Globally, falls are the second most common cause of accidental or unintended injury mortality, with those over 65 years of age having the greatest number of fatal falls (World Health Organization (WHO), 2018). Of course, most falls are not fatal, but they may require a healthcare intervention, and some cause ongoing disability and, as such, they are a cause of significant cost to the NHS and other health systems (Florence et al, 2018). One in three people aged over 65 years living in the community experience at least one fall a year, with some suffering multiple falls (National Institute for Health and Care Excellence (NICE), 2013). Therefore, falls in older people are a major public health issue and a concern for district nursing teams.
Public Health Outcomes Framework 2019/20 (Public Health England (PHE), 2019) reported that there were approximately 220 150 emergency hospital admissions of people aged 65 years and over related to falls, with two-thirds of these admissions being for people aged 80 years and over. In England, fall hazards in the home are estimated to cost the NHS £435 million, to which needs to be added the annual cost of fractures in the UK, which is estimated at £4.4 billion (£2.0 billion for hip fractures and more than £1.0 billion for social care). Further, hip fractures are associated with increased one-year mortality (18–33%) as well as reduced independent activities of daily living, such as walking and shopping, and life satisfaction and, for some, a hip fractures is a precursor to entering long-term care. Indeed, the impact at the personal level can be significant, as a fall may lead to a loss of confidence due to fear of falling and withdrawal from normal activities with consequent social isolation and loneliness.
A fall occurs due to gravity when the normal processes that keep a person upright fail. ‘A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’ (WHO, 2018) and should be distinguished from slips, trips, faints and stumbles, because each leads to different treatment and has different prevention strategies. While faints describe a short-lived loss of consciousness due to hampered blood flow to the brain, it is also important to distinguish between a loss of consciousness (although not always) caused by suddenly abnormal electrical activity in the brain, which is generally associated with abnormal muscle contractions of the body and may be labelled a fit or seizure. The sensation of dizziness may be reported prior to a fall, but different people may use different terms such as ‘dizzy’, ‘vertigo’, ‘unsteady’, ‘off-balance’ and ‘feeling light-headed, all of which may mean different things to different people.
Falls happen throughout the life cycle but are more prevalent with increasing age (Blain et al, 2016). Unfortunately, with increasing age, the body is less resilient to a fall, and significant injury is more likely. Skin and blood vessels become more fragile, with fractures occurring in 10% of older people who fall, with 2% fracturing a femur (Blain et al, 2016a). Although falls are prevalent, there is a reluctance to report a fall for a variety of reasons, which include:
Gravity and anatomy
Humans have evolved over millions of years to manage the effects of gravity. The head comprises a heavy skull protecting the brain and, unlike in apes, the human skull is positioned centrally to accommodate the body's upright position, and the spine is S-shaped to distribute the upper body weight directly over the broader base of deep and curved pelvis bones to support organs sitting above them to help maintain balance (Seeley et al, 2011). The femur points inwards to the large knee joint, focusing the centre of gravity over the foot so that body weight is centred over the feet. Large and strong ankle joints and pedal arches offer strength and stability. Compromises such as muscle weakness, arthritis or joint replacement may increase the risk of falls because the normal mechanisms for maintaining upright balance are undermined.
The brain receives data continuously to sustain body balance: (i) visual data about body position relative to other objects and whether the environment is stationary or moving; (ii) inner ear data about speed and acceleration of movement; and (iii) data from skin, muscles and joints, including those of the feet, regarding stretch and pressure so that we know what our limbs are doing and where they are. The brain integrates the data, and we respond to avoid losing balance accordingly. Thus, loss of a data source, such as sight, may result in people feeling unsteady (disequilibrium); however, the existence of multiple sources of data usually ensures that if we mistakenly believe we are moving backwards when a train moves out of a station, the inner ear data and data from skin, muscles and joints confirm that there is no such movement. If there is long-term loss of one source of sensory information, such as limb or visual loss, the brain learns to adjust and compensate over time.
The ageing body
The number of brain cells declines with age, but most people cope well with no ill-effects. However, hypertension, high cholesterol, smoking and alcohol can speed up this decline and affect walking, balance and the ability to react to a loss of balance. A healthy lifestyle is a mitigation that district nurses should promote as part of their practice.
There are many age-related changes in the eye, of which the most important include the reduced ability to see contrast and, therefore, small elevations or steps; slower pupil reaction, which reduces vision in poor light; reduced peripheral vision; and the need to wear spectacles. Regular vision tests, protecting eyes from sunlight, avoiding bi- and varifocal lenses and allowing extra time to adjust when moving from bright to dim light and vice versa are mitigations that district nurses should promote to their clients.
The flexibility of blood vessels declines with age and may result in postural hypotension pressure even in the presence of hypertension. District nurses should encourage their clients to be well hydrated, avoid smoking and remain active as mitigations. Similarly muscle loss increases and strength reduces with age, which may impact upon the maintenance of balance, thereby increasing the risk of falls. Remaining active and doing strength exercises are solutions that should be recommended to district nursing clients and their carers where possible.
Inevitably, joints can become damaged through wear and tear over time. To compensate, people change their walking style, which may alter the data flow to the brain and undermine the normal process for maintaining balance. Stiffness and pain in the feet are not uncommon with advancing age. Remaining active, having a healthy weight and wearing appropriate shoes mitigate the risk of falls under such circumstances.
Understanding why a fall has occurred
There is always at least one reason why someone has fallen, but there may even be a combination of factors (multi-factorial) (Terroso et al, 2014). Accidental falls are those that could happen to anyone, while medical falls are those related to a specific medical problem, and postural falls describe those occurring due to impaired balance and/or gait. A risk factor for falling is something that increases the chance of a fall, and identifying risk factors is an essential component of fall prevention.
The WHO (2007) suggested that risks fell into four categories, namely, biological, behavioural, environment and socioeconomic (Table 1), and acknowledged that there may be interaction between various risk factors. Terroso et al's (2014) literature review identified the factors reported in 87 key papers published between 1995 and 2010, with behavioural risk factors being the most frequently reported followed by biological risk factors (Table 2). The biological indicator of decline in functional independence is also an indicator of frailty, which is associated with recurrent falls (Turner and Clegg, 2014). Terroso et al (2014) also identified the neurological, musculoskeletal, cardiovascular and other conditions associated with falls (Table 3).
| Category | Examples |
|---|---|
| Biological | Non-modifiable: age, gender, race Age-related: decline of physical, cognitive and affective capacities and comorbidities |
| Behavioural | Risky behaviour, e.g. intake of multiple medications, excess alcohol use and sedentary behaviour Previous fall in last 12 months |
| Environmental (interaction between individual and their environment) | Home hazards, e.g. narrow steps, slippery floor or step surfaces, loose rugs and poor lighting. |
| Socioeconomic | Low income/poverty, limited education, poor housing, lack of social interaction, limited access to health and social care and lack of community resources |
| Category | Examples |
|---|---|
| Biological |
|
| Behavioural |
|
| Environmental |
|
| Socioeconomic |
|
| Category | Examples |
|---|---|
| Neurological conditions |
|
| Musculoskeletal conditions |
|
| Cardiovascular conditions |
|
| Other conditions |
|
Multifactorial falls risk assessment
The NICE Quality Standard (2018) acknowledged that there are more than 400 risk factors associated with falls, with the risk of falling increasing in the presence of more risk factors. Identifying the particular risk factors and circumstances for an individual is an essential component to preventing future falls and is best undertaken using a multifactorial falls risk assessment (NICE, 2018). Further, NICE (2018) noted that practitioners should view fragility fractures as sentinel events upon which future preventive care should be built.
NICE (2013) (clinical guideline being updated) recommended that any person aged 65 years or older who presents to healthcare with a fall or reports recurrent falls should receive a multifactorial assessment (Table 4). However, the presence of an increasing number of risk factors or physiological deficits increases the risk of falls and fractures as well as the likelihood that the person is frail. Where frailty is suspected, the British Geriatric Society (BGS) recommends a holistic assessment based upon comprehensive geriatric assessment (CGA) (Turner and Clegg, 2014), but the BGS does not recommend population screening for frailty.
| Identification of falls history | Note: Even cognitively intact older people are unable to recall documented falls 3 months after the event |
| Assessment of gait, balance and mobility, and muscle weakness | Timed up and go test Dynamic Gait Index Watch person stand and walk Lower limb strength |
| Assessment of osteoporosis risk | See NICE (2017) |
| Assessment of the older person's perceived functional ability and fear relating to falling | Barthel ADL Index Activity-specific Balance Confidence Scale (ABC) ‘Fear of falling’ syndrome |
| Assessment of visual impairment | NHS eye tests are free for 60-year-olds and over |
| Assessment of cognitive impairment and neurological examination | Multiple mini-interview (MMI) Neuropathy and vestibular function tests Proprioceptive assessment |
| Assessment of urinary incontinence | Bladder control problems are common problem in those over 60 years. Use local protocols |
| Assessment of home hazards | Loose rugs, etc. Ill-fitting shoes and slippers Poor lighting Using a walking stick or frame (because many are the wrong size) |
| Cardiovascular examination | Include lying and standing blood pressure |
| Medication review | Taking four or more medicines (regardless of what they are) Note: psychotropic medications |
Gaining an accurate picture of the circumstances of a fall or series of falls can be difficult, so where it is possible, it may be useful to ask a district nursing client to maintain a simple falls diary. Each time a fall occurs, a district nursing client should be encouraged to record the incident in the diary as soon as possible, which helps overcome the problem of poor recall. Sometimes, the frequency and timing of falls can provide vital clues to the causation of falls.
The most obvious injuries following a fall include bruises, grazes and cuts, although people age and their skin and vessels become more fragile, these injuries may appear more visible. A minority will suffer a fracture. However, a significant non-physical injury is fear of falling, which may lead to avoiding some activities or limiting life to staying in the home. Fear of falling impacts not only the individual but also the wider family through reduced contact, heightened concern from family and potentially increased dependence upon others, as well as reduced social contact, including with friends and attendance at social events.
Fear of falling reflects a person's belief in their own ability to perform a task safely, without losing balance or falling. A fear of falling involves real anxiety and can result in physical sensations, such as nausea and palpitations, associated with the fear. They often appear after a fall, although they may also affect people who have not had any falls. It is important to consider fear of falling because it can lead to the avoidance of activities, which, in turn, leads to a person moving less and, therefore, becoming less fit and losing strength, mobility and balance, which increases the risk of more falls. A vicious cycle of falling and fear can ensue. The Falls Efficacy Scale-International (FES-I) (Yardley et al, 2005) was developed drawing upon a systematic review and expert workshops (Jørstad et al, 2004). It has been validated in four European countries (Kempen et al, 2007) and found to be feasible within clinical practice (Helbostad et al, 2010). However, it may be worth considering the shorter version (Short-FES-I) comprising seven rather than 16 items (Kempen et al, 2008), which is probably more feasible and also has good validity and reliability, including for those with cognitive impairment (Hauer et al, 2011).
Conclusion
Falls are common among older people, and understanding their causation is essential to the development and implementation of effective preventive strategies. District nurses are well placed to undertake and/or contribute to a falls risk assessment of their clients and to recommend preventive interventions, thereby reducing the falls risk.
A second article Falls and older people: preventive interventions will discuss specifically how district nurses can help prevent falls in older people.