Despite extensive research over the past decade, the rates of fall related hospitalisations have not reduced. Professor Keith Hill outlines some of the factors limiting the effectiveness of recent strategies, and argues for a national commitment to reduce the unacceptably high rate of falls related deaths and hospitalisations.
Falls are far too common an occurrence for older people, and can have a major impact on the older person, their friends and social network, and the wider community. There needs to be a substantially stronger coordinated focus at the national level in Australia to impact on the unacceptably high rates of falls related emergency department presentations, hospitalisations and deaths associated with falls.
One in three people aged over 65 years fall each year. Given that Australia currently has over three million people in this age group, this means approximately one million people in this age group will experience one or more falls each year. Fortunately, less than 10 per cent of these falls cause a serious injury that will require emergency department or hospital admission.
However, for these people the personal and societal cost is high. In Australia in 2010-11, there were 92,150 people aged over 65 hospitalised for fall related injuries, and they were in hospital on average seven days. Most common injuries among those hospitalised are head injuries and hip fractures. Around half of these falls causing hospital admissions occur at or around the home, and about one quarter occur in residential care facilities. Many of these people who fall do not regain previous levels of mobility and independence.
Falls and fear
Many falls that do not cause injuries can also have a large impact through affecting an older person’s confidence. A common response of many older people who experience a fall that does not cause an injury is to curtail a range of activities they have previously been engaged in, without considering if there are ways the activity could be modified so it could be continued with lower risk associated with it (for example, use a walking stick to walk to the local shops, rather than stopping outdoor walking), or if undertaking other interventions such as a balance training exercise class, may result in confidence and balance and mobility being regained. Curtailing activities unnecessarily has the effect of further reducing confidence in the curtailed activities (such as walking outdoors), but also often results in reduced balance, reduced muscle strength and reduced general physical health, because of the substantial reduction in use of these important systems that need to be used to maintain their function. The longer term effect of inappropriate curtailment of activity is that the person develops an increased risk of future falls.
Health professionals and others involved in health care or general care for older people living at home or in residential care need to look for the presence of fear of falling or loss of confidence in mobility related activities after any fall has occurred. Presence of fear of falling can be evaluated through discussion about the fall and how the person is managing since the fall, in particular discussing any changes in activities after occurrence of a fall, or may be more formally investigated through a falls efficacy questionnaire. There are a number of these type of questionnaires available that investigate a person’s confidence in performing activities without falling, and these can be used together with an assessment of balance and mobility, to determine whether the level of falls efficacy is appropriate for the person’s balance and mobility.
Keeping the momentum
A second important factor that is critical in maximising the likely effectiveness of any falls prevention intervention is the level that the older person participates in the interventions recommended by their doctor or other health professional such as physiotherapist or occupational therapist. Research indicates that a number of interventions such as exercise programs (especially those that involve a challenge to balance ability), medication reviews, home safety modifications, using distance glasses rather than bi/multifocals for outdoor activity, and vitamin D supplementation for people who are vitamin D deficient, as well as multifactorial interventions, can be effective in reducing falls or fall related injuries for older people living in the community setting. There is substantially less research in the residential care setting, where the main approaches shown to reduce falls are vitamin D supplementation, and multifactorial interventions often based on a fall risk assessment.
However, the level of uptake and sustained participation in any of these effective interventions is variable, and often less than 60 per cent are persisting with an intervention 12 months after it has been commenced. Most of these interventions require a long-term commitment (for example, to exercise, or a change in medication) if short-term benefits are to be sustained. Health professionals need to consider effective strategies in informing, engaging and empowering older people, and their social network, in order to maximise uptake and sustained participation, and therefore likely effect in reducing falls long term.
Research informed practice
A final essential element to improve the unacceptably high rate of falls and falls injuries among older Australians is that systems need to be improved to assist health practitioners, community care and residential care staff to keep abreast of the large volume of research being produced in this area, and about how this research can be meaningfully applied into practice change consistent with the new research. Regular training and upskilling of health professionals, community and residential care staff with high quality fall prevention information and practices will facilitate improved quality of falls prevention practice.
A new commitment
There is an urgent need for a refocusing of attention at a national level on reducing falls among older people. In comparison, enormous resources are spent in media, policy and planning, regulatory practices, prevention and management in what has been an extremely successful campaign to reduce the impact of the other major cause of injury related hospitalisations in Australia – motor vehicle accidents. However, now there are more than twice as many hospitalisations and 30 per cent longer length of hospitalisations from falls injuries in Australia than motor vehicle accidents.
And despite the successful research in falls prevention, this has not translated into practice, as trends over the past 10 years show no reduction in rates of fall related hospitalisations – and in the oldest Australians (those aged over 85 years of age) falls related hospitalisation rates have increased over this period (in contrast to large reductions in rates of motor vehicle accident deaths and hospitalisations). Yet the resources allocated to preventing falls among older Australians remains very low relative to those allocated to reducing motor vehicle accidents.
Greater commitment at a national and state level through substantial resourcing and coordinated support for improved research translation is required if major inroads are to be made into the unacceptably high falls related deaths and hospitalisation rates in Australia.
Professor Keith Hill is head of the School of Physiotherapy and Exercise Science at Curtin University. He will be facilitating the webinar on falls prevention in older people hosted by the Australian Association of Gerontology next Wednesday, 2 April.
Australian Ageing Agenda is the media partner of the AAG.