessment without direct interven-tion into the identi?ed risk factors does not appear to be effective.25–28,32,33,36–38Attention to the following do-mains are particularly effective:environmental adaptation; balance,transfer,strength,and gait training;reduction in medications,particularly psychoactive medications;and management of visual de?cits,postural hypotension,and other cardiovascular and medical problems.The effective-ness of visual interventions other than?rst cataract surgery is less clear.
Minimization of Medications
Medications have consistently been associated with risk of falls.The strongest risk associations occur with psychotro-pic medications and polypharmacy.39–41The strongest ev-idence supports withdrawal of psychotropic medication,as a single intervention and as a component of multifactorial and multicomponent intervention.If discontinuation of a particular high-risk medication is not possible because of medical conditions,dose reduction should be considered. Although some clinicians believe that selective serotonin reuptake inhibitors(SSRIs)are generally safer to use in older adults than tricyclic antidepressants,in terms of fall prevention,evidence is building that SSRIs increase fall risk as much as the older tricyclic antidepressants.Reduction of psychotropic medication as a single intervention has been found to reduce fall rate,14whereas assessment,adjust-ment,and discontinuation of medication regimens as part of a multifactorial intervention,has also been found to be effective in reducing falls.19–21,23,34,42
Initiation of a Customized Exercise Program
A range of exercise types have been investigated,both in-dividual and group exercises that can be used in isolation or in combination including balance exercises,strength train-ing,?exibility(muscle and joint stretching techniques),tai chi,and cardiovascular,endurance,and?tness training. Because a large body of evidence supports the recommen-dation that exercise,in the form of resistance(strength) training and balance,gait,and coordination training,is effective in reducing falls,the panel concluded that exercise, in the form of strength training and balance,gait,and co-ordination training,15,16,43should be included as part of a multifactorial or multicomponent intervention to prevent falls in older persons and may be considered as a single intervention.In most positive trials,the exercise program was longer than12weeks(1–3times per week)with vari-able intensity.
Exercise may be more effective when applied alongside other interventions.Exercise programs were associated with fewer falls in multifactorial and multicomponent stud-ies.14,19,21,24,31,35Exercise programs should be initiated with caution because some studies have shown that exercise may increase the rate of falls in persons with limited mo-bility who are not accustomed to physical activity.Some trials that included balance training43–48as part of the in-tervention showed signi?cant reduction in falls in addition to other bene?ts in gait,balance,and reduced fear of falling. Treating Vision Impairment
Aging is often associated with changes in visual acuity,de-velopment of cataracts,macular degeneration,glaucoma, and other conditions that would suggest an effect on risk of falling.If patients report problems or concerns,their vision should be formally assessed,and any remediable visual ab-normalities should be treated,particularly cataracts.
A systematic review15found no evidence that referral for correction of vision in community-dwelling older people was effective in reducing the number of people falling,al-though this conclusion was based on a single RCT.24Two RCTs assessing the effect of a cataract operation and wait-ing list time for surgery showed a lower rate of falling for immediate surgery than delayed surgery.49,50Three studies that included vision correction as part of a multifactorial assessment and intervention had mixed results.21,24,51It remains unclear whether vision is an essential component of multifactorial intervention.One randomized trial examin-ing a vision assessment and follow-up intervention alone indicated that vision assessment and intervention increased risk of falling.This may be related to the effects of adjusting to new glasses.52
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Managing Postural Hypotension
Postural hypotension is associated with greater risk of falls. It most commonly occurs as a result of dehydration,con-comitant medications,and autonomic neuropathy.Many multifactorial fall prevention programs that have shown bene?t for fall prevention have included medication reduc-tion and simpli?cation to modify postural blood pressure, as well as speci?c strategies such as hydration,elastic stockings,abdominal binders,and medications(e.g.,?u-drocortisone and midodrine).Managing postural hypoten-sion should be included as a component of multifactorial intervention in community-living older persons.
Three RCTs have demonstrated a bene?t associated with treatment of postural hypotension in addition to in-terventions such as medication reduction,optimization of ?uids,and behavioral intervention.19,20,23
Managing Heart Rate and Rhythm Abnormalities
The most common cardiovascular disorders associated with falls are carotid sinus hypersensitivity,vasovagal syndrome, bradyarrhythmias(e.g.,sick sinus syndrome and atrioven-tricular block),and tachyarrhythmias.Two mechanisms have been proposed.The?rst is transient loss of conscious-ness with amnesia in which the patient has no recollection of short episodes of syncope;this has been reported with postural hypotension and carotid sinus hypersensitivity.53 Given that up to70%of falls in older persons are not wit-nessed,these patients may present with a report of a fall rather than syncope.A second proposed mechanism is that of transient hypotensive episodes,due to primary hypoten-sion or hypotension secondary to arrhythmias,which cause a person with comorbid gait and balance instability to lose balance and fall without frank syncope.Cardiac pacing treats bradycardia.One RCT of cardiac pacing in commu-nity-dwelling older people who had recurrent unexplained falls,reported a signi?cant reduction in fall rates at12-month follow-up.54For the subset of older adults who meet the necessary diagnostic criteria,dual-chamber cardiac pacing for bradyarrhythmias(including carotid sinus hypersensitivity and conduction disorders)and treatment of tachyarrhythmia are components of a multifactorial intervention designed to reduce the risk for falls.
Vitamin D Supplementation
Vitamin D de?ciency is common in older people and when present impairs muscle strength and possibly neuromuscu-lar function.Several recent meta-analyses and RCTs have shown a bene?cial effect of vitamin D supplementation in fall prevention distinct from its effect on bone health.55–60 Some of these trials have also shown bene?t even in older persons with normal serum vitamin D levels.Given the low number needed to treat of15and the evidence of signi?cant fall risk reduction,as well as the fact that vitamin D is safe and inexpensive,older persons with suspected vitamin D de?ciency should be routinely offered supplementation to reduce fall risk.Moreover,vitamin D supplementation at appropriate levels should also be considered for all older adults.Managing Foot and Footwear Problems
Foot problems are common in older people and are asso-ciated with impaired balance and performance in tests of function.Serious foot problems(moderate or severe bun-ions,toe deformities,ulcers or deformed nails)predispose older adults to falls.12Also,foot position awareness is sig-ni?cantly poorer in older persons.
The type and condition of footwear may also contrib-ute to the risk of falling.Footwear that?ts poorly,has worn soles,has high heels,or is not laced or buckled when worn has been associated with a higher risk of falling.61Shoes with low heel height and high surface contact area may reduce the risk for falling.62–65Most of the studies that implemented a multifactorial assessment for reducing the risk of falling,included a foot assessment coupled with advice or referral for appropriate treatment,if any foot problems were identi?ed.27,29,66,67(See Multifactorial In-tervention.)Assessment and recommendations for use of appropriate shoes were also included in home hazards studies.51,68One small study found that antislip shoe de-vices were effective in reducing outdoor falls in slippery conditions.69
Modi?cation of the Home Environment Environmental hazards are any objects or circumstances in the environment that increase an individual’s risk of falling and may be within the home and grounds(commonly termed home falls hazards)or away from the home(public falls hazards).Identi?cation and mitigation of environmen-tal hazards has been a recommended component of many successful fall prevention programs.The panel concluded that screening of the home environment with follow-up for any needed modi?cations by a healthcare professional is an effective targeted intervention for people with a previous fall history or other fall risk factors.Programs include home hazard assessments by trained individuals,removal or modi?cation of identi?ed hazards,installation of safety de-vices such as handrails on stairs and grab bars on bath-rooms,and improvements in lighting.
Although evidence supporting the use of home environment assessment and intervention alone as a strategy to reduce falls in community-dwelling older adults is mixed(not supportive,24,70supportive71),evi-dence for home environment assessment and intervention as part of a multifactorial fall prevention program is strong.19–21,23–27,31,32,35–37,72,73Further insights regarding effectiveness of the interventions are gained through the meta-analysis.15One RCT found particular bene?t in high-risk frail older subjects with a falls history.30
Providing Education and Information
All fall prevention programs include educational and health promotion https://www.wendangku.net/doc/0a3812342.html,cation of patient and caregiver can be considered as primary and secondary prevention measures and is also important for implementation and sustained use of fall prevention strategies.Many effective programs include opportunities for older adults to access fall prevention resources(e.g.,durable medical equipment, local exercise programs)and to take speci?c actions that maintain or improve health or build fall prevention skills
152PANEL ON PREVENTION OF FALLS IN OLDER PERSONS JANUARY2011–VOL.59,NO.1JAGS
(e.g.,transferring safely into the bathtub,learning how to use mobility devices).
Speci?c educational goals may be considered funda-mental components of fall prevention interventions(e.g., increasing older adults’activity level,improving ability to identify and mitigate fall hazards in the home,and provid-ing information to make good choices about footwear); however,there is little evidence to determine the incremen-tal bene?t of such educational input on fall rates in a mul-ticomponent intervention27,30,37,70,74or as a sole fall prevention intervention.31,66,67,75In one RCT of a cogni-tive-behavioral falls prevention program,‘‘Stepping On,’’that was part of a multicomponent community-based pro-gram,falls were31%lower in the intervention group.21 OLDER PERSONS IN LONG-TERM
CARE FACILITIES
Falling is more frequent in ambulatory residents of long-term care facilities than in older persons residing in the community.Approximately half of ambulatory long-term care residents experience at least one fall each year.
Trials in long-term care facilities have addressed single interventions administered alone and multiple interventions administered together.76Single interventions include use of hip protectors,fall alarm devices,removal of physical re-straints,medication review,and supplementation with cal-cium and vitamin D.Many factors,such as variation in type and severity of disability of residents,differences in struc-ture of care and terminology used to describe facilities,lack of information about the cognitive or physical functioning of participants,and insuf?cient description of the interven-tions,complicate interpretation of the evidence from RCTs in the long-term care setting.
Multicomponent Interventions
These are the most commonly studied strategies in long-term care settings.‘‘Targeted’’or‘‘customized’’multifacto-rial interventions have also been tested.Staff training and feedback,environmental adaptations,balance and gait training,strength training,training in the use of appropriate assistive devices,and decrease in psychotropic medications are interventions that have frequently been included in multicomponent intervention and multifactorial trials in this setting.The effectiveness of multicomponent studies in reducing falls in long-term care is uncertain.Three77–79of the eight trials of multiple component interventions were effective in reducing fall risk;the others found no signi?cant effects.38,51,80–82Medication review as part of a multicom-ponent intervention has provided inconclusive evidence as to whether medication assessment,adjustment,and discon-tinuation results in fewer falls.51,78,79
Environmental components were included in six of the eight studies of multicomponent interventions in the long-term care setting,of which three studies were ineffec-tive51,78,80and three effective.76,78,83Two RCTs incorpo-rating multifactorial interventions and achieving signi?cant reductions in falls incorporated environmental assessment and modi?cations.77,78No data were reported on the effec-tiveness of the environmental modi?cations alone.
The education of long-term care staff has resulted in mixed results but has probably contributed to reduction of falls in some large studies.Some evidence supports the effectiveness of healthcare team training in awareness and prevention strategies,although several multifactorial stud-ies failed to show signi?cant reduction in falls.
Exercise
Although exercise may provide certain bene?ts for long-term care residents,particularly in terms of quality-of-life parameters,confounding variables(differences in frailty levels,cognitive function,prior falls history,small size of many studies)mitigate against clearly de?ned con-clusions.81,84–89Some studies found a greater risk of falls with exercise.85There are currently no clinical RCTs to recommend,for or against,the use of individually custom-ized exercise programs to prevent falls in long-term care settings.
Vitamin D
Studies from meta-analyses and recent RCTs support the use of combined calcium and vitamin D3supplementation to reduce fracture rates in older people in long-term care.55,90,91
OLDER PERSONS WITH COGNITIVE IMPAIRMENT Older people with cognitive impairment and dementia are at greater risk for falls,with an annual incidence of ap-proximately60%.12,92Cognitive impairment is an inde-pendent risk factor for falls.Mobility problems experienced with dementia are associated with falls,fractures,and ad-mission to long-term care.
At this time,there is insuf?cient evidence to recom-mend,for or against,single or multifactorial interventions in community-living older adults with known cognitive impairment.13,82,83The only study that speci?cally inves-tigated cognitive impairment in the community demon-strated lack of ef?cacy.82
Physical activity was evaluated for its effectiveness in reducing falls in a systematic review of11RCTs of cogni-tively impaired subjects.The investigators observed only limited effectiveness of physical training or exercise in re-ducing fall risk.13
A study of education as part of a multicomponent in-tervention program that included staff education,drug re-view,environmental adjustment,exercise,aids,hip protectors,and postfall problem-solving conferences ob-served that education was associated with a signi?cant intervention effect on falls in the group with higher Mini-Mental State Examination scores but not in the group with lower scores.83
The effectiveness of a customized multicomponent in-tervention after multifactorial clinical assessment was in-vestigated in older patients with cognitive impairment and dementia presenting to the emergency department after a fall.82Interventions included optical correction,medical assessment,physiotherapy,occupational therapy,and foot care.No signi?cant difference between the intervention and control groups in fall risk was found.
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RECOMMENDATIONS:SCREENING
AND ASSESSMENT
All older individuals should be asked whether they have fallen(in the past year).
1.An older person who reports a fall should be asked
about the frequency and circumstances of the fall(s).
2.Older individuals should be asked whether they expe-
rience dif?culties with walking or balance.
3.Older persons who present for medical attention be-
cause of a fall,report recurrent falls in the past year,or report dif?culties in walking or balance(with or with-out activity curtailment)should have a multifactorial fall risk assessment.
4.Older persons who cannot perform or perform poorly
on a standardized gait and balance test should be given
a multifactorial fall risk assessment.
5.Older persons who report a single fall in the past year
should be evaluated for gait and balance.
6.Older persons who have fallen should have an assessment
of gait and balance using one of the available evaluations.
7.Older persons who have dif?culty or demonstrate un-
steadiness during the evaluation require a multifacto-rial fall risk assessment.
8.Older persons reporting only a single fall in the past
year and reporting or demonstrating no dif?culty or unsteadiness during the evaluation do not require a fall risk assessment.
9.A clinician(or clinicians)with appropriate skills and train-
ing should perform the multifactorial fall risk assessment.
10.The multifactorial fall risk assessment should include
the following.
A.Focused History
(i)History of falls:detailed description of the circum-
stances of the fall(s),frequency,symptoms at time of fall, injuries,other consequences
(ii)Medication review:all prescribed and over-the-counter medications with dosages
(iii)History of relevant risk factors:acute or chronic med-ical problems(e.g.,osteoporosis,urinary incontinence, cardiovascular disease)
B.Physical Examination
(i)Detailed assessment of gait,balance,and mobility levels
and lower extremity joint function
(ii)Neurological function:cognitive evaluation,lower ex-tremity peripheral nerves,proprioception,re?exes, tests of cortical,extrapyramidal and cerebellar function (iii)Muscle strength(lower extremities)
(iv)Cardiovascular status,heart rate and rhythm,postural pulse and postural blood pressure,and if appropriate heart rate and blood pressure responses to carotid sinus stimulation
(v)Assessment of visual acuity
(vi)Examination of the feet and footwear
C.Functional Assessment
(i)Assessment of activity of daily living skills,including use
of adaptive equipment and mobility aids,as appropriate (ii)Assessment of the individual’s perceived functional ability and fear related to falling
(assessment of current activity levels with attention to the extent to which concerns about falling are protec-tive(appropriate given abilities)or contributing to deconditioning or compromised quality of life(indi-vidual is curtailing involvement in activities he or she is safely able to perform due to fear of falling))
D.Environmental Assessment
INTERVENTIONS:OLDER PERSONS LIVING IN THE COMMUNITY
12.Direct interventions customized to the identi?ed risk
factors,coupled with an appropriate exercise program should follow the multifactorial fall risk assessment.
[A]
13.A strategy to reduce the risk of falls should include
multifactorial assessment of known fall risk factors and management of the risk factors identi?ed.[A]
14.The components most commonly included in ef?ca-
cious interventions were:
(a)Adaptation or modi?cation of home environment[A]
(b)Withdrawal or minimization of psychoactive medica-
tions[B]
(c)Withdrawal or minimization of other medications[C]
(d)Management of postural hypotension[C]
(e)Management of foot problems and footwear[C]
(f)Exercise,particularly balance,strength,and gait train-
ing[A]
15.All older adults who are at risk of falling should be
offered an exercise program incorporating balance, gait,and strength training.Flexibility and endurance training should also be offered but not as sole compo-nents of the program.[A]
16.Multifactorial or multicomponent interventions should
include an education component complementing and addressing issues speci?c to the intervention being pro-vided,customized to individual cognitive function and language.[C]
17.The health professional or team conducting the fall risk
assessment should directly implement the interventions or ensure that other quali?ed healthcare professionals conduct the interventions.[A]
18.Psychoactive medications(e.g.,sedative hypnotics,an-
xiolytics,antidepressants)and antipsychotics(e.g., new antidepressants or antipsychotics)should be min-imized or withdrawn,with appropriate tapering if in-dicated.[B]
19.A reduction in the total number of medications or dose
of individual medications should be pursued.All med-ications should be reviewed and minimized or with-drawn.[B]
20.Exercise should be included as a component of multi-
factorial interventions for fall prevention in commu-nity-residing older persons.[A]
21.An exercise program that targets strength,gait,and
balance,such as tai chi or physical therapy,is recom-mended as an effective intervention to reduce falls.[A]
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22.Exercise may be performed in groups or as individual
(home)exercises because both are effective in prevent-ing falls.[B]
23.Exercise programs should take into account the phys-
ical capabilities and health pro?le of the older person
(i.e.,be customized)and be prescribed by quali?ed
health professionals or?tness instructors.[I]
24.The exercise program should include regular review,
progression,and adjustment of the exercise prescrip-tion as appropriate.[I]
25.In older women in whom cataract surgery is indicated,
surgery should be expedited because it reduces the risk of falling.[B]
26.There is insuf?cient evidence to recommend for or
against the inclusion of vision interventions within multifactorial fall prevention interventions.[I]
27.There is insuf?cient evidence to recommend vision as-
sessment and intervention as a single intervention for the purpose of reducing falls.[D]
28.An older person should be advised not to wear mul-
tifocal lenses while walking,particularly on stairs.[C] 29.Assessment and treatment of postural hypotension
should be included as components of multifactorial in-terventions to prevent falls in older persons.[B]
30.Dual-chamber cardiac pacing should be considered
for older persons with cardioinhibitory carotid sinus hypersensitivity who experience unexplained recurrent falls.[B]
31.Vitamin D supplements of at least800IU per day
should be provided to older persons with proven vita-min D de?ciency.[A]
32.Vitamin D supplements of at least800IU per day
should be considered for people with suspected vitamin
D de?ciency or who are otherwise at high risk for falls.
[B]
33.Identi?cation of foot problems and appropriate treat-
ment should be included in multifactorial fall risk as-sessments and interventions for older persons living in the community.[C]
34.Older people should be advised that walking with
shoes of low heel height and high surface contact area may reduce the risk of falls.[C]
35.Home environment assessment and intervention per-
formed by a healthcare professional should be included in a multifactorial assessment and intervention for older persons who have fallen or who have risk factors for falling.[A]
36.The intervention should include mitigation of identi?ed
hazards in the home and evaluation and interventions to promote the safe performance of daily activities.[A] https://www.wendangku.net/doc/0a3812342.html,cation and information programs should be con-
sidered part of a multifactorial intervention for older persons living in the community.[C]
https://www.wendangku.net/doc/0a3812342.html,cation should not be provided as a single interven-
tion to reduce falls in older persons living in the com-munity.[D]
39.There is insuf?cient evidence to recommend for or
against multifactorial or multicomponent interventions in long-term care settings.[C]
40.Exercise programs should be considered for a variety of
bene?ts to reduce falls in older persons living in long-term care settings(with caution regarding risk of in-
jury),although their effect on fall risk in these settings is unproven.(C)
41.Vitamin D supplements of at least800IU per day
should be provided to older persons residing in long-term care settings with proven or suspected vitamin D insuf?ciency.[A]
42.Vitamin D supplements of at least800IU per day
should be considered in older persons residing in long-term care settings who have abnormal gait or balance or who are otherwise at high risk for falls.[B]
43.There is insuf?cient evidence to recommend for or
against multifactorial or single interventions to prevent falls in older persons with known dementia living in the community or in long-term care facilities.[I] ACKNOWLEDGMENTS
Panel members and af?liations
The American Geriatrics Society and British Geriatrics Society Panel on the Clinical Practice Guideline for the Prevention of Falls in Older Persons includes:Rose Anne M. Kenny,MD,(Chair),Trinity College and St James Hospital, Dublin,Ireland;Laurence Z.Rubenstein,MD,MPH (Chair),UCLA School of Medicine,Los Angeles,CA; Mary E.Tinetti,MD(Chair),Yale University School of Medicine,New Haven,CT;Kathryn Brewer,PT,MEd, GCS,Mayo Clinic Hospital,Phoenix,AZ;Kathleen A. Cameron,RPh,MPH,American Society of Consultant Pharmacists Research and Education Foundation,Alexan-dria,VA;Elizabeth A.Capezuti,PhD,RN,New York Uni-versity College of Nursing,New York,NY;David P.John, MD,Caritas Carney Hospital,Dorchester,MA;Sallie Lamb,DPhil(Oxon),MSc,MCSP,SRP,University of War-wick,Coventry,UK;Finbarr Martin,MD,MSc,FRCP,St Thomas’Hospital,London,England;Paul H.Rockey,MD, MPH,American Medical Association,Chicago,IL;Mary Suther,National Association for Home Care and Hospice, Dallas,TX;Elizabeth Walker Peterson,MPH,OTR/L, University of Illinois,Chicago,IL.
The following organizations endorsed the Clinical Practice Guideline for the Prevention of Falls in Older Per-sons:The American College of Emergency Physicians,the American Medical Association,the American Occupational Therapy Association,and the American Physical Therapy Association.
Oded Susskind,MPH,Medical Education Consultant, Brookline,Massachusetts,provided guideline development facilitation.Sue Radcliff,Independent Researcher,Denver, Colorado,provided research services.Katherine Addleman, PhD,provided editorial services.Marianna Drootin,Elvy Ickowicz,MPH,and Nancy Lundebjerg,MPA,American Geriatrics Society,New York,New York,provided addi-tional research and administrative support.
Peer Review:The following organizations with special interest and expertise in the prevention of falls in older persons provided peer review of a preliminary draft of this guideline:American Academy of Family Physicians, American Academy of Home Care Physicians,American Academy of Ophthalmology,American Academy of Otolaryngology,American Academy of Physical Medicine and Rehabilitation,American College of Emergency Phy-sicians,American College of Physicians,American Medical
AGS/BGS CLINICAL PRACTICE GUIDELINE FOR PREVENTION OF FALLS155 JAGS JANUARY2011–VOL.59,NO.1
Association,American Occupational Therapy Association, American Physical Therapy Association,British Associa-tion for Emergency Medicine,Chartered Society of Physio-therapists College of Occupational Therapists(UK), National Association for Home Care and Hospice,Geron-tological Advanced Practice Nurses Association,Royal Pharmaceutical Society of Great Britain,Society for Aca-demic Emergency Medicine,and the Society for General Internal Medicine.
Financial Disclosure:Dr.Tinetti,Dr.Rubenstein,Dr. Kenny,https://www.wendangku.net/doc/0a3812342.html,mb,Dr.Rockey,Ms.Brewer,Ms.Peterson, and Mr.Susskind report no?nancial relationships with rel-evant commercial entities.Ms.Cameron holds shares in Johnson&Johnson.Ms.Suther holds shares in various pharmaceutical companies.Dr.Capezuti is a board member of Medco Health Solutions,Inc.Dr.John receives grants from the American College of Emergency Physicians.Dr. Martin has received hospitality,but no fees from P?zer, Orion,and Pharmacia.
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