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Aged care residents the ‘poor cousins’ in falls research

There is simply not enough research done in residential aged care to truly understand falls, their causes and to evaluate a range of interventions, writes Dr Frances Batchelor.

Falls are common in older people living in the community with one in three people aged 65 and over falling each year. Considerable effort has been devoted to understanding falls in community-dwelling older people and in developing and testing interventions that work to prevent falls, with good results.

Dr Frances Batchelor

Dr Frances Batchelor

We now understand a great deal about risk factors for falls. We now have a range of interventions that have been shown to be effective in preventing falls for those who are living at home. While we haven’t solved the issue of how best to translate effective interventions into practice to reduce people going into hospital, inroads are being made into understanding factors such as adherence, uptake and preference for different types of interventions for older people living at home.

The same cannot be said when a person moves into residential aged care. Unfortunately, falls are more common in residential aged care with the incidence up to three times higher than in the community. On average, half of a facility’s residents will fall in any given year; this equates to 135,000 Australians. This higher rate of falls is understandable given that people living in residential care facilities are older, more likely to have cognitive impairment, are frailer and less physically able than their home-dwelling counterparts.

Of great concern are the residents who fall frequently. On average a resident may have between two and three falls a year but some residents fall very frequently, even several times a day. This is distressing not only for the person who experiences the falls, but also for family, staff and other residents. The impact of falls is also greater for people living in aged care facilities than for those still at home. Recent studies have found that, in contrast to community settings, more than half of falls in residential aged care result in some type of injury. Fortunately, injuries are minor in most cases. However, serious injuries such as hip fracture, dislocations and head injuries are associated with poorer quality of life and, in some cases, can precipitate a downward spiral that, in the worst case, can lead to death.

None of this should be accepted as inevitable. This is where research plays a role: to produce high quality evidence in understanding and preventing falls. Yet older people living in facilities seem to be the poor cousins when it comes to falls prevention research.

‘Not enough research’

In the last Cochrane review conducted by Ian Cameron and colleagues in 2012, 43 randomised controlled trials examining falls prevention in care facilities were included. In stark contrast, there were over three and half times as many community-based falls prevention trials included in the 2012 Cochrane Review by Lesley Gillespie and colleagues.

There is simply not enough research done in residential aged care to truly understand falls, their causes and to evaluate a range of interventions. This leads to the situation in which many facilities and aged care providers are proactive in working with staff, residents and families in attempts to prevent falls and injury, but many of the strategies do not have a strong evidence base.

So what does work? Complex problems require complex solutions and this also applies to residential aged care where there is no silver bullet for preventing falls. In order to implement effective interventions we first need to understand how and why people fall. This is particularly challenging in residential aged care as most falls are unwitnessed and residents may not always be able to accurately describe a fall.

Ground-breaking research is providing valuable insights. Canadian researcher Stephen Robinovitch has used digital video recording in communal areas of facilities (not bathrooms or bedrooms) to capture falls. The videos are not easy to watch but clearly show how and why falls occur. One video shows a resident attempting to sit down but falling backwards as the wheelchair rolls away from him.

Another video shows a woman losing her balance when stepping backwards then landing heavily on her right side. Robinovitch’s research points to the following as falls prevention strategies: ensure furniture and equipment is stable and clutter is minimised; and look at ways to improve balance and recovery strategies.

Currently the evidence for successful approaches to preventing falls in residential aged care is limited. The highest level of evidence, Cameron’s 2012 Cochrane review, indicates that vitamin D supplementation is effective, and possibly a medication review by a pharmacist. The use of multifactorial interventions, which include a suite of falls prevention strategies, is supported by the research literature, as is staff education.

However, it is less clear that exercise, as a single strategy, is effective and may possibly contribute to an increase in falls in some residents. That’s not to say that exercise programs should be discarded! Exercise has a range of other very important benefits and may be effective in falls prevention if targeted correctly. Again, additional research is required to evaluate innovative approaches to exercise and to understand the most effective exercise type, dosage and frequency and crucially, how to maximise adherence.

What can be done?

At an individual level we know that addressing identified falls risk factors as well as reducing the risk of injury is required for every resident. This includes implementing the proven strategies as well as strategies that are largely untested in care settings but may be effective. Examples include correction of cataracts, use of single vision distance glasses and environmental hazard reduction. Secondly, we need to consider falls as a red flag. A resident who is falling more frequently than usual should trigger investigation of what could be causing the increased frequency.

We urgently need to educate the sector including government, funding bodies, managers, carers, residents and their families about the need for research in residential aged care and the risks that exist if this research is not undertaken. Too often research in residential aged care is placed in the “too hard” basket: difficult to attract funding, difficult to recruit participants and difficult to undertake.

But without well-funded, targeted research conducted in partnership with residents and residential care facilities we will continue to offer band-aid solutions to the complex issues facing older people living in residential aged care, one of which is falls.

Dr Frances Batchelor is the deputy director of health promotions and stream leader for falls and balance at the National Ageing Research Institute.

For more on falls prevention, see the current issue of AAA magazine (March-April).

Want to have your say on this story? Comment below. Send us your news and tip-offs to editorial@australianageingagenda.com.au 

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4 Responses to Aged care residents the ‘poor cousins’ in falls research

  1. Brenton March 18, 2016 at 10:30 am #

    Interesting that despite scant evidence from residential care settings regarding the supposed dangers of restraint residents are still subjected to having safety measures removed against their will and without their consent. While restraint reduction is important it should not be implemented without individualised assessment and without respect for consumer rights. If a bed rail is requested by a resident to prevent them from falling out of bed then it ceases to become restraint. Restraint is the involuntary imposition of restriction of movement. While the vast majority of bedrail research relates to injuries in acute settings that were caused by inappropriate installation or faulty equipment this ‘data’ is then extrapolated to all settings and used to demonise equipment that actually protects people if used appropriately.

    Part of falls prevention strategy should be developed in consultation with the older person or their legally appointed guardian where appropriate. A person should never be subjected to interventions that place them at serious risk when they have not had the risk explained to them and they have been denied the right to choose. If you believe that you are a champion for human rights by removing ‘restraint’ while simultaneously denying a person’s right to free will and self determination you are deluding yourself.

    While we appear to have no issue with locking people in ‘secure’ dementia units or the more politically correct ‘memory support’ units, we also appear to have no issue with removing bed rails and allowing people to continuously fall out onto the floor.

  2. Dave March 18, 2016 at 12:08 pm #

    We dont need further research, we need some common sense. Cause of falls? Gravity. Now let’s move on.

    Falls research is a soft target. Rather than spending more money just to arrive at the same conclusions, let’s direct those funds to educating care staff on the basics.

    Data collection? Simply counting the number of falls each month achieves nothing. Comprehensive details on who fell and where, what time, were the lights on, could they reach their call bell, (how many staff were on duty?), polyphamacy, proximity of walking aids, floor surface, footware, etc. all need to be considered in order to arrive at any meaningful conclusions.

    Safety ?(for their own good). Brendon and others need to stop slavishly clinging to the use of restraint. It’s 2016 and you’re still using bedrails? Buy some low beds. Our residents have lived through more ‘risk ‘ than you and I ever will …

    The nanny-state mentatlity that tries to protect everyone from everything has to be replaced with clever thinking and the courage to tell families that we cant prevent every fall…but we can minimse the risk with well educated care staff and the correct environmental modifications.
    Raising the human rights angle is tantamount to invoking Godwin’s Law.

  3. Peter Leith March 18, 2016 at 1:35 pm #

    As Dave says….Not more research? How many of the people interviewed will actually be residents with vision, balance and mobility impairment? Like so many other industries much of the aged care industry is self- obsessed rather than customer focused…. What a shame.

  4. Louise March 19, 2016 at 11:31 pm #

    I agree with Dave and Peter Leith’s comments – we have a resident who despite living with Dementia, when she feels a fainting spell she lowers herself to the floor to prevent herself from falling but this is counted as a fall !! When a resident is in a low low bed with mattress on both sides and roles onto the mattress this is also considered a fall. When a resident truly falls because of restlessness or sundowning etc – we do not look at the environment, were they agitated etc as Peter Leith highlights – and again it comes down to not enough care staff in areas where there is a higher level of residents in these areas living with dementia. When you have two staff for 14 – 16 people, all high care, all requiring toileting etc by 2 people then what happens to the rest of the residents?

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