What is a fall?
A fall is a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force (World Health Organisation).
Prevalence of falls
Falls in older people are a serious public health problem and a needless cause of ill-health, disability and death. The risk of falling increases as people get older with one in three older people falling every year; two-thirds of whom fall again within six months. In 2015, falling was one of the main reasons for elderly patients’ presentation to the A&E Department at University Hospital Galway (Freedom of Information request, 2016). Indeed, as Ireland’s population ages, the burden of falls and related injuries could double over the next 25 years. Currently there is no specialist falls service in Galway (August, 2016).
The effects of a fall
1. Psychological effects
Older people suffer profound psychological effects due to falls related injuries including fear of further falls, a reduction in activity levels and social isolation.
Older people find it difficult to recover from a fracture. For example, of those who survive a hip fracture, less than half regain their pre-fracture level of function, less than 50% of people return directly home upon hospital discharge and over 20% need long term care. The inability to regain function or to be physically active leads to more bone loss and higher fracture risk. One fracture, regardless of where in the body, doubles the risk of subsequent fractures.
3. Hospital admission
Over 7,000 older people are admitted to hospital each year for treatment of falls related injuries. Falls related injuries have the longest lengths of hospital stay for older people. One investigation into the outcomes for those who are admitted to hospital following a fall, found that almost a third were discharged to a nursing home.
Three-quarters of fall related deaths in Ireland occur to people who are aged 65 years and over. Since 1990, death rates from accidental falls in this age group have increased significantly.
Able Ageing Falls Prevention Programme
Prevention is better than cure and identifying people at risk of falls and fractures is paramount. Assessing an individual’s risk factors can assist health professionals to target those most vulnerable to injury and to implement effective intervention measures to reduce the likelihood of future falls and fractures. In line with best practice guidelines from the National Institute for Health and Care Excellence, Able Ageing provide a comprehensive multifactorial falls assessment in the home. This assessment addresses the following:
1. Bone Health and Osteoporosis
Older people are at higher risk of developing osteoporosis of which a major complication is a fragility fracture. We use an evidence based assessment tool to identify a client’s risk of a fragility fracture.
2. Blood pressure
Orthostatic hypotension, or a drop in blood pressure on standing, is a strong predictor of falls in older adults. Different to conventional methods of measuring blood pressure, Able Ageing record precise, optimally timed blood pressure readings to increase accurate identification of orthostatic hypotension.
Cognitive impairment has been shown to increase risk of falls. We use a brief validated screening tool to assess brain functions such as memory, attention and information processing.
4. Home Environment
Between 25% and 75% of falls in older people involve some environmental component. We complete a functional assessment within the home environment and provide you with a report detailing recommendations for equipment and adaptations (if required) for your local council. See below for grants available.
5. Detailed falls history
We gain an in-depth history of any previous falls as this is one of the best predictors of a future fall, increasing the risk threefold.
6. Fear of falling
Fear of falling is reported as one of the most common fears of older adults. This can lead to a decline in overall quality of life and increase the risk of falls through a reduction in the activities needed to maintain self-esteem, confidence, muscle strength and balance. In addition, fear can lead to maladaptive changes in balance control which may further increase the risk of falling. We use a validated measure to complete an in depth assessment of fear of falling.
7. Activities of daily living
A screen of current level of independence to include an assessment of how the demands of an activity may contribute to an increase in falls risk.
8. Mobility, muscle strength and balance
People with mobility, strength and balance problems are three times more likely to have a fall. We will complete assessments of your strength, mobility, balance and walking speed using validated tools.
People with visual deficits such as reduced acuity or contrast sensitivity, reduced accommodation to light and darkness, or altered depth perception are more likely to fall.
10. Footwear and clothing
As people age, their height and posture change so clothes such as dressing gowns or trousers, which may have fitted well in the past, can cause tripping hazards. Footwear which fits poorly, has worn soles, is not fastened or is of an unsuitable heel height for the individual, can contribute to falls.
11. Bladder and bowels
Issues with passing urine such as frequency, urgency and incontinence can increase the risk of falls, as can bowel habits.
We will complete a basic screen of your medicines for drugs which may increase risk of falls and highlight the need for an in depth review by your GP if required. We also assess your ability to manage your own medication if needed.
13. Goal setting
We collaboratively discuss any achievable goals for rehabilitation with our clients.
If rehabilitation goals are identified, programmes usually involve one or more treatment approaches:
- Retraining in activities of daily living
- Cognitive restructuring (confidence building)
- Strength and balance training
- Environmental modification
- Mobility practice
- Guidance and practical demonstrations to help in the event that a fall does occur
Gains are usually expected within 2-3 rehabilitation sessions but we discuss progress on an ongoing basis. Following the programme, we will send a comprehensive report to the client and his/her GP.
Equipment & adaptations
There are various grants available in Galway city and county for any equipment/adaptations recommended by Able Ageing as part of the Falls Prevention Programme:
1. Mobility aids grant scheme
- For older people with a disability
- Available to those with an income of less than €30,000.
- Maximum grant available €6000
2. Housing adaptation grant for people with a disability
- For older people with a disability
- Means tested based on level of income
- No specified maximum grant limit
3. Housing aid for older persons scheme
The Scheme of Housing Aid for Older People is available to assist older people over 66 years of age living in poor housing conditions to have necessary repairs or improvements carried out. The types of works grant aided under the scheme include
- Structural repairs or improvements.
- Re-wiring, repairs to/replacement of windows and doors.
- The provision of heating (where none exists).
- Water and sanitary services.
Galway City Council – application forms
Galway County Council – application forms
Case Example – Catherine
Catherine was an 85 year old lady who lived alone and had been experiencing falls which led to repeated hospital admissions. Her most recent fall resulted in a small fracture of the arm and several bruises. She was finding it increasingly difficult to live independently at home following these falls. She had a past medical history of arthritis, diabetes, and a previous stroke. A falls assessment was completed with Catherine and her daughter which identified the following:
1. Falls history: Following a detailed discussion, it became apparent that most of her falls occurred in the home, often just after getting out of bed to go to the toilet but also when showering. She reported often feeling “woozy” and attributed her falling to her lack of balance. She had a total of 7 falls in the last 12 months, often not being able to get up herself and spending prolonged periods on the ground. This led to the development of pressure areas on her hip and back.
2. Blood pressure: On examination her blood pressure showed a significant drop when she stood up.
3. Cognition: Catherine did not report any memory difficulties. However following completion of a cognitive screen it was identified that she had deficits in sustained attention (the ability to concentrate).
4. Continence: Catherine had been recently experiencing urinary frequency and urgency, often getting up several times during the night.
5. Functional assessment: Due to pain and reduced range of movement in her arm following her recent fall, she found it very difficult to complete basic activities such as washing and dressing. She also found it difficult to get out of bed and out of the shower.
6. Balance: Her balance score showed mild-moderate impairment.
7. Home environment: Several falls hazards were identified.
8. Bone Health: A score on bone health suggested that Catherine was at risk of osteoporosis, which can lead to increased risk of having a bone fracture.
9. Medications: Catherine suffered from high blood pressure and took quite a high dose of an antihypertensive, as well as her diabetes medicine. She was taking a moderate dose of a mild painkiller.
10. Fear of falling: Very high score on this measure.
11. Goal setting: Catherine was very determined to maintain her independence but was increasingly reliant on her daughter to help. Her top priority was to be able to look after her dog again, but we convinced her that she needed to look after herself first!
Following Catherine’s Falls Assessment the above problems were addressed:
1. Catherine’s GP was informed of the results of the assessment. The GP changed her blood pressure medicine which stopped her feeling “woozy”, she was started on medication to protect her bones to help prevent future fractures, a bladder scan was organised to investigate her urinary symptoms and her pain medication was changed.
2. Rehabilitation: Catherine had several rehabilitation sessions which involved strengthening exercises for her arm, balance training, confidence building exercises and retraining in her activities of daily living. She was also taught strategies to improve her concentration as this was contributing to her falls. Her confidence and balance tests were repeated, which showed a significant improvement. Most importantly, after her rehabilitation programme she was no longer relying on her daughter for help, and she got back to looking after her dog again. Catherine’s falls significantly reduced, she only fell once more when she tripped over a shopping bag. However, she was better able to get herself off the ground following the advice and rehabilitation given during her rehab programme.
3. Home Environment: Catherine’s family removed several falls hazards identified around the home and rearranged the layout to increase her safety. Because Catherine rehabilitated so well, she did not need any equipment or adaptations to help her get around her house. However, Catherine was suffering from pressure sores that were slow to heal therefore was recommended specialist pressure relieving products for her chair and bed and was given pressure sore prevention advice.