Falls account for one of the most common and serious issues contributing to a disability, especially among older individuals. Over 30% of people aged >65 fall every year and approximately half of the falls are recurrent ⁽³⁾. One in two of people aged >80 fall at least once a year. Additionally, falls among inpatients are the most frequently reported safety incident in NHS hospitals. Injuries occur in around 30% of hospital falls ^(4,5).

The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Up to 90% of older patients who fracture their neck of femur may fail to recover their previous level of mobility or independence (NPSA 2007). In fact, falls are the most common cause of injury-related deaths in people over 75 in England (Age UK).

This should be performed by a health care professional with appropriate skills and experience, and this should be individualised.

You can refer to the flowsheet column for guidance in multifactorial assessment on Epic.

Day time presentation (08:30 to 17:00)

• Patients presented with falls and no major injuries: refer to Frailty team on

07920757286 (Frimley), 07787275775 (Wexham)

Out of hours presentation (17:00 to 08:30)

• Clerk patient, do a multifactorial assessment to rule out major injuries.

• Put patient on the medical take list.

• Frailty team will screen in the morning and take over if deemed appropriate.

Falls History

• Activity before, during and post Fall

• When and where

• Frequency of falls

• Ability to get up from the floor unassisted (unassisted, not requiring help from another person)

• How many falls in the past twelve months

• Changes to lifestyle as a result of falling, e.g. not going out alone, now uses walking aid, not getting to the bath etc

• What footwear was worn at time of fall

Investigations to be considered

U&E, FBC, B12, folic acid, vitamin D, Bone profile, LFT, BM, TSH, 12 lead ECG, Urine dipstick and CT scan/CXR as clinically indicated.

Epic flowsheet column: Mobility and Fall History

Assessment tools may include:

• Timed ‘get up and go’ test

• Timed Unsupported Steady Stand (TUSS) Timed sit to stand from standard 18” chair Berg Balance test

Check use of and / or provide appropriate mobility aid.

Footwear examination/check

• Review if suitable on suitable shows and foot health

Epic flowsheet column: PT assessment

Subjective questioning of ability to manage personal and domestic activities of daily living.

Refer to Occupational therapist to consider:

• Rehabilitation Programme

• Provide appropriate mobility aid and equipment

• Environmental or Home Hazard assessment

• Refer to Social Services if needs functional support at home

Epic flowsheet column: OT evaluation

Ask:

Are you frightened of falling? What frightens you? (eg lying there all night, fractures)

Assess:

Ability to summon help and use of pendant alarm.

Ability to prepare for a long lie.

Refer Occupational Therapist (OT) for:

• To teach strategies to get up from floor

• Provide info re summoning help

• Teach coping strategies to prepare for long lie

Epic flowsheet column: GAD-7 Anxiety scale

• History of fragility fractures (any fracture caused by a fall from standing height): upper limbs, hip and vertebral.

• Smoking and alcohol history.

• Taking long term corticosteroids.

• Parental hip fracture.

• Body mass index less than 19.

• Medical conditions independently associated with bone loss, such as rheumatoid arthritis.

Refer to osteoporosis pathway for consideration of anti-resorptive drugs if indicated.

Epic flowsheet column: FRAX score

Has there been any change in vision?

Has the individual visited Optician during the last 12 months?

Is the individual wearing their glasses and are they clean?

Epic flowsheet column: visual and hearing assessment

• Check hearing aid working / batteries fitted and working.

• Ensure correct use of hearing aid.

• Advise about having hearing tested and corrected.

• Check for ear wax.

Epic flowsheet column: visual and hearing assessment

Mini ACE/MOCA assessment.

To get collateral history for any cognitive impairment.

To complete THIS IS ME leaflet/Hospital passport for LD patients.

Refer to GP for subsequent memory clinic referral.

Epic flowsheet column: Mini Addenbrooke cognitive assessment.

• Is there frequency/urgency of micturition?

• Is person taking diuretics?

• Does s/he have problems at night?

• History of recurrent UTI.

• Does s/he have access to commode at night? Is s/he wearing appropriate aids?

• Faecal incontinence and wearing pads.

Refer to the trust faecal/urinary incontinence guideline.

Epic IRIS flowsheet column: continence

Any environmental hazards, i.e poor lighting, stairs, cluttered room, pets.

Need safety equipment.

Epic flowsheet column: OT evaluation (As above)

• 4 or more drugs including medicines bought ‘over the counter’ and herbal remedies.

• Recent change in medication

• Compliance / ability to take medication.

• Taking drugs that may increase the risk of falls, refer to STOPP/START Screening tools.

Determine units of alcohol consumed per week.

Advise about risks of taking alcohol with medications.

Give sensible drinking advice.

Refer to the Alcohol Liaison team if patient is exhibiting alcohol withdrawal symptoms.

Advise about immediate and long-term risks of falling due to dulling of neurological capacity from alcohol.

Advise on smoking cessation.

Epic flowsheet column: CIWA-Ar score

Nutritional Screening to identify if at risk of malnutrition/ or nutritional support required. Ask if

• Difficulties with eating, e.g., badly fitting dentures

• Difficulties with handling meals/drinks, e.g., arthritic condition, visually impaired Problems with digestion/absorption, e.g., constipation

• Reduced appetite/intake Special dietary needs

• Unintentional weight loss (3kg/12months)

• Nutritional Screening tools: MUST screening.

• A minimum of 8 glasses of 250mls daily will improve these symptoms and postural hypotension.

If problems identified, refer as appropriate to

• Dietitian for full nutritional assessment, intervention, monitoring Therapy /Dental services for physical problems handling food.

• Refer diabetes specialist nurse for diabetes control.

• Speech & Language Therapy for problems with dysphagia

• Social Services: for help with meal provision where there is limited support for cooking and feeding, and the ability to do this is impaired; delivery services; lunch clubs for social situation.

• Medical/Pharmacy to adjust prescribed medication if reduces appetite.

• CPN/Psychological service for mental health/psychological problems.

Epic flowsheet column: IRIS Nutrition.

Review analgesia using WHO guidelines.

Use BOLTON pain assessment tool in patients with cognitive impairment.

Epic flowsheet: Bolton pain assessment

If a patient has had a fall, you can go to the Falls Navigator to complete any necessary post-fall documentation.

This is a shared navigator between doctors, nurses and therapists.

Doctor’s workflow

• After a post fall review done by medical team.

• Post falls plan under the Falls navigator on Epic should be incorporated in the progress notes.

1. Ang, G.C., Low, S.L. and How, C.H. (2020) 'Approach to falls among the elderly in the community', Singapore Medical Journal, 61(3), pp. 116-121. Available at: https://doi.org/10.11622/smedj.2020029
2. Lord, S.R., Sherrington, C. and Naganathan, V. (eds) (2021) Falls in older people: risk factors, strategies for prevention and implications for practice. 3rd edn. Cambridge: Cambridge University Press.
3. Appeadu, M.J. and Bordoni, B. (2023) Falls and falls prevention in older adults. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560761/ (Accessed: 07 May 2024).
4. Hester, A.L. et al. (2016) 'Predicting injurious falls in the hospital setting: implications for practice', American Journal of Nursing, 116(9), pp. 24-31. Available at: https://doi.org/10.1097/01.naj.0000494688.10004.85
5. Hill, A-M. et al. (2010) 'Measuring falls events in acute hospitals-a comparison of three reporting methods to identify missing data in the hospital reporting system', Journal of the American Geriatrics Society, pp. 1347-1352. Available at: https://doi.org/10.1111/j.1532-5415.2010.02856.x
6. National Institute for Health and Care Excellence [NICE] (2013) Falls in older people: assessing risk and prevention. CG161. Available at: https://www.nice.org.uk/guidance/cg161 (Accessed: 07 May 2024).
7. National Institute for Health and Care Excellence [NICE] (2017) Falls in older people. QS86. Available at: https://www.nice.org.uk/guidance/qs86 (Accessed: 07 May 2024).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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