GP Connect Clinical by Felicity Fane, Senior Physiotherapist, Falls Specialist Program, Osborne Park Hospital*
Falls have a huge impact on the individual and the health care system. One in three patients over 65, living in the community fall yearly and rates are higher in residential aged care. GPs play an important role in identifying and addressing the organic causes and risk factors to help prevent future falls. Proactive management can reduce the burden on the health care system and improve quality of life for patients.
A detailed history of the patient’s fall can provide valuable clues. Ask the patient about:
- Where did the fall happen?
- What was the environment like?
- What were they doing at the time?
- Was there a behavioural or cognitive element such as rushing, dual tasking, or risk taking activities (e.g. climbing ladders, complex gardening)?
- Was it mechanical (slip/trip/stumble)?
- Are there symptoms of an underlying medical issue (dizziness, palpitations, loss of consciousness, weakness)?
- How did they get off the floor? (this can give you an understanding of the patient’s physical function and ability to problem solve).
- Was there was a recent change in medications, including centrally acting medications and antihypertensives.
Are they reporting a fear of falling? Fear leads to reduction in activities and participation, and increased risk of social isolation. This leads to deconditioning; reductions in their strength, balance and endurance, globally reducing their functional reserve.
Assessing their balance and strength provides useful information to compare them to their age-matched normative values. Quick tests include the Five Times Sit-to-Stand Test and the Rhomberg’s Test.
Five Times Sit-to-Stand Test : Time the patient standing and sitting from a chair five times. Taking more than 15 seconds indicates a high falls risk. Using their arms indicates a lower limb strength deficit. Observe their technique and steadiness throughout the task. Tentativeness or a poor technique (e.g. not achieving a full stand) also indicate increased falls risk.
Rhomberg’s Test: Observe the patient for 30 seconds standing with feet together and their eyes closed. Sensation, proprioception, vision and the vestibular system contribute to balance. If Rhomberg’s is positive (e.g. increased sway, stepping out of position), it indicates they are more reliant on vision and may have reduced function in proprioception or the vestibular system. This may relate to their falls history.
Observing gait patterns also informs falls risk factors. If a patient habitually has their centre of gravity in front of their base of support (e.g. off-loading lumbar spine pain, body habitus, kyphotic spine) their risk of falling forward is increased. Consider if teaching compensating behaviours (e.g. lift your feet higher) is worthwhile versus addressing the impairment (e.g. postural and balance retraining.) Other gait issues such as foot drop, Parkinsonism, hemiplegia, also increases falls risk.
Advice from the GP to the patient encouraging participation in exercise is important. In the absence of contraindicating past medical history, patients should be educated to undertake ideally 150 minutes of moderate intensity exercise weekly.
Falls specialist physiotherapy involves a detailed subjective assessment covering history of falls, function, social history and the home environment. Questioning around medication compliance, polypharmacy, nutrition, continence, foot health, vision, hearing, vestibular function, sleep/wake cycle, bone density and cognition are included. Objectively the patient’s functional mobility, posture and gait pattern, strength, range of motion, postural blood pressures, proprioception and sensation are formally assessed. Based on this assessment, advice and education around modifying intrinsic and extrinsic risk factors is provided. This includes goal setting and a tailored exercise program.
Referral to physiotherapy should be considered if the patient is open to participation, has adequate cognition to follow instructions and carry over information. If their cognitive score (MMSE or MOCA) is below 20/30 they will need significant carer support to engage. Before referring a patient, establish whether the patient is motivated and able to establish goals they’d like to achieve from therapy.
Each health service (including country areas) has a falls assessment service and there are also some services provided by private hospitals.
*The author would like to knowledge this article was written with input and consolation from Dr Minoti Bhagat, Geriatrician and Dr Kate Ingram, Geriatrician