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Falls are often referred to as one of the "geriatric giants",
generating diagnostic and rehabilitative dilemmas for a variety of
specialists in a range of settings. In older people, falls are
associated with significant mortality and morbidity and frequently
lead to a decline in physical and/or psychological function,
ultimately encroaching on independence and autonomy. In addition to
the costs to the individual and immediate carers, falls consume
significant resources in terms of hospital admissions, bed
utilisation, and use of other health and allied services. With an
ageing population, the problems associated with falls and injury
will escalate unless there is a coordinated and effective approach to
prevention and intervention.
Given that most falls result from a dynamic interaction between
intrinsic and extrinsic factors, a multidisciplinary approach to
their management -- incorporating medical, functional, and
environmental assessment -- is likely to be most rewarding. To date,
there is limited evidence to support a population-based preventive
strategy -- it thus becomes imperative to focus on high-risk groups
with the potential to benefit. For any falls prevention strategy to be
effective and of direct clinical relevance, it should:
- be acceptable and applicable to the affected population
(applicability);
- alter outcome in terms of falls and fall-related injury
(efficacy);
- be cost effective (cost-effectiveness); and
- be readily applicable to everyday practice
(practicability).
There is increasing evidence to support intervention in specific
populations, although caution is advised when extrapolating
results from one setting and population to another. Tinetti and
colleagues' seminal article showed the benefits of undertaking risk
factor modification in older people in the community with specific
risk factors for falls,1 while Campbell et al have
shown a reduction in risk of falling after individually tailored home
exercise programs for women 80 years or older.2 T'ai chi undertaken in a
group setting has also been shown to reduce the risk of recurrent
falls.3 More recently, Campbell and
colleagues reported a significant reduction in falls after
withdrawal of psychotropic medication in older people.4 However, within
a month of completion of the study, 47% of their patients had
recommenced psychotropic medication, highlighting the need to
provide continuing support. The role of the occupational therapist
and home environment modification has not been established. A
recently published study by Cumming et al showed a reduction in falls
in patients having a home environment assessment by an occupational
therapist on discharge from hospital.5 Interestingly, the
observed reduction was for both indoor and outdoor falls, raising
questions as to the mechanism of the observed effect. Perhaps
modifying the home environment enhances safety awareness
generally.
It should be remembered that most people who fall do not sustain any
injury and do not present to any medical service,6 despite
increasing evidence supporting targeted intervention. Older
people presenting to emergency departments are an easily
identifiable, high-risk population. Studies have reported that,
among older people discharged from emergency departments, up to half
show an increase in dependency, usually secondary to
trauma.7,8 A two-year follow-up of
patients for whom a geriatric consultation was requested in the
emergency department showed 34% had died and 52% were in a long term
care facility.9
Falls contribute significantly to the emergency department
workload, as highlighted by Bell and colleagues in this issue of the Journal.10 They report data on older
people presenting after a fall to an inner-city teaching hospital in
Sydney. Their results emphasise the multifactorial nature of falls.
A UK inner-city teaching hospital with comparable baseline
demographics has produced evidence of the benefits of a structured
interdisciplinary assessment of such patients.11 The high rate
of injury and admission reported by Bell et al is not surprising and
reflects our own experience -- elderly people are four to five times
more likely to be admitted to hospital than younger people -- and this
must be taken into consideration in the context of demographic
projections for the next 25-30 years.
The emergency department represents a key interface between the
hospital and the community and, as such, affords a unique opportunity
for interdisciplinary and multiprofessional cooperation across
health and social care sectors. However, assessment in the emergency
department focuses largely on injury and limited time is available
for investigating underlying causes or implementing preventive
strategies. It is neither practical nor feasible for all older people
who fall to undergo a detailed assessment in the emergency
department, or to be assessed by geriatricians. However, using
derived and easily identifiable predictors of risk, it is possible to
streamline referrals to a falls program or clinic, which would be in
keeping with an attainable level of service commitment. Predictors
of future risk, as identified in the emergency department, include a
history of one or more falls in the previous year, a fall occurring
indoors, inability to get up from the floor after a fall, and
polypharmacy (four or more regularly prescribed
medications).12
Only through effective liaison with services within and outside
hospital can we improve the outcome for older people presenting with
falls. The increasing provision of falls programs fulfilling the
effective intervention criteria provides the ideal opportunity to
bring together existing, but frequently fragmented, services to
enhance the care of older people.
Jacqueline C T Close
Physician
Clinical Age Research Unit
Department of Health Care of the Elderly
King's College School of Medicine and Dentistry
London, UK
jacqueline.closeATkcl.ac.uk
Ed Glucksman
Physician, Department of Accident and Emergency Medicine
King's College Hospital, London, UK
- Tinetti ME, Baker DI, McAvay G, et al. A multifactorial
intervention to reduce the risk of falling among elderly people
living in the community. N Engl J Med 1994; 331: 821-827.
-
Campbell AJ, Robertson MC, Gardner MM, et al. Randomised
controlled trial of a general practice programme of home based
exercise to prevent falls in elderly women. BMJ 1997; 315:
1065-1069.
-
Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in
older persons: an investigation of Tai Chi and computerized balance
training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative
Studies of Intervention Techniques. J Am Geriatr Soc 1996;
44: 489-497.
-
Campbell AJ, Robertson MC, Gardner MM, et al. Psychotropic
medication withdrawal and a home-based exercise program to prevent
falls: a randomized, controlled trial. J Am Geriatr Soc 1999;
47: 850-853.
-
Cumming RG, Thomas M, Szonyi G, et al. Home visits by an occupational
therapist for assessment and modification of environmental
hazards: a randomized trial of falls prevention. J Am Geriatr
Soc 1999; 47: 1397-1402.
-
Graham HJ, Firth J. Home accidents in older people: role of primary
health care team. BMJ 1992; 305: 30-32.
-
Gerson LW, Rousseau EW, Hogan TM, et al. Multicenter study of case
finding in elderly emergency department patients. Acad Emerg
Med 1995; 2: 729-734.
-
Khan SA, Miskelly FG, Platt JS, Bhattachryya BK. Missed diagnoses
among elderly patients discharged from an accident and emergency
department. J Accid Emerg Med 1996; 13: 256-257.
-
Sinoff G, Clarfield AM, Bergman H, Beaudet M. A two-year follow-up
of geriatric consults in the emergency department. J Am Geriatr
Soc 1998; 46: 716-720.
-
Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and
outcomes of older patients presenting to the emergency department
after a fall: a retrospective analysis. Med J Aust 2000; 173:
179-182.
-
Close JCT, Ellis M, Hooper R, et al. Prevention of falls in the
elderly trial (PROFET): a randomised controlled trial.
Lancet 1999; 353: 93-97.
-
Close JCT, Ellis M, Hooper R, et al. Predictors of falls -- results
from Prevention of Falls in the Elderly Trial (PROFET). Age
Ageing 1999, 28 Suppl 1: 14.
©MJA 2000
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