Mastering Falls Assessment and Prevention Guidelines for MRCP Geriatrics

Mastering Falls Assessment and Prevention Guidelines for MRCP Geriatrics

Falls are a critical topic in geriatric medicine, not just for clinical practice, but also as a high-yield area frequently tested across all parts of the MRCP examination (especially in written papers requiring guideline knowledge and clinical scenario management). As an expert preparing for consultant-level practice, you must be fluent in the systematic assessment and management strategies for falls in older adults.

This guide breaks down the essential guidelines for assessing and preventing falls, focusing on the frameworks endorsed by major bodies like the British Geriatrics Society (BGS) and NICE.

1. The Scope of the Problem (Why MRCP Cares)

Falls are the leading cause of accidental death in older people and represent a significant proportion of emergency hospital admissions. For the MRCP, understanding the systemic approach to falls reflects competence in managing complex multi-morbidity common in this patient group.

2. Initial Assessment: Screening and History

All older people (usually defined as those aged 65 and over) presenting to medical services, or those consulting their GP, should be asked about falls in the last year.

A. Single Fall vs. Recurrent Falls

B. Key History Components

For a patient who has fallen, the history must cover:

• Circumstances of the fall: Where, when, activity at the time, symptoms preceding (dizziness, chest pain, palpitations, visual changes).

• Injury assessment: Immediate and delayed injuries (e.g., head injury, fracture, soft tissue damage).

• Medical review: Review of acute and chronic conditions (including neurological, cardiac, and musculoskeletal disease).

• Medication review: Focus on psychotropics, antihypertensives, diuretics, and any new drug starts.

• Fear of Falling: This itself is an independent risk factor for future falls and functional decline.

3. The Comprehensive Falls Assessment (CFA)

The CFA is a detailed, multidisciplinary assessment carried out by a specialist team (Geriatrics, Falls Clinic, or equivalent).

Essential components of the CFA include:

1. Cardiovascular Assessment: Orthostatic hypotension (drop of >20mmHg SBP or >10mmHg DBP within 3 minutes of standing), heart rate/rhythm assessment (looking for arrhythmia or bradycardia).

2. Neurological Assessment: Cognitive screening (MMSE, MoCA), motor examination, peripheral neuropathy testing, and coordination.

3. Visual Assessment: Acuity, visual fields, and ruling out conditions like cataracts or glaucoma.

4. Musculoskeletal Assessment: Strength testing (especially lower limbs), range of motion, and assessment for foot deformities or inappropriate footwear.

5. Gait and Balance Assessment: Objective measures (e.g., Berg Balance Scale, functional reach tests).

6. Environment Assessment: Identification of home hazards (rugs, poor lighting, stairs).

MRCP Tip: When presented with a falls scenario, always mention the full CFA as the gold standard management step for recurrent falls, justifying the necessity for multidisciplinary input.

4. Multifactorial Intervention Strategies

The most effective prevention strategy is a targeted, individualised, multifactorial intervention plan, addressing all identified risk factors from the CFA.

A. Exercise Interventions

• High-intensity, high-challenge exercise programs, often group-based, focusing on balance, strength, and gait training (e.g., Otago Exercise Programme).

• Tai Chi is often recommended due to its focus on slow, controlled movements and balance.

• Crucially: Simple walking programs alone are not sufficient for falls prevention.

B. Medication Review and Optimisation

This is a critical area for MRCP.

• Action: Systematically review and reduce/withdraw medications associated with increased fall risk (Polypharmacy, especially benzodiazepines, Z-drugs, TCAs, and anticholinergics).

• Orthostatic Hypotension (OH): Non-pharmacological measures first (increased fluid, compression stockings). If medication is required, fludrocortisone or midodrine may be considered, but only after careful specialist assessment.

C. Environmental Modification

Referral to Occupational Therapy (OT) for a home hazard assessment is essential. Common modifications include:

• Installing grab rails in bathrooms and stairs.

• Improving lighting, especially nocturnal lighting.

• Removing trip hazards (loose rugs, wires).

D. Other Targeted Interventions

• Vitamin D: Recommended for older people who have fallen, especially if Vitamin D deficient or housebound (standard dose often 800 IU daily).

• Vision Correction: Ensure up-to-date prescription. Caution: Bifocal or varifocal glasses may increase risk when walking outside; specialists often recommend separate glasses for reading/distance.

• Footwear/Podiatry: Addressing foot pain or poor footwear.

5. Specific Scenarios Tested in MRCP

1. Falls + Syncope: Requires thorough cardiac investigation (ECG, Holter/Loop recorder, Echocardiogram).

2. Falls + Gait Impairment (Parkinsonian): Requires review and optimisation of anti-Parkinsonian medications.

3. Falls + Fear of Falling: Requires psychological support and targeted balance training to regain confidence.

Mastering these guidelines ensures you are equipped not only for MRCP success but also for providing high-quality, evidence-based care to older adults.