FINDING BALANCE ALGORITHM
Healthcare Referrals
All health care professionals can be involved with:
-
Ensuring that falls prevention is part of standard practice
-
Implementation of Universal Fall Precautions
-
Understanding the role of other disciplines so that referrals can be made when appropriate
-
Education of older adults, caregivers and families on general falls prevention principles. Many falls are preventable, and for those falls that are not, the focus should be on injury reduction strategies. These strategies include protection such as the use of hip protectors, floor cushioning, floor mats, low bed heights, etc.
-
Understanding that the most effective interventions for the prevention of falls are individualized, often multifactorial and interdisciplinary
-
Participating in interdisciplinary falls prevention programs
-
Screening and assessment for falls risk factors within their scope of practise
-
Interventions within their scope of practise to reduce specific falls risk factors
-
Screening, assessment, and intervention for falls risk factors within their abilities and competencies
-
Addressing issues related to accessing services/programs such as transportation and cost
Consider Referral to Health Care Professionals
Dietitians
Nutrition is of vital importance to all ages. It can be particularly important for older adults as they require fewer calories to maintain their weight but not fewer nutrients. Dehydration is common among older adults. This is partly because as we age our sense of thirst diminishes but there are a variety of other factors contributing to this challenge.
Adequate protein intake is a concern for some older adults related to factors such as changes in appetite, health conditions, finances and psychosocial situations like eating alone. Older adults identified at risk for falls should be assessed for nutritional status to allow for early intervention to help maintain muscle strength and general health.
Bone health is important for all individuals and particularly those who fall as their risk of fracture is greater. Calcium and vitamin D intake and requirements should be reviewed, and appropriate levels of supplementation should be prescribed as indicated.
Refer to a dietitian for assessment and intervention when:
-
Body Mass Index (BMI) less than 22 for age 65 years and older
-
Unplanned weight loss of > 5% in 1 month or > 10% in 6 months
Other indicators which place clients at nutrition risk and require monitoring or community services include:
-
Poor appetite
-
Changes in dental health or difficulty biting and /or chewing
-
Difficulty accessing groceries or making meals related to access, finances or mental health
-
Concerns with meal patterns including routinely skipping of meals or lack of variety in food intake
Dietitians are available in most Primary Care Clinics, Home Care Programs, Chronic Disease Management Programs such as Living Well and some Meals on Wheels Programs. Family physicians can make a referral to Outpatient Dietitian services available in most hospitals.
Nurses
Nurses can play a varied and broad role in falls prevention. In many service areas, it often is the nurse who performs the initial falls risk screen and/or many aspects of a multi-dimensional falls risk assessment (e.g., medical, physical, social, environmental). Nurses' knowledge of medications (side effects, interactions, dosages) may help them to flag medication-specific falls risk factors and trigger them to refer on to a pharmacist, physician, or nurse practitioner for further assessment when appropriate.
Nurses can also support good sleep hygiene, address toileting routines, mobilize, help create and maintain a safe client environment in hospital settings and follow safe client handling techniques (for safe transfers).
Occupational Therapists (OT)
Refer to or consult an OT for:
-
Assessment and interventions for safety and independence in Basic Activities of Daily Living (ADL) and Instrumental ADLs (e.g., shopping, cleaning, banking etc.)
-
The ability to perform ADL and Instrumental ADL activities can be impacted by depression, fear of falling and anxiety. Identification and interventions that consider these factors together can be a contribution of the OT.
-
Identification of behaviours that increase falls risks.
-
Recommendations for transfers (in bathroom, bed, chair and vehicle).
-
Indoor and outdoor environmental assessment and recommendations for modifications and equipment.
-
Assessment and prescription of an assistive device (e.g., walking aid, environmental modifications to help with problems in transfers). For those already with an assistive device, evaluation of its appropriateness including determination of whether it is in good repair.
-
Advice on the older adults' daily routine to minimize, if not eliminate, high risk activities (e.g., stooping, reaching overhead, climbing up on chairs/ ladders).
-
Cognitive and perceptual assessment and interventions.
-
Screening for depression (a known falls risk factor) and interventions.
-
Awareness of social isolation and interventions to support socialization. This could be group interventions, day programs or social programs in senior’s centres.
-
Foot assessment and recommendations for footwear. A referral to an orthotist or podiatrist may be indicated.
-
To find an OT, contact the New Brunswick Association of Occupational Therapists at 506-458-1001 or 1-888-896-2244 or email info@nbaot.org
Pharmacists
The role of the pharmacist is primarily focused on medications and the pharmacologic management of medication conditions. Pharmacists also have some knowledge of non-pharmacologic treatments, and the scope of practice is expanding.
Structured Medication Reviews: Pharmacists are able to review the medication regimes of older adults who are at risk of falling. The high risk medications can be identified and possible alternatives considered. Some pharmacists have prescribing privileges and may be able to change the medications, but in all cases the high risk medications will be discussed with the original prescriber. A medication review also identifies medications that can be changed or added to improve the management of a condition that is increasing the risk of falling.
Ambulatory assistive devices: Devices such as canes or crutches are available at many pharmacies. Pharmacists have basic training in fitting and use of these devices.
Referrals: If a high risk medication cannot be changed the pharmacist can refer the client to another healthcare provider or program to implement non-pharmacological interventions for falls prevention.
Education: All healthcare providers, including pharmacists, are responsible for educating other healthcare providers and the public regarding medications that are associated with falls in older adults.
Physicians
Family physicians are encouraged to integrate falls prevention into the care they provide to older adults. They play a key role in identifying older persons at high risk for falls and may be comfortable in performing a multifactorial falls risk assessment, initiating interventions targeted at identified falls risk factors and referring to other healthcare providers as needed. If not, they are encouraged to refer older persons at an increased risk of falling to a consultant or service that would be able to deal with this issue. Some family physicians may have a particular interest in falls and may be part of an interdisciplinary falls prevention service.
Family physicians may be called upon for help in particular aspects of the assessment and care provided to older persons at risk of falling such as with the diagnosis and treatment of specific conditions, deciding on the need for further laboratory or radiological investigations, reviewing (and where appropriate altering) medications or deciding on the need for referrals.
Geriatricians would have additional training and experience in the assessment and management of falls risk in older persons. They could be called upon for assistance, particularly where the clinical challenges are complex. Some have a particular interest in falls and may be part of an interdisciplinary falls prevention service.
A variety of other medical consultants may be called upon to help with the care of an individual client. Who that might be would depend on the specific issue that needs to be addressed.
Physiotherapists
Refer to or consult a physiotherapist for:
-
Assessment of the physical factors contributing to falls risk factors.
-
Some physiotherapists provide detailed assessment and treatment of vestibular function and continence issues.
-
Prescription of individualized programs to reduce the physical factors contributing to falls risk, based on assessment findings and client goals. These prescriptions and treatment can encompass but are not limited to:
-
improving balance and gait
-
muscle strengthening
-
improving endurance
-
increasing or maintaining range of motion (ROM)
-
reducing pain
-
Assessment and prescription of appropriate assistive devices for safe mobility.
-
Provision of relevant education concerning reduction of fall risk factors.
-
Foot assessment and recommendations for footwear. A referral to an orthotist or podiatrist may be indicated.
-
Recommendations for transfers.
-
To find a physiotherapist, contact the College of Physical Therapists of New Brunswick at 506-642-9760 or email physionb@nb.aibn.com
Recreation Therapists
Recreation therapy acknowledges the significance of leisure and recreation as integral components of optimal health and well-being for individuals.
Refer to a recreation therapist to:
-
Assess abilities and provide leisure needs to promote an active lifestyle.
-
Provide advice on how to build activities into daily routine and what resources are available to individuals in the community.
For more information on recreation therapy or if there is no recreation therapist in your setting, contact the Therapeutic Recreation Association of Atlantic Canada .
Social Workers
Social workers can address the psychosocial aspects of falls risk factors, which are primarily those related to anxiety and/or depression. Social Workers can provide assessment and counselling for fear of falling. A social worker can offer helpful strategies and provide resources to minimize or limit fear of falling.
Social workers can facilitate the access and purchase of emergency response systems, home modifications, hip protectors and safe housing options. They can also assist those who struggle with the problem of hoarding or cluttered environments, accessing community resources and programs.
Specialized Services
Referral to a specialized falls clinic should be considered if further expertise is needed to determine falls risks or appropriate interventions. Refer to specialized geriatric programs if no specialized falls clinic is available in your area.
Other Health Care Professionals
Depending on the assessment findings, referrals to other healthcare professionals such as podiatrists, orthotists, etc. may be appropriate.