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  • Print publication year: 2007
  • Online publication date: May 2010

12 - Medical management of older people at risk of falls


Older people present to a wide range of healthcare specialists with problems related to or causing falls. The role of individual professions and institutions in the assessment and management of the older faller is not always apparent with frequent blurring of professional and organizational boundaries.

Only one-quarter of falls amongst community-dwelling older people are reported to any healthcare professional, but of those who do report a fall, 75 % do so to their general practitioner (GP). It is therefore imperative to ensure that GPs are aware of existing evidence-based assessment tools and intervention strategies, and have available to them appropriate referral pathways to allow for more detailed assessment and intervention if required.

This chapter discusses the role of the medical practitioner in the identification and management of the older person at risk of falling. It focuses on assessments and interventions that are traditionally within the skill set of a doctor, but also acknowledges that as professional boundaries and areas of specialization change, others may undertake some of the assessments and interventions covered.

Identification of at risk populations

Identification of at risk populations is key to the delivery of effective interventions to prevent falls in older people. At present there is limited evidence to support a population-based approach to falls prevention. It is interesting to note that such interventions have developed in parallel with the individual randomized controlled trials and have not in all cases used known evidence-based approaches to prevention.

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Graham, H. J. & Firth, J., Home accidents in older people: role of primary health care team. British Medical Journal, 305 (1992), 30–2.
McClure, R., Turner, C., Peel, al., Population-based interventions for the prevention of fall-related injuries in older people [Review]. The Cochrane Database of Systematic Reviews (2005), CD004441.
National Institute for Clinical Excellence, Clinical practice guideline for the assessment and prevention of falls in older people. (National Institute for Clinical Excellence, 2004).
Rubenstein, L. Z., Josephson, K. Z. & Robbins, A. S., Falls in the nursing home. Annals of Internal Medicine, 121 (1994), 442–51.
Close, J., Ellis, M., Hooper, al., Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. The Lancet, 353 (1999), 93–7.
Tinetti, M. E., Williams, T. F. & Mayewski, R., Fall risk index for elderly patients based on number of chronic disabilities. American Journal of Medicine, 80 (1986), 429–34.
Dey, A. B., Stout, N. R. & Kenny, R. A., Cardiovascular syncope is the most common cause of drop attacks in the elderly. Pacing and Clinical Electrophysiology, 20 (1997), 818–19.
Kenny, R. A. & Traynor, G., Carotid sinus syndrome – clinical characteristics in elderly patients. Age and Ageing, 20 (1991), 449–54.
Lawlor, D. A., Patel, R. & Ebrahim, S., Association between falls in elderly women and chronic diseases and drug use: cross sectional study. British Medical Journal, 327 (2003), 712–17.
American Geriatrics Society, British Geriatric Society, American Academy of Orthopaedic Surgeons Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49 (2001), 664–72.
Podsialdo, D. & Richardson, S., The timed “up and go”: a test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39 (1991), 142–8.
Shumway-Cook, A., Baldwin, M., Polissar, N. al., Predicting the probability for falls in community-dwelling older adults. Physical Therapy, 77 (1997), 812–19.
Rose, D. J., Jones, C. J. & Lucchese, N., Predicting the probability of falls in community-residing older adults using the 8-foot up-and-go: a new measure of functional mobility. Journal of Aging and Physical Activity, 10 (2002), 466–75.
Gunter, K. B., White, K. N., Hayes, W. C. & Snow, C. M., Functional mobility discriminates nonfallers from one-time and frequent fallers. Journal of Gerontology, 55 (2000), M672–6.
Berg, K. O., Wood-Dauphinee, S. L., Williams, J. al., Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83 (1992), S7–11.
Csuka, M. & McCarty, D. J., Simple method for measurement of lower extremity muscle strength. American Journal of Medicine, 78 (1985), 77–81.
Lord, S. R., Murray, S. M., Chapman, al., Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people. Journal of Gerontology, 57A (2002), M539–43.
Lord, S. R., Ward, J. A., Williams, al., Physiological factors associated with falls in older community-dwelling women. Journal of the American Geriatrics Society, 42 (1994), 1110–17.
Lord, S. R., Tiedemann, A., Chapman, al., The effect of an individualized fall prevention program on fall risk and falls in older people: a randomized controlled trial. Journal of the American Geriatrics Society, 53 (2005), 1296–304.
Campbell, A. J., Robertson, M. C., Gardner, M. al., Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal, 315 (1997), 1065–9.
Brannan, S., Dewar, C., Sen, al., A prospective study of the rate of falls before and after cataract surgery. British Journal Ophthalmology, 87 (2003), 560–2.
Harwood, R. H., Foss, A. J. E., Osborn, al., Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. British Journal Ophthalmology, 89 (2005), 53–9.
Lord, S. R., Clark, R. D. & Webster, I. W., Visual acuity and contrast sensitivity in relation to falls in an elderly population. Age and Ageing, 20 (1991), 175–81.
Verbaken, J. H. & Johnston, A. W., Clinical contrast sensitivity testing; the current status. Clinical and Experimental Optometry, 69 (1986), 204–12.
Davies, A. J. & Kenny, R. A., Falls presenting to the accident and emergency department: types of presentation and risk factor profile. Age and Ageing, 25 (1996), 362–6.
Brignole, M., Alboni, P., Benditt, al., Guidelines on management (diagnosis and treatment) of syncope. European Heart Journal, 22 (2001), 1256–306.
Parry, S. W. & Kenny, R. A., Drop attacks in older adults: systematic assessment has a high diagnostic yield. Journal of the American Geriatrics Society, 53 (2005), 74–8.
Shepherd, R. F. J. & Shepherd, J. T., Control of the blood pressure and circulation in man. In Autonomic Failure: a Text Book of Clinical Disorders of the Autonomic Nervous System, 4th edn, ed. Mathias, C. & Bannister, R.. (Oxford: Oxford University Press, 1999).
Grubb, B. & Karas, B., Clinical disorders of the autonomic nervous system associated with orthostatic intolerance: an overview of classification, clinical evaluation, and management. Pacing and Clinical Electrophysiology, 22 (1999), 798–810.
Kosinski, D. & Grubb, B., Pathophysiological aspects of neurocardiogenic syncope: current concepts and new perspectives. Pacing and Clinical Electrophysiology, 18 (1995), 716–24.
Lurie, K. & Benditt, D., Syncope and the autonomic nervous system. Journal Cardiovascular Electrophysiology, 7 (1996), 760–76.
Grubb, B. P., Neurocardiogenic syncope. New England Journal of Medicine, 352 (2005), 1004–10.
Sheldon, R., The Prevention of Syncope Trial (POST) results. Late breaking Clinical Trials, Heart Rhythm, (San Francisco, 2004).
Kaufmann, H., Saadia, D. & Voustianiouk, A., Midodrine in neurally mediated syncope: a double-blind, randomised, crossover study. Annals of Neurology, 52 (2002), 342–5.
Perez-Lugones, A., Schweikert, R., Pavia, al., Usefulness of midodrine in patients with severely symptomatic neurocardiogenic syncope: a randomized control study. Journal Cardiovascular Electrophysiology, 12 (2001), 935–8.
Girolamo, E. D., Iorio, C. D., Sabatini, al., Effects of paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on refractory vasovagal syncope: a randomized, double-blind, placebo-controlled study. Journal American College Cardiology, 33 (1999), 1227–30.
Sutton, R., Brignole, M., Menozzi, al., Dual-chamber pacing in treatment of neurally mediated tilt-positive cardioinhibitory syncope: pacemaker versus no therapy: a multicenter randomized study. Circulation, 102 (2000), 294–9.
Connolly, S. J., Sheldon, R., Thorpe, K. al., Pacemaker therapy for the prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. Journal of the American Medical Association, 289 (2003), 2224–9.
Raviele, A., Giada, F., Menozzi, al., Vasovagal Syncope and Pacing Trial Investigators. A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope. The Vasovagal Syncope and Pacing Trial (SYNPACE). European Heart Journal, 25 (2004), 1741–8.
McIntosh, S., Costa, D.Da & Kenny, R. A., Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a ‘syncope’ clinic. Age and Ageing, 22 (1993), 53–8.
Jankovic, J., Gilden, J. L., Hiner, B. al., Neurogenic orthostatic hypotension: a double-blind, placebo-controlled study with midodrine. American Journal of Medicine, 95 (1993), 38–48.
Kenny, R., O'Shea, D. & Parry, S., The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders. Heart, 83 (2000), 564–9.
Davies, A. & Kenny, R., Frequency of neurological complications following carotid sinus massage. American Journal Cardiology, 81 (1998), 1256–7.
Munro, N., McIntosh, S., Lawson, al., Incidence of complications after carotid sinus massage in older patients with syncope. Journal American Geriatrics Society, 42 (1994), 1248–51.
Puggioni, E., Guiducci, V., Brignole, al., Results and complications of carotid sinus massage performed according to the “method of symptoms”. American Journal Cardiology, 89 (2002), 599–601.
Richardson, D., Bexton, R., Shaw, al., Complications of carotid sinus massage – a prospective series of older people. Age and Ageing, 29 (2000), 413–17.
Kenny, R. A., Syncope in the elderly: diagnosis, evaluation, and treatment. Journal of Cardiovascular Electrophysiology, 14 (2003), S74–7.
Mangoni, A. A., Ouldred, E., Allain, T. al., Paradoxical vasodilation during lower body negative pressure in patients with vasodepressor carotid sinus syndrome. Journal of the American Geriatrics Society, 51 (2003), 853–7.
Moore, A., Watts, M., Sheehy, al., Treatment of vasodepressor carotid sinus syndrome with midodrine: a randomized, controlled pilot study. Journal of the American Geriatrics Society, 53 (2005), 114–8.
Kapoor, W., Diagnostic evaluation of syncope. American Journal Medicine, 90 (1991), 91–106.
Fitzpatrick, A. P., Ambulatory electrocardiographic (AECG) monitoring for evaluation of syncope. In The Evaluation and Treatment of Syncope: a Handbook for Clinical Practice, ed. Benditt, D., Blanc, J. -J., Brignole, al. (New York: Futura Publishing, 2003), pp. 63–70.
Department of Health, National Service Framework for Older People. (London: Department of Health, 2001).
Campbell, A. J., Borrie, M. J. & Spears, G. F., Risk factors for falls in a community-based prospective study of people 70 years and older. Journal of Gerontology, 44 (1989), M112–17.
Yip, Y. B. & Cumming, R. G., The association between medications and falls in Australian nursing-home residents. Medical Journal of Australia, 160 (1994), 14–18.
Campbell, A. J., Robertson, M. C., Gardner, M. al., Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. Journal of the American Geriatrics Society, 47 (1999), 850–3.
Niederehe, G. & Schneider, L., Treatments for depression and anxiety in the aged. In A Guide to Treatments that Work, ed. Nathan, P. & Gorman, J.. (New York: Oxford University Press, 1998).
Nowell, P., Buysse, D., Morin, al., Effective treatments for selective sleep disorders. In A Guide to Treatments that Work, ed. Nathan, P. & Gorman, J.. (New York: Oxford University Press, 1998).
Morin, C., Culbert, J. & Schwartz, S., Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. American Journal of Psychiatry, 151 (1994), 1172–80.
Murtagh, D. & Greenwood, K., Identifying effective psychological treatments for insomnia: a meta-analysis. Journal of Consulting and Clinical Psychology, 63 (1995), 79–89.
Brown, C. & Schulberg, H., The efficacy of psychosocial treatments in primary care: a review of randomized clinical trials. General Hospital Psychiatry, 17 (1995), 414–24.
Alessi, C., Schnelle, J., MacRae, al., Does physical activity improve sleep in impaired nursing home residents?Journal of the American Geriatrics Society, 43 (1995), 1098–102.
Vitiello, M., Prinz, P. & Schwartz, R. S., The subjective sleep quality of healthy older men and women is enhanced by participation in two fitness training programs: a non-specific effect. Sleep Research, 23 (1994), 148.
King, A., Oman, R., Brassington, al., Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. Journal of the American Medical Association, 277 (1997), 32–7.
Alessi, C. A., Yoon, E. J., Scnelle, J. al., A randomized controlled trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?Journal of the American Geriatrics Society, 47 (1999), 784–91.
Kanda, K., Tochihara, Y. & Ohnaka, T., Bathing before sleep in the young and in the elderly. European Journal of Applied Physiology and Occupational Physiology, 80 (1999), 71–5.
Morgan, K., Sleep, insomnia and mental health. Reviews in Clinical Gerontology, 2 (1992), 246–53.
Davison, J., Bond, J., Dawson, al., Patients with recurrent falls attending Accident and Emergency benefit from multifactorial intervention – a randomised controlled trial. Age and Ageing, 34 (2005), 162–8.
Tinetti, M. E., Baker, D. I., McAvay, al., A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine, 331 (1994), 821–7.
Rubenstein, L. Z., Robbins, A. S., Josephson, K. al., The value of assessing falls in an elderly population. A randomized clinical trial. Annals of Internal Medicine, 113 (1990), 308–16.
Ray, W. A., Taylor, J. A., Meador, K. al., A randomized trial of a consultation service to reduce falls in nursing homes. Journal of the American Medical Association, 278 (1997), 557–62.
Shaw, F. E., Bond, J., Richardson, D. al., Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. British Medical Journal, 326 (2003), 73.
Gloth, F. M., 3rd, Osteoporosis in long term care. Part 1 of 2. Recognizing bone and beyond. Review Director, 12 (2004), 175–6.
Sambrook, P., Cameron, I., Cumming, al., Vitamin D deficiency is common in frail institutionalised older people in northern Sydney. Medical Journal of Australia, 176 (2002), 560.
Peacock, M., Liu, G., Carey, al., Bone mass and structure at the hip in men and women over the age of 60 years. Osteoporosis International, 8 (1998), 231–9.
Boonen, S., Lysens, R. & Verbeke, G., Relationship between age associated endocrine deficiencies and muscle function in elderly women: a cross-sectional study. Age and Ageing, 27 (1998), 449–54.
Pfiefer, M., Begerow, B., Minne, al., Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women. Journal of Bone and Mineral Research, 15 (2000), 1113–18.
Dhesi, J., Bearne, L., Monitz, al., Neuromuscular and psychomotor function in elderly subjects who fall and the relationship with vitamin D status. Journal of Bone and Mineral Research, 17 (2002), 891–7.
Bischoff, H., Stahelin, H., Dick, al., Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial. Journal of Bone and Mineral Research, 18 (2003), 343–51.
Chapuy, M. C., Arlot, M. E., Duboeuf, al., Vitamin D3 and calcium to prevent hip fractures in the elderly women. New England Journal of Medicine, 327 (1992), 1637–42.
Dhesi, J. K., Moniz, C., Close, J. al., A rationale for vitamin D prescribing in a falls clinic population. Age and Ageing, 31 (2002), 267–71.
Vieth, R., Vitamin D supplementation, 2,5-hydroxyvitamin D concentrations and safety. American Journal of Clinical Nutrition, 69 (1999), 842–56.