Preventing falls in older people

In a three armed randomised parallel trial (doi:10.1136/bmj.e4547), Clemson and colleagues examine the effectiveness of a multifactorial integrated intervention in the prevention of falls among people aged 70 years or more who were assessed to be at high risk of falling.1 By the year 2050 around 1.5 billion people will be aged 65 years or more, and many of those will live in developing countries.2 At least a third of healthy people over 65 years who live at home fall once a year; about 20% of such falls require medical care, and many result in fractures.3 Rates of falling events and injuries from falls increase with advancing age, and rates are particularly high for people with chronic conditions, such as Parkinson’s disease.4 The economic burden of falls in old age is substantial. After motor vehicle accidents, injuries from falls contribute most to lifetime costs of injuries, with wrist and hip fractures contributing the most in elderly people.5 It is worrying that hospital admissions related to falls have declined little over the past decade, and given the predicted changes in global demographics it is time to take proper action on falls.

Multifactorial interventions that target strength, balance, home hazards, vision, footwear, drugs, cognition, vitamin D levels, and education on reducing the risk of falls have been shown to reduce slips, trips, and falls in people at home, in hospital, and in some nursing care facilities.1 6 7 8 However, few older people regularly perform strength and balance exercises, and those who do are often comparatively fit and healthy in the first place. So how can we engage older people in regular exercise and physical activities and educate them about fall prevention? Important insights are provided by Clemson and colleagues, who showed that, compared with a sham control programme, a lifestyle integrated approach (LiFE) to balance and strength training reduced the rate of falls in high risk people aged 70 years or more who were living at home. In contrast, the rate of falls for participants in the routine exercise group was non-significantly reduced compared with those who received the sham control programme.

The LiFE programme is based on the understanding that many people struggle to adhere to standard home based exercises over the long term, so the exercises and strategies to prevent falling in this programme were embedded into daily routines. Tasks such as walking, stepping over objects, turning, changing direction, and moving from sitting to standing were modified according to individual needs and circumstances to include components that promoted balance, strength, or mobility. As a result, movement and balance “exercises” were performed many times every day rather than two or three times a week, which is usual for standard exercise programmes. The LiFE training programme sought to prevent falls by increasing habitual physical activity and exercise levels, and by improving balance confidence during daily tasks.

The trial results suggest that older people are more likely to adhere to home based fall prevention strategies if treatment is embedded in goal directed activities of daily living. They also highlight the importance of ensuring that enough dosage of the intervention is delivered to result in an effective outcome.

The trial monitored falls over 12 months, using calendars to record the date, time, location, and nature of each fall, which is the gold standard method of systematically documenting the occurrence of falls over long periods of time.9 10 It is more accurate than simply asking a person how many falls they have had during the past year. The rapid evolution of “smart” technologies to monitor and respond to falls via telephones, tablets, and the internet will improve the accurate collection of fall data and help prevent falls in the future.11 However, clinicians will need to embrace these new technologies rapidly and help older people to use them.

The development and translation of global and local policies on prevention and management of falls and fall related injuries must be given urgent priority. Policies need to take into account cultural context, population demographics, and the structure of health workforces and health systems. The National Institute for Health and Clinical Excellence recommends that fall monitoring and education about fall prevention are routinely integrated into consultations with older people and those at risk.12 It is also important to look for gait and balance disorders, refer for multifactorial fall risk assessments, refer to exercise programmes and fall prevention programmes when needed, and to monitor fall events over the long term.12

The current trial suggests that for fall prevention programmes in older people to be effective, therapeutic exercises, education, and physical activities need to be sustainable, enjoyable, and effective over the long term. One way to provide greater protection against falling would be to increase adherence and avoid the disengagement that sometimes occurs by embedding treatment into lifestyle activities. The belief that falls should be accepted and tolerated as part of the ageing process is a myth that needs dispelling. Many falls can and should be prevented.