Falls are common in the ageing population with 30% of people over the age of 65 years falling at least once yearly increasing to 50% in the over 80 years age group.

The human cost of falls includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falls also cost the health service over £2.3 billion a year and an estimated four million bed days. With the number of people aged 65 and over predicted to increase by two million by 2021, costs are set to rise further.

Falls are not just the result of getting older and many falls can be prevented. As a result, falls prevention services have been set up across the country that include specialist falls practitioners such as nurses, occupational therapists and physiotherapists. These services help reduce the risk of falling, raise awareness of fall hazards and make changes to the home environment to prevent falls from occurring.

The key to an effective falls service is understanding the phenomenon, adhering to the evidence, coordinating across all boundaries and ensuring the outcome.

Understanding the phenomenon

This means assessing the common detectable intrinsic and extrinsic factors. These include the ageing processes (diminished physiological reserve), suboptimal physical fitness, stable specific impairment (e.g. sensory, motor, visual, central nervous system), unstable systemic illness (diagnosed or undiagnosed) and environmental risk factors.

Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences and possibilities for future prevention. A Lancet study found that the most common attributable medical problems identified with falls were strength/balance impairment (72%) followed by visual impairment (59%). Other causes included cardiovascular/circulatory issues (postural hypotension, arrhythmias, carotid sinus syndrome, pacemaker failure) (17%), cataracts (35%), decreased lower limb power (28%), peripheral neuropathy (20%), measured cognitive impairment (34%), depression (18%) and undiagnosed malignancy (2%).1

Another study identified 4,039 individuals at risk of falls and found that 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. There was also a significant number of individuals with new diagnoses ranging from cognitive impairment to Parkinson's disease.2

Adhering to the evidence

It is clear that more research is needed as most falls interventions research looks at the highest risk category which includes A&E attenders and ambulance callers. Studies in heterogeneous studies and settings (e.g. acute. non-acute, mixed) often have inconsistent or negative findings with single factor or non-tailored interventions. Risk factor prediction tools are also insufficiently sensitive or specific.

A study looked to assess the effects of exercise interventions for preventing falls in older people living in the community. The Cochrane review found that exercise reduces the rate of falls by 23%. Different forms of exercise had different impacts on falls - balance and functional exercises reduced the rate  by 24% and tai chi by 19%. The authors were uncertain of the effects of programmes that primarily involve resistance training, dance or walking, but concluded that given the certainty of evidence effective programmes should now be implemented.3

Coordinating across all boundaries

NICE guidance on falls states that older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment.

This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. This should include the assessment of gait, balance and mobility, and muscle weakness, osteoporosis risk, visual impairment, environmental hazards and a cardiovascular examination and medication review.

 

 

Measuring the outcome

A national audit found that there was an unacceptable variation in the quality of falls and fracture services and a major gap between what organisations report and actual services.

The national audit of falls and bone health by the Royal College of Physicians (RCP) in 2011 also found important deficiencies in the commissioning, organisation and provision of care.5

In an update in 2017 it recommended that all trusts and local health boards had a patient safety group, which included falls prevention in its remit and reports to the board. This group should regularly review their trust’s data on falls and moderate harm, severe harm and deaths per 1,000 occupied bed days and assess the success of their practice against trends in these figures.6

Other recommendations included structured rapid assessment procedures (including standardised delirium tools) and robust data and reporting on falls and fractures. Auditing against NICE QS86 quality statements 4–6 was seen as a way to identify areas of weakness and improve the care of these vulnerable patients. This should be along side regular audits of postural blood pressure, vision, medication and walking aid reviews.

For local implementation, clear lines of accountability with seamless specialist referral access and criteria are needed. A falls coordinator is also essential so that fall identification/documentation (especially in A&E and ambulance call-outs) as well other data collection such as falls recurrence, hospital admission/re-admission can be sent to the Fragility Fracture Audit Programme (FFFAP) to assess cost-effectiveness.

Falls diagnosis, management and prevention is vitally important but it can be challenging. It can be effective and cost-effective as well as coordinated, systematic and focused yet it is still insufficiently implemented and in need of rigorous research.

 


Professor Cameron Swift is Emeritus Professor of Health Care of the Elderly at King's College London, and a past President of the British Geriatrics Society.

 


 

  1. Close J, et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet1999; 353(9147): 93-7
  2. Parry SW, et al. A Novel Approach to Proactive Primary Care-Based Case Finding and Multidisciplinary Management of Falls, Syncope, and Dizziness in a One-Stop Service: Preliminary Results. J Am Geriatr Soc.2016; 64(11): 2368-73
  3. Sherrington C, et al. Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic Review. Br J Sports Med.2019 
  4. NICE. Falls in older people: assessing risk and prevention. https://www.nice.org.uk/guidance/cg161
  5. https://www.rcplondon.ac.uk/projects/national-audit-falls-and-bone-health
  6. https://www.rcplondon.ac.uk/projects/outputs/naif-audit-report-2017

 

 

The article was based on a talk given at the GM Conference: The Ageing Patient: Midlife and Beyond