Key learning points:
– A first fall should trigger a multidisciplinary falls assessment and intervention
– Even the most simple of measures are effective at falls prevention
– Consider a community call alarm for those who are unable to get up following a fall
Having previously experienced a fall is the single most important risk factor behind falling again. This is because the odds of falling are three times greater in someone who has previously suffered a fall.1 Therefore, it is essential that action is taken as soon as possible following the first fall in order to begin preventative measures.
In the immediate period following a fall a rapid assessment should take place to triage how serious the situation is, beginning with basic life support and calling for help if necessary. If the individual’s life is not threatened, an attempt should be made to assess for any serious injuries or medical problems (such as bone fractures, head injuries, or the possibility of a new stroke), which may require the emergency services. If the individual feels well enough to stand up it may be helpful to encourage them to roll or crawl to the nearest chair so they can use their upper body to help them up into the chair. If it is not possible to assist the individual into a chair it may be necessary to call for community assistance, some teams have inflatable devices that can assist people up from the floor. Beware of helping someone stand if they have ongoing dizziness as it may result in a further fall. Dizziness should be allowed to pass before attempting to stand.
If it is safe to leave the individual in their own home there may be some very simple falls prevention measures that healthcare professionals can take before they leave:
– Footwear – Is the persons’ footwear safe and appropriate? Are the heels too high, the soles too smooth or the shoes/slippers worn through?
– Floor, passages and stairs – are they free from clutter and trip hazards? Is there adequate lighting?
– Vision – Have they seen an optician within the past year?
– Blood pressure (BP) – Do they have a postural drop in their BP?
– Dizziness – Does the person need to see a clinician in regards to their dizziness?
– Calling for help – Will the patient accept a mobile phone or community alarm, and do they keep it nearby?
All individuals should be considered for assessment by a falls team. This assessment should be multidisciplinary in nature, in order to identify contributory risk factors and lead to a multifactorial intervention. A team would typically include a physician, a physiotherapist and an occupational therapist, but a wider team may include an optometrist, podiatrist, pharmacist or a nurse specialist.
A basic multifactorial intervention would include a medication review, strength and balance exercise and a review of home hazards. A medication review would typically explore whether culprit medications can be withdrawn. Those that increase the risk of falls include antipsychotics, antidepressants, benzodiazepines, sedatives and anti-hypertensives.2
Exercise is one of the most important falls prevention measures and has a very strong evidence base.3 However, not all exercises are effective. Multi-component exercises (usually a combination of strength and balance) are the most effective and need to be delivered for several weeks to be successful. They need to be individually tailored according to an individual’s ability and can occur in an exercise group or in an individual’s home. Several trials have claimed that Tai Chi (a form of gentle exercise focusing on movement, balance and breathing) is effective in preventing falls, however, a Cochrane meta-analysis found that the benefits are limited to those who are at a lower risk of falling.3
A review of an individual’s home, garden, place of work or
other surroundings is a key component to falls prevention and has been shown to be more effective when delivered by an occupational therapist.3,4
A multidisciplinary assessment may reveal other contributory factors, including cardiac, neurological, rheumatological and ophthalmological problems, which need onward referral and attention.
Some people, particularly those who are unable to stand after a fall, may require a community call alarm. There is often great reluctance by some people to be seen wearing these alarms, in this situation it may be worth encouraging them to carry a mobile telephone at all times. For others, it is possible for a physiotherapist to work with an individual to help them learn how to stand safely. Another consideration is arranging a key safe, or other method, to allow community teams’ access into the house if they are unable to stand.
An often unrecognised consequence of falls is the fear of falling syndrome. This is a vicious cycle in which a fall leads to a loss of confidence, then a change in gait pattern, which leads to an increased risk of falls, perpetuating the cycle. For some people the fear of falling can be so severe that it can be considered a phobia. For others it may be avoidance of specific situations, leading to social isolation, reduced quality of life and depression.5 Physiotherapy is one method to build up confidence and break the vicious cycle, but emerging research also suggests that cognitive-behavioral therapy may also be an effective treatment.6
In the longer term it is important to consider bone health. The National Institute for Health and Care Excellence (NICE) recommends calculating the risk of fracture to guide investigation and treatment. Those at low risk require dietary and lifestyle advice, those at intermediate risk require a bone density scan and those at high risk may need medication.7 NICE recommends using online fracture risk assessment tools such as FRAX or QFracture.8
Falls are preventable even with very simple measures. Those who have fallen are at an increased risk of further falls so action is required. A multi-disciplinary team approach is the most effective. Ability to get up from the floor may determine how much community assistance will be required.
1. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society 2001;49(5):664-72.
2. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of Internal Medicine 2009; 169(23): 1952-60.
3. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012. DOI: 10.1002/14651858.CD007146.pub3. (accessed 28 September 2015).
4. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. Journal of the American Geriatrics Society 2011;59:26-33.
5. Delbaere K, Crombez G, Vanderstraeten G, Willems T, Cambier D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age Ageing 2004;33:368-73.
6. Parry SW, Deary V, Finch T, Bamford C, Sabin N, McMeekin P, O’Brien J, Caldwell A, Steen N, Whitney SL, Macdonald C, McColl E. The STRIDE (Strategies to Increase confidence, InDependence and Energy) study: cognitive behavioural therapy-based intervention to reduce fear of falling in older fallers living in the community – study protocol for a randomised controlled trial. Trials 2014;15(6):210.
7. NICE TA160. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women, 2008. nice.org.uk/guidance/ta160 (accessed 28 September 2015).
8. NICE CG146. Osteoporosis: assessing the risk of fragility fracture, 2012. nice.org.uk/guidance/cg146 (accessed 28 September 2015).