Falls Management: Accidental Falls and Physiotherapy in the Elderly

An NHS bulletin released in 1996 mentioned that in the UK, according to 1991 statistics, 1 in every 6 cases of accidental falls was of persons above 65 and this proportion is expected to reach 1 in every 5 by the end of 2021 with a relative increase of falls in people above 75.

According to a more recent report by the Health Development Agency (NHS) in 2003, Millward et al claim that accidental injury is a leading cause of death and disability and according to the WHO, injuries and falls will be the largest reason for loss of human life.

According to a British Medical association report cited by Millward et al. (2003), in the UK, non-fatal injury results in 720,000 people being admitted to hospitals annually and more than six million visits to accident and emergency departments. According to Cryer (2001), over 50% of deaths due to injuries and over 60% of serious accidental injuries occur in elderly people over 65 years of age. Cases for accidental injuries leading to hospitalization or injuries causing fatality are higher for elderly people than for any other age group (Cryer 2001).

Falls management are aimed at prevention, assessment, diagnosis and therapeutic interventions and treatments of people affected by falls and fractures. Millward et al (2003) reports of:

Office of National statistics report falls as the major cause of mortality due to injury in older people and a fifth of older people die due to falls and from among people those who survive, only a third regain the same level of mobility as before. Each year, in the UK falls from stairs account for more than 1000 deaths in older people and cause 330,000 serious injuries. Falls can also lead to early admission to permanent residential care. The costs of falls management by the NHS have been increasing steadily and it is apprehended that by 2015 there will be 120,000 cases of fall each year (NHS report 2005).

Research Evidence

Giving evidential information on the effectiveness of such falls prevention programs, Theodos (2004) examines the impact of falls prevention program on the fall incidents among residents in a nursing home. It was hypothesized that diagnostic, therapeutic and preventive approach should be used for nursing home residents who are identified a being at high risk for falls to reduce the number of fall incidents and to improve the quality of life for this category of vulnerable people, especially the elderly.

The program targeted to identify intrinsic and extrinsic factors in order to help reduce risks of falling faced by the nursing home residents. The effectiveness of such an intervention program was evaluated by examining the changes in the rate of falls and by doing a comparative analysis of rates of falls before and after the program was implemented. The results suggested that a multifaceted program with multiple personalised interventions was effective in reducing the falls rate of frail and old residents along with the suggestion that muscle strengthening practices and interventions may be beneficial for such a population.

The program outcomes and results indicated that case managers and nurses can have considerable impact on the quality of life of frail and elderly nursing home residents by promoting and encouraging their health, independence and safety dealing with their problems resulting from inactivity due to falls and injuries. Theodos highlights that prevention; monitoring and investigation into falls are essential parts of the research and intervention program.

Moreland et al (2003) give evidence based guidelines for secondary prevention of falls in older adults. The authors point out that accidental falls are a significant problem for older adults and individuals who have sustained a fall immediately come to the attention of health care providers as they are at a risk of further falls. Moreland and colleagues suggest that apart from a summary of evidence regarding falls that may be useful to researchers in the field, a practice guideline is needed to promote the highest quality of care and to reduce variations in the care standards provided.

The objectives were to set up essential guidelines based on evidence for assessment, prevention and treatment of falls in older adults and to provide data on risk factor studies and fall prevention statistics for health care workers. The authors used a template for development of practice guidelines from the Agency for Health Care Policy and Research and evidence for risk factors was also obtained after which a schema for evaluating the risk factor was used. Evidence for interventions and strength of the evidence was examined.

The information obtained was from 46 risk factor studies and 37 randomised controlled trials that helped develop a practice guideline and recommended intervention techniques for community dwelling and institution dwelling older adults. Moreland et al concluded form their study that for community dwelling older adults, there is evidence of multi-factorial specific risk assessment and targeted treatment. Within the intervention program, balance exercises are recommended for all individuals who have had a fall and evidence for homo-physiotherapy for women over 80 years regardless of risk factor status was also seen.

Moreland et al suggests that in case of institutional settings, the establishment of a falls programs is associated with safety checks, ongoing staff education and monitoring as substantiated by research. Residents who have fallen are assessed for risk factors and clinical indicators are used as measures to determine the relevant management options that have to be used in their treatment.

Means et al (2005) discuss the effects of a rehabilitation exercise program to recover balance and mobility and to manage falls related injuries in elderly persons. The objective of the study was to assess the short-term effects of an exercise based rehabilitation intervention on balance, mobility, falls and injuries. For this purpose, randomised controlled trials with repeated measures was performed at an outstation rehabilitation centre and elderly and ambulatory community dwelling volunteers went through 6 weeks of supervised stretching, balance, endurance, coordination and strengthening exercises.

Control subjects attended seminars and data were recorded for quality performance and time on a functional obstacle course for self reported falls and injuries. A six month follow up program was conducted and participants in exercise group were found to outperform people in the control group. Post intervention, the exercise group's functional obstacle course quality and performance improved and course completion time improved to 7.69% at post intervention. 87% of baseline fallers in the intervention group reported no falls in 6 months compared with 34.5% of controls.

During the 6 months post intervention stage, 89.7% fallers in the intervention group reported no injuries at 6 months post intervention phase compared with 55.6% of controls. Means et al concluded that interventions can improve functional performance and protect against further falls and falls related injuries.

In a related study Houghton et al (2004), describes a falls and injuries assessment clinic, especially the first two years of operation of the clinic which provides assessment of falls risks and individual preventive interventions in a public hospital setting. Houghton et al used falls prevention evidence to establish a specialist medical assessment and physiotherapy treatment intervention program. The authors note that over 2 years, 386 patients attended the clinic and the most frequent intervention for patients was referral to falls education.

Program maintained by an allied health staff at the clinic. Elderly patients who attended balance and exercise classes through this program showed significant improvement in test scores and showed considerable reduction in their future falls risks. Another important aspect of the treatment program and intervention was detection and treatment of osteoporosis in older adults attending the clinic. The authors conclude that the falls Assessment clinic provides access to evidence based strategies in treatment for the patients and waiting lists of patients wanting to attend the clinic has increased dramatically in recent years.

The paper suggests that many of the interventions which are given in such specific clinical settings should also be made available in primary care settings to increase access for those in the community who are at risk of falls. The importance of balance education, exercises and physiotherapy treatment within a falls assessment and intervention program is highlighted in this study.

The importance of physiotherapy and physical activity interventions to prevent falls among older people is a public health issue as recognised by Sherrington et al (2004). Sherrington and colleagues presents a review on the evidence that relates to the effects of various physical activity (PA) or exercise intervention strategies on prevention of unintentional falls among older people. The authors incorporated six systematic reviews and three randomised controlled trials.

Sherrington et al claim that there is clear evidence that targeted supervised home exercise program of strength and balance exercise and walking practice prescribed by a trained health professional can prevent falls among older community dwellers. They also suggest that untargeted group exercise can prevent falls among community dwellers, especially with Tai Chi or such other exercises that challenge balance. Individualised prescription and customised physical activity depending on individual needs seems to be important and effective for very frail patients.

The authors suggest that further investigation and research is needed to establish effects of physical activity in residential aged care and to examine the relative and different effects of physical activity (PA) among different populations. They also suggest that multidisciplinary, multifactorial, health and environmental risk factors and screening or intervention programs have been found to be effective in preventing falls. For elderly individuals who are at high risks of falls having either impaired physical strength or lack of balance and functional ability, physical activity itself is alone capable of reducing instances of falls.

However for elderly individuals with additional risk factors such as visual impairments, other interventions are also required. Exercises, balance re-education and physiotherapeutic approaches may also form active part of physical activity training and is an essential form of falls prevention and recovery.

In fact Bean et al (2004) highlights the benefits of exercise and physical activity for community dwelling adults as it forms part of study guide on geriatric rehabilitation in Self-directed Physiatrist Education Program that is used by practitioners and trainees in physical medicines and rehabilitation. Considering conditions of morbidity, mortality and disability, the benefits of physiotherapy and physical activity and exercise have been highlighted. However pre-exercise screening and evaluation procedures are important suitability of older adult who are planning to take up exercise programs.

The benefits of exercise have been studied with respect to positive effects on chronic medical conditions in the elderly such as arthritis, diabetes, pulmonary disease, osteoporosis, heart diseases and stroke or cerebral attacks. Bean et al concluded that their study definitely points out to the therapeutic befits of an exercise program for community dwelling older adults who have had falls, injuries and disabling medical conditions.

Studies on increasing ambulatory competence in elderly women are based on the fact that the optimal prevention of osteoporotic fractures in the elderly consists of increasing bone density and preventing further falls. Iwamoto et al (2004) highlight the efficacy of training programs for ambulatory competence in elderly women. In their study, 25 elderly women were enrolled in their 3 month training program consisting of a dynamic balance training combined with static balance and resistance training. The participants were of age rage 61 to 86 years.

It was reported that after 3 months of training, step length, knee extensor muscle strength and maximum standing time on one leg increased significantly although walking speed and hip flexor muscles strengths were not significantly altered. No serious adverse events such as further falls, new vertebral fractures or adverse cardiovascular or cerebral symptoms were seen in any participant and the authors conclude that the training program may have the potential to promote and maintain ambulatory competence after falls and injuries, especially in elderly women.

Davison et al (2005) studied the effectiveness of multifactorial intervention program using randomised control trials to prevent falls in older persons who are cognitively intact yet have a history of recurrent falls. The design used randomised controlled trials using multifactorial post fall assessment and intervention and this was compared with conventional care patterns. The multifactor intervention program included medical, physiotherapy and occupational therapy and were given to patients in accident and emergency departments in University teaching hospitals and district general hospitals.

For the design, 313 elderly men and women above 65 years who were otherwise cognitively intact and yet were admitted to Accidents and Emergency units with a fall or fall related injury and with one additional fall were chosen. 159 of these subjects were randomly assigned to the multifactorial intervention program, whereas the remaining 154 were given conventional care. The outcome measures included determining the number of falls and the fallers within 1 year of the intervention. Secondary outcomes were related to measures on injury rates, mortality, fear of falling and fall related hospital admissions in the following year.

The results indicated that there were 36% fewer falls in the intervention group with the proportion of people continuing to fall lower than people at relative risk. However the number of fall related attendances and hospital admissions were not different between the groups.

However a significant finding form this study is that duration of hospital admission was reduced and falls efficacy was much better for people in the intervention group than in conventional care. Davison et al concluded that multifactorial intervention with physiotherapy and occupational and medical therapy is quite effective in reducing fall burden in cognitively intact older adults with history of recurrent falls attending Accident and Emergency treatment procedures, although this type of intervention program has not been found to reduce the proportion of subjects who continue to fall in future.

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Conclusion:

In March 2001, the Government launched the National Service Framework (NSF) for older people. The NSF has set up specific goals for health systems and these include: reviewing the local system of services for falls, including prevention of falls and identifying those at risk, minimising the risk of falls and improving and providing care for those who have fallen, providing continual care to those who are suffering from long term consequences, including rehabilitation.

The other steps include agreeing and implementing local priorities to reduce incidence of falls, reducing the adverse impact which the fall can have on health, well-being and independence including advice and practice to prevent osteoporotic fractures. The Government along with NSF set up the targets that by April 2005, all local health and social care systems should establish an integrated falls management service to reduce risks of people falling.

Usually a local falls prevention program has intervention techniques at several levels including physical activity services, home safety schemes and Falls clinics. Falls prevention strategy implemented by the health department is a multidisciplinary approach and local and national intervention strategy involve the coordinated working of Occupational therapists, falls coordinators, physiotherapists, health promotion specialists, NSF coordinators and implementation managers, Local councils, Nurses and immediate care service managers.

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www.hda.nhs.uk/

Office of National Statistics

www.statistics.gov.uk/

www.nhsdirect.nhs.uk

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