Falls in older adults are common and the rate is three times higher in people in care homes than in those living in their own homes. Falls in care homes are associated with considerable mortality and morbidity-hip fractures are significantly more prevalent than in community-dwelling older people, with rates in female care home residents estimated as high as 50.8 hip fractures per 1000 person-years.1
Although extensive research has been carried out into interventions to reduce falls in community-dwelling older people, there is limited evidence of the effectiveness of such measures within care homes. Oliver2 concluded that it makes sense to identify risk factors for the individual so that they can be reversed or reduced where possible. However the protocols used to perform risk assessments for falls in care homes are often not validated, vary from care home to care home, and do not necessarily trigger individually-tailored interventions. These assessments invariably attempt to stratify risk but because each individual within the care home is already at high risk, opportunities for interventions to reduce the risk of falling are often missed.
We know that falls are generally due to a combination of diverse risk factors and situations, many of which can be prevented and corrected.3 In particular, falls are often a symptom of unstable underlying frailty and illness.4 The majority of elderly residents in care homes are frail with multiple needs, but over half of them do not have access to all the NHS services that they may require.5 According to a report published by the Care Quality Commission and the British Geriatric Society (BGS) in 2012, the residents of care homes in England have limited access to specialist geriatric care and variable access to community health services.5
Falls are emotive and engender anxiety and fear of litigation and complaints, which may sometimes lead to care home staff discouraging a person from walking or moving around. This is not based on a desire to deprive a person of independence, but rather on a lack of understanding of the factors that can contribute to falls. Falls in care homes are a question of balance-a balance between control and autonomy, risk-taking and risk-avoidance, maintenance or loss of independence. Care home managers have a legal responsibility to manage the risk of falls within their home, in order to provide a safe environment and an ethos of well-being and quality of life. The health service has a responsibility therefore to provide proactive, multidisciplinary, expert care to the residents of our care homes, to help older people and their family and carers to understand their risk of falling, to intervene to modify risk factors when we can and to manage the risk when we can't.
We can't prevent all falls in care homes, but we can significantly improve the health and well-being of older people within the care home, we can provide education and training so that staff understand the multifactorial nature of falls, and we can support carers and older people in taking actions to reduce or manage their individual risks.
Kate Robertson will be speaking at the BGS Falls and Postural Stability conference in September
1. Rapp K, Lamb S, Büchele G, et al. J Am Geriatr Soc 2008; 56(6): 1092-7
2. Oliver D, Connelly JB, Victor CR et al. BMJ. 2007: 334(7584): 82
3. NICE. The assessment and prevention of falls in older people. http://www.nice.org.uk/CG161
4. Gillespie LD, Gillespie WJ, Robertson MC, et al. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000340/pdf/standard
5. BGS. Failing the Frail: A Chaotic Approach to Commissioning Healthcare Services for Care Homes (2012)