BMJ 2001;322:855-857 ( 7 April )

Education and debate

Care of older people

Falls in late life and their consequences---implementing effective services

This is the last in a series of four articles

Cameron G Swift, professor of health care of the elderly. 

Department of Health Care of the Elderly, Guy's, King's and St Thomas's School of Medicine, London SE22 8PT

cameron.swift{at}kcl.ac.uk

A new national service framework published last week has set out clear standards of care for older people throughout England.1 I consider here the basis for and the implications of the inclusion in the framework of a defined service model for falls and their consequences. Consideration of the service implications of current evidence has become relevant not only in the United Kingdom but wherever demographic and epidemiological trends identify falls as an important health issue.


Summary points

Falls and their consequences are a major public health and economic issue
Falls are often a sensitive signal of unidentified and unmet health risk and healthcare need in individual older people
Evidence exists that falls can be prevented
Evidence exists that skilled and well organised clinical management after falls and fractures improves services and so benefits patients




    Why focus on falls?

The justification and impetus for a defined service model for treating and managing falls is both well founded and timely. Each year in Britain a third of the population aged over 65 has a fall, and half of these people fall at least twice.2-5 Women are at greater risk (particularly those living alone) than men, with half of all women aged over 85 in any one year having a fall.3-6 As most surveys depend on patients' recall, these figures are probably an underestimate.7 Mortality associated with falls in older people is high.8-11 In 1997, 67% of accidental deaths in females aged over 65 were due to falls.11 Fractured femur is associated with a 33% mortality within one year (probably also an underestimate because of the widespread failure to certify femoral fracture as a cause of death12).10

Patients aged over 75 admitted after an accident (most often a fall) occupy a hospital bed for an average of 18 days.13 In the community serious handicap or disability often lasts for several months or longer after a fall.14 If the rate of increase in the annual incidence of hip fractures in England and Wales seen in the early 1990s (then accounting for a quarter of all orthopaedic bed occupancy) continues, the annual incidence would rise by 60% to 96 000 by 2031.15 In economic terms this translates to 1.6 million extra bed days and £507m ($760m) in direct hospital costs.16

The capacity to stand upright is a fundamental human homoeostatic mechanism. Like other mechanisms, this capacity, when under stress, diminishes as we get older. The mechanism depends on sensory input (visual, proprioceptive, and vestibular), cerebral central processing, and robust voluntary and involuntary muscular effector responses.17 The reduced reserve may reflect age changes in one or more of these components.

The major consequence, however, is that any physiological, pathological, or pharmacological perturbation affecting one or more components of the mechanism may exceed the reserve capacity and result in falling. Falls are therefore a key syndrome in medical gerontology. They may be the first indicator that all is not well medically, and they should prompt a diagnostic appraisal aimed at early detection and intervention. Such diagnosis is often elusive and a challenge to the clinician's acumen.

The past decade has seen the publication of several controlled intervention studies signalling the value of preventive strategies. Given the normally multifactorial basis of falls in older people, it is not surprising that those incorporating a multidimensional assessment and intervention approach, targeting particularly those identified as at high risk, have given the most compelling results.18-22 This type of strategy can achieve annual reductions in rates of fall of 30-50% (compared with controls).19-22 The evidence is now substantial enough to justify the introduction of organised health service initiatives, although further work is needed to determine the most effective and efficient pathway of care, both in the United Kingdom and elsewhere.

Systematic reviews of the research on the effects of combined specialist (orthopaedic and geriatric) models of multidisciplinary rehabilitation after fractures---in particular, fractured proximal femur---show improvements on key outcome measures, but there is methodological inconsistency.23 The situation is similar to that of stroke rehabilitation a decade ago, before studies that controlled for prognostic variables and for categories and quantity of therapy and which used similar outcome measures allowed robust conclusions to be reached on the effectiveness of organised stroke rehabilitation. The research on falls urgently needs to be more rigorous.


    How to introduce effective measures

The recommendations fed into the national service framework are based on evidence in four main areas: primary prevention; measures for the early systematic detection of increased risk; what to do when increased risk is identified; and best practice in clinical management and rehabilitation after falls and fractures. Throughout, the need to target both falls and osteoporosis is recognised, as is the need to direct scarce resources towards priority interventions with strong supporting evidence.

Primary prevention
Prevention approaches that target specific populations (independently of individual risk status) need to be considered. Research evidence on the impact of such strategies on the incidence of falls and fractures is currently of poor quality, but it is logical (from the NHS standpoint) to promote low cost measures in primary prevention. The framework lists the following objectives: raised safety awareness among the public; improved environmental safety measures; lifelong healthy eating (with particular reference to calcium and vitamin D); and healthier levels of physical activity and exercise.

Two important principles need emphasis. Firstly, no evidence exists that any of the above measures become less useful with increasing age. Secondly, taking such objectives beyond platitude requires the inclusion of primary preventive measures in written local implementation plans; this would entail a costed and timetabled strategy for the prevention and management of falls and fractures---to be established in conjunction with agencies outside the healthcare system (such as social services departments, housing departments, and the voluntary sector).

Measures for early systematic detection of increased risk
The box outlines recognised modifiable and non-modifiable risk factors for falls and osteoporotic fracture. As prevention can be achieved by targeting those at risk, identification systems are needed---such as prospective screening in primary care and opportunistic assessment of risk as a part of good clinical practice in primary and secondary care.


Risk factors for falls and osteoporotic fracture

Falls

  • Readily detectable impairment of balance, gait, or mobility

  • Polypharmacy---in particular, drugs acting on the central nervous system and drugs to lower blood pressure

  • Visual impairment

  • Impaired cognition or depression

  • Stroke or history of stroke; Parkinson's disease; or degenerative lower limb joint disease

  • Postural hypotension

Osteoporotic fracture

  • Radiographic evidence of osteopoenia

  • Loss of height associated with osteopoenic vertebral deformity

  • Previous fragility fracture

  • Prolonged corticosteroid treatment

  • Chronic disorders associated with osteoporosis

  • History of premature menopause

  • History of maternal hip fracture

  • Low body mass index

The practical implementation of the systems in England and Wales requires an auditable "tightening up" of existing activity, with modification of the "over 75" screen and the use of evidence based assessment protocols in hospitals and general practices (box). Judging from experience in the main research studies, we may expect the efficacy yields to be high in relation to any modest additional costs entailed, but this should be the subject of prospective research.


Standards for early identification and preventive management of those at high risk

  • Incorporation of a falls risk assessment---using a standardised, evidence based assessment tool---into the modified health check of people aged over 75

  • Provision of a corresponding risk assessment, to be used opportunistically by primary care staff and, where appropriate, staff in partner agencies

  • The introduction of standardised, more structured proformas for clinical case records (incorporating key indicators of falls risk) for auditable use in primary and secondary health services in the assessment and care of older people

  • The development of clear and agreed referral pathways to and from an appropriate specialist falls service

  • Written strategies for the prevention of falls as part of risk management in hospitals

Some groups are already identifiable as being at high risk, including older people in nursing and residential homes24 and those admitted with medical or psychiatric illness to acute hospitals. Identification of people at risk of osteoporosis is through selective case finding---on the basis of the risk factors listed---or is triggered by the occurrence of a fragility fracture.25

What to do when increased risk is identified
The starting point for intervention (based on the accumulated evidence of benefit) is to ensure that a multidimensional specialist assessment takes place---if one has not already been done or if health or functional status has changed since a previous assessment.

The arrangements for this may vary. "Falls clinics" exist in some hospital based departments specialising in the medical care of older people, and they work to defined clinical protocols (currently in the process of being jointly agreed by the American and British Geriatrics Societies). Such protocols may become part of usual outpatient practice in the field. The focus is on placing existing good clinical practice on an auditable and more structured footing. Both intrinsic and extrinsic (environmental) risks are assessed in the context of functional capability, normally involving interdisciplinary working.

The resulting management of identified problems entails interdisciplinary teamwork, referral to relevant medical and surgical subspecialties, and access where appropriate to specialist syncope facilities.

Several contributory factors to falls risk are usually found in each individual. Therefore, the observed reduction in the incidence of falls19-22 is mostly attributable to the detailed and systematic nature of the overall multidimensional assessment and the appropriate action taken, rather than to single defined interventions. The "black box" character of this in no way limits the implications of its efficacy.
 
(Credit: ARTHUR TRESS/PHOTONICA)

For osteoporosis the need is for a "safety net" service structure to ensure that cases do not go unidentified. Protocols for falls clinics incorporate the relevant assessments, and joint specialist clinics for osteoporosis and falls are increasingly emerging. Agreed policies for osteoporosis surveillance and intervention (in line with the Royal College of Physicians' guidelines25) are a requirement of the framework, coordinated by a designated lead consultant---for example, a clinical biochemist, gerontologist, or rheumatologist---working in collaboration with one or more named general practitioners.

The nature and organisation of intervention for the high risk groups in nursing and residential homes and hospitals is so far more difficult, in view of the paucity of evidence for successful preventive strategies. This is an undoubted priority for further research.

Management and rehabilitation after falls and fractures
"Non-injurious" falls (those not associated with fractures) signal the need for a careful diagnostic review, and they often also lead to a reversible loss of functional independence and confidence. If an illness has caused the fall, recovery may take longer (and therefore require a longer stay in hospital), with the patient receiving parallel medical and rehabilitative treatment.

Patients who incur fractures for which surgery is inappropriate---for example, proximal humeral or carpal fractures---often present a particular challenge to rehabilitation. Incapacity is often substantial yet continued inpatient treatment is not indicated.

Although the relative efficacy of the various collaborative service models for orthopaedic surgery and geriatric medicine has not been conclusively determined,23 the case for local authorities operating a model of this sort is strong and is a requirement of the English framework. The models use early referral pathways, joint or cross specialty ward rounds (sometimes incorporating orthogeriatric units), and early or supported discharge programmes. The framework requirement for local purchasers and providers to identify and implement a preferred model may well provide an impetus for more research.

Although the rationale for consistent osteoporosis assessment in older people who fall (with or without a fracture) is clear, many patients still do not receive such an assessment, and the framework will assist in driving implementation of the required standards. Automatic risk assessment after a fall should ensure that those with clinical and radiographic evidence of osteoporosis after fractures routinely receive treatment.

As (potentially injurious) falls are likely to happen more than once, follow up should be vigilant and based on information exchange (shared standardised records), continuing joint primary and secondary health care, and collaboration with social services for ongoing surveillance and support.


    Conclusions

Treatment and prevention of falls in older people spans primary and secondary prevention, diagnostic ascertainment and assessment, acute medical and surgical care, functional assessment and rehabilitation, continuity and organisation of follow up, and, for some patients, long term supportive or institutional care. Hence the quality, cohesion, and cost effectiveness of falls services is to some extent an indirect marker of health services for older people as a whole. This element of the national service framework should lead to an improvement in the appropriate services, and the main outcome measure---the incidence of falls and fractures---should not be too difficult to ascertain. The lessons learned could be applied to, and lead to improvements in, the future health care of ageing populations.

    Acknowledgments

I thank Dr J Close for help in scrutinising the literature.

    Footnotes

Series editor: Ian Philp i.philp{at}sheffield.ac.uk

Funding: No special funding.

Competing interests: None declared.


    References

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11. Office for National Statistics. 1997 Mortality statistics: injury and poisons. London: Stationery Office, 1999.
12. Calder SJ, Anderson GH, Gregg PJ. Certification of cause of death in patients dying soon after proximal femoral fracture. BMJ 1996; 312: 1515[Free Full Text].
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25. Royal College of Physicians. Osteoporosis clinical guidelines for prevention and treatment. London: RCP, 1999.

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