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Introduction  

1.1 Falls, falls-related injuries and fear of falling are important public health issues for older people and society generally. A good deal is now known about the causes and consequences of falls and fractures and the interventions which can reduce them.

1.2 Various strategies to address falls and their consequences have become a prominent part of health and social care policy for older people in the UK and many other countries. So far, implementation is patchy but improving. The prospect of abolishing falls among older people, however, is both impossible and undesirable. A balance must be struck by society, and by individuals, between reducing the chance of falls and injury on the one hand and an unhealthy restriction of activity and autonomy of older citizens on the other.

1.3 Designing or running a service for falls CANNOT be done effectively without considering bone health, fractures and rehabilitation after injury. All these need to be linked together, e.g. in a clinical pathway. Clinical governance must cover both and how they are linked in practice.

1.4 This Compendium item cover the falls aspects but must be read in conjunction with the advice on management of osteoporosis [1,2,3,4] and the clinical management of fragility fractures. This along with orthogeriatric liaison and rehabilitation services are also considered elsewhere. [5,6]

2. Epidemiology in Brief 78

2.1 The rates of falls on community dwelling people are reported to be in the region of 30% for those over 65 years and over 40% for those over 75. Variability in reported rates reflect different data collection methods [9] as well as real differences due to case-mix, season, ethnic and cultural factors, and perhaps historical trends. About 50% of falls are in people who fall twice or more in a year. The risk factors for falling and injury and the best approaches to prevention are influenced by context, so below we consider falls in hospitals and care homes as well as in the community.

3. The consequences of falls

3.1 Falls cause a range of adverse effects on individuals, their carers and on health and social care providers. Loss of dignity and confidence may result in activity restriction which in turn is associated with future falls and poorer health. Concern of families or other care providers is understandable and may lead both to helpful hazard avoidance but further limit healthy activity. Frequent falling is associated with anxiety and depression, particularly when individuals have specific activity-related fear of falling.

3.2 Falls are the commonest cause of accidental injury in older people and the commonest cause of accidental death in the 75+ population. About 6% of falls in those over 65 result in a fracture, including 1% being of the hip. Having fallen is the commonest reason for older people to attend the A&E and for being admitted to hospital. Injury occurs more commonly in frailer persons and the nature of the fall affects injury risk and type. Falls due to syncope are particularly likely to result in injury including facial bruising. In more active and younger people, wrist fractures are more common whereas after from 75 plus, hip fractures predominate.

3.3 The economic costs to the NHS and local government associated with the management of unintentional falls is considerable, about half of which is associated with inpatient fracture management and almost as much with long term care provision. [10] Fragility fracture management alone is estimated to cost about £1.7 billion per year, mostly for hips. The major determinant of this cost is hospital length of stay [11] for which there is considerable national variation, suggesting scope for improvement.

4. The causes and management of falls

4.1 Anyone can fall given a difficult enough activity. Likewise, anyone can fall doing something quite ordinary if their functional ability is severely hampered by illness, medication or alcohol. The focus of falls services is on those people who are prone to fall and do so, or fear that they might, whilst doing less demanding activities.

4.2 At one end of the spectrum are people who fall suddenly and unexpectedly. This includes syncope (blackouts) which can be associated with cardiac or neurological symptoms but can occur without either. Sometimes the person realizes or was seen to have passed out temporarily but sometimes not, although they may not recall the fall very clearly. Recognition and assessment of syncope is a skilled medical task and frequently requires specialist investigation and treatment. Assessment algorithms and clinical guidelines are available. [12 13 14]

4.3 Falls without syncope are often associated with impairment of postural instability. This can result from a large range of factors. Often multiple factors act together. These include ageing changes of sensory function, frailty, mental health, and medical illness, plus medication and footwear. [15 16] They can be detected by systematic multidisciplinary assessment. [17 18] Environmental factors at home or in public spaces are implicated in some falls, [19 20] and systematic home hazard assessments have been developed [21 22] and may be effective. [23]

4.4 The effectiveness of multi-component programmes in reducing subsequent falls rates is now well established [24 25 26 27] and is the core of the clinical guidelines. [28 29] These combine general approaches with targeted interventions. Strength and balance training is an important component for most individuals and some training programmes are effective alone for primary and secondary falls preventions in certain patient groups. [30] Despite good evidence of efficacy, there is no evidence to support inclusion of hip protectors in community wide injury prevention strategies.

5. Reducing falls and injuries in hospitals

5.1 Falls are common among hospital inpatients, with variable rates reported from 2.9–13 falls per 1,000 bed days. Injury rates are higher than for community falls, up to 30%, and result in distress, death, anxiety and depression, impaired rehabilitation, increased lengths of hospital stay and higher rates of discharge to long-term institutional care, complaints and litigation. The risk factors and how to identify them are well documented. [31] Although there have been several negative clinical trials, strong evidence is emerging to support the effectiveness of a holistic approach encompassing patient, staff and institutional factors. [32] Use of hip protectors remains controversial, with no clear evidence to guide an effective strategy for their use in this setting.

6. Reducing falls and injuries in care homes

6.1 Repeated falls and instability are very common precipitators of nursing home admission. Many residents of residential and nursing care homes, with predominantly physical or mental health problems, are at high risk. The risk profile and the interplay of individual, staff and institutional factors present a distinct challenge. Approaches used successfully in the community are less effective but several components singly or together have moderate benefit. [33] Evidence is emerging that a holistic approach encompassing resident, staff and institutional factors can be successful. [34] There is some evidence that targeted use of hip protectors in care homes is worthwhile. [35 36]

7. Health Policy on Falls

7.1 Chapter 6 of the National Service Framework for Older People (NSF-OP) is devoted to falls, and includes specific standards for falls and related bone health services. [37] By April 2005, local health services working in partnership with local government were required to have established an integrated multi-agency strategy for the prevention of falls and the treatment and rehabilitation of falls and related injuries. Similar requirements have been made by the Scottish Office.

7.2 The specific services and treatments needed are set out in a number of clinical guidelines most specifically in England from the National Institute of Health and Clinical Excellence, NICE. The NSF-OP requires that all health and social care professionals working with older people should be able to inquire about falls or fear of falling and offer referral for further assessment if needed. Validated overview assessments incorporate relevant questions 38 and can be used to identify needs, with local arrangements to provide the general and where necessary the specialist assessments and targeted interventions.

8. Audit

8.1 The NSF-OP includes the requirement that local health services conduct audit to monitor their service delivery in line with the NSF-OP standards, and that the views of older people are systematically obtained to inform service improvement. The Health Commission has commissioned the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians of London to conduct national audits on the organization and on the delivery to patients of the falls and bone health services in England. [39] This audit has a multidisciplinary steering group and is actively supported by the BGS. Most trusts in England, Wales and Northern Ireland are participating, and results will be disseminated widely.

9. Training

9.1 The NSF-OP includes the requirement that health and social care staff be trained appropriately to conduct the case finding and referrals mentioned above.

The curriculum of specialist registrars training in geriatric medicine includes a component on the management of falls and related bone health issues and suggests a dedicated 4 week module on orthogeriatric medicine.

10. References

1. Royal College of Physicians of London. Osteoporosis: clinical guidelines for prevention and treatment. Update on pharmacological interventions and an algorithm for management. RCP London, 2000.
2. NICE guidance on the secondary prevention of osteoporosis (TA 87, 2005).
3. NICE guidance on the secondary prevention of osteoporosis 2007. http://guidance.nice.org.uk/page.aspx?o=437523.
4. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fractures in older people. SIGN publication No. 56. Edinburgh: SIGN 2002. http://www.sign.ac.uk/guidelines/fulltext/56/index.html
5. British Orthopedic Association. The care of fragility fracture patients (“the blue book”). BOA, London, 2003. Available from www.boa.ac.uk.
6. BGS Compendium
7. Masud T, Morris RO. Epidemiology of Falls. Age and Ageing 2001; 30-S4:3-7.
8. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35-S2:ii37-ii41.
9. Hauer K, Lamb SE, Jorstad EC, Todd C. Systematic review of definitions and methods of measuring falls in randomized controlled fall prevention trials. Age and Ageing 2006; 35:1-5
10. Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. Journal of Epidemiology and Community Health. 2003; 57(9):740-4.
11. Lawrence TM, White CT, Wrenn R, Moran CG. The current hospital costs of treating hip fractures. Injury 2005; 36(1):88-91; discussion 92.
12. Brignole M. Distinguishing syncopal from non-syncopal causes of fall in older people. Age and Ageing 2006; 35:ii46-ii50.
13. Kennt RA. Neurally medicated syncope. Clinics in Geriatric Medicine 2002; 18(2):191-210.
14. Brignole M, Alboni P, Benditt D et al. Guidelines on management (diagnosis and treatment) of syncope – update 2004 – executive summary and recommendations. European Heart Journal 2004; 25:2054-72.
15. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls amongst elderly persons living in the community. New England Journal of Medicine 1998; 319, 1701-1707.
16. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35-S2: ii37-ii41.
17. American Geriatrics Society, British Geriatrics Society and American Academy of Orthopedic Surgeons. Panel on Falls Prevention. Guidelines for the prevention of falls in older persons. Journal of the American Geriatrics Society 2001; 49: 664-672.
18. Swift CG. The role of medical assessment and intervention in the prevention of falls. Age and Ageing 2006; 35:ii65-ii68.
19. Lors SR, Menz HB, Sherrington C. Home environment risk factors for falls in older people and the efficacy of home modifications. Age and Ageing 2006; 34: ii55-ii59.
20. Gill TM, Williams CS, Tinetti ME. Environmental hazards and the risk of non syncopal falls in the homes of community-living older persons. Medical Care 2000; 30, 1174-1183.
21. Clemson L. Home fall hazards: a guide to identifying fall hazards in the homes of elderly people and an accompaniment to the assessment tool, the Westmead Home Safety Assessment (WeHSA). Co-ordinates Publications, West Brunswick Victoria 1997.
22. British Association of Occupational Therapists and College of Occupational Therapists. Falls Management. 2006. Available from http://www.cot.org.uk/members/publications.
23. Cumming RG, Thomas M, Szonyi G, O’Neill E, Westbury C, Frampton G. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society 1999; 47, 1397-1402.
24. Tinetti ME, Baker DI, McAvay G et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. The New England Journal of Medicine 1994; 331, 821-827.
25. Tinetti ME. Clinical Practice on Preventing Falls. The New England Journal of Medicine 2003; 348: 42-49.
26. Chang JT, Morton SC, Rubenstaein LZ et al. Interventions for the prevention of falls in older adults: a systematic review and meta-analysis of randomized clinical trials. British Medical Journal 2004; 328 (7441): 680-684
27. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Art. No.: CD000340. DOI: 10.1002/14651858.CD000340. Date of last substantive update: July 12. 2003.
28. American Geriatrics Society, British Geriatrics Society and American Academy of Orthopedic Surgeons. Panel on Falls Prevention. Guidelines for the prevention of falls in older persons. Journal of the American geriatrics Society 2001; 49: 664-672.
29. National Institute for Health and Clinical Excellence. The assessment and prevention of falls in older people. Clinical Guideline 21. November 2004 http://www.nice.org.uk/CG021.
30. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal 1997; 315: 1065-1069.
31. Oliver D, Daly, F, Martin FC, McMurdo MET. Risk Factors and Risk Assessment Tools for Falls in Hospital Inpatients: A Systematic Review. Age and Ageing 2004; 33 (2):122-3.
32. National Patient Safety Agency. Slips, trips and falls in hospital. The third report from the patient safety observatory. Available from www.npsa.nhs.uk/site/media/documents.
33. Oliver D, Connelly JB, Victor CR et al. The prevention of falls and fractures in hospitals and care homes. Systematic review and meta-analyses of clinical studies of prevention strategies, with an exploration of cognitive impairment as an effect modifier. British Medical Journal 2007; 334(7584):82.
34. Magaziner J, Miller R, Resnick B. Intervening to Prevent Falls and Fractures in Nursing Homes: Are We Putting the Cart Before the Horse? Journal of the American Geriatrics Society 2007; 55:464-466.
35. Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip fractures in older people. Cochrane Database Systematic Review 2005; 3: CD001255.
36. Honkanen LA, Schackman BR, Mushlin AI, Lachs MS. A cost-benefit analysis of external hip protectors in the nursing home setting. Journal of the American Geriatrics Society 2005; 53:190-7.
37. National Service Framework for Older People. Department of Health; 2001.
38. Department of Health. Single Assessment Process.
39. www.rcplondon.ac.uk/college/ceeu/fbhop/.

Review date July 2010 Author : Finbarr Martin for BGS Policy Committee