Our data suggest that the Fallpoliklinikken has received referrals of appropriate patients. They have many of the well-established risk factors for falls (2, 3) and a high risk of falling again. A number of diseases in the elderly can manifest as a tendency to fall, and this is reflected in the breadth of our pathological findings. We discovered several cases of serious underlying pathology, which underlines the importance of a thorough, interdisciplinary assessment.
It may be argued that many fall because they are frail, with age and previous falls being key risk factors (6). All parts of the health service must be able to conduct a basic clinical examination of tendency to fall, which should cover at least the following three elements:
Thorough medical history, from others if necessary, including information on the circumstances of the fall, the frequency of falls and any walking difficulties
Medication review with emphasis on drugs that can cause dizziness, unsteadiness and orthostatism
Measurement of blood pressure in supine and upright positions, in addition to ECG in cases of suspected cardiac triggers
Patients who have experienced a fall that required medical attention, who have walking difficulties or who have fallen repeatedly, should be referred for a broad-based assessment by a doctor with knowledge of geriatrics and experience in interdisciplinary work (9). Falls where there is suspicion of syncope should generally also trigger a referral (21). Based on our experience, a geriatric outpatient clinic is suitable for investigating such falls, because the patients often have significant comorbidity and several factors contributing to their falls (22).
Our patients comprise a selected group, which probably does not include the most frail. Because the investigation is lengthy and requires cooperation, appointments were not given to patients with severe dementia or without the ability to walk independently. All lived at home, and were self-sufficient with regard to most basic activities of daily living. In cases of moderate to severe dementia or where assistance is required for walking and mobility, there are thus far no grounds for recommending an extensive assessment (7, 9), but a review of the patient’s medication with emphasis on adverse effects of psychopharmaca and symptomatic orthostatism must be performed. Beyond this, the most frail should probably be offered treatment of functional deficits and protection against falls, such as hip protectors, walkers and an increased level of care, rather than looking for specific causes.
Our findings and interventions concur well with the few studies that have been published by similar institutions (5, 8). The average age in these studies was 78 years, and just over 70 % of patients were women. Around 1 in 5 was cognitively impaired and the most commonly proposed interventions were increased physical activity and changes to medication. In contrast to us, none of the other authors assessed syncope, and they recommended eye examination, hip protectors and interventions at home far more often. Both studies report a likely effect in terms of a reduction in falls with and without injury, but one lacked a control group and the other was relatively small. The percentage of patients referred to our outpatient falls clinic from GPs and hospitals was not noticeably different from that in the other studies.
The best documented effect is that of strength and balance training (2) – (6, 9, 23), and this was also the most commonly proposed intervention in all studies. However, there are still few training options available for this group, and the training is often not sufficiently intensive (24, 25). Training can be difficult to access for those who are already frail, and for these patients it is important that medical interventions (e.g. cataract surgery) or practical interventions in the home (e.g. removal of steps) are implemented so that the patients can make use of their training (3).
Our study is descriptive, we had no control group and we have not counted falls or followed up patients over time. We therefore cannot say anything definite about the effects of our interventions. Data collection was carried out in conjunction with clinical patient work and may thus have been somewhat imprecise, but the fact that all patients were examined by the same nurse, doctor and physiotherapist is a strength of our study. Models resembling the Fallpoliklinikken, where various interventions are offered directly, have shown good results in international studies (4, 5).
There is a need for increased awareness and understanding of falls in the elderly, so that we can determine with greater certainty than at present which groups are at high risk of falling, how falls should best be assessed in elderly patients with different levels of functioning and, not least, which measures are most effective in preventing falls. However, there is no reason to delay offering falls assessment at geriatric outpatient clinics, and referring elderly individuals who experience falls for strength and balance training.