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Table 1 Intervention protocol for the Falls Assessment Clinical Trial

From: Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics

Falls prevention health assessment Management Falls & Fracture Nurse action Referral
Circumstances of previous fall Changes in environment and activity to reduce risk of further falls Directs further assessment and management. Address any immediate safety issues Referral according to categories below
Medication review:
High risk medications: benzodiazepines, other sleeping medications, neuroleptics, antidepressants, anti-convulsants [15]
Review and reduction of medications [6, 15] Request family physician review of medications according to protocol Family physician or geriatrician
Vision:
Acuity < 20/60; decreased depth perception, contrast sensitivity (Melbourne edge test) [21, 50]
Ample lighting without glare; avoidance of multifocal glasses while walking Arrange correction of lighting, highlight potential hazard edges Optometrist, ophthalmologist (e.g. cataracts), family physician, geriatrician; if visual acuity 6/24 or worse, offer referral to Royal NZ Foundation of the Blind
Postural blood pressure (after > 5 mins in a supine position, immediately after standing, and 2 minutes after standing):
Standing systolic blood pressure < 100 mmHg or = 20 mmHg postural drop if systolic blood pressure < 130 mmHg or with symptoms (immediate or > 2 mins)
Diagnosis and treatment of underlying cause Adequate hydration, compensatory strategies (e.g. elevation of head of bed, rising slowly, dorsiflexion exercises), pressure stockings Family physician or geriatrician: diagnosis and treatment of underlying cause, review and reduction of medications, or pharmacological therapy for postural hypotension
Balance and gait:
Patient's report or observation of unsteadiness. Impairment on brief assessment (timed up and go test [48, 51, 52], 4-test balance scale [38])
Diagnosis and treatment of underlying cause Coordinate Otago Exercise Programme (see below) or referral as appropriate Family physician or geriatrician review Physiotherapist: assistance devices, supervised gait and progressive balance training if specific neurological problem or unable to do Otago Exercise Programme
Targeted neurologic examination:
Impaired proprioception [53]; decreased muscle strength (chair stand test [37])
Diagnosis and treatment of underlying cause Increase proprioceptive input (assistance device, appropriate footwear), caretaker's awareness of cognitive deficits Family physician or geriatrician: review medications that impede cognition Physiotherapist: supervised gait, balance and strength training
Targeted musculoskeletal examination:
Legs (joints and range of motion) and examination of feet to identify problems interfering with function
Diagnosis and treatment of underlying cause Offer Otago Exercise Programme (see below) or referral as appropriate Physiotherapist: supervised strength, range-of-motion, gait and balance training, assistance devices, appropriate footwear; Podiatrist or chiropodist: assist with feet Family physician address impairments (e.g. osteoarthritis)
Targeted cardiovascular examination:
Syncope or arrhythmia [54, 55]
   Family physician or geriatrician for ECG ± cardiologist referral, carotid-sinus massage (in case of syncope) [56]
Continence/overactive bladder:
Particularly if related to circumstances of previous fall [57]
  Nightlights, bladder retraining Continence service/nurse for assessment, bladder retraining; family physician or geriatrician for medical management, exclusion of other pathology
Home hazards assessment   
Hazard identified according to protocol [14] Changes in environment to reduce risk of further falls Identify and modify minor home hazards (e.g. remove loose rugs, use nightlights) Occupational therapist assessment for major hazards (e.g. bath/toilet grab rails) [17]
Bone health assessment   
Osteoporosis risk from osteoporosis screen questionnaire Consider calcium and vitamin D supplementation if not receiving   Refer to family physician for appropriate management with suggestion of vitamin D and calcium supplementation with guidelines [18, 46]
Previous fragility fracture [58] Consideration for appropriate management (including bisphosphonates) [58] Organise vouchers and referral Referral for voucher for DEXA scan and review by family physician for application for bisphosphonates [47]
Otago Exercise Programme [10, 45]   
All participants Increase muscle strength and balance Offer delivery of Otago Exercise Programme Otago Exercise Programme delivered by accredited physiotherapist or nurse [45]
Unable to commence the Otago Exercise Programme or chronic neurological problem (e.g. existing CVA, Parkinson's disease), timed up and go test > 30 seconds, or cognitive impairment Increase muscle strength and balance Referral Referral to physiotherapist for individualised rehabilitation programme
  1. NZ denotes New Zealand.
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