While walking my dog in the forest recently, I tripped over a hidden tree root and there was nothing I could do to stop myself falling. I tried to avoid hitting my head, fell heavily on my right shoulder and pummelled my left elbow into my rib cage. Fortunately, nothing was broken but I suffered significant pain and bruising for a number of weeks. It gave me quite a fright and I have avoided this woodland path ever since. Some days later I saw a preschool child fall hard on his hands and knees, but he bounced up as if he were made of rubber and carried on playing as if nothing had happened! In contrast, falls for the elderly are both frightening and something they dread happening.
Patient falls account for the most frequently reported safety incident in NHS hospitals (Morris and O'Riordan, 2017). As in my own case, no fall in older adults is harmless: falls in hospital can cause physical injury in 30-50% of cases, with fractures occurring in up to 3% of cases. Falls can also lead to a range of associated psychological and physical morbidities, such as loss of patient confidence, and delays in recovery and subsequent discharge (Morris and O'Riordan, 2017).
Background
Falls among older adults is a global phenomenon. The World Health Organization (WHO) (2018) suggests that falls are the second leading cause of accidental death; there are 646 000 annual fatalities, the greatest number being among adults aged over 65. Furthermore some 37.3 million falls across the world each year are of such magnitude as to warrant medical intervention. Patient falls also incur significant economic costs, with those among older people estimated to amount to £2.3 billion per year (National Institute for Health and Care Excellence (NICE) (2013). This is clearly not sustainable.
Given the magnitude of the economic costs associated with falls it is not surprising that WHO urges health services to invest in prevention strategies: in many instances, the risks can be significantly reduced by implementing simple, low-cost changes in an individual's behaviour and habits. Although falls are associated with serious morbidities, they are not an inevitable part of ageing.
Although there is a range of national standards and guidelines linked to falls reduction and prevention, the implementation of complex multiprofessional interventions remains challenging and those NHS trusts that have succeeded in tackling patient falls have placed great emphasis on building a culture of vigilant safety consciousness among all staff in the frontline of care delivery.
The problem of falls in older adults can be alleviated by implementing preventive strategies. These can include falls risk assessment of people's living environments, clinical interventions to identify risk factors (medication review, treating low blood pressure, vitamin and calcium supplementation, treating correctable visual impairment), and community-based group programmes that may incorporate falls prevention education and tai chi-type exercises, or dynamic balance and strength training.
The use of exercise to reduce risk
The Cochrane Library recently published a systematic review that examined exercise as a method for preventing falls in older people living in the community, which showed that exercises targeting balance, gait and muscle strength can prevent falls in elderly people (Sherrington et al, 2019).
Exercise programmes that reduce falls primarily involve balance and functional exercises, while those that probably reduce falls include multiple exercise categories (typically balance and functional exercises, plus resistance exercises).
Tai chi, which is an ancient Chinese system of exercise that combines deep breathing and relaxation with flowing movements, is practised around the world, and may help prevent falls (NHS England, 2018). It has been shown to help people aged 65 years and older to reduce stress, improve posture, balance and general mobility, and increase leg muscle strength, although more research is needed.
In addition, a study by Trombetti et al (2011) showed that participation in music-based multitask exercise classes once a week can improve gait and balance, helping reduce falls and the risk of falling in elderly adults.
Sepsis and delirium
Delirium, which is often attributed to unrecognised sepsis, is increasingly recognised as a prime cause of patient falls. Patients affected by delirium are at greater risk of falling which, in turn, increases their risk of developing dementia, leading to longer hospital stays or admission to a care home.
The NHS Long-Term Plan (NHS England and NHS Improvement, 2019) paved the way for the introduction of a wide range of funded programmes to upgrade technology enabled care across the NHS. As part of this investment, digital devices are among the tools being made available in hospitals to help prevent dementia and falls in older people through early recognition of sepsis. For example, in Salford, timely diagnosis, alongside a symptoms checklist on a mobile computer or handheld device, is helping prevent falls. The introduction of screening for all over-65s admitted to hospital has increased the number of patients correctly diagnosed with delirium by 34% (NHS England, 2019).
Discussion
Given the devastating effects falls can have on patients and their families, screening and assessment for falls risk is a priority for nurses. Evidence from the Royal College of Physicians (RCP) suggests that assessment and intervention could help reduce falls by up 25–30%, and its FallSafe initiative (RCP, 2015) consists of care bundles to reduce inpatient falls. Analysis of data from hospital wards that participated in developing FallSafe showed that:
A patient falls improvement collaborative initiative under the auspices of NHS Improvement (2017) is seeking to further support providers to help reduce inpatient falls and increase the reporting of patient falls. The collaborative has spotlighted some key facts about patient falls, namely that:
To clarify advice on falls NICE (2019) has introduced guidance to help nurses and other health professionals to better assess people at risk This includes identifying patients aged over 65 years who have had one or more falls in the preceding 12 months and establishing how often they:
However, no matter how much advice bodies such as NICE produce it is often nurses who have to reconcile the reality of care delivery and the quest to reduce falls. Studies, such as that by Griffiths et al (2018), have shown that reduced numbers of registered nurses and a greater reliance on nursing assistants to replace them are associated with increased patient risk.
Conclusion
Falls can have serious consequences for elderly people in hospital and the costs to the NHS are significant. The RCP (2016) has developed the Falls Prevention in Hospital guide to help older people avoid serious injury and potential healthcare costs. The guide is free to download and should be freely available in all elderly care wards.
The Care Quality Commission (CQC) is also taking falls very seriously and has developed Regulation 12 to prevent people receiving unsafe care and treatment, and the occurrence of avoidable harm or risk of harm (CQC, 2018a).
To help NHS trusts tackle incidents such as falls more successfully, the CQC (2018b) published a series of resources entitled ‘Learning from safety incidents’ to help health care managers to more fully ensure the safety and wellbeing of service users. One of the key themes addressed within these resources is problems with the use and application of risk assessments such as those used to identify patients who are susceptible to falls.