Falls Prevention WorkbookIdentifying the Modifiable Risks with Multifactorial Falls Screening ( MFS )

Contents

IntroductionLearning OutcomesService OutcomesDefinition of a FallScale of the ProblemAn Ageing PopulationIdentifying Those at Risk of FallingMultifactorial Screening (MFS)What Causes a Fall?Anxiety About Falling & ‘Post Fall Syndrome’Muscle Weakness & Poor BalanceUnsafe Transfers & Activities of Daily LivingPoor Nutrition & DietOsteoporosisMedicationAlcoholEyesight ProblemsPoor Footwear & Foot ProblemsDementia / Cognitive ImpairmentEnvironmentPrevention of a ‘Long Lie’ — Getting Up After a FallAdditional ResourcesReferences

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Falls PreventionIdentifying the Modifiable Risks with MFS

This Falls Prevention resource has been developed to assist in the implementation of the following strategies and documents which aim to improve the health and well being of our older population in Scotland.

• Reshaping Care for Older People (Change Fund)• Framework for Adult Rehabilitation in Scotland• SIGN Guideline — Management of Osteoporosis• SIGN Guideline — Management of Hip Fracture in

Older People • NICE CG161 Falls — Assessment & Prevention of Falls in

Older People

This workbook is intended for all staff required to complete Falls Prevention Multifactorial Screening (MFS). Originally created for use within NHS Highland. Originally intended for use with the NHS Highland Multifactorial Screening form for Prevention of Falls in older people.

Introduction

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Falls PreventionIdentifying the Modifiable Risks with MFS

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LearningOutcomes

On completion of the workshop and workbook individuals will develop an understanding of:

• The underlying causes of falls• Which risk factors for falls can be modified• Their role in reducing the risk of falls & promotion

of self-management• Why falls are not an inevitable part of ageing

ServiceOutcomes

In line with the model of care the workbook and workshop enables staff to:

• Support people to live in their communities for longer

• Anticipate, recognise & prevent difficulties that may contribute to falls

• Follow an enablement approach allowing individuals to regain skills & confidence

• Deliver care that is dignified, respectful & person centred

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Definition of a Fall

A fall is ‘an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’ (World Health Organisation). Injurious falls, including over 70,000 hip fractures annually, are the leading cause of accident-related mortality in older people (National Audit, 2010). Often only the trauma of a hip fracture ensures that an individual and their carers enter the chain of professional care. By then it may be too late (DOH, 2009).

Do not wait until a fall occurs — take preventative action.

Scale of the Problem

• One third of people over the age of 65 & half of people older than 80 fall each year (NICE, 2013)

• Approximately half of those who fall will fall again within the year (Rubenstein, 2002)

• The majority of falls that do not cause injury are not reported to a health professional (Scottish Government, 2012)

• Only 1% of falls result in hip fracture but 90% of hip fractures are caused by falls (Cryer, 2001)

• Hip fracture is fatal in 20% of cases and 50% of people are permanently disabled (NICE, 2012)

• Over 6000 hip fractures in Scotland occur every year (Scottish Government, 2012)

• Over 90% of hip fractures occur in older people with osteoporosis (Cryer & Patel, 2001)

• The daily cost of falls to the NHS is £4.6 million (RCP, 2008)• Hip fractures cost the NHS £1.7 billion per year (RCP, 2008)

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An Ageing Population

The ageing of Scotland’s population is a particular challenge to health and social services. In 2012 in Scotland the percentage of people over the age of 65 was 17%. Current projections for 2037 indicate that the number of people over the age of 65 will increase by 59% (Scottish Government, 2012).

Identifying Those at Risk of Falling

Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall(s) (NICE, 2013). Older people who present for medical attention because of:• a fall• or report recurrent falls in the past year• or demonstrate abnormalities of gait and / or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a worker with appropriate skills and experience. This assessment should be part of an individualised, multifactorial intervention (NICE, 2013).

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Multifactorial Screening (MFS)

Multifactorial assessment is an evidence based approach recommended by NICE (2013) and the Scottish Government (2012). It is used extensively across the UK. Interventions directed to modifiable risk factors can reduce the incidence of falls. Multifactorial screening (MFS) allows the identification of factors that predispose someone to a fall and is used to direct the individual to the appropriate assessment.

Whose responsibility is it to complete a Multifactorial Screening (MFS)?All staff working with older people should develop and maintain a basic professional competence in falls assessment and prevention (NICE, 2013). Individuals completing a MFS have a responsibility to action a plan to address the risks identified. This may include onward referral to the appropriate disciplines. Rapid response staff are not expected to complete an MFS (ambulance staff and A & E staff). They should however identify those at risk and refer appropriately for an MFS.

Where will this information be kept?In order to prevent duplication, allow access by relevant teams and evaluation of services the aim is that the completed MFS will be in a central local database e.g. MiDIS.

Familiarise yourself with the Falls Multifactorial Screening documentation for your area.

Activity

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What Causes a Fall?

There are many factors that can cause falls. These risks are categorised intrinsic (occur within the body) or extrinsic (out with the body). It is the combination and number of risks which increases risk of falling. Behaviours can also increase risk. Below are a few examples of risk factors to falls.

Extrinsic factors

�� Medications — multiple, culprit

�� Poor nutrition & diet

�� Badly fitting footwear / clothing

�� Uneven or slippery surfaces

�� Loose mats or rugs

�� Inadequate light — especially on stairs

�� Poor stairway design and repair

�� Lack of safety rails

�� Inappropriate height of chair, bed, toilet etc.

�� Trailing flexes and cables

�� Unfamiliar environment

�� Cluttered environment

�� Alcohol misuse

Intrinsic Risks

�� History of falls

�� Muscle weakness

�� Unsafe walking / transfers

�� Poor balance

�� Problem with vision / eyesight

�� Problem with feet / footwear

�� Infection

�� Postural hypotension

�� Incontinence

�� Fear of falling

�� Age

�� Cognitive impairment / dementia

�� Arthritis

�� Depression

�� Medical conditions e.g. stroke, Parkinson’s disease

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Behavioural Risks

�� Getting up in the middle of the night in the dark

�� Rushing to answer the phone or door

�� Standing to put on lower garments

�� Over stretching & over reaching

�� Poor safety awareness

Some of the risk factors associated with a fall cannot be modified. However, many of them can be modified or changed to reduce the risk of falls. Check which ones you consider to be modifiable below. On completion of this task, press the button below to reveal the answers:

Activity

Anxiety About Falling& ‘Post Fall Syndrome’

Post fall syndrome is common in older people. It is characterised by a fear of falling, loss of confidence and voluntary restriction on activity. It results in negative thinking and reduces self-esteem. Changes in behaviour include avoidance and reduction in activities, social withdrawal and agoraphobia. A phobia of falls can increase levels of depression and generalised anxiety in older people who have fallen. As a result an individual’s functional capacity may be reduced to a point where independent living becomes too demanding. The psychological consequences of a fall should not be underestimated. A fall is often attributed to factors out with the person’s control however anxiety about falling does not have to be a permanent state. Addressing modifiable risk factors will have a positive effect in reducing an individuals’ fear of falling.

What is my role in modifying ‘fear of falling?’Everyone working with older people has a role to play in identifying those who are at risk of falling and/or are worried about falling. If you are working with an older person you should enquire if they have had a fall or are afraid of falling. Completion of the MFS will help to identify modifiable risk factors. The MFS action plan will be bespoke to each individual and it is critical to ensure appropriate actions are taken to help reduce risks. Addressing modifiable risks such as poor balance and reduced muscle strength will make an individual safer and will reduce anxiety and fear. It may require several different interventions or advice to help an individual reduce their fear of falling. Telecare can sometimes help reduce a fear of falling and help to reduce the risk to an individual who may fall.

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Muscle Weakness & Poor Balance

Strength & balance exercise is one of the most effective ways to reduce fallsA young fit person can normally recover from a slip or trip. As people age muscle strength, balance and coordination decrease as a normal part of ageing. Reflexes can become slower resulting in a reduced ability to react to challenges to the balance. However, disuse and an inactive lifestyle are major contributory factors. Physical activity and exercise will help an older person to maintain their strength, walking, balance and flexibility. This will help them to remain independent and enable them to perform household and personal tasks. There is a strong evidence base that balance and strength exercise as a single intervention prevents falls (Cochrane review, 2012). Exercise must include balance and strength training and has to be specific to the individual. It can be delivered at home or in a group setting. Strength and balance exercises are suitable for the frailest of individuals. Even those in their 90s can improve their strength and balance to help avoid falls. As well as benefitting strength and balance, physical activity maintains bone health to prevent fractures. It has been identified that less than 70% of falls services in the UK recommend exercise (Ali, 2004) despite the strong evidence identifying it as the most effective way to reduce falls.

What is my role in modifying ‘muscle weakness & loss of balance?’If you identify an individual has a balance and strength deficit your plan should include a referral to the physiotherapy service for exercise prescription. The physiotherapist may prescribe an individual programme of exercise or refer the person to a class. This will vary between localities. Encouraging people to do as much as they can for themselves helps them to stay active and strong. It may take longer to let someone do something for themselves than for you to do it for them but this helps them stay independent. If an older person is active and independent they may wish to attend local exercise groups. It is therefore beneficial if you are aware of what facilities exist locally.

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Unsafe Transfers & Activities of Daily LivingCoordination, sensory awareness, balance, strength and endurance are components in safe transfers and walking. Many older people are impaired in at least one of these components. This can affect their ability in activities of daily living and can reduce their independence. Walking even a short distance, as part of a daily routine, helps maintain mobility, strength and function. Moving correctly and transferring safely helps to maximise independence. Allowing someone to do things for themselves may take a little longer but it can help them to regain independence.

What is my role in modifying ‘unsafe transfers and activities of daily living?’Completion of an MFS may raise concerns about an individual’s ability to transfer and mobilise. They may require a referral to physiotherapy for a walking aid assessment or to OT for equipment. If you are working as lead professional for a patient you may have a role in advising carers (informal and formal) about the correct moving and handling of an individual. Ensure the moving and handling documentation in the careplan gives an adequate description of what the individual needs. This is an important part of the enablement process. Encourage independence and mobility where possible. Correct moving and handling helps to keep an individual as independent as they can be. Some individuals can regain independence if encouraged appropriately.

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Poor Nutrition & Diet

Poor nutrition can affect anyone but is particularly common in older people and those who are socially isolated. Poor mobility, poor general physical health or mental health problems are also contributory factors. Older people may develop swallowing difficulties or dental problems and this requires investigation. Grief, anxiety and depression can lead to a loss of appetite and subsequent malnutrition. Dehydration has been identified as one of the risk factors for falls in older people, since it can lead to a deterioration in mental state, and increase the risk of dizziness and fainting. The maintenance of adequate levels of hydration in older people can help prevent falls.

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Osteoporosis

The health of your bones makes a big difference to the effects of a fall. Osteoporosis is present in 90% of hip fractures. Fifty percent of people over 80 years of age have osteoporosis. After the age of 35 bone loss begins to occur very gradually. The cells responsible for breaking down bone (osteoclasts) begin to work more quickly than the cells responsible for building bone (osteoblasts). The result is age related bone loss, if this loss becomes severe, osteoporosis can develop. Osteoporosis causes the bones to become porous and fragile, with a higher risk of fracture. It is often referred to as the silent disease, as sometimes no symptoms are present until a bone is broken. Spinal fractures can be painless, and osteoporosis may still go undetected until late stage complications are present e.g. kyphosis. The healthcare cost of fragility fractures in the UK is estimated at £2 billion a year (RCP, 2011). Osteoporosis should not be viewed as an inevitable part of the ageing process, but as a preventable illness of the older adult skeleton. All health professionals should be aware of risk factors for osteoporosis and should be able to identify those at risk.

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Osteoporosis Risk Factors — Some of These are Modifiable

• Inactivity• Poor dietary calcium• Vitamin D deficiency • Smoking • Excess alcohol • Low body weight (BMI <19)• Age• Sex• Untreated early menopause (<45)• History of a low trauma fracture• Certain medical conditions• Family history• Rheumatoid arthritis• Long term corticosteroid therapy

Prevention & Treatment of Osteoporosis

• Calcium• Vitamin D• Stop Smoking• Increase activity• Reduce alcohol intake• Medications including bisphosphonates

Diagnosis of Fracture Risk & OsteoporosisNICE Clinical Guideline CG146 (2012) advises that all women over 65 years and all men aged over 75 years should be considered for fracture risk assessment. Those under these age groups with risk factors for osteoporosis should also be considered for assessment. Fracture risk assessment can be performed using FRAX™ or QFracture which predict the risk of fracture over the next 10 years. FRAX™ was developed by the World Health Organisation (WHO). Bone density measurement may form part of this assessment but is not always necessary. Results from the fracture risk assessment will determine the appropriate intervention. Please press the following link buttons to access further information:

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Are older people in your care getting enough Calcium?Calcium is essential for the formation and maintenance of strong healthy bones and teeth. It is recommended that the calcium intake for adults is 700mgs per day to prevent osteoporosis. Larger supplement doses may be prescribed for patients who are diagnosed as already having osteoporosis. The best and easiest source of calcium for the body to absorb is found in dairy products (National Osteoporosis Society leaflets — Healthy Living for Strong Bones). For more information, please press the following link button:

Are older people in your care getting enough Vitamin D?Vitamin D allows the body to absorb the calcium from our diet. Supplementing levels of vitamin D can improve neuromuscular function, reaction and strength in those who are Vitamin D deficient. Most people get enough vitamin D from sunlight but if someone is rarely in the sun or they are housebound they may need a supplement. UK Health Departments recommend that before applying sunscreen, people should expose their face, hands and arms for 10 to 15 minutes each day. This should take place between the hours of 10am and 3pm. Doing this during the summer months of April to September will make enough vitamin D for the year. Care must be taken not to burn. The UK Health Departments also recommend that those over the age of 65 take a daily supplement of Vitamin D. Advice on purchasing a suitable supplement can be obtained from community pharmacists as supplements are not suitable for everyone. Certain foods contain Vitamin D. These include oily fish (herring, sardines, mackerel, salmon, tuna), egg yolks and certain margarines, breads and cereals that have been fortified with vitamin D. Calcium and vitamin D (Adcal- D3) should be prescribed as monotherapy for the prevention of fractures in ambulant females over the age of 65 who are housebound or in a care home.

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Osteoporosis MedicationsThe treatment for osteoporosis depends on a number of factors including your age, sex, medical history and which bones you have broken. Osteoporosis drug treatments aim to strengthen existing bone, to help prevent further bone loss and, most importantly, reduce the risk of broken bones by 50%. Most drugs work by slowing down the activity of the osteoclast cells that break down old bone. These are anti resorptive drugs and are known as bisphosphonates. Bisphosphonates must be taken at least 30 minutes before the first food or drink (other than plain tap water) of the day. These instructions are important because bisphosphonates will only be effective if taken on an empty stomach. Tablets must be swallowed whole and taken with a glass of plain water. It is necessary to stay upright (sitting, standing or walking) for at least 30 minutes after taking the tablet. Other medications should not be taken at the same time of day as bisphosphonates. Avoid taking Calcium and Vitamin D (Adcal D3) within 4 hours of a bisphosphonate. Possible side effects of not following the instructions include inflamed oesophagus, sore throat and swallowing difficulties. Chest pain or worsening heartburn requires a review by the GP. If an individual is intolerant to bisphosphonates they may be prescribed Denosumab which is delivered by subcutaneous injection. For more information, please press the following link button:

What is my role in ‘Osteoporosis’?The completion of an MFS should highlight any issues regarding osteoporosis diagnosis and medications. If you are concerned about a patient being at risk of a fragility fracture refer them to their GP. If a patient is on bisphosphonates ensure their careplan allows a suitable amount of time to take this if they require help with medication. Encourage patients in your care to eat a balanced diet and drink enough fluids. Encourage clients to go outside for short periods if it is safe to do so. The National Osteoporosis Society Booklet — Introduction to Osteoporosis contains this information and should be issued to the individual. Please press the following link button to learn more:

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Some medications are a risk factor for falls.

Multiple MedicationsIndividuals on six or more medicines, prescribed or bought, are at greater risk of having a fall.

Culprit MedicationsMedicines can contribute to falls by a variety of mechanisms. Effects caused can include disturbed balance, drowsiness, dizziness, hypotension, blurred vision and confusion. Regular medication reviews are essential. If an individual loses weight or develops a new medical condition for example the existing medications may not be appropriate. The GP or pharmacist will determine whether the ongoing use of each medicine is of more benefit than risk.

Postural HypotensionPostural hypotension is a drop in someone’s blood pressure when they assume an upright position. This can occur when going from lying to sitting or from sitting to standing. Medications are often implicated in postural hypotension. The symptoms of postural hypotension include:

• Dizziness• Faintness• Light-headedness• Weakness• Changes in vision such as blurring or

blackening vision• Losing consciousness with or without warning

i.e. black out, faint, syncope

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Medication

What is my role in modifying ‘medications / low blood pressure?’The completion of an MFS will identify if an individual is experiencing symptoms that could increase their risk of falls. These symptoms may be due to their medications. This may be the first time an individual considers that these side effects may be responsible for previous falls or fear of falling. If an individual reports side effects arrange a medication review and a postural hypotension check. Sometimes dizziness is not treatable. Encourage these individuals to take their time getting up, move slowly and in stages. Bending and straightening their arms and legs a few times and marching on the spot before getting up from a seated position helps the circulation. When rising from a lying position, sitting on the side of the bed for a few minutes before standing up can be helpful. The Staying Steady Booklet contains this information on medications and should be given to the individual. Please press the following link button to learn more:

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Alcohol

Refer to the ‘Brief Alcohol intervention’ training for further advice. You can access this material by pressing the following link button:

What is my role in modifying ‘alcohol’ consumption?Advise clients to:

• Read the labels of medications they are taking• Observe the recommended limits• Use soft drink spacers• Eat when drinking• Check the strength/cut quantity• Have alcohol free days• Avoid binge drinking

The MFS should ask if an individual feels that alcohol has contributed to a previous fall.

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Eyesight Problems

Eyesight and hearing play a vital role in maintaining balance and during movement. Older people with sight problems, including wearing the wrong prescription glasses or dirty glasses, are more likely to fall. Glasses with bifocal and varifocal lenses make objects and surfaces seem closer than they are and can cause falls. This can be especially problematic when on the stairs. Many older people blame changes to their eyesight on ageing, but only an eye examination can separate a serious visual impairment from ‘normal’ ageing changes. In addition to age related vision loss, there are four main eye conditions that are associated with the elderly:

• Macular Degeneration• Cataracts• Glaucoma• Diabetic Retinopathy

It has been shown recently that surgery to remove cataracts can significantly reduce the risk of falls and fractures in elderly women. NHS Domiciliary visits free of charge may be available to those who are unable to attend the optician due to a physical or mental disability. It is recommended that everyone has their eyes checked every 2 years. If you are over 75 or a diabetic a yearly check is recommended. Eye tests in Scotland are free.

What is my role in modifying ‘eyesight problems?’The MFS will identify appropriate actions for individuals with eyesight problems. Encourage individuals to only wear their prescribed glasses. Identify local Optometrists / Opticians who offer domiciliary visits. Ask if clients with glaucoma or diabetes are taking their medication or inserting eye drops correctly. The Staying Steady Booklet contains this relevant information and should be given to an individual when completing an MFS. Please press the following link button to access more information:

Age related changes in the feet and ankles can affect mobility. Stiffness and decreased joint range of motion around the ankle joint as a result of osteoarthritis may lead to a rigid foot. Reduced strength of the muscles around the ankles can result in difficulties clearing the ground when walking. Having a stiff ankle joint causes postural instability during gait (as the trunk moves over the foot) making it difficult to negotiate rough terrain. Shock absorption is decreased. In addition, somatosensory changes to light touch, pressure, vibration and proprioceptive changes may occur as a result of neurological conditions such as peripheral neuropathy or stroke. This also makes it difficult to adjust to changes in the terrain and in knowing where the foot is placed. Specific ankle exercises can help improve strength and increase range of motion. Basic strength and balance exercises help stretch and strengthen the joints and muscles. Suitable footwear that is properly designed and fitted will protect and support the foot. It will not solve these problems but can help. This is important for maintaining independent mobility and preventing falls.

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Poor Footwear& Foot Problems

What is my role in modifying ‘poor footwear?’Refer to the podiatrist if completion of the MFS indicates. Advise your clients about the following points on shoes and falls prevention:

• Soles should be flexible (allows ‘feeling’ the floor)

• High heels & leather soles should be avoided• Laces, buckles or Velcro straps hold the feet

firmly in place, preventing them from slipping forwards

• Open backed slippers should be avoided• Garments such as trousers / skirts / dressing

gowns should not trail on the ground

The Staying Steady Booklet contains this relevant information and should be given to the individual when completing an MFS. The physiotherapist can advise on a programme of exercises to improve gait and ankle strength and flexibility.

Refer to Promoting Excellence in Dementia to determine what level of training you should complete and how to access the learning resources. Please press the following link button to complete this task:

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Dementia / Cognitive Impairment

When individuals are fit most activities within the home can be completed with little effort or thought. Sometimes due to ill health or reduced mobility normal activities may become more challenging. Small changes in the home environment can reduce that risk.

What is my role in modifying ‘environment’?Completion of the MFS will highlight environment issues or challenge within an individual’s home. More complex situations will require onward referral to Occupational Therapy.

Environment

What is my role in falls prevention with individuals with dementia?If you have completed an MFS and highlighted that an individual may have memory or comprehension problems they may require a referral to the GP or community mental health team. It is appropriate to complete an MFS and action plan with an individual who has dementia / cognitive problem. If they cannot answer some questions arrange to complete the MFS when their carer / relatives are present.

Although this falls prevention workbook focuses on the prevention of falls. It is important to consider the consequences of someone enduring a long lie. Telecare can support an individual to get help should they fall. Informing someone about the easiest way to get up off the floor after a fall can help reduce the fear of a long lie and give valuable tips that may allow an individual to get up off the floor independently. This is included in the MFS and as part of most individuals’ action plan. The Staying Steady Booklet details the steps an individual can take to rise from the floor. It also covers the topics discussed in this Falls Prevention Workshop. It should be issued to individuals who have had an MFS. Press the following link button to access this resource:

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Prevention of a ‘Long Lie’ — Getting Up After a Fall

This completes the MFS / Falls Prevention workbook. We hope it has been beneficial to you and as a result the older people that you support.

Prevention & Management of Falls & Fragility Fractures in Older People Training Programme — Guidance on legislation, policies & codes of conduct

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Additional Resources

Taking Positive Steps — NHS Health Scotland written from the older person’s perspective

Prevention of Falls in Older People — Scottish Government publication written from a policy perspective

Learnpro Module (access for NHS staff) Falls Prevention

NHS Education Scotland

Age UK Leaflets: Staying Steady

The National Osteoporosis Society Leaflets: Introduction to Osteoporosis,Exercise & Osteoporosis, Healthy Living for Strong Bone, Bone Health — The Facts About Food

Had a Fall Poster

Age Uk Tavis House 1-6 Tavistock Square, London, WC1H 9NASTAY STEADY http://www.ageuk.org.uk

Alcohol Brief Interventionshttp://www.healthscotland.com/topics/health/alcohol/alcohol-brief-interventions-communications-and-guidance.aspx

Ali A, Morris RO, Skelton DA, Masud T (2004). Falls Services in the UK – A Survey of UK Geriatricians. 5th National Conference on Falls and Postural Stability. Manchester

Cochrane Review (2012) Interventions for preventing falls in older people in the community. Gillespie, L D et al. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007146.pub3/abstract

Cryer and Patel (2001) Falls, Fragility and Fractures.http://www.kent.ac.uk/chss/docs/falls_fragility_fractures.pdf

Department of Health (2010) Falls and fractures: Effective intervention in health and social care. London, Department of Healthhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_103146

The Institute of Alcohol Studies, Alcohol and the elderly, IAS Factsheet, 1 The Quay, St Ives, Cambs., PE27 5AR Tel: 01480 466766 Fax: 01480 497583 http://www.ias.org.uk

Joint Improvement Scotland (2011). Telehealthcare and Falls - Using telehealthcare effectively in the support of people at risk of falling http://www.jitscotland.org.uk

National Aging Research Institute The university of National Ageing Research Institute (2012)www.mednwh.unimelb.edu.au/resource-package/contents/falls-prevention-training-expo.html

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References

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References

National Institute for Clinical Excellence (2012) Assessing the risk of fragility fracture. Clinical Guideline 146 London, NICEhttp://publications.nice.org.uk/osteoporosis-assessing-the-risk-of-fragility-fracture-cg146

National Institute for Clinical Excellence (2013) Falls: The assessment andprevention of falls in older people. Clinical Guideline 21 London, NICEhttp://www.nice.org.uk/Guidance/CG161

The Scottish Government - Demographicshttp://www.scotland.gov.uk/Topics/People/Equality/Equalities/DataGrid/Age/AgePopMig

NHS Quality Improvement Scotland (2010) Up & About Pathways for theprevention and management of falls and fragility fractures. Glasgow, NHS QIShttp://www.healthcareimprovementscotland.org/default.aspx?page=13131

Royal college of Physicians (2008) National Audit of the Organisation of Services for Falls and Bone Health of Older People http://old.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Documents/National-Falls-and-Bone-Health-Public-Audit-Report-March-2009.pdf

Royal College of Physicians (2011) Fallen standards, broken promises. Reportof the national audit of falls and bone health in older people. London, RCPhttp://www.rcplondon.ac.uk/sites/default/files/national_report.pdfRubenstein LZ, Josephson KR (2002) The epidemiology of falls and syncope. Clinical Geriatric Medicine 2002;18:141-58.

Rubenstein LZ, Josephson KR (2002) The epidemiology of falls and syncope. Clinical Geriatric Medicine 2002;18:141-58.

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References

Scottish Intercollegiate Guidelines Network (2009) Management of hip fracturein older people. Edinburgh, SIGN.http://www.sign.ac.uk/guidelines/fulltext/111/index.html

Scottish Intercollegiate Guideline Network (2003) Management of osteoporosis. Edinburgh, SIGN http://www.sign.ac.uk/pdf/sign71.pdf

Scottish Government (2011) Reshaping Care for Older People: A Programmefor Change 2011 – 2021. Edinburgh, Scottish Governmenthttp://www.jitscotland.org.uk/downloads/1299249359-ReshapingCareProgrammeFinal4March.pdf

Scottish Government (2012) Up and About or Falling Short? – A report of the Finding of a mapping of Services for Falls Prevention in Older PeopleISBN 9781780458106 May 2012-11-21http://www.scotland.gov.uk/Publications/2012/05/6979/0

Tinetti et al (1994) A Multifactorial Intervention to Reduce the Risk of Falling among Elderly People Living in the Community N Engl J Med 1994; 331:821-827

World Health Organisation (2010) Fact sheet No 344 August 2010 http://www.who.int/mediacentre/factsheets/fs344/en/

World Health Organization (2004) What are the main risk factors for fallsamongst older people and what are the most effective interventions to preventthese falls? Copenhagen: WHO Europe.

World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK FRAX - fracture risk assessmenthttp://www.shef.ac.uk/FRAX

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Acknowledgements

Many thanks to all those who contributed to the creation and trialling of the falls prevention resources.

Created by:NDP Media

Original workbook produced by:Steph Hay —Bute Lead PhysiotherapistChristine McArthur —NHS Highland Falls Prevention CoordinatorSheila Morris —Community Falls Lead South & Mid Operational Unit

With support from:Fiona FraserProject Lead/ RRHEALNHS Education for ScotlandCentre for Health Science Old Perth Road Inverness IV2 3JHwww.rrheal.scot.nhs.uk

Ann Murray —National Falls Programme ManagerMary Wilson —Lead AHP, A&B CHP

For further information please contact: Christine McArthur —NHS Highland Falls Coordinatorchristinemcarthur@nhs.net

Falls Prevention TeamArgyll & Bute CHPNHS HighlandAssynt HouseBeechwood ParkInvernessIV2 3BW

NHS Highland Website

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