Keywords

4.1 Introduction

A fall is the usual mechanism of injury for fragility fractures. A fall is defined as ‘an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’ [1]. Syncope, seizures or acute stroke are not considered falls, although they can also present as an episode of instability and a change of position to a lower level [2] and may be risk factors for falls. Common mechanisms of falls are slips, trips, and instability while walking or changing position. Falls can have diverse and complex causes and predisposing risk factors and are considered a geriatric syndrome since they are generally the result of the accumulated effect of impairments in multiple systems, particularly among those over 80 years old. They can also occur at any age and level of functioning when there is an inconsistency between physiological function, environmental demand and individual behaviour [3].

It is estimated that one-third of older people fall annually [4,5,6]. Fall-related injuries are a leading cause of hospitalisation of those aged 65 years and older [4, 6]. Falls are also a common cause of death in people over 60 years of age [4] and are among the ten health conditions that contribute to more years lived with disability [7].

Fractures occur in 5% of fall events, with 1% of these being a hip fracture [8]. Among musculoskeletal diseases, fractures are the third condition most responsible for years lived with disability demanding rehabilitation [9]. It is estimated that half of women and a quarter of men will suffer a fracture due to a fall during their lifetime [10]. Preventing falls and fall-related injuries in older adults is a global priority.

The mechanism of injury for most fragility fractures is a fall from standing height, usually by falling sideways [11]. Fragility fractures are defined as fractures that result from mechanical forces that would not lead to a fracture in a person with good bone density. Thus, a fracture after a fall from a standing height would be considered a fragility fracture, whereas a fracture after a fall from a high surface or a motor vehicle accident would generally not be considered a frailty fracture [12, 13]. Falls and fractures are closely linked in all age groups, but in older people, a combination of falls and fragile bone (osteoporosis) frequently leads to fragility fractures with frailty contributing further to the risk of falls and impeding recovery from injury (see Chaps. 2 and 3 for further information about osteoporosis and frailty).

Falls and fragility fractures can result in both short- and long-term disability and can have a significant impact on individuals, communities and health and social care services. For older people, the consequences of fragility fractures due to falls can be life-changing with considerable deterioration in health-related quality of life, increased dependency and social isolation [14]. As few as 40–60% of older people who sustain a hip fracture are likely to recover their pre-fracture level of mobility, and only half will regain their pre-fracture level of independence in instrumental activities of daily living, resulting in increased long-term care needs [15].

Falls are sometimes wrongly viewed as an inevitable consequence of the ageing process. They have, however, been shown to be avoidable with effective care and preventive measures [4]. Nurses and other health professionals working with patients following fragility fractures are in a unique position to integrate fall prevention into every aspect of the patient care pathway in the acute and rehabilitation phase of recovery as well as in secondary fracture prevention and community/home care settings.

The aim of this chapter is to explore the role of the practitioner working in acute hospital units, ambulatory care/outpatient clinics and community/home care settings and with people transitioning from hospital to home in preventing further falls in older people who have sustained a fragility fracture.

4.2 Learning Outcomes

At the end of this chapter and following further study, the practitioner will be able to

  • Outline the impact of falls following fragility fracture on the older person.

  • Explain the importance of preventing further falls.

  • Identify their own and others’ roles in fall prevention.

  • Assess the causes of and risk factors for falls.

  • Plan evidence-based care for the prevention of further falls in the acute hospital setting and/or the ambulatory care/outpatient clinic/community setting.

  • Appropriately refer patients who have fallen to other services.

4.3 Understanding the Risk Factors for Falling from an Individual Perspective

As outlined above, the causes of falls are individual and multifactorial. Consequently, the risk factors for falls can interact dynamically [4, 16]. Over the years, more than a hundred risk factors have been identified in the literature, and these can be broadly classified into three main categories [17]:

  1. 1.

    Demographic: relating to issues such as age, gender, culture

  2. 2.

    Intrinsic: relating to individual biological and psychological factors, especially physical function, which are influenced by nutritional status, pre-existing medical conditions, medications, cognition, mood and sensory perception

  3. 3.

    Extrinsic: relating to the environment such as living conditions, home hazards and family/carer support

Table 4.1 provides examples of the most common risk factors for falls in older adults, based on the above classification.

Table 4.1 Categories of fall risk factors and examples
Full size table

High risk of falling in older people is frequently associated with advanced age, multimorbidity and gait and balance problems. However, it is important to recognise that younger and more active older people, usually categorised as having a low-to-moderate risk, may also experience falls and should also be screened and assessed.

The prevalence/incidence of falls is different around the world, depending on culture, lifestyle and community practices. Availability of health and community services designed to prevent falls also varies significantly. Considering this, the strategy used in fall prevention will be influenced by region (location) and setting [19]. While the causes of falls, and therefore risk factors, are many, there are three main factors that strongly predict future falls [20]:

  1. 1.

    Falls and fall-related injuries in the last year

  2. 2.

    Fear of falling

  3. 3.

    Feeling unsteady when standing or walking

Box 4.1 provides an illustration of the risk factors for falls through a case study. The case study will continue later in the chapter.

Box 4.1 Case Study: The Fall Journey Part 1

Rosanna is 84 years old. She lives alone in a second-floor apartment (with a lift) in a city suburb. She is supported by two daughters and a son who live nearby. Since the COVID-19 pandemic, she has not been leaving her apartment as much as she used to and feels unsafe walking any distance. She now only goes out if her daughters or son take her.

About 8 months ago, Rosanna fell on the landing just outside her apartment while putting out the rubbish. She does not know why she fell. She sustained a fracture of her left wrist, which healed after several weeks in a lightweight plaster cast. Since then, she has been anxious about falling again, so she is very careful when she is walking around her apartment. She tends to hold onto her furniture to steady herself. Her children are concerned about her living alone and asked her to try not to go out for shopping without help.

Rosanna’s husband died 5 years ago. She has become less socially active since then and feels that her life has contracted over those years. On many days now, she struggles to pay attention to the books and television she used to love, and she lacks the motivation to go out or join in social events. She does not like to admit that she has had a few falls since her wrist fracture but has, fortunately, been able to get up and has not been injured again at this stage. She has not told her family about these other falls.

Consider:

What else would you like to know about Rosanna?

What risk factors for further falls can you already see here?

What opportunities can you see for health professional intervention during this phase of Rosanna’s care journey?

4.4 The Link Between Frailty, Sarcopenia, Falls and Fragility Fractures

Frailty, sarcopenia, falls and fragility fractures are highly correlated and often overlap. Sarcopenia is a major component for frailty [4], frailty can cause falls and falls can accelerate the frailty process as well as increase the risk of fragility fractures [21]. Falls are also considered a marker of sarcopenia and are one of the items of the SARC-F, an instrument designed to detect the risk of sarcopenia.

In older people, fractures are usually the consequence of two factors:

  1. 1.

    A fall

  2. 2.

    Bone fragility

Risk factors for falls significantly increase the risk of fracture and are linked to the risk factors for osteoporosis [22]. Another condition of great interest to clinicians is osteosarcopenia—the coexistence of osteopenia/osteoporosis and sarcopenia in the same patient—and it is associated with higher risk of falls, fractures, frailty and mortality [23]. Its prevalence ranges between 5 and 37% in community-dwelling older adults, with the highest rates observed in those with fractures [24]. Chapter 3 provides more information about sarcopenia and frailty.

The pathophysiology of osteosarcopenia is the consequence of multidirectional abnormalities in the bone-muscle crosstalk and local changes. Another important characteristic is that it can coexist with obesity, characterised by increasing levels of fat infiltration that are observed inside the bone marrow in osteoporotic bone and the dramatic levels of intramuscular fat infiltration observed in sarcopenic muscle.

Risk of falling has been shown to be more predictive of fractures than bone mineral density alone. Hence, fracture prevention should focus on identifying risk and preventing falls as much as on diagnosis and treatment of bone fragility (osteoporosis) and sarcopenia [25]. Optimum fracture prevention is, therefore, likely to require strategies to address falls as well as bone density.

4.5 Screening and Assessment

Screening is the process of identifying people at higher risk of falling (and stratifying their level of risk of falling) so that early preventive strategies can be personalised and implemented. This is an interdisciplinary activity that is the responsibility of all members of the team in all fragility fracture settings like acute/emergency care, rehabilitation, fracture prevention services and continuing care. Most patients with a fragility fracture will have fallen, so they can be automatically considered at risk of further falls. It is, however, still important to undertake assessment to enable the clinical team to do two important things:

  1. 1.

    Identify the level or risk of falling.

  2. 2.

    Understand the modifiable factors that can be altered with the aim of preventing future falls.

Nurses are particularly well placed to undertake screening and assessment because of their numbers and their 24-h contact with patients in some settings.

Various algorithms such as the CDC’s STEADI [25], the American and British Geriatrics Societies’ Clinical Practice Guideline for Fall Prevention [26] and the World Falls Guidelines (WFG) [19] recommend screening as an entry point for determining older people at risk of falling. All older adults should be considered a potential faller, even when they do not have any other risk factor.

Based on the complexity of identified problems, the input and support of other specialists (e.g. audiologists, ophthalmologist, podiatrists) and other members of the team with specific expertise or responsibilities may be needed to complete the assessment. This must take place as soon as possible, especially if there is a hospital admission and collaborative discharge planning needs to take place. In some countries and regions, there may not be any other specific services in place, and the nursing team and other health professionals will need to be trained and educated to undertake these assessments as part of the assessment/CGA process (see Chap. 5).

For example:

  • Home hazard assessment: As early as possible, even immediately following hospital admission for hip fracture, so that measures can be in place well before discharge. In some countries, this is the role of a community/home care outreach team, social care specialist or occupational therapy service.

  • Vision assessment and referral: Poor vision is a significant risk factor in falling and postural stability, assessment of visual acuity can be conducted early in the process of assessment and referral for a complete assessment should take place as soon as possible after the fracture [e.g. contrast sensitivity (CS), depth perception, binocular vision and binocular visual field]. Identifying those who wear multifocal/varifocal glasses is essential since they increase the risk of falling by impairing the distance contrast sensitivity and depth perception in the lower visual field of near-vision lenses, reducing the ability to detect environmental hazards.

  • Medication review: Involving alteration of prescription and/or withdrawal of medications that increase the risk of falls. Some types of medication, and polypharmacy, are significant factors in falls. Medication should be reviewed either by the general practitioner or, during a hospital stay, by a geriatrician/physician/advanced practitioner and changes put in place and communicated to the patient’s general practitioner/community team.

  • Malnutrition and sarcopenia: Recognising undernutrition is essential in the management of frailty and sarcopenia (see Chap. 3), particularly in hospital where nearly 40% of older people are malnourished. Malnutrition is associated with poor health outcomes, hampering the management of other underlying conditions and diseases. The Mini-Nutritional Assessment (MNA®) was specifically developed and validated to identify older people who are malnourished or at risk of malnutrition, so intervention can be started early, and it has been translated into several languages (https://www.mna-elderly.com/mna-forms). The identification of possible cases of sarcopenia (risk of sarcopenia) can be conducted using the SARC-F tool, and the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) algorithm can be used to guide further steps into the assessment and confirmation of sarcopenia, including its severity [22]. Nutritional assessment and intervention are considered in more detail in Chap. 11.

Many assessment tools have been evaluated for their accuracy in identifying individuals’ risk factors for consideration when planning preventive interventions that specifically address individual needs. A detailed fall assessment and prevention planning document is an important aspect of the patient record, and careful recording of information gained at each point is essential in ensuring that it can be shared among members of the team. Risk of falls is transitory and requires periodic assessment.

The NICE (2013) [21] guidelines recommended that:

… following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function.

Nurses and therapists are particularly well placed to understand fall history through casual conversations with patients during care episodes such as fundamental care and rehabilitation activities, for example, during personal hygiene interventions and when supporting mobilising.

It is essential that practitioners working in any setting where patients are admitted with fractures undertake a multidimensional fall risk assessment (MFRA). Identifying the individual causes of, and modifiable risk factors for falls that have led to injury is the first step in an effective care pathway. Such risk assessment can then inform planning of prevention measures most likely to meet individual needs in preventing further falls.

Nearly all fall risk assessment tools/scales have been developed in high-income countries and are usually written in the English language. Health professionals working in lower income countries and where English is not the first language (a) are less likely to use MFRA tool, and (b) available tools are inappropriate due to language and/or cultural differences. Tools, therefore, may need to be adapted and/or translated to reflect local conditions. A few tools have been translated into other languages.

The World Guidelines for Falls Prevention and Management for Older Adults [20] provide detailed advice about selecting an appropriate tool for local practice which the reader should access. These can be accessed in full at https://doi.org/10.1093/ageing/afac205. These guidelines focus on primary care settings, so those working in secondary care and acute hospital settings, for example (for which limited advice about fall prevention tools is available), will need to consider the needs of their local setting.

It is important that individual clinical settings work together as an interdisciplinary team to select a risk assessment tool that is

  1. (a)

    Meaningful to the care and management of their patient group, e.g. community-dwelling, hospitalised, post-fracture, ambulatory/outpatient care and peri-operative settings

  2. (b)

    Agreed by the interdisciplinary team as clinically appropriate following consideration and discussion

  3. (c)

    Uncomplicated to administer and record (simple to perform, require minimal space, equipment and time)

  4. (d)

    Easily included in care documentation, has a good predictive capacity to identify fall risk and is sensitive to change

Besides previously discussed usual gait speed test and TUG test, other fall risk assessment tools are the Berg Balance Scale, Performance-Oriented Mobility Assessment, Functional Reach test and fall history. Overall, these fall risk assessment tools have insufficient predictive performance when used alone, but they can be used in combination with the clinical judgement and expertise of healthcare professionals [27] while bearing in mind that they have been developed for primary care/community settings. The STEADI algorithm suggests assessing patients’ modifiable risk factors and falls using the TUG, the 30-Second Chair Stand and the 4-Stage Balance Test [25].

A person-centred care plan based on the assessment of the older person’s care needs, expectations and values can be built over the course of the interdisciplinary assessment/CGA process (see Chap. 6). Practitioners can build individualised fall prevention plans and tailor interventions with the participation of older people and their carers, improving short- and long-term concordance with prevention plans and interventions. An interdisciplinary assessment must then lead to early commencement of prevention strategies (including during any hospital stay), and the implementation of fall prevention measures should never be assumed the responsibility of another service or practitioner.

4.6 Evidence-Based Interventions for Fall Prevention

In all settings, fall prevention needs to be incorporated into the approach to fundamental daily care, be it in the hospital, secondary care or home care setting.

Many countries and localities now have evidence-based guidelines that identify those interventions most likely to prevent falls [28, 29] (see Box 4.2). It is widely accepted that preventing falls is an interdisciplinary undertaking as no one member of the team has all the skills required for successful outcomes in this complex activity. However, there is a danger with this approach that members of the team may perceive fall prevention interventions as the responsibility of someone else, making interdisciplinary collaboration ineffective—and resulting in worse outcomes for older people.

The focus, here, is on those interventions which might be considered specifically ‘nurse-sensitive’ or ‘care-sensitive’ measures. Nurses are the largest group of team members, and they are, therefore, well placed to co-ordinate the fall prevention care of those patients who have recently sustained a fragility fracture following a fall while working collaboratively with other team members, especially physiotherapists. Nurses are also the team members who spend the most time interacting with patients over the 24-h period, particularly during a hospital stay. It is important to stress, however, that these interventions are not the sole responsibility of nurses and should be planned and delivered in collaboration with other members of the team while appreciating the individual skills and roles of each. For this reason, it is advisable that education and training of clinical interdisciplinary teams in the prevention of falls involve all members of the team being educated together through multiprotection education.

Box 4.2 Examples of Fall Prevention Guidelines International/Worldwide

Abraha I, Rimland JM, Trotta F, Pierini V, Cruz-Jentoft A, Soiza R, O’Mahony D, Cherubini A. Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series. J Nutr Health Aging. 2016;20(9):927–936. Doi: 10.1007/s12603-016-0719-9. https://pubmed.ncbi.nlm.nih.gov/27791223/

World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing, Volume 51, Issue 9, September 2022, afac205, https://doi.org/10.1093/ageing/afac205. https://worldfallsguidelines.com/

Step safely: strategies for preventing and managing falls across the life-course. Geneva: World Health Organization; 2021. https://www.who.int/publications/i/item/978924002191-4

Australia

Australian Commission on Safety and Quality in Health Care (ACSQHC) (2009) Preventing Falls and Harm from Falls in Older People: Best practice guidelines for Australian hospitals https://www.safetyandquality.gov.au/sites/default/files/migrated/Guidelines-HOSP.pdf

Royal Australian College of General Practitioners. Guidelines for Preventive Activities in General Practice, 9th ed. Published 2016. Accessed November 5, 2021. https://www.racgp.org.au/download/Documents/Guidelines/Redbook9/17048-Red-Book-9th-Edition.pdf

Canada

RNAO. Preventing Falls and Reducing Injury From Falls. 3rd ed. Registered Nurses’ Association of Ontario; 2017. https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries

Korea

Kim KI, Jung HK, Kim CO, et al.; Korean Association of Internal Medicine, The Korean Geriatrics Society. Evidence-based guidelines for fall prevention in Korea. Korean J Intern Med. 2017;32(1):199–210. Doi: 10.3904/kjim.2016.218 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214733/pdf/kjim-2016-218.pdf

UK

British Geriatrics Society (BGS) (2017) Clinical Guidelines on Falls and Fractures https://www.bgs.org.uk/resources/clinical-guidelines-on-falls-and-fractures

NICE (National Institute for Health and Clinical Excellence) (2013) Falls in older people: Assessing risk and prevention. Clinical guideline [CG161] https://www.nice.org.uk/guidance/cg161

Public Health England (2020) Falls: Applying all our health https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health

Scottish Government (2019) National falls and fracture prevention strategy 2019–2024 draft: consultation https://www.gov.scot/publications/national-falls-fracture-prevention-strategy-scotland-2019-2024/pages/6/

USA

American Family Physician/U.S. Preventive Services Task Force: Interventions to prevent falls in community dwelling older adults: Recommendation statement. Published August 15, 2018. Accessed November 1, 2021. https://www.aafp.org/afp/2018/0815/od1.html

Stevens JA, Phelan EA. Development of STEADI: a fall prevention resource for health care providers. Health Promot Pract. 2013;14(5):706–714. https://doi.org/10.1136/injuryprev-2012-040580e.14

Falls and their prevention are recognised as a fundamental aspect of maintaining and improving health and well-being in older people. The preventive measures for falls are also included in the interventions for the management of frailty, which are considered in Chap. 3. Prevention measures have been investigated in numerous research studies over several decades, so there is now significant understanding of which are most likely to be successful.

NICE (2013) Guidelines [21] recommended that:

…following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function

Fall prevention measures should be integrated into daily care activities and need to be implemented over time to enable older people to embed them into their everyday life. In inpatient units where older people are managed following a fall that has led to a fragility fracture, there are several evidence-based interventions that are most likely to contribute to fall prevention in older people following a fracture once an assessment for risk of falling and individual risk factors has been made:

  1. 1.

    Patient and carer education and collaboration

  2. 2.

    Improving muscle strength and balance

  3. 3.

    Improving mobility, increasing physical activity and avoiding sedentary behaviour

  4. 4.

    Supporting optimum nutrition

  5. 5.

    Monitoring cognitive fluctuations and medical conditions

  6. 6.

    Recommending assistive devices

  7. 7.

    Managing fear of falling

  8. 8.

    Managing polypharmacy and fall risk inducing drugs (FRIDs)

  9. 9.

    Collaborating with and referring to other members of the interdisciplinary team

4.6.1 Fall Prevention in Hospital

Even though there are many priorities in the care of the patient with an acute significant fragility fracture, it is essential that fall prevention measures are implemented throughout the hospital stay for two main reasons:

  1. 1.

    To ensure that fall prevention is an integral part of the patient’s care to facilitate the prevention of future falls and associated fractures

  2. 2.

    To prevent further injuries and complications from in-hospital falls

The number of falls during hospital stay tends to be even higher than at home. It is common that falls occur when patients transfer themselves from the bed to the bathroom without caregiver supervision. During the hospital stay, it is important to embed some simple practices into care to prevent falls:

  1. 1.

    Monitoring the environment: Familiarise the patient with the environment to give them confidence - including aspects like lighting, bed height, furniture stability and patient call bells within reach.

  2. 2.

    Monitoring nutrition: Malnutrition can lead to muscle weakness, decrease the bone density and affect cognitive function. See Chap. 11 for further information.

  3. 3.

    Improving mobilisation, functionality and physical activity: Poor mobility and function and reduced activity are highly correlated with falls, fractures and risk of secondary falls. In hospital, individuals can undertake tailored exercise and can be encouraged to increase their level of physical activity by adopting an active attitude. Being active and mobile play an essential role in preventing the functional and cognitive decline associated with fractures and hospitalisation. Being active in the hospital, particularly after a hip fracture, is influenced by several factors such as the patient’s age and surgical intervention, as well as the philosophy of care in acute care settings. Encouraging increased activity and mobility levels needs close collaboration with the therapy team. If no physiotherapist or other exercise/rehabilitation specialist is available, nurses can instruct simple exercises of mobilisation based on individuals’ risk of falls: for example; sit and stand from a chair, knee flexion and extension, ankle plantar flexion and dorsiflexion, tandem position, and walking and turning around. Chapter 8 provides further information about mobility and exercise.

  4. 4.

    Assessing patient’s risk of falls: As previously discussed in Sects. 4.5 and 4.6, nurses are well placed to assess the risk of falls. Following assessment, a team discussion can identify the strategies that should be used and which may include referral to specialists or a targeted prevention programme.

  5. 5.

    Managing fear of falling: Fear of falling can have a significant impact on recovery, decreasing mobility, balance, social participation and motivation, for example. The dialogue of all health professionals, including nurses, with the patient is crucial in developing their confidence. Those health professionals who spend more time with the patient are ideally placed to help them develop increased confidence.

  6. 6.

    Providing education: This is an important action for both patient and family. Explaining the importance of and strategies that can help to reduce the risk of falls, for example, encourages patients to maintain physical activity aimed at fall prevention, encourages them to report falls and ask for help when they need and provides support in the period after discharge.

  7. 7.

    Monitoring progress: Clinicians such as nurses, who spend regular and extended time with patients, are well placed to observe patient progress and share findings with the interdisciplinary team. Patients and their families need to actively engage with fall prevention programmes. It is important that, at discharge or transfer, fall prevention programmes begun in the hospital continue. It is crucial to adjust the discharge plan, if necessary.

4.6.2 Fall Prevention at Home/Community and Secondary Care

Continuing with fall prevention strategies and programmes instigated during the hospital stay is essential. In the community or secondary care setting, the following strategies should be considered:

  1. 1.

    Improving muscle strength, mobility and balance: An international expert consensus guideline recommends resistance training aimed at improving muscle strength and power. This should involve balance and gait exercises, progressing in intensity and in complexity as well as dual-task exercises and Tai Chi exercises progressing in complexity [30]. Implement exercise for strength, and specific balance exercise is important to increase functional ability as well as recovery confidence and socialisation. A regular and progressive strength and balance training programme should be considered for all older adults. It is also important to encourage them to maintain the exercise routine continuously. The ideal would be referring the patient to a specific programme near where they live so that they can get there easily.

  2. 2.

    Managing fear of falling: It is important to maintain the previously discussed measures, especially the dialogue with the patient. Fear of falling often presents as anxiety and extreme reluctance to mobilise, which leads to avoidance of the activity perceived to have resulted in the fall (i.e. walking) as well as depleted motivation in the rehabilitation process, leading to a decline in function, loss of independence and reduced quality of life [31]. Older people fear falling partly because they often perceive it as a catalyst for loss of independence and, even, moving to a care home, so they are reluctant to discuss their experiences and tend to underplay the number and significance of previous falls.

  3. 3.

    Providing education: To empower engagement and motivation, it is important to deliver positive messages and facilitate their understanding that future falls can be prevented by specific actions. It is important to stress to individuals that falls are not a normal part of ageing and can be prevented, but that effective prevention measures are based on an assessment of the factors and circumstances that led to falls for that person. Hence, providing details about the fall is particularly important in clarifying the mechanisms that caused a particular fall event. The process of interviewing and discussing the event contributes to active engagement in establishing a preventive and rehabilitative care plan. Education that reflects the preferred learning style of the individual needs to be delivered continuously so that important messages are integrated into their thinking. Educational interventions can take several forms, including verbal health improvement conversations during care episodes, multimedia options, paper-based materials and online options. Verbal conversations should be reinforced with written materials with simple messages that are easily remembered. See Fig. 4.1a–d for an example.

Fig. 4.1
An infographic for preventive measures for avoiding falls within the home, covering areas such as the bedroom, kitchen, stairs, steps, pets, floors, garden areas, lighting, cords, cables, and bathroom.figure 1figure 1figure 1

(a) Fall prevention infographic (reproduced with permission from the National Office of Clinical Audit, Ireland [32]). (b) Staying safe at home to prevent fall infographic (reproduced with permission from the National Office of Clinical Audit, Ireland [32]). (c) Home safety checklist infographic (reproduced with permission from the National Office of Clinical Audit, Ireland [32]). (d) Active at home infographic (reproduced with permission from the National Office of Clinical Audit, Ireland [32])

Full size image

4.7 Incorporating the Individual Experience of Falls into Care: The Person’s Perspective

The consequences of falls are life-changing for older people, particularly after a fracture. For many individuals, falls and injuries such as fractures lead to fear of further falls (see Sect. 4.6), resulting in lack of confidence in mobilising and avoidance of physical activity. In turn, this leads to decreased physical activity and sedentary behaviour, decline in physical function, increased dependency, depression, anxiety and chronic pain. Some older adults might believe that being at rest and not moving is the best intervention for healing a fracture. These beliefs and experiences are inaccurate and negatively affect motivation to engage in both rehabilitation and fall prevention strategies. It is important, therefore, that practitioners understand the beliefs and experiences of older people following a fall so that they can ensure that the care process is focused on individual beliefs, needs and concerns.

These individual experiences are highlighted in qualitative research studies that have explored how it feels to be an older adult who has fallen. Gardiner et al. [34] conducted a narrative review of qualitative research to examine studies that explored experiences of falling and the perceived risk of falling in the community. They reviewed 11 studies that revealed four themes: ‘falls as a threat to personal identity’, ‘falls as a threat to independence’, ‘falls as a threat to social interaction’ and ‘carefulness as a protective strategy’. These findings highlight that encouraging a proactive, constructive approach to managing the risk of falling and avoiding pervasive messages related to dependency and incompetence are practical implications for nurses and other professionals implementing fall prevention strategies.

Fall prevention programmes should be individualised, considering individual beliefs, attitudes and priorities [20]. The older adult’s perspective is essential for the success of the prevention programme, so they should be included in all stages of the process. Patient’s concordance with fall prevention programmes is often low. It is influenced by individual characteristics, environmental factors and perception of the benefits [33, 34], for example [33]:

I saw the others doing the exercises and I couldn’t do the same. I thought I was disturbing them.

I found myself walking better.

The problem was that I had to take the bus during rush hours, and it was overcrowded.

Clearly, understanding the older adult’s point of view is a good strategy to reduce lack of engagement and dropout from fall prevention programmes. Including them in group activities and near to where they live is a small action that can change their approach to involvement. It is also important that health professionals avoid using negative words and deliver positive messages to help the individuals to stay in the programme.

4.8 Working Collaboratively to Prevent Falls Within an Interdisciplinary Team

Every member of the interdisciplinary team is essential in delivering interventions for the prevention of falls. This team includes practitioners working in all the health and social care settings in which the patient will receive acute, rehabilitation, secondary and/or home care. Team members should be educated and led together so that a positive attitude to working collaboratively is developed to ensure that all members believe that they should be active in fall prevention and not think that they can simply delegate it to the therapist or for home care and community services. The prevention of future falls needs to begin immediately at the point of first fracture, be that in the emergency, hospital or community setting.

Each member of the team brings a specific set of skills, and these skills need to be made the most of by recognising every member’s potential contribution from the geriatrician/physician to the therapist and to the nurse. Fall prevention is most effective when the team works collaboratively towards the same goals. No single member of the team can successfully support patients in preventing falls in isolation. The patient and their family are at the centre of this collaborative effort as patient and carer involvement in decision-making about interventions is fundamental to successful outcome.

Box 4.3 Case Study: The Fall Journey Part 2—An Example of Interdisciplinary Working for Fall Prevention in the Hospital Setting

Rosanna has, unfortunately, now suffered a serious fall at home. On this occasion, she has fractured her hip and has undergone orthopaedic surgery. She is now 3 days post-surgery and is beginning to mobilise.

The interdisciplinary team have collaborated to identify those factors which contribute to Rosanna’s continuing risk of falls. The most important factor has been identified as her reduced mobility due to fear of falling and changed social circumstances. This has been discussed with both Rosanna and her family, and they are beginning to work on a plan to devise strategies for gradually increasing her engagement with her local community again.

The nurses and physiotherapists have discussed a plan of care for early rehabilitation that involves a gradual increase in activity with a focus on remobilisation. This starts with sitting on the edge of the bed, moving to a chair and gradually increasing the number of steps taken. The therapy team have provided a walking frame and have shown Rosanna how to use it. The plan involves using every opportunity during fundamental care to support her in standing, sitting and walking, gradually increasing the distance and time with a goal of her walking to the toilet*. The nurses and medical team have a plan in place to ensure that Rosanna’s post-operative pain is well managed during this period with regular pain assessment and administration of analgesia.

The team have also begun to implement an education plan for Rosanna and her family, which focuses on them understanding why she fell, and the actions that can be taken to prevent future falls. This is also focused on increasing Rosanna’s motivation, decreasing her fear of falling. The team are using Rosanna’s fundamental activities such as mobilising and washing and dressing to engage her in conversation about how her risk of falling can be modified and her quality of life can be improved at the same time.

(*See Chap. 8 for further discussion relating to remobilisation plans and interventions, including exercise).

Summary of Main Points for Learning

  • Falls are preventable and should not be viewed as an inevitable consequence of the ageing process.

  • Falls and fragility fractures frequently result in both short- and long-term disability and can be life-changing with considerable deterioration in health-related quality of life, increased dependency and social isolation.

  • Causes of falls are individual and multifactorial. Risk factors interact dynamically and can be broadly classified into three main categories: demographic, intrinsic and extrinsic.

  • Frailty, sarcopenia, falls and fragility fractures are linked and should be identified and receive proper intervention.

  • Evidence-based processes and tools for multidisciplinary screening, assessment and management of risk of falling are available and can guide healthcare professionals.

  • Involving patients and their families is essential in developing and implementing a person-centred fall prevention care plan.

4.9 Suggested Further Study

World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing, Volume 51, Issue 9, September 2022, afac205, https://doi.org/10.1093/ageing/afac205. https://worldfallsguidelines.com/ (See Box 4.3 for links to other falls prevention guidelines)

Blain, H., Miot, S., Bernard, P.L. (2021). How Can We Prevent Falls? In: Falaschi, P., Marsh, D. (eds) Orthogeriatrics. Practical Issues in Geriatrics. Springer, Cham. https://doi.org/10.1007/978-3-030-48126-1_16

Lord, S., Sherrington, C., & Naganathan, V. (Eds.). (2021). Falls in Older People: Risk Factors, Strategies for Prevention and Implications for Practice (3rd ed.). Cambridge: Cambridge University Press. https://doi.org/10.1017/9781108594455

4.10 How to Self-Assess Learning

  • Identify an older adult for whom you have recently provided care, and make some notes about your answer to the following questions:

    1. 1.

      How do you feel about the care the person received? Was it satisfactory?

    2. 2.

      Given what you have learned from this chapter and your further reading, what could you and your team have done to improve their care and, potentially, their outcomes?

    3. 3.

      Discuss with your team what priorities are there for improving your service, and make a plan of action.