SCIE research briefing 1: Preventing falls in care homes

Published April 2004 (updated April 2005)

Definitions used in this briefing

The term "care homes" includes residential care homes, nursing homes and intermediate care facilities.

What is the issue?

Older people (aged 65 years and older) frequently fall (1), (2), (3), especially when resident in long-term care (4): up to 35% of falls here result in serious injury and up to 8% in fractures (5). A fall is defined as "... an event in which the resident unintentionally came to rest on the ground or floor, regardless of whether an injury was sustained..." (6) and may be "... other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force ..." (3). Falls in care homes may lead to increases in death rates, fall-related injuries (particularly hip fractures) (7), individual physical and psychological damage, loss of independence (1, 8) and health costs (9). Fall prevention strategies and interventions need to take into account the fact that falls can have a number of causes, such as frailty, confusion and the effect of certain prescribed drugs, that require many different interventions (4, 34, 35). There are also implications for care staff with likely increases in anxiety, workload and complaints.

Why is it important?

Research concentrates on how falls in care homes might be prevented in an active way: in this, individualised falls/risk assessment forms an important part. But there is little agreement between studies on the interventions that work consistently well. A Cochrane review in 2001 (10) states that the following interventions are likely to be beneficial:

• An individualised programme of muscle strengthening and balance retraining
• Tai Chi group exercise
• Hazard assessment and modification for older people with a history of falling
• Withdrawal of psychotropic medication
• Multidisciplinary, multi-method and holistic, health/environmental risk factor screening/intervention programmes. There is an increasing consensus that no one intervention can effectively prevent falls or reduce injuries: a multi-interventional approach is needed (11), (12), as reflected by recent NICE guidance on the assessment and prevention of falls in older people (36), and a recent systematic review on the same topic (37).

A further Cochrane review in 2005 (13) stated that the use of hip protectors for those living in institutional care with a history of hip fracture appeared to reduce the occurrence of hip fractures. However, recent user consultation in Sheffield suggests that users may not understand clearly the linkage between falls and hip protectors as a form of prevention. This may help to explain the high drop-out rate in the wearing of hip protectors. Expert knowledge has also indicated that the wearing of hip protectors can lead to incontinence due to difficulties in removing them quickly. It has also been demonstrated that exercise programmes can have a beneficial effect on a person's walking and muscle strength, but there is little evidence to suggest that this intervention actually prevents or reduces the numbers of falls (37), (38), (39).

What are the ethical considerations?

Living in a care home can result in residents becoming less independent (14) which can impact on their ability to exercise their rights and responsibilities (15). Routine restraint of residents (through methods such as cot sides, lap belts and cocoon beds) has not been found to reduce falls or injuries (16) and may result in other problems occurring such as pressure sores, incontinence, muscle-wasting and worsening mental health (16), and increased risk of injury, because patients who seek to climb over rails fall from greater heights (40).Expert knowledge has also indicated that there are ethical issues around the use of surveillance and passive alarms. There are also potential difficulties in user participation in interventions: refusals, high drop-out rates (17) and the need for written consent (7), (9). One study (18) actively recruited participants through the use of presentations and assessed the reaction of participants to the exercise programme at the end of the study. There are also resource implications, particularly where multi-agency, individualised and multifaceted interventions are recommended: one example is the appointment of a falls co-ordinator for each home (19).

What are the views of users and user groups?

Research on user views on and involvement with falls prevention is not readily available apart from at a local level. Recent user consultation in Sheffield revealed that all participants were worried about falling, aware that it could cause broken bones and concerned about summoning help. Participants gave the following reasons for falling: environmental hazards (trips, slips, patterned carpets), footwear, dizziness, loss of balance, rushing and non-use of walking aids. Also, many falls occur from bed or in a bedroom. Unfortunately, users sometimes saw falling as a 'way of life’ and that nothing can be done to prevent falls. Conversely, the users were positive about group exercise programmes to improve muscle strength, balance and provide motivation. The apparent lack of studies of user views may indicate that barriers to effective resident consultation could include dementia (9) and confusion (16). It is clear that more research and guidelines are needed in this area.

What do I need to do?

Read the following Department of Health documents:

• National Service Framework for Older People (2001) Standard Six: Falls - pp. 76-89 (20)
• "How can we help older people not fall again?" - Implementing the Older People's NSF Falls Standard: Support for commissioning good services (2003) (21)
• Preventing Accidental Injury - Priorities for Action: section 3.4 - Injuries to older people from falls and fractures (22)

Read the following practice guidelines and research summaries:

• National Institute for Clinical Excellence (2004). Falls: the assessment and prevention of falls in older people.
• Guidelines for the prevention and management of falls in the elderly: residential care (revised 2002) produced by Dorset HealthCare. (23)
• Cornwall and Isles of Scilly Falls Prevention and Management Strategy (2001). (24)
• Feder G. Cryer C. Donovan S. Carter Y. (2000) Guidelines for the prevention of falls in people over 65 (3)
• American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001) Guidelines for the Prevention of Falls in Older Persons (25)
• NSW Health Department (2001) Preventing Injuries From Falls in Older People (26)
• Shanley C. Putting your best foot forward: preventing and managing falls in aged care facilities (27)

Find out what advice on falls prevention is given in your area and ensure that a falls audit is carried out and regularly updated for your own residential home.

Consider setting up or encouraging the establishment of local networks between homes to encourage support, share good practice and facilitate training.

Treatment Notes, which are produced by the Consumers' Association (CA), have published Worried about falls?
This document explains why falls are so common among older people, and describes ways to prevent them. It also discusses how to reduce the fear of having a fall.

Who can I contact?

• Help the Aged (advice on preventing falls)
• Age Concern
• National Primary Care Development Team (Falls Collaborative)

Where can I find examples of innovative practice?

• North Bradford PCT has published a description of their falls exercise programme for older people (41)
• Older Inpatients' Falls Support and Prevention Education Programme - coordinated by Age Concern Stockport.
• Falls Prevention for Older People through Differentiated Physical Activity Provision, led by Wiltshire Health Promotion Service.
• Joint Strategy for the Prevention of Falls in Older People - coordinated by North Derbyshire Health Authority.
• Mind Your Step project, run by Birmingham North East PCG
• Preventing Falls & Promoting Independence project, run by Merton, Sutton and Wandsworth Health Authority
• The specialist falls service at King's College Hospital in London
• Falls Education Programme at the Elderly Health Unit of Broadgreen Hospital in Liverpool
• Age Concern and ROSPA have produced a training pack for use in the workplace with staff specialising in the care of older people
• A document has been produced by Help the Aged providing examples of falls services in England, and describing ways in which community based health workers and others concerned with the welfare of older people are developing strategies to reduce the likelihood of falls and moderate the effects of an accident. It also discusses the National Service Framework for Older People, assessment for falls risk, working in partnerships and single interventions (42).

Resource sites

• Social Care Online

Acknowledgements

Thank you to experts and service users for their contributions to this briefing.