Falls prevention: risk assessment and intervention

Falls are not an inevitable part of the ageing process. However, as we age our risk of falling does increase and, as has been well documented, our population is ageing. Thus a consistently increasing number of our patients are at risk of falls. Currently a third of those over 65 years of age and a half over 80 years fall every year, and of those who do fall, a third will fall again within six months. 

With more than 300,000 Irish people aged 50 years and over having osteoporosis, the possibility of many of these falls resulting in fragility fractures is grave. In a person with normal bone mineral density (BMD) a simple fall, that is a fall from a standing height or less, would not result in a fracture.¹ But with a diagnosis of osteoporosis (a BMD of 2.5 standard deviations below the mean) the propensity for fragility fractures is acute.

The statistics of recovery from fractures do not make for pleasant reading. Of those who sustain hip fractures for example, less than half will return to their baseline or go directly home, and more than a fifth will require long-term care. Indeed recovery from fractures can often initiate a vicious cycle where an inability to regain baseline function or activity level can lead to an increase in bone loss and in turn an increased risk of fracture. 

Falls that do not result in fractures also have serious consequences, including reduced quality of life, fear of falling, reduced confidence and social isolation. Falls are not only associated with morbidity and mortality in the older population, but are also linked to poorer overall functioning and early admission to long-term care facilities. 

The current and predicted economic burden of falls in Ireland and internationally is difficult to overlook. The economic burden of illness study conducted by the Irish Centre for Social Gerontology reported that if current trends continue the annual cost of falls and fractures could be €1 billion by 2020 and €2bn by 2030.²

Multifactorial falls risk assessment and intervention

The strategy to prevent falls and fractures in Ireland’s ageing population published in 2008 delineates the lack of integrated service provision in the areas of falls risk screening, assessment and intervention on a comprehensive population basis. 

Best practice guidelines outlined in the strategy stipulate that a patient presenting with recurrent falls, an unexplained fall, difficulties with gait or balance, or a fear of falling should have a multifactorial assessment and relevant intervention. 

A patient presenting with a single explained fall should have a balance assessment and then either be screened annually for their risk of falling or have a multifactorial assessment and intervention.

The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) updated their clinical practice guidelines for the prevention of falls in older persons in 2010.³ They use a clinical algorithm to describe the process of decision-making and intervention that should occur in the management of older people who present with recurrent falls, with difficulty walking or who present to an emergency department following a fall. The updated guidelines make recommendations in the assessment and intervention process.

In the area of assessment it is recommended that, as well as those who present with a fall and have observed gait and balance problems, patients who simply report difficulties with their gait or balance should have a multifactorial falls risk assessment.³

A falls history should include:

• Frequency of falls
• Symptoms at time of falls
• Any injuries sustained.

In addition, a falls assessment should incorporate:

• Examination of feet and footwear
• A functional assessment, including an individual’s perceived functional ability and fear of falling
• An environmental assessment including home safety.

Intervention

A detailed assessment is of limited clinical use if it does not lead to tailored intervention. The updated BGS/AGS guidelines stress the importance of risk factors identified during assessment being addressed in interventions. 

Exercise: Exercise that includes balance, gait and strength training should be included in interventions with community-dwelling older adults. 

Environment: Environmental adaptation should follow domiciliary appraisal and should address the safe performance of daily activities as well as fall risk factors. 

Vitamin D: Daily vitamin D supplementation is recommended for all older adults at risk of falls, and there is strong evidence to support vitamin D supplementation for older adults with known deficiencies residing in long-term care. In their 2011 report Ross et al concluded that calcium and vitamin D have a key role in skeletal health. The recommended daily allowance (RDA) for men and women over 70 years is 1,200mg/day of calcium and 800IU/day of vitamin D.⁴

Medication review: Previously medication review was recommended for anyone on four or more medications; now medication review is encouraged for all older people. 

Vision and postural hypertension: The importance of vision assessment as part of the overall assessment is highlighted, as is the need to include assessment and treatment of postural hypotension. 

Home safety: Home safety assessments are recognised as being a valuable part of a multifactorial falls prevention programme. Persons at risk of falls should have their home environment made safer not only through the removal, replacement or modification of hazards, but also by being taught awareness of hazards and how to avoid them.⁵ It is also important that assistive devices that are prescribed are used appropriately; otherwise they in turn can become a falls risk.  

Community settings

International and national guidelines recommend that those working in the community should ask older people about any falls and undertake a brief mobility screen annually. The need for screening in the community is negated if a patient presents with two or more falls in the previous year, and these patients should proceed directly to having a detailed assessment.^3,6

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Acute screening

Formal falls risk screening tools may not be the ideal platform for identifying at-risk patients in emergency departments, given the nature of the environment and the fact that patients who present with fall-related injuries do not necessarily have falls assessments completed.⁷ More consistent identification of at risk patients may be achieved through specific questioning which addresses recent falls history, observed or perceived balance difficulties, level of independence with activities of daily living, and identification of other fall risk factors.

Falls are one of the most common adverse clinical incidents in acute settings. Acute admissions are often associated with a change in physical and/or cognitive functioning. Combined with an unfamiliar environment this change in functioning can increase the risk of falls. 

Screening tools have been developed to identify those with a risk of falling who have been admitted to an acute setting. The modified STRATIFY is one of the more commonly used tools^8,9 and patients identified as at risk of falls through it, need more in depth assessment to ensure intervention can be specific. 

Falls rate per 1,000 bed days is a commonly used statistic to measure and track falls. A simple calculation of the number of patient falls divided by the number of patient days multiplied by 1,000 provides a falls rate. The literature is divided on a set standard rate acceptable or common to acute hospitals, but a range of 3-13 falls per 1,000 bed days with a recognised average rate of 4.8 has been reported.^10-12

Many tools have been developed for identifying those at risk of falling. Whichever one is used, it is in everyone’s best interest if it leads to a full assessment and relevant intervention that addresses all the risk areas identified.

References

1. World Health Organisation. Assessment of fracture risk and its application to screening for post menopausal osteoporosis. WHO Technical Report Series 843, Geneva, WHO, 2003
2. Gannon B, O’Shea E, Hudson E. The Economic Cost of Falls and Fractures in People aged 65 and over in Ireland – Technical Report 1. Irish Centre for Social Gerontology: National University of Ireland, 2007
3. American Geriatrics Society & British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc 2011; 59: 148-57
4. Ross AC, Manson JE, Abrams SA et al. The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. J Clin Endocrinol Metab 2011; 96(1): 53-8
5. Falls the assessment and prevention of falls in older people. National Institute for Clinical Excellence (NICE). Clinical Guideline 21, November 2004
6. Australian Commission on Safety and Quality in Health Care. Falls prevention guidelines – preventing falls and harm from falls in older people: best practice guidelines for Australian hospitals, residential aged care facilities and community care. 2009. www.health.gov.au/internet/safety/publishing.nsf/content/fallspreventionguidelines
7. Donaldson MG, Khan KM, Davis JC et al. Emergency department fall-related presentations do not trigger fall risk assessment: a gap in care of high-risk outpatient fallers. Arch Gerontol Geriatr. 2005; 41(3): 311-7
8. Papaioannou A, Parkinson W, Cook R et al. Prediction of falls using a risk assessment tool in the acute care setting. BMC Med 2004; 2: 1
9. Close JCT, Lord S. Fall assessment in older people. BMJ 2011; 343: d5153
10. Healey F, Scobie S, Oliver D et al. Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports. Quality and Safety in Healthcare 2008; 17: 424-30
11. Oliver D. Preventing falls and fall injuries in hospital: a major risk management challenge. Clinical Risk 2007; 13: 173-8
12. Oliver D, Connelly JB, Victor CR et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analysis. British Medical Journal 2007; 334(7584): 82-7