Falls among older people present a significant public health concern. Approximately 30% of people aged over 65 years, and 42% of people aged over 75 years, fall at least once a year (Meekes et al, 2022). Worldwide, over 37 million falls that require medical attention occur annually, resulting in nearly 646000 deaths each year. In the context of the UK, a quarter of a million fall-related emergency hospital admissions, for people aged 65 years and over, were reported in 2019–20, with two–thirds of these admissions for people aged 80 years and over, at a significant cost to the NHS (While, 2020a; Meekes et al, 2022). This cost is estimated by the National Institute for Health and Care Excellence (NICE) (2013) to be more than £2.3 billion per year. Therefore, falls represent a pressing concern for healthcare professionals caring for older people, especially community nurses whose expertise, ability to leverage the therapeutic relationship and intimate access to their patients’ lives and daily routines, gives them the capacity to effect real change in this domain.
Understanding why people fall
The underlying causes of a fall are often multifactorial, with the World Health Organization (WHO) (2007) suggesting that risks can be grouped into four categories: biological, behavioural, environment and socioeconomic (Table 1). The community nurse has the ability to influence many of these factors, especially those in the behavioural and environmental domains—for instance, a community nurse can advise on the positioning of home furniture or establish an exercise routine with the patient to reduce their falls. Frailty, a complex clinical condition associated with adverse health outcomes that falls under the biological domain, often plays a significant role in a person's risk of falling, alongside any other comorbidities, such as Parkinson's disease or osteoporosis. These disease- and age-related factors need to be considered by the community nurse. The first step to providing appropriate care is a comprehensive risk assessment.
| Category | Examples |
|---|---|
| Biological | Non-modifiable: age, gender and race Age-related: decline of physical, cognitive and affective capacities, and comorbidities |
| Behavioural | Risky behaviour (intake of multiple medications, excessive alcohol use and sedentary behaviour) Previous fall in the last 12 months |
| Environmental (interaction between individuals and their environment) | Home hazards (eg narrow steps, slippery floor, step surfaces, loose rugs and poor lighting) Poor building design, slippery surface, uneven pavements and poor lighting in public places |
| Socioeconomic | Low income, poverty, limited education, poor housing, lack of social interaction, limited access to health and social care and lack of community resources |
Adapted from the World Health Organization (2007)
Preventing future falls: strategies for success
Risk assessments
The focus of care should be preventative, so the community nurse should begin with a multifactorial risk assessment. NICE (2013) states that there are more than 400 factors associated with falls, but the components identified in Table 2 should form the foundation of any falls risk assessment, which should be performed if the patient has a history of falls or where frailty is suspected (While, 2020b).
| Identification of falls history | Even cognitively-intact older people might be unable to recall documented falls 3 months after the event |
| Assessment of gait, balance, mobility, and muscle weakness | Timed Up and Go Test |
| Assessment of osteoporosis risk | See clinical guideline: ‘Osteoporosis: assessing the risk of fragility fracture’ (NICE, 2017) |
| Assessment of the older person's perceived functional ability and fear of falling | Barthel Index for Activities of Daily Living |
| Assessment of visual impairment | NHS eye tests are free for people aged 60 years and over |
| Assessment of cognitive impairment and neurological examination | Multiple mini interviews |
| Assessment of urinary incontinence | Bladder control problems are a common problem in people aged 60 years and over Use local protocols |
| Assessment of home hazards | Loose rugs, etc |
| Cardiovascular examination | Include lying and standing blood pressure |
| Medication review | Taking four or more medicines (regardless of what they are) |
Note: Adapted from While (2020b); Osteoporosis: assessing the risk of fragility fracture, National Institute of Care and Excellence (NICE, 2017)
Personalised care plans
Following a comprehensive multifactorial risk assessment, it should then be possible for the community nurse to create a personalised care plan for the patient. These care plans should be tailored to address the identified risk factors and meet the specific needs of each older adult, and can comprise a number of elements, including:
When recommending an appropr iate exercise regimen, it is worth noting that there is strong evidence of multicomponent exercise programmes delivered to groups, or individually at home, significantly reducing the rate of falls and risk of falling (Centre for Reviews and Dissemination (CRD), 2014). Tai chi classes have been found to significantly reduce the risk of falling, but are less effective in those already at a higher risk of falling (CRD, 2014). The Otago home exercise programme and the falls management exercise programme have been found to result in a statistically significant reduction in falls rate when compared to usual care (While, 2020a). The first comprises 30 minutes of leg muscle strengthening and balance retraining exercises 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. The second features an hour-long instructorled exercise class and two 30-minute home exercise sessions per week over 24 weeks, using resistance bands, leg, trunk and arm muscle strengthening and flexibility and balance retraining exercises.
A personalised care plan may also include amendments to medications in response to the review conducted as part of the risk assessment, as polypharmacy and even certain medications increase the risk of falls. For instance, diuretics, beta blockers and vasodilators, which are used to address hypertension, carry a high fall risk, as do the alpha-blockers, nitrates and antipsychotics used to treat difficulty with bladder emptying, angina and agitation, respectively (Nazarko, 2023). A medication review and subsequent amendments should address medications that increase the risk of falls, while aiming to identify inappropriate prescribing at the same time. This involves assessment of whether the risks of harm from a particular medication outweigh the benefits. Tools available to achieve this include the Screening Tool of Older People's Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START) (Nazarko, 2023).
The barriers to falls prevention
While there are many opportunities for a community nurse to make a difference in a patient's falls risk, there are also barriers to falls prevention and management that must be overcome. These are related to the care provider, patient, context or the prevention strategy being implemented (Meekes et al, 2022). The nurse may have limited time to incorporate a time-consuming and complex falls prevention regime; collaboration with other healthcare professionals, such as physiotherapists, may not be possible due to constrained resources, and patients may display a lack of motivation or unrealistic expectations as to what a falls prevention programme can achieve (Meekes et al, 2022).
Patients’ shame about falling and fear concerning falls and a potential loss of independence can also present a significant barrier, as they may not be transparent about their falls history. Healthcare professionals should consider a person's beliefs about risk and negotiate choices for intervention, recognising that some individuals prefer to drive the decision-making process to preserve their identity as a competent and independent person (McInnes et al, 2011).
Conclusions
With their close proximity and established therapeutic relationships with the patients, community nurses have the potential to make a real difference in falls prevention. The variety of strategies available—such as comprehensive assessments, individualised care plans and interdisciplinary collaboration—means that, whatever the older person's needs and preferences when it comes to fall prevention; an option that maintains independence while safeguarding wellbeing will hopefully be available and effective.