Staying upright and strong: Reducing the impact of falls in older people

Falls are my favourite subject, and I think I could write a book about them; however, here is a very brief summary and some further reading. Older people, of course, don’t like to think about falls and disability, so reframing this as “staying upright and strong”, “keeping positive” and “keeping going” will make your messages to them more palatable.

Falls are an unintentional change in position resulting in landing on a lower level. Being pushed over is not a fall – that is intentional.

Approximately 30 per cent of those over age 65 living in the community and more than 50 per cent of those living in aged residential care will fall every year. Not so much is known about retirement villages, but I expect prevalence to be in the middle.

The consequences are significant. Of those who fall, about 70 per cent will have loss of confidence and fear of falling, 40 per cent will have a significant injury and reduced mobility, 5 per cent will have a fracture and 1–3 per cent will have a hip fracture. I don’t have to remind you that hip fracture hastens death, placement in aged residential care and general all-round misery.

Older people can recover from injury related to falls, but they have to be encouraged and offered rehabilitation. Disparities in outcomes from injury are significant for Māori, with far less engagement with the health system and ACC, and less access to assistive devices. Māori are also less likely to receive appropriate financial support after injury. It is time to address these inequities.

The important thing about older people is that they are fragile and very likely to have negative consequences from falls, compared with children who fall over all the time but seem to bounce. Older people don’t bounce.

Osteoporosis is a significant issue for older women (and some men) and for people treated with anticonvulsants, long-term antipsychotics or lots of corticosteroids. Osteoporosis causes excess bony injury for minimal force trauma, and it can be treated.

First and foremost, falls can result from any acute illness and, as such, can be thought of as hot falls. Falls are the great “mask” and can be the common presentation of several illnesses from several aetiologies. Urinary tract infection in older people in residential care is the most common example; myocardial infarction presenting with vague symptoms and a fall is another.

If a fall is not a direct result of acute illness, it is usually the result of multiple overlapping risk factors. I like Venn diagrams (see figure below – the sum of risk factors goes up exponentially with any two or more risks in any of the circles), and I think falls occur through the interaction of dynamic risk situations.¹ The event of a fall may only occur when everything aligns, and then only sometimes.

For example, the older person with personal risk factors of age >80, female gender and knee osteoarthritis may usually be fine outside (environment), bending over to do gardening (exposure activity), except when there is cold weather, a strong wind (dynamic environmental risk) and she climbs her ladder to trim the grape (dynamic exposure), or she has stayed in for several months because of COVID-19 and has now become deconditioned and lost her confidence (dynamic personal risk).

Similarly, an older man disabled with a stroke and residual hemiparesis may be quite mobile and safe with the appropriate mobility aide and environmental modifications, but variation in his capacity related to his heart failure may compromise his strength and a fall may occur.

The personal risk factors are well described and not rocket science. Risk factors differ between residential care and the community, with the most important realisation being that reduced mobility increases risk in the community dweller, whereas any mobility (capacity to stand) increases risk in the residential care dweller.^2,3

The environmental risks are also reasonably well known but perhaps could do with some more consideration as each person’s environment is such an individual thing. Then there is the car park where the parking blocks get in the way and the individual’s reactive responses are not ideal. Simple things such as loose mats and low lighting seem straightforward to fix. However, older people like their mats (they brighten up the room), even those with low vision,⁴ and who does one get to change the lightbulb?

The activity or exposure risks are not well studied. It is clear that habits and lifestyles make a difference. Caution is common in some, but less so in others. Anxiety protects from falls, and there is some suggestion that our “she’ll be right, have a go” attitude predicts greater falls. Being careful is perhaps not as valued as it could be.

Balancing human rights and falls prevention is most salient in residential care where it is no longer desirable to tie people down to prevent falls, and falls-free activity is emerging as an important concept.⁵ It may be necessary to accept some trade-off between safety and mobility.

If the patient presents after a fall, it’s relatively easy. The usual things are necessary, so take a history: what happened (what were you doing)? Were/are you injured? Were there predisposing or associated features (fever, shortness of breath, dizziness)? What was the environment (hazards to trip over)? What medications are you taking, have you taken any new ones, or any from anyone else? What current conditions may have contributed? Is there anything in the past or family history that is relevant?

Then do an examination: vital signs, including lying and standing blood pressure; the area of injury; cardiovascular system (emphasis on rate and rhythm); neurological system, including balance; and musculoskeletal system, including gait and a weight-shifting activity such as turning.

Investigations may be needed, with an electrocardiogram, full blood count and urinalysis being the most common.

Then, of course, you need to try to work out if there is a reason for this fall that can be remediated. Remember, postural hypotension is common, often undetected and contributes to falls, so look for it and manage it. If the fall is because of acute illness, then manage the illness. Some patients need to go to hospital now or later. I recall a patient who had a haemoglobin level of 75g/L upon evaluation after a fall, and gastric carcinoma was subsequently detected.

Next, the focus is on rehabilitating, increasing safe mobility and preventing future falls. Optimising management of existing medical conditions and reviewing all medications are effective in reducing falls. Psychotropic medications cause falls and may be needed, but may also be able to be reduced.

Opportunistically, you can have the biggest impact in fall prevention

Opportunistically, you can have the biggest impact in fall prevention. Ask all your older patients about falls, trips, slips and injuries all the time. What you don’t know can hurt them, and you will miss opportunities if you don’t ask: how many falls have you had in the last 12 months? Any injuries? How is your confidence about mobility?

Remember the dynamic risk Venn diagram and talk to your patients. This kind of framework can lead to very useful discussion (patient education, self-management), especially while discussing “what happened”. Medical condition optimisation and medication review are mandatory. Preventing future falls is the objective, so promote behaviour modification, assist with understanding that risk plays a role, and give a firm idea about what works.

There have been hundreds of trials on fall prevention in the community. ^6,7 There is overwhelming support for exercise in the form of lower-leg strengthening and balance retraining, using individual or group delivery and via several forms for those living in the community. Thai chi is also effective.

ACC accredits community strength and balance programmes as part of the Live Stronger for Longer programme (livestronger.org.nz), and there are thousands available around New Zealand. Most DHBs have a way for GPs to refer patients directly. In-home, one-on-one delivery for those who are home bound is also available in most DHBs.

The new aspect of activity programmes is perturbation training – actively tripping older people to reactivate reaction responses.⁸ Please don’t try this at home! It needs to be done with protection in place and will be available in some places via a special treadmill or a walking track, with sudden tripping devices randomly activated.

Home hazard modification through occupational therapist assessment is effective and accessible through older peoples’ health services from all DHBs.

Medical review and some specific medical interventions (eg, pacemaker insertion for those with carotid hypersensitivity), comprehensive geriatric assessment and intervention, combined with home occupational therapist referral for those with a falls injury resulting in emergency department attendance are effective. Medication review and modification by GPs reduces falls.

Attention to correction of visual impairment due to cataracts also reduces falls, and switching from multifocals to single-lens glasses helps; however, new glasses seem to increase the risk of falls. Footwear improvement can help, especially in icy places.

Multifactorial interventions (several of these strategies at once) are helpful, especially if there is an individualised risk assessment to direct the interventions.

For those in aged residential care, vitamin D supplementation and increasing protein and calories in the daily diet prevents falls and fractures.^9,10

Specially designed gym equipment used under direction of a physiotherapist, with additional balance exercises, reduced falls in one trial. This HUR (Helsinki University Research) computerised air pressure equipment is available in New Zealand in at least one site.

Overall, GPs and nurse practitioners in primary care can have a large impact on falls in older people. The long-term support from the primary care provider, along with referral, coordination of prevention and rehabilitation will make a difference to outcomes related to falls and injury.

Ngaire Kerse is a professor of general practice and primary health care, and the Joyce Cook Chair in Ageing Well, University of Auckland

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