Interdisciplinary practice in the prevention of falls - A review of working models of care

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Interdisciplinary practice in the
prevention of falls—a review of
working models of care
JACQUELINE C. T. CLOSE
Kings College Hospital (Dulwich), East Dulwich Grove, London SE22 8PT, UK
Fax: (q44) 207 3466476 Email: jacqueline.close@kcl.ac.uk
Introduction
Falls in older people are often referred to as one of
the ‘geriatric giants’ generating diagnostic and rehabil-
itative dilemmas in everyday clinical practice. The
importance of a fall lies in its effect on an older person’s
health, function, and independence. A fall may be the
first indication of undetected illness and repeated falls
often herald a decline in functional ability.
One third of people aged 65q fall each year, rising
to 50% of women aged 85 years and over [1]. Falls are
mentioned as a contributing factor in 40% of admissions
to nursing homes where the incidence of falls is reported
at 1.5 falls/bed/year [2].
Approximately 2.2% of injurious falls are fatal and
almost 50% of men and women who die, do so as a
result of a hip fracture. In a UK study it was found that
15% of patients presenting with a fractured neck of
femur die in hospital and 33% are dead within 1 year
[3]. Of those who survive a hip fracture, approximately
2/3 will return to their own home, 2/3 will have
impaired mobility and up to 50% will have continued
postoperative pain [4].
Fear of falling is a commonly identified although
poorly defined phenomena among older persons. For
those who do not sustain any major physical injury as a
result of a fall, the psychological trauma or fear of
falling itself may lead to self imposed reduction in
physical activity beyond that due directly to physical
disability.
Risk factors associated with falls
Identification of risk factors serves as a useful tool in
the selection of high-risk populations and provides a
framework on which to structure an intervention
program. The populations studied have varied enorm-
ously with respect to age, place of residence, method
of identification and length of follow up, and as such
care should be taken when extrapolating risk factors
from one setting to another. Table 1 highlights risk
factors, identified in at least two papers in the literature,
which have been shown to increase risk of fall and/or
recurrent falls and/or serious injury as a result of a
fall. The diversity of risk factors identified reaffirms
the multifactorial nature of falls and supports the need
for an interdisciplinary approach to prevention and
management.
Preventative strategies
With an ageing population the problems associated with
falls will become ever more evident unless there is a
co-ordinated and effective approach to prevention.
For any strategy to be effective and of direct
relevance in the clinical setting, it should be shown to:
(i) be acceptable and applicable to the relevant
population (applicability),
(ii) alter outcome in terms of falls and fall-related injury
(efficacy),
(iii) be cost effective (cost-effectiveness) and
(iv) be readily applicable to every day practice
( practicability).
Given that most falls result from a dynamic
interaction between intrinsic and extrinsic factors, a
multidisciplinary approach incorporating medical,
functional and environmental assessment is likely to be
most rewarding. At present it is unclear as to who is
most likely to benefit from intervention or indeed
which intervention strategy is most beneficial and
cost effective. Patient acceptability and compliance as
well as cultural differences are important issues which
are often overlooked when extrapolating findings from
one country and culture to another. Most inter-
ventions are costly and therefore it is important to
determine the effective intensity and duration of an
intervention program as well the most appropriate
means of delivery.
Age and Ageing 2001; 30-S4: 8–12
#
2001, British Geriatrics Society
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Table 2 highlights the major randomized controlled
trials which have had an impact on falls in older people.
Intervention strategies incorporating
a medical component
The most striking feature of this group is the relative
paucity of studies that have incorporated a medical or
health component in the intervention.
Tinetti’s seminal paper published in 1994 focused
on people living at home with documented risk factors
for falls [5]. The intervention program was aimed at
modifying and reducing specific risk factors in order to
prevent falls. Modifications included review of medica-
tions, balance and gait training and improvement in
functional skills. At one-year follow up there were
statistically fewer falls and a significant reduction in
the number of risk factors present at reassessment in the
intervention group. The study impacted favourably on
level of function, with statistically significant differences
in measures of balance, transfer skills and gait impair-
ment and trends in favour of a reduction in number of
hospitalizations and bed days occupied. This was the
first well designed and executed randomized controlled
trial to show the benefit of interdisciplinary assessment
in the prevention of falls in the older person.
The Prevention of Falls in the Elderly Trial
(PROFET) has shown the benefits of assessing older
people presenting to the Accident and Emergency
Department with a fall [6]. A structured medical and
OT assessment with referral to existing services pro-
duced a significant and sustained reduction in number
of falls and recurrent falls whilst also preserving level
of function. There was an observed 50% reduction in
the number of fractures during the one-year follow
up period. Like Tinetti’s paper, there were observed
trends in reduction of hospital admissions and bed
days occupied.
Campbell and colleagues looked at the benefits of
a psychotropic withdrawal program and a home based
exercise program in community dwelling individuals
aged 65 and over on psychotropic medications [7]. The
44-week follow up period saw fewer falls in the
psychotropic medication withdrawal group. However,
within one month of completion of the study, 47%
of those who had been withdrawn from their psycho-
tropic medication had restarted, highlighting the need
to provide continuing support for these individuals.
Whilst not the first study to highlight the increased
risk of falls associated with the use of psychotropic
medication, it is the first to objectively demonstrate the
potential benefits of withdrawal.
Studies focusing on exercise and balance
There have been many studies looking at the effect of
exercise on gait, balance and strength. However few have
been designed with falls as a primary endpoint.
Table 1. Risk factors consistently shown to be associated with falls, recurrent falls and injurious falls
Risk factor Falls Recurrent falls Injurious falls
.........................................................................................................................................................................
General Age Y Y Y
Female gender Y Y Y
Previous falls Y Y Y
Living alone Y Y
Physiological/functional Impaired muscle strength Y Y Y
Impaired balance/gait Y Y Y
Impaired mobility Y Y Y
Sensory abnormality Y Y
Impaired vision Y Y Y
Impaired ADL’s Y Y Y
Medical risk factors No. of diagnoses Y Y
Postural hypotension Y Y
Cardiac failure Y Y
Cognitive impairment Y Y Y
Stroke Y Y Y
Depression Y Y
Incontinence Y Y
Arthritis Y Y
Medication Number of drugs Y
Any psychotropic medication Y Y Y
Sedative/hypnotics Y Y Y
Antidepressants Y Y
Digoxin Y Y
Vasodilators Y Y
Analgesics Y Y Y
Diuretics Y
Interdisciplinary practice in the prevention of falls
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Table 2. Summary of key RCT’s in the prevention of falls in older people
Study }Setting Interventions Outcome Author
...........................................................................................................................................................................................................................................
RCT Multifactorial risk factor
abatement strategy
Age: 70q
N = 301
C I: Nurse assessed participants for risk factors
and targeted interventions accordingly.
Therapist gave home exercise routines
C: Friendly visits
1 year follow up. Fewer falls in intervention
group: 35% vs 47% ( P = 0.04). Also significant
reduction in risk factors at reassessment
e.g. medications, balance impairment, gait
impairment and toilet transfer skills
Tinetti et al., 1994 [5]
FICSIT Meta analysis
7 Separate RCT’s all with
exercise element
2NH
5C
10–36 weeks of exercise—different
programs in each centre
2– 4 year follow up. Subjects assigned to an
exercise intervention were less likely to fall
No exercise component was significant for
injurious falls
Province et al., 1995 [9]
RCT to evaluate the effect of
Tai Chi compared to conventional
balance training
Age: 70q
N = 200
C 1: Tai Chi
2: Conventional balance training
3: Education
4 month follow up
Significant reduction (45%) in multiple falls in Tai Chi
group. Also fear of falling reduced when compared
to education group
Wolf et al., 1996 [8]
RCT of effect of individually
tailored home exercise program.
Women aged 80q
N = 233
C I: Individually tailored program of strength
and balance training in the home. 4 one hour
sessions with physiotherapist in the first two
months of the study
C: Social visits
1 year follow up. Significantly fewer falls in the
intervention group (152 vs 88)
Intervention group had significantly reduced
relative hazard for falls and fall with injury and
also had improved balance scores
Campbell et al., 1997 [10]
RCT; OT home assessment
targeted on environmental
modifications in older people
discharged from hospital
Age: 65q
N = 530
C I: Home visit by OT with advice and help
with modifications
C: Usual care
1 year follow up period
Reduction in number of falls in intervention group
as compared to control ( P = 0.05)
Intervention only effective in those with history of falls
Cumming et al., 1999 [13]
RCT
Interdisciplinary assessment of older
people presenting to A&E with a fall
Age: 65q
N = 397
C I: Comprehensive medical assessment in
Day Hospital with onward referral where
need identified. Single OT home visit
C: Usual Care
1 year follow up period
Statistically significant reduction in falls,
number of people falling, recurrent fallers
Barthel scores significantly better in intervention group
50% reduction in number of fractures (8 vs 16) P = NS
Close et al., 1999 [6]
J. C. T. Close
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The largest study looking at the effect of exercise
in the older population is the ‘Frailty and Injuries:
Co-operative studies of intervention techniques’—
FICSIT. This multicentre study, involving seven
sites across the USA, was designed so each site
tested a different exercise intervention strategy in
selected target groups of older adults both in the
community and institutions. Tinetti’s multifactorial
intervention programme [5] was one of the seven
sites as was Wolf et al.’s Tai Chi study which showed
that balance training using this martial art under-
taken in a group setting reduces the risk of recurrent
falls [8].
A common database across all sites allowed for
‘meaningful’ comparisons of intervention potency. Meta-
analysis of the data from the seven sites showed that
subjects assigned to an exercise intervention were less
likely to fall in the follow up period and the incidence of
falls was lower in subjects whose intervention included
exercise to improve balance [9].
A well designed randomized controlled trial on the
benefits of exercise with a positive outcome was
reported by Campbell and colleagues in 1997 [10].
They selected a relatively high risk population;
women aged 80 and over who undertook individually
tailored home exercise programs. Each participant
in the intervention group had 431 hour exercise
sessions in the home during the first two months
of the study. At the end of the initial one year
follow up period there was a significant reduction
in the number of falls and fall related injury. A
further publication showed that the benefits observed
were sustained at two years of follow up [11].
More recently, Campbell and colleagues have shown
that it is possible for physiotherapists to train district
nurses to effectively deliver exercise programmes in
such a manner as to lead to a reduction in number of
falls [12].
Studies incorpora ting a home/environm ental
assessment
A recently published study on the benefits of home
assessment is that by Cumming and colleagues in
1999 who looked at 530 people aged 65 and over
identified in the hospital setting and subsequently
discharged home [13]. The intervention consisted of an
OT home assessment and help with modifications.
Individuals were not eligible if an OT home assessment
was already being considered as part of the discharge
planning process. There was a significant reduction in
the number of falls in the one year follow up period and
sub group analyses showed that those who benefited
most were those with a history of falls. Interestingly the
observed reduction was for both indoor and outdoor
falls raising questions as to the mechanism of observed
effect.
RCT; 2
*
2 Factorial Design to
assess effectiveness of
psychotropic medication and
home-based exercise programme
Age: 65q on psychotropics
N = 93
C I1: Gradual withdrawal of psychotropic medication
I2: Home based exercise program
44 week follow up
Fewer falls in medication withdrawal group
(0.34; 95% CI 0.160.74)
No significant reduction in falls in the exercise group
Campbell et al., 1999 [7]
RCT; District nurse delivered
individually tailored home
exercise programme
Age 75q
N = 240
C I: District nurse delivered individually
tailored exercise programme
C: Usual care
1 year follow up
Fewer falls in the intervention group
(0.54; 95% CI 0.320.9)
Robertson et al., 2001 [12]
}Settings: C = Community; NH = Nursing Home; RH= Residential Home; H = Hospital.
Interdisciplinary practice in the prevention of falls
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Conclusion
The prevention of falls in older people is a
problem being addressed by many professionals in
health and allied services. Whilst the evidence
base is expanding, care must be taken when inter-
preting studies and extrapolating data into different
settings.
Multidisciplinary assessment and intervention has
the strongest evidence base with data supporting this
approach both in primary and secondary prevention.
More studies are starting to emerge supporting exercise
in defined groups of individuals although further
information is required with respect to the appropriate
type of exercise, the method of delivery and the effective
duration of input. Assessment of the home environment
and function within the home appears to be beneficial in
selected high risk individuals.
Despite the increasing number of studies published
in the literature, there are still several areas requiring
further research and evaluation. Population based
screening has yet to be addressed and there are no well
validated and published screening tools for use in the
primary care setting. More evidence is needed as to the
role of intervention to prevent falls in the institutional
care setting. Preventive strategies for those with
dementia are currently being evaluated. The problem
of falls occurring in the hospital setting has yet to be
adequately addressed and whilst tools exist to identify
those most at risk of falling in hospital, there is as yet no
evidence that intervention alters risk.
No randomized controlled trial on falls prevention
has shown a significant reduction in fracture risk and the
prevention and treatment of osteoporosis in older
people needs to be considered in parallel with assess-
ment of risk factors for falls. Hip protectors also deserve
further evaluation.
When considering prevention of falls in older people,
any service development must be supported by ongoing
audit and evaluation. Interdisciplinary working is almost
certainly the way forward and collaboration between
academics and those responsible for delivering a service
is vital to further strengthen and expand the existing
evidence base. Only through effective liaison with
services within and outside the hospital setting can one
effectively alter outcome for older people presenting
with falls. The increasing provision of Falls Clinics
fulfilling the effective intervention criteria, provide the
ideal opportunity to bring together existing but
frequently fragmented services to enhance the care of
older people.
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