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.
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).
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