Clinical update: preventing falls in hospital

Inpatient physiotherapists can play a crucial role in preventing falls in older people, says Louise McGregor.

According to a National Institute for Health and Care Excellence (NICE) clinical guideline, inpatients should be regarded as being at risk of falling if they are aged 65 or over. Another at-risk group is those aged 50-64 years who are judged by a clinician to be at a higher risk of falling due to an underlying condition. 
Patients in both groups should receive individualised and multifactorial assessments. The NICE quality standard Falls in Older People was updated in January. This covers prevention of falls and assessment after a fall in older people who are living in the community or staying in hospital. Three new statements have been added and all other statements, originally published in 2015, have been retained.  

The inpatient physiotherapist’s role in multifactorial falls risk assessments may include:

  • identifying falls history
  • assessing gait, balance and strength
  • assessing functional ability and fears related to falling
  • assessing visual impairment
  • taking lying and standing blood pressure (BP)
  • assessing bone health (via the Q factor or FRAX tools) 

Next steps

It is important to have discussions with the patient on what the next steps might be. These might include measures to prevent falls, such as wearing glasses appropriately or moving a call bell so that the patient can see it. Think about the environment, including the lighting and bed and chair orientation. Liaise with the multidisciplinary team about your findings. Consider onward referral to sensory impairment teams. 
The Royal College of Physicians’ Falls and Fragility Fracture Audit Programme (FFFAP) has recently published guidance on standardising the measurement of lying and standing BP. For more information, see and the two panels on the opposite page. In the last national inpatient falls prevention audit in 2015, only 16 per cent of the sample of 4,846 people had a lying and standing BP recorded by their third day in hospital. Physiotherapists working in acute settings are ideally placed to carry out postural BP measurements. 

Multifactorial intervention

The multidisciplinary team should address risk factors for falling and take into account whether these can be treated, improved or managed during an admission. Remember that a patient’s risk of falls in hospital may alter rapidly with a change in medical status. As a patient’s acute illness resolves and the patient becomes more mobile, the risk may increase. Likewise, a deterioration in the patient’s medical stability may also affect the falls risk, such as in the onset of delirium. Falls risk assessment and care plans should be reviewed and communicated as the patient’s condition changes. 
The multidisciplinary team should, with the patient’s agreement, provide relevant information and support for patients, their family members and carers. Take into account the patient’s ability to understand and retain information. Information should include explanations about the patient’s individual risk factors for falling in hospital. Show patients how to use the call bell and encourage them to use it when they need help. Provide consistent messages about when a patient should ask for help before getting up. Help patients engage in interventions aimed at addressing their risk factors and discuss potential referrals to falls prevention services. fl 
  • Louise McGregor is the chair of Agile, the CSP professional network for physiotherapists working with older people 
* For list of references and resources, see here.  

Bedside vision check: practice points

  1. Ask the patient when they last had a sight test (these should be conducted annually).  Does the patient wear glasses? Are the lenses up-to-date? What are the glasses for? Do they have an eye condition, such as glaucoma, and, if so, are they using a prescribed treatment?
  2. Check distance vision: Can the patient see the television clearly? Show an image from about two metres away. If they have distance glasses, they should use them.
  3. Check near vision: Can they see to read newspaper print or medicine labels? Show them a card with an image in a comfortable reading position. If they have reading glasses, they should wear them.
  4. Check peripheral vision: Sit face to face with the patient. Ask them to keep looking at your face during the test. Raise your right hand to the 2 o’clock position (towards the edge of your field of vision) and wriggle your fingers. Ask: ‘Can you see my fingers moving?’ If you can, so should they.Repeat the above steps, holding your hand at 4 o’clock.Change to your left hand and test at 8 o’clock and 10 o’clock.
  5. Check eye movements: Ideally, sit face to face with the patient, knees nearly touching. Ask, ‘Do you ever get double vision/see two of things?’ Are their eyes not pointing straight ahead, or jiggling? Move a pen forward and back, left and right in front of their eyes. Do their eyes move together, following the pen all the way across and up and down? Source: FFFAP. 

Taking blood pressure (BP)

Are you going to need assistance to stand the patient up and simultaneously record his or her BP?

Use a manual sphygmomanometer if possible and do so without fail if the automatic machine fails to record:

  • Explain procedure to the patient.
  • The first BP should be taken after the patient has been lying down for at least five minutes.
  • The second BP should be taken after standing in the first minute.
  • A third BP should be taken after the patient has been standing for three and a half minutes. This recording can be repeated if the pressure is still falling.
  • Symptoms of dizziness, light-headedness, vagueness, pallor, visual disturbance, feelings of weakness and palpitations should be documented.
  • A positive result is: (a)a drop in systolic blood pressure of 20mmHg or more (with or without symptoms) (b) a drop to below 90mmhg on standing, even if the drop is less than 20mmHg (with or without  symptoms) (c) a drop in diastolic blood pressure of 10mmhg with symptoms (although clinically much less significant than a drop in systolic blood pressure).
  • Advise the patient of the results and if the result is positive, inform the medical and nursing team. Take immediate action to prevent falls and or unsteadiness. In the case of positive results, repeat regularly until resolved.
  • If symptoms change, repeat the test. Source: FFFAP

More information

Louise McGregor, Chair of Agile, CSP professional network for physiotherapists working with older people

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