Falls and older people: preventative interventions

The Public Health Outcomes Framework 2019/20 (Public Health England (PHE), 2019) reported that there were nearly a quarter of a million emergency hospital admissions for people aged 65 years and over related to falls, with two-thirds of these admissions being for people aged 80 years and over, causing a significant cost to the NHS and at a personal level to the individuals who experience a fall. Hospital costs are not the only cost of falls, because a substantial number of those who fall are unable to return to independent living and are discharged to care homes, and many of those who do manage to return to their own homes may have a fear of falling, which causes a reduction in activity levels and a consequent loss of strength, in turn resulting in a greater risk of future falls and an increased need for community support from relatives, social care and health services (PHE, 2018).

This article builds upon the previous article Falls and older people: understanding why people fall (While, 2020), which set out the potential causes of falls among older people and discussed how district nurses may contribute to falls risk assessments. While it is not possible to prevent all falls, there is evidence that some falls can be prevented using effective interventions.

Public Health England (PHE, 2018) has assessed four interventions that could be applied within UK community settings, namely, the Otago programme (Iliffe et al, 2014); the falls management exercise programme (Iliffe et al, 2014); tai chi or tai ji quan exercises (Li et al, 2016); and home assessment and modification (Tse, 2005).

Otago home exercise programme

This programme comprises 30 minutes of leg muscle strengthening and balance retraining exercises that progress in difficulty and are performed at home at least three times per week, together with walking for up to 30 minutes at a moderate pace at least two times each week over 24 weeks. Participants receive an instruction booklet and ankle cuff weights (starting at 1 kg) to provide resistance for strengthening exercises. The programme is introduced by trained staff who have tailored it to participants in a group session or at the participants' homes if they are unable to attend a group session. Trained peer mentors undertake home visits to start the exercise programme and undertake a further four home visits (as required), as well as providing up to 12 telephone contacts (Iliffe et al, 2014).

Falls management exercise programme

This is a community-based group programme delivered by a postural stability instructor (PSI) and comprises a 1-hour-long PSI-delivered group exercise class in a local community centre for a maximum of 15 participants, and two 30-minute home exercise sessions per week over 24 weeks (as with the Otago exercise programme, an instruction booklet is provided). Participants were advised to walk at least twice per week for up to 30 minutes at a moderate pace. The programme uses resistance bands and mats with leg muscle strengthening and balance retraining exercises that progress in difficulty, progressive trunk and arm muscle strengthening, bone loading, endurance (including walking) and flexibility training, functional floor skills and adapted tai chi. The group exercises include retraining of the ability to get up from, and down to, the floor (using a backward chaining approach); floor exercises to improve balance; trunk and lower body strength and flexibility; and coping strategies to reduce the risk of complications resulting from a long lie. The weekly classes last between 45 and 75 minutes, with additional home exercises over at least 6 months (Iliffe et al, 2014).

Comparison of the Otago home exercise and falls management exercise programmes

The Otago home exercise programme, the falls management exercise programme and usual care were compared in a pragmatic trial (Iliffe et al, 2014) using a sample of 1256 older people (aged ≥ 65 years) recruited from 43 general practices in London and Nottingham/Derby. The trial was conducted to provide evidence for public health policy and to test how habitual physical activity might be improved in light of the evidence that recommended physical activity levels help prevent functional decline and thereby mitigate frailty, falls and fractures in older people (McClure et al, 2005).

Among the sample reporting at least 150 minutes of moderate to vigorous physical activity (MVPA) per week, the MVPA per week rose between baseline and 12 months after the intervention (40–49% for those receiving the falls management exercise programme, 41–43% for those receiving the Otago home exercise programme; and 37.5–38.0% among those receiving usual care). A significant difference (p=0.02) was found in MVPA per week among those who had received the falls management exercise programme compared with those receiving usual care at 12 months; there was no significant difference in the MVPA per week between those who had received the Otago home exercise programme and those who received usual care at 12 months. Those who had received the falls management exercise programme added about 15 minutes of MVPA per day to their baseline physical activity level, and, during the 12 months following the end of the intervention, those older people had a statistically significant reduction in falls rate compared to those receiving usual care (incidence rate ratio=0.74, p = 0.042). Scores on the Physical Activity Scale for the Elderly (PASE) (Washburn et al. 1993) showed a small but statistically significant benefit for the falls management exercise programme compared with usual care (p=0.04), as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months for those receiving the falls management exercise programme (p=0.027) and the Otago Home exercise programme (p=0.029) compared with usual care. There were no statistically significant differences between either exercise programme and usual care regarding other secondary outcomes such as mental and physical wellbeing, balance confidence, falls risk, functional abilities, quality-adjusted life-years, social networks and self-efficacy. Using 2011 costing, the falls management exercise programme was found to be more expensive to deliver than the Otago home exercise programme delivered with peer mentors (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham), and the cost per extra person exercising at or above the target of 150 minutes of MVPA per week was £1919.64 in London and £1560.21 in Nottingham (mean=£1739.93) (Iliffe et al, 2014).

Tai chi (or tai ji quan)

Tai chi exercises combine deep breathing and relaxation with flowing full-body movements, and, although they were designed as a community group-based intervention, they can be undertaken as either a community-based group or at home on a regular basis (Li et al, 2016). Li et al's (2016) single-group pre- and post-intervention study recruited 511 physically mobile older people (aged ≥ 65 years) across 32 senior care centres in the US. In the study, each session began with 5–10 minutes of preparatory exercises based on tai ji quan movements, followed by teaching and practising a set of eight single forms constituting the core routine, along with a set of therapeutic movements (40–45 minutes). Each session ends with a simple set of breathing exercises (3–5 minutes). Synchronised breathing and forms were performed with weight shifting, weight bearing, head–shoulder–trunk alignment and rotation, and coordinated eye–head–hand movement. All the exercises were designed to stimulate and integrate the musculoskeletal, sensory and cognitive systems. After 4–6 weeks, a DVD outlining examples of forms and movements was distributed to the sample participants, who were encouraged to use the material for additional 15-minute daily home practice. Li et al (2016) reported a 49% reduction in the total number of falls, with a declining incidence over the 48 weeks of the study, together with improved physical performance (up and go test, 50-foot speed walk, chair to standing and functional reach). Interestingly, ongoing adoption of the exercise regime was well maintained after the study's completion. Using 2016 costing, the average cost-effectiveness was $917 per fall prevented and $676 per fall prevented for multiple falls.

Home assessment and modification

This intervention comprises relevant professionals assessing an older person's home to identify environmental hazards, which include objects and physical circumstances, and implementing actions to reduce the identified hazards. Typical environmental hazards include loose mats and other trip hazards, poor lighting and the absence of handrails. Tse's (2005) review of 18 studies found no evidence that individual interventions (i.e. change in lighting, bed height, etc.) on their own were effective. However, there was evidence that a multi-pronged strategy was effective, especially when targeted at older people with a history of falls. This finding was confirmed by Gillespie et al's (2012) Cochrane review, which included 159 trials with 79 193 participants.

PHE (2018) compared the four interventions mentioned above using a 2-year time horizon (total costs of implementation for up to 2 years using published study data to estimate the number of falls over the same period, together with likely health and social care costs associated with falls). The impact on the quality of life of older people was included using quality-adjusted life years as an outcome measure; a reduction in falls is accompanied by higher quality-adjusted life years scores. Only one intervention, namely, home assessment and modification, yielded a return on financial investment (cost savings outweigh the cost of implementation), and this was not cash releasing but rather opportunity cost saving through a reduction in inpatient admissions and other costs. Home assessment and modification is already implemented in the UK, so that, unlike the other three interventions, there are no additional set-up costs.

Although multifactorial risk assessment (including history of falls, muscle weakness, balance impairment, visual impairment, polypharmacy and home hazards) by health professionals and management (including medication adjustment, exercise programmes and vision correction) was also identified as a cost-effective intervention (PHE, 2018), there were insufficient cost data to assess cost-effectiveness (National Institute for Health and Care Excellence (NICE), 2013).

District nursing and fall prevention

Where possible, district nursing clients should be encouraged to keep as active as possible, as this helps to keep the body healthy during the ageing process. Physical activity not only improves muscle strength and function, balance and stamina but also helps people maintain a healthy cardiovascular system. Further, it helps keep nerve signals strong and the inner ear healthy.

Although exercise in general is good for health, not all exercises help prevent falls. Strength and balance exercises are the most effective type of exercise to help prevent falls and, when undertaken in a group, these have the added benefit of social engagement. However, not everybody can attend a group class, and similar exercises performed at home are equally effective at reducing falls. Some recommend tai chi, which can also help reduce falls, but it seems to have greater benefit for those who have a lower risk of falling. Simply practising exercises that strengthen muscles on their own does not reduce falls, because it does not improve balance and stamina, and sometimes focusing on strength exercises alone results in injuries. Walking is good for general health, especially when undertaken at a moderate or faster pace, but on its own, it has not been shown to help reduce falls.

As well as assessing for environmental hazards such as loose mats and trailing cables/electric wires, footwear and mobility aids should be assessed. A walking stick that is too long can place too much pressure through the wrist, causing strain and injury. A stick that is too short can cause the centre of gravity to lean forwards, reducing balance. The correct height is indicated by a slight bend in the elbow. Similarly, a Zimmer frame should be set at the right height; a physiotherapist should make the initial assessment. Issues to consider when assessing the condition of the foot and footwear are set out in Boxes 1 and 2.

Box 1.Keeping the foot healthy

• Feet should be kept clean, dry and moisturised
• Socks should be changed every day
• Hard skin should be removed gently with a foot file/pumice stone, or help should be sought to do this
• Feet should be protected from damage, such as blisters
• Nails should be cut to the correct length, or help should be sought to do this
• Comfortable shoes should be worn
• Advice should be sought for foot pain, as it is not a normal or acceptable part of ageing
• Muscle and joint stiffness should be prevented through exercise and activity.

Box 2.Assessment of footwear

• How well they fit
• Whether they will damage the skin or nerves
• How much grip the soles will provide
• How high the heels are
• Whether they provide ankle support
• How heavy they are
• Whether they will wear loose over time
• Wearing more than just socks or tights indoors
• Buying new shoes in the afternoon as our feet swell over the course of a day.

Many district nursing clients will be on four or more medications, which increases the risk of falls. All such clients should have their medications reviewed regularly as part of a comprehensive assessment (British Geriatric Society (BGS), 2019), and this should include an assessment of:

• The benefits of each medication
• The potential harm or side-effects of each medication (including fall risk)
• Identification of which medications in particular may be contributing more than others
• Detailed discussion with the client of any proposed medication changes.

While well meaning, many carers adopt fall-prevention strategies that do not align with best-practice guidelines according to Wilkinson et al's (2018) integrative review of 17 studies. Carers mainly focus on the protection of the older person from falling, and older people themselves seek to minimise their fall risk. However, both these approaches discourage the older person's independence. Remarkably, the review suggested that older people at risk of falls rarely engage in exercise, particularly those that enhance strength and balance (Wilkinson et al, 2018).

Unfortunately, despite the best efforts of professionals and carers, older people will experience falls. If a client has a fall, they should be assessed as set out in Table 1, so that tailored interventions may be offered to reduce the risk of future falls.

Conclusion

While it is not possible to prevent all falls among older people, there is evidence that group and home-based exercise programmes and home safety interventions reduce the rate of falls and risk of falling. The evidence suggests that multifactorial assessment and intervention programmes reduce the rate of falls but not risk of falling. At present, only home assessment and modification is a cost-effective intervention in the UK setting, partly because it already exists, and, therefore, there are no additional implementation costs. At the individual level, district nurses should promote exercise, particularly those that enhance strength and balance, and assess environmental hazards that can addressed as part of their practice.

Key Points

• Home assessment and modification is cost-effective in reducing falls
• All exercise is good for general health, while strength and balance exercises help reduce falls
• Foot health, footwear and mobility aids should be assessed regularly to prevent client falls
• All clients should be assessed after a fall.

CPD REFLECTIVE QUESTIONS

• How many of your clients have fallen in the past 12 months? Have they all been assessed?
• What are the benefits of exercise for older people?
• How can you motivate your clients to increase their levels of exercise particularly related to strength and balance?