Table 1 Intervention protocol for the Falls Assessment Clinical Trial

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