It is only comparatively recently that falls in later life have been recognised as an important health issue.
The scale of the problem is in part directly associated with an ageing population. In developed societies, approximately a third of people over 65 years sustain a ‘significant’ fall each year, and half of these individuals have at least two falls. The prevalence rises to 50% in women over 80 years.1-4
The ratio of health- and/or environment-related risk to that of risk-taking behaviour by healthy individuals increases with age. The focus of any proposed intervention is, of course,on tackling health and environmental risks.
Several sets of evidence-based consensus recommendations have been disseminated internationally,5-7 and the most recent, NICE Clinical Guideline 21, is the most relevant to the UK healthcare system.
The need for a guideline
In addition to prevalence, there are several reasons why it is important to detect risk and prevent falls.
The consequences of falls
Fractures, particularly of the proximal femur, are the most obvious and widely publicised consequence of falls. Although in older people only 5% of all falls cause fractures,8 over 95% of fractures are caused by a fall.9 In addition, only about half of proximal femoral fracture risk is attributable to reduced bone mass, the remainder being due to ‘non-skeletal’ risk, particularly the risk of falling.10
As well as increasing the risk of fractures, falls also reduce independence and bring about lifestyle changes, with a wide range of health consequences.
Falls in the over-60s result in about 650 000 accident and emergency attendances and 200 000 hospital admissions annually in the UK, at an estimated cost to the NHS and social services of more than £900 million. About two-thirds of those treated are over 75 years.11 Around 90 000 hip fractures occur annually, costing the NHS £1.7 billion.12
Falls as a signal of unidentified health need
The network of physiological mechanisms that enables humans to maintain an upright position exhibits a variable decline in functional reserve capacity in later life.13 It is thus more vulnerable to the effects of illness or pharmacological action.
Falls, therefore, especially if recurrent, should be seen as a kind of early warning signal and activate the diagnostic antennae of clinicians. It is neither chance nor a solely social phenomenon when sick older people are found on the floor by the home help. Identifying falls and falls risk is rightly an integral element of primary and preventative care in this age group.
Evidence for falls prevention
Based on prospective or opportunistic risk identification, annual falls prevention rates of 30-50% and higher in those at risk have been well documented in randomised controlled intervention studies.14-18 Translating these results into service delivery has considerable potential at population level.
It follows that falls prevention strategies are wholly logical elements of healthcare provision for ageing populations in developed societies.
How good is the evidence?
The evidence from controlled intervention studies for the effectiveness of prevention in individuals identified as at risk is now robust. It is important to note that this evidence does not apply to the general population, and successful intervention studies have accurately identified and selected those at risk.
A recent US-based meta-analysis of 40 randomised controlled trials reinforced the fact that these findings on prevention can be replicated internationally.19
Of the approaches investigated, multifactorial intervention tailored to the individual and based on multidimensional assessment has the strongest evidence base,19 and this is reflected in the guideline (Figure 1, below).
|Figure 1: Algorithm showing patient referral and care pathway|
|Reproduced from Falls the assesment and prevention of falls in older people by kind permission of NICE|
Single interventions are appropriate for some individuals, but only after careful assessment and analysis of other risks. These interventions include strength and balance training, home hazard assessment and intervention, medication review/ withdrawal, vision assessment and referral and cardiac (usually dual-chamber) pacing for carotid sinus syndrome.
The guideline also identifies strategies for which – however superficially persuasive they may be – supporting evidence is either deficient or lacking. These include programmes providing non-individualised exercise or non-targeted group exercise, educational, cognitive or behavioural modification interventions, and hip protectors (for fracture prevention).
Although fractures are not the sole serious consequence of falls, it is legitimate to ask whether preventing falls prevents fractures. In practice, this requires a very large trial population, such as those of the large-scale studies of bone anti-resorptive therapy.
Evidence gathering and risk analysis hitherto has been limited by the fact that falls are not recognised by Read codes or other routine data collection instruments.
Studies are under way, and the precise contribution of falls reduction and osteoporosis therapy to fracture prevention will emerge. However, interventions that target both skeletal and non-skeletal risk are likely to maximise benefit, and any proposed delivery models must ensure that falls services and bone health services are closely dovetailed.20
Because of the potential service costs, service investment must be limited to measures of demonstrable efficacy. Nevertheless, there is at present a substantial gap between evidence and implementation. Preliminary health economic modelling, undertaken as part of the guideline development process, indicates that implementing multifactorial intervention would – at worst – prove cost neutral in terms of the effect on proximal hip fractures alone.
Implications for practice
The NICE guideline, in common with many others, envisages a broadly two level strategy (see Figure 1).
Case and risk identification
The first level involves a practical approach to the early detection of a much higher proportion of older people at risk than at present – a straightforward population ‘safety net’ in primary and secondary care.
Two of the most useful predictors for falling are a history of previous falls and an observable abnormality of gait or balance.1 It is essential therefore to identify and document them at every opportunity, and to recognise that if they occur together, the individual is at risk and probably in need of a second level risk assessment.
A major strength of this basic approach is its simplicity. Although it is not onerous, it is not necessarily a routine element of every clinical encounter at present. If every clinician treating an older person were to make a habit of asking about falls, and then ask that individual to stand up, take a few steps, turn round and sit down again, the evidence is that this alone would have a major effect on early risk detection.
Multifactorial risk assessment
The second level is a more complex and comprehensive process involving a degree of definition and specialised focus (Box 1, below).
|Box 1: Multifactorial falls risk assessment|
A multifactorial risk assessment should be part of an individualised, multifactorial intervention and may include:
While in some cases it may prove possible to complete an assessment in routine practice, not every general clinician in primary or secondary care will feel able or willing to do so.
In many instances, a multidisciplinary approach will be required, together with access to tilt table services and to new methods for measuring aspects of functional status and impairment to enable intervention to be individualised.
It is envisaged that while clinicians will compile as much information as possible and provide this on referral of those deemed at risk, the second level, multifactorial assessment will be an auditable activity within the framework of a defined falls service, however that is configured.
The implications for GPs will vary, therefore, depending on local service configuration and individual involvement and interest in the field. The commitment may, for example, be limited to basic first level risk detection and referral. Alternatively, it could embrace a leadership or coordinating role in the falls service.
The NSF for Older People
Standard 6 of the NSF for Older People enshrined the general concept of the falls service in NHS policy and set out a patient care pathway.21 This rightly focused on the individual, but did not elaborate on how care would be delivered.
Nearly four years on, the NICE guideline development group has been able to build on a wealth of new evidence to produce a clinical guideline with an auditable service model that is tailored to integrate economically and realistically into NHS structures. It provides a much clearer (and, importantly, evidence-based) broad service specification for commissioning purposes and, in effect, provides the mechanism for PCTs to deliver the NSF requirements.
Methods of delivering falls services
Wherever the falls service is based, it will need to bridge primary and secondary care effectively and ensure that it is successfully linked to or integrated with bone health services. Until now, most services have been based in secondary care, but there are recent examples led by GPs with a special interest in the field.
Fracture liaison services, linked to orthopaedic surgery and/or elderly care departments, have developed secondary prevention programmes. These are primarily focused on raising the take-up of bone densitometry and other aspects of osteoporosis assessment, and on rehabilitation following fracture and follow-up shared with primary care. These services are now increasingly integrating their activity with falls prevention programmes, because a high rate of early re-fracture is linked to the risk of falls.
In other instances, falls programmes have been set up, usually in elderly care departments, to provide referral or liaison services to orthopaedic departments and at the same time develop the necessary links or integration with osteoporosis services and primary care. Elsewhere, bone health services based in rheumatology, endocrinology, gynaecology and clinical biochemistry departments have taken the lead.
While there is a need nationally for a number of freestanding specialised falls/bone health service units with a strong research and development agenda, in many centres this would be uneconomical.The key then lies in modifying practice and enhancing links between existing services.
It should be possible routinely to carry out a multifactorial risk assessment, involving clinicians from a range of disciplines, in the outpatient or day patient services of any elderly care department. Increasingly, it should also be practicable for a wider range of risk assessment and subsequent review to take place in primary care, particularly with the increasing use of shared records.
In order to realise the results apparent from research, falls services must work to common protocols and outcome measures and offer a comprehensive range of interventions.These requirements will govern performance assessment as well as further research and development.
The NICE guideline comes at a time when there is a genuine prospect of reducing the individual, public health and economic burdens of falls in later life and their consequences.
Although further research is required, there is already ample evidence to inform service change.The guideline presents commissioners with a key responsibility and the opportunity to meet the requirements of Standard 6 of the NSF for Older People.
NICE Clinical Guideline 21. Falls: the assessment and prevention of falls in older people can be downloaded from the NICE website: www.nice.org.uk
- Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981; 10: 264-70.
- Prudham D, Evans JG. Factors associated with falls in the elderly: a community study. Age Ageing 1981; 10: 141-6.
- Lach HW, Reed AT,Arfken CL et al. 1991. Falls in the elderly: reliability of a classification system. J Am Geriatr Soc 39: 197-202.
- Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med 1989; 320: 1055-9.
- American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons.J Am Geriatr Soc 2001; 49: 664-72. www.americangeriatrics. org/products/positionpapers/Falls.pdf
- National Osteoporosis Society. Primary Care Strategy for Osteoporosis and Falls. A framework for health improvement programmes implementing the National Service Framework for Older People. London: NOS, 2002. www.nos.org.uk/
- Marsh D, Simpson H, Wallace A. The Care of Fragility Fracture Patients. London: British Orthopaedic Association, 2003. www.boa.ac.uk/ PDFfiles/careoffragilityfractures.pdf
- Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319: 1701-7.
- Youm T, Koval KJ, Kummer FJ, Zuckerman JD. Do all hip fractures result from a fall? Am J Orthop 1999; 28: 190-4.
- Marks R,Allegrante JP, Ronald MacKenzie C, Lane JM. Hip fractures among the elderly: causes, consequences and control. Ageing Res Rev 2003; 2: 57-93.
- Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health 2003; 57(9): 740-4.
- Torgerson DJ, Iglesias CP, Reid DM. The economics of fracture prevention. In Barlow DH, Francis RM, Miles A, eds: The Effective Management of Osteoporosis. London: Aesculapius Press, 2001. pp. 111-21.
- Wolfson LI,Whipple R,Amerman P et al. Gait and balance in the elderly.Two functional capacities that link sensory and motor ability to falls. Clin Geriatr Med 1985; 1: 649-59.
- Rubenstein LZ, Robbins AS, Josephson KR et al. The value of assessing falls in an elderly population. A randomized clinical trial. Ann Intern Med 1990; 113: 308-16.
- Tinetti ME, Baker DI, McAvay G et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331: 821-7.
- Ray WA,Taylor JA,Meador KG et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997; 278: 557-62.
- Campbell AJ, Robertson MC, Gardner MM et al. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999; 47: 850-3.
- Close J, Ellis M, Hooper R et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93-7.
- Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Br Med J 2004; 328: 680-6.
- Swift CG. Care of older people: falls in late life and their consequences – implementing effective services. Br Med J 2001; 322: 855-7.
- Department of Health. National Service Framework for Older People. London: DoH, 2001. www/doh.gov.uk/nsf/olderpeople