Table 2 Overview of PreFIT MFFP risk assessment and recommended treatment referral pathways

Falls History

Introduce yourself and explain purpose of the appointment. Use exploratory screening questions to initiate discussion. Explore balance difficulties with non-fallers. Conduct full history with fallers using questions from Table 3. (Therapist Manual provides more detailed advice e.g. use clear language and explanations, develop skills to follow relevant leads, incorporate open exploratory questions and allow the older person to tell their ‘story’ without rushing or interrupting them.) Explore specific falls and also near-miss events.

Q. Have you fallen the last 12 months?

Q. Do you have any difficulties with your balance whilst walking or dressing?

Refer to Falls Service Doctor (Consultant Geriatrician), GP or other speciality depending upon risk factor identified. Notify GP of any red flags identified during assessment.

Record date, service and name of person referred to.

Red Flags

A “red flag” is a warning sign of more serious underlying medical causes. Red flags indicate that referral to a GP or medical specialist is warranted e.g. bradycardia, history of near fainting or syncope. Any symptoms suggestive of seizure activity e.g. visual aura, tongue biting. There is no single question or validated algorithm for taking a comprehensive falls history, it requires good listening skills and ability to link different risk factors to each other. Ask ALL questions in Table 3 of those who have fallen previously.

Balance and Gait

Conduct Timed Up and Go Test (TUGT) [22]. Observe gait whilst walking and turning. Observe for signs of unsteadiness, shuffling walk, uneven stride length, veering or grabbing for furniture. Any TUGT ≥14 s, gait problems or fear of falling requires referral to PreFIT physiotherapist.

Referral to PreFIT physiotherapist to initiate PreFIT exercise programme.

Postural hypotension

Q. Do you ever feel dizzy or lightheaded if you stand up too quickly?

Q. Do you ever feel dizzy or lightheaded first thing in the morning when you get out of bed?

Screen for postural hypotension. Regardless of response to screening questions, check heart rate and rhythm, conduct lying and standing blood pressure (BP).

Use recently calibrated manual or electronic sphygmomanometer. Explain procedure; ask participant to lie on couch. Wait 2-3 min before taking first BP reading. Record radial pulse and assess rate/rhythm: sinus bradycardia (<50 bpm), sinus tachycardia (>100 bpm). Take lying BP and record. Ask to stand, repeat measurement on same arm, as soon as standing and again within 3 min of standing. Record measurement.

Patient has symptoms and any of the following between 1 to 3 min of standing up:-

Test positive if drop in systolic BP of at least 20mmHG;

Test positive if drop in systolic BP <100 mmHg;

Test positive if drop in diastolic BP of at least 10mmHG.

ECG: An electrocardiogram (ECG) should be undertaken on anyone with an irregular pulse, bradycardia or tachycardia. If possible, use an electronic ECG machine with a printed report.

If symptomatic postural hypotension:

- Conduct full medication review and consider culprit drugs e.g. anti-hypertensives, vasodilators, CNS drugs etc.

- Change timing of diuretics to avoid nocturnal micturition.

- Give PH information leaflet

Consider referral to consultant-led falls service if arrhythmia with syncope.

ECG should be interpreted by the GP, doctor, specialist nurse or trained cardiac technician. ECG findings inform decision about treatment or referral for further assessment e.g. cardiology or medical referral.

Medication review

Q. Are you taking any medications to help you sleep?

Q. Are you taking any medications to lift your mood?

A visual review of all prescribed drugs combined with face to face discussion conducted on all patients (Level 1). Any patient prescribed one or more of the following drugs referred for Level 3 comprehensive GP-led medication review:- .

Psychotropic and related drugs: antidepressants, psychotropics, sedatives, and anti-manic.

Hypnotics and Anxiolytics (Night Sedation – British National Formulary Section 4.1), Antipsychotics (Section 4.2), Antidepressants (Section 4.3).

Culprit drugs

Cardiovascular (Section 2), Diuretics (Section 2.2), Anti-arrhythmia (Section 2.3)

Beta-adrenoceptor blocking (Section 2.4), Hypertension and heart failure (Section 2.5), Nitrates, calcium-channel blockers & others (Section 2.6), Drugs used in Parkinsonism & related disorders (Section 4.9).

GP to conduct medication review if prescribed any psychotropic or culprit medication.

Vision

Q. Have you had your eyes checked by an optician in the last 12 months?

Q. Has your eyesight changed or have you had any problems with your vision since your last appointment with the optician?

Other exploratory questions include:-

Q. any problems with reading? (suggests problem with near vision)

Q. Any problems with watching TV? (suggests problem with distance vision)

Q. Do you wear bifocal glasses?

The Snellen Chart should be wall mounted and in a well-light position. The person should stand EXACTLY 3 m from the chart (adjusted for 6 m), distance calculated and marked with tape on the ground. Can wear distance vision glasses, cover one eye with patch and ask to read down chart until they reach the smallest line of letters they can distinguish on the chart. Conduct on both eyes. Any visual acuity at less than 6/6 requires referral to optician for eye test.

Other advice includes wearing of bifocals/multifocals whilst walking outdoors should be avoided; taking care when wearing new spectacles [28].

Encourage all participants to attend free eye check. If had eye test in last 12 months but vision has deteriorated, ask to make optician appointment. If eye disease or cataracts suspected, refer to optician.

If visual impairment, consider home environment assessment and referral to occupational therapy.

Foot problems

Q. Do you have any problems with your feet?

Q. Any pain in your feet?

Q. Any numbness in your feet?

Q. Do you have diabetes?

Q. Do you attend chiropody / podiatry services?

Visual examination of feet to check for bunions, hammertoes, calluses or in/overgrowing nails that may cause pain or gait disturbances [32]. Conduct proprioception check if concerned about numbness or food positioning (refer to manual). Assess footwear and give advice on recommended shoes (supportive heel collar, heel height of less than 2 cm, slightly bevelled heel, fastened using laces, straps or buckles, thin firm midsole to allow sensory input, slip resistant sole and wide fitting [33].

Refer to local podiatry or chiropody services if available. Consider referral to physiotherapy for balance retraining if concerned about gait style or foot placement.

Give AgeUK advice leaflet. Consider referral to secondary care services if indicated e.g. diabetic services.