Art & science |

The synthesis of art and science is lived by the nurse in the nursing act

JOSEPHINE G PATERSON

ASSESSMENT AND PREVENTION OF FALLS IN OLDER PEOPLE Following the amalgamation of two guidelines, Wendy Barker offers an interpretation of revised advice on this crucial aspect of care Correspondence [email protected] Wendy Barker is deputy chief nurse, Vale of York Clinical Commissioning Group Date of submission March 24 2014 Date of acceptance May 13 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com

Abstract In June 2013 the National Institute for Health and Care Excellence updated and replaced its 2004 clinical guideline 21 (CG21) on falls with clinical guideline 161 (CG161). Two priorities were outlined in the latter: preventing falls in older people (unchanged from CG21) and preventing falls in older people during a hospital stay (new). CG161 is for health and social care clinicians who care for older people who have fallen or who are at risk of falling. It provides clinicians and commissioners with evidence to implement effective care pathways and recommendations on the assessment and prevention of falls in older people. The amalgamation of the two guidelines has resulted in some disconnection. This article summarises the evidence and supports clinicians in the interpretation of the revised falls guideline. Keywords Falls, falls assessment, falls clinical guidelines, falls prevention, inpatient care A FALL is not a simple occurrence and can have far-reaching consequences for those it directly or indirectly affects. A fall may not cause serious injury, but the consequences for individuals of falling or not being able to get up after a fall can be detrimental to their recovery (Fleming and Brayne 2008). The psychological aspects, especially fear of falling, loss of confidence and increased anxiety, can be more disabling than the physical ones of

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pain, discomfort, injury and reduced mobility. For a person who is unable to get up from the floor, falls can often result in a ‘long lie’ of 12 hours or more. A long lie can affect a person’s recovery and result in the development of hypothermia, pneumonia or pressure ulcers. Falling is not an inevitable result of growing older, however, ageing influences such as reduced mobility, comorbidities and cognitive impairment all affect falls risk. Osteoporosis does not increase the risk of falling, but it does increase the risk of fracture after a fall (National Institute for Health and Care Excellence (NICE) 2012). Simple steps can be taken to reduce a person’s falls risk (NICE 2013a). Falls risk assessments and interventions must be effective and designed to address each individual risk factor. Any single risk can leave an individual vulnerable to falls or potential injury (World Health Organization (WHO) 2007). The aim should be to identify each risk and ensure that processes are in place to reduce or eliminate that risk. A comparison can be made with completing a jigsaw: omit any risk or piece of the puzzle and the full picture will not be seen with the intervention ineffective in the long term.

The evidence Age People aged 65 and older are at greatest risk of falling. One in three people over the age of 65, and one in two over the age of 80, fall each year in the UK (Age UK 2012). Approximately 2.5 million people in England will fall at least once in a year (Perell et al 2001). Injury from falls is the leading NURSING OLDER PEOPLE

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Art & science | guidance Falls are estimated to cost the health service more than £2.3 billion a year, which is unsustainable in the current economic climate cause of mortality in people over the age of 75 in the UK. Hospitals and mental health units across England report around 282,000 patient falls each year, including around 840 hip fractures, 550 other types of fracture and 30 intracranial injuries. A minority of these will result in death or in severe or moderate injury (National Patient Safety Agency (NPSA) 2011). Community hospitals report 28,000 falls among patients each year in England (NPSA 2007). It is estimated that up to 30% of older people living in the community will fall every year. Although only one in five might require medical attention, the effect on these individuals and their care networks can be significant (Gillespie et al 2012). The severity of injury increases with the height of the fall, but also depends on body and surface features and the manner of impact. For some people, even a fall from sitting position to flat ground may cause serious injuries. Cost The research base is growing and shows that effective intervention and prevention can significantly reduce falls (Grant et al 2013, NICE 2013a). Falls are a leading cause of fatal and non-fatal injury (WHO 2007). Falls and falls-related injury are a common and significant problem for the NHS and social care and can result in high levels of personal and financial cost (Royal College of Physicians (RCP) 2011, 2012). They are estimated to cost the health service more than £2.3 billion a year, which is unsustainable in the current economic climate (Age UK 2012, NHS Confederation 2012). The true cost of a fall may never be known, however, because there are too many variables to take into consideration. The negative effect of a fall is a significant underestimation, with 90% of older people who fall and fracture their neck of femur failing to recover their previous level of mobility or independence (Murray et al 2007). As well as the physical and financial costs of an individual falling, there are other costs that are more difficult to quantify. The human cost of falling includes so many different factors. Delivering an effective falls intervention is about preventing a crisis occurring in the first instance. It requires long-term commitment and robust planning to achieve efficiency. Prevention and maintenance are the answer, rather than a quick fix to solve 20 July 2014 | Volume 26 | Number 6

an individual problem. There are interventions to reduce immediate risk, for example, reviewing the environment and making it safe, but in isolation these will be ineffective in reducing long-term falls risk (Royal College of Nursing 2004, NICE 2013a). Interventions need to reduce the number of falls that result in serious injury, and ensure effective treatment and rehabilitation for those who have fallen. Evidence shows that effective interventions to prevent falls are important to benefit patient health outcomes (Cameron et al 2012).

Clinical guideline 161 The NICE guideline development group was not given the finances, capacity or time to review clinical guideline 21 on falls in the community (NICE 2004) – a decision that was made after a routine guideline review in 2011 (NICE 2011). The decision by NICE to focus on the new element of the guideline – inpatient hospital falls – was a missed opportunity to draw the two guidelines together. The 2004 section has been reformatted, but not reviewed or updated. This has resulted in nine years of potential new research evidence not being evaluated. There are visible differences between the two elements in terms of writing style and layout. The resulting inconsistency affects the quality of the guideline and makes interpretation more difficult for clinicians who work across different care settings. A bonus is that the updated guideline now recognises the significance of falls in all care settings (NICE 2013a). The emphasis is on the preventable nature of falls and ensuring that those who have fallen or who are at risk of falling are given adequate information to help minimise falls risk. This includes patients’ families and care networks. The NICE (2013a) guideline offers best practice advice on the care of older people who are at risk of falls. Table 1 (pages 22-23) offers a visual interpretation of the guideline to support clinicians implementing the recommendations. The rationale for this approach is that there are some gaps and differences between the community and hospital inpatient components. The main areas relate to: ■■ Population. ■■ Case identification. ■■ Observation. ■■ Multifactorial assessment and intervention. ■■ Information giving. The population covered in the guideline is people aged 65 years or older irrespective of location. The new hospital inpatient section recommends including patients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of NURSING OLDER PEOPLE

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an underlying condition. Although not specified in the community section, this cohort of people could equally benefit from assessment and intervention if judged by a clinician to be at risk in the community. The guideline advises against the use of a risk prediction tool in hospitals because the validity and reliability of the tools reviewed were uncertain and the quality of the evidence was considered to be low or very low (NICE 2013a). The NICE guideline development group was not asked to re-evaluate the use of a risk prediction tool in a person’s own home or in an extended care setting, such as residential, nursing or supported accommodation. There is a danger that an individual assessed as having a low or medium risk of falls in the community could potentially experience an avoidable fall and subsequent injury. Having low falls risk identification could result in a significant singular high falls risk factor being missed, for example, footwear or psychotropic medication. In hospitals the multifactorial intervention is to address the individual’s identified risk factors for falling promptly and take into account whether the risk factors can be treated, improved or managed in the hospital environment. This should be true for any care setting, irrespective of location. Preventing an individual from falling will not make the person immune from the consequences of a fall. A successful intervention should result in making them safe and reducing or eliminating their falls risk. There is a gap in the guideline in relation to effective falls management on discharge from hospital. The inpatient section focuses on immediate risk and omits discussion on potential action to be taken in preparation and during the discharge planning process. Pathway To support clinicians NICE has developed a falls in older people pathway (NICE 2014), which is designed to be used interactively on the NICE website. During their working day not all clinicians will have access to the internet. The online version is a single pathway diagram and uses numbering to link the boxes in the diagram to the associated recommendations. The paper version is not user friendly and more difficult to follow as it prints on 12 pages. NICE does not recommend certain interventions to reduce the risk of falling due to no, insufficient or conflicting evidence to support their use. Some of these interventions have not been reviewed since 2004: ■■ Brisk walking. ■■ Low intensity exercise combined with incontinence programmes. NURSING OLDER PEOPLE

■■ Group exercise (untargeted). ■■ Cognitive/behavioural interventions. ■■ Referral for correction of visual impairment. ■■ Vitamin D. ■■ Hip protectors.

Conclusion There is consensus that there is a lack of awareness about falls risk across all care sectors. Patients receive inconsistent messages about their falls risk from staff (Age UK 2012, NICE 2013a). Visual cues about falls prevention, such as leaflets, posters, alert signs and stickers, can reduce misunderstanding. Some people might forget that they are at risk of falling or may not seek help because they do not want to be a burden to those supporting them. Clinicians must ensure that they are competent to manage this defined cohort of people and that their knowledge and skills to support people who have fallen or who are at risk of falls are up to date. Training is available at little or no cost apart from staff time. There is also information to help reinforce advice to those at risk and their care network (Box 1). There is a significant risk that commissioners will not fund all the NICE (2013a) guideline recommendations and, as a result, clinicians will miss opportunities to reduce or eliminate falls in older people. The NICE (2013b) costing statement concluded that the implementation of the guideline is unlikely to have a significant cost impact for the NHS. The statement assumed that most parts of multifactorial assessment and intervention, such as assessing mobility and continence, were already standard practice. The RCP (2011) national audit highlighted that the NICE (2004) guideline was poorly implemented and that there were major variations in the provision of care between organisations. The greatest risk to implementing the revised NICE (2013a) guideline Box 1 Additional falls resources to support clinicians ■■ Age UK (simple, patient-focused advice and resources) tinyurl.com/oazbsad ■■ The Cochrane Library (research evidence) tinyurl.com/nha9rl7 ■■ NHS Choices (patient-focused advice) www.nhs.uk/Conditions/Falls/Pages/Prevention.aspx ■■ Royal College of Physicians (includes access to FallSafe resources and falls prevention e-learning course) www.rcplondon.ac.uk/resources/fallsprevention-resources (All last accessed: May 27 2014.)

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Art & science | guidance xxx Table 1

Interpreting the National Institute for Health and Care Excellence clinical guideline 161

Domain

NICE clinical guideline 21 (2004) version – recommendations (unchanged)

NICE clinical guideline 161 (2013a) version – inpatient recommendations (new)

Location

Living in own home or extended care setting (nursing home/supported accommodation).

Hospital inpatient.

Age

People aged 65 years and older.

All patients aged 65 years and older (clinical judgement for those aged 50 to 64 years considered to be at higher risk due to underlying condition).

Case/risk identification

People aged 65 years and older asked routinely if they have fallen in the past year and asked about the frequency, context and characteristics of the fall(s).

Include all those in the age range above. Do not use a falls risk prediction tool to predict inpatient risk of falling in hospital.

Observation

Reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.

Ensure that aspects of the inpatient environment, including flooring, lighting, furniture and fittings such as hand holds, that could affect risk of falling are systematically identified and addressed.

Multifactorial falls risk assessment

Patients who present for medical attention in last year because of a fall, report recurrent falls or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. Undertaken by a healthcare professional with appropriate skills and experience, normally in a specialist falls service. Consider a multifactorial assessment and multifactorial intervention. ■■ Identification of falls history. ■■ Assessment of gait, balance and mobility and muscle weakness. ■■ Assessment of osteoporosis risk. ■■ Perceived functional ability and fear of falling. ■■ Assessment of visual impairment. ■■ Assessment of cognitive impairment and neurological examination. ■■ Assessment of urinary incontinence. ■■ Assessment of home hazards. ■■ Cardiovascular examination. ■■ Medication review.

Identify patient’s individual risk factors for falling in hospital that can be ‘treated, improved, or managed’ during hospital stay. Consider a multifactorial assessment and multifactorial intervention. ■■ Cognitive impairment. ■■ Continence problems. ■■ Falls history, including causes and consequences (injury and fear of falling). ■■ Footwear that is unsuitable or missing. ■■ Health problems that may increase the risk of falling. ■■ Medication. ■■ Postural instability, mobility problems and/or balance problems. ■■ Syncope syndrome. ■■ Visual impairment.

Multifactorial interventions

■■ Strength and balance training. ■■ Home hazard assessment and intervention. ■■ Vision assessment and referral. ■■ Medication review with modification/withdrawal.

Ensure that any multifactorial intervention addresses: ■■ Do not offer falls prevention interventions that are not tailored to address the patient’s individual risk factors for falling. ■■ Single interventions should not be used to reduce the risk and/or severity of inpatient falls. ■■ Promptly addresses the patient’s identified individual risk factors for falling in hospital.

Following injurious fall, assessment should include: ■■ Identifying and addressing future risk. ■■ Individual interventions aimed at promoting independence and improving physical and psychological function.

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Domain

NICE clinical guideline 21 (2004) version – recommendations (unchanged)

NICE clinical guideline 161 (2013a) version – inpatient recommendations (new)

Strength and balance training

■■ Those with a history of recurrent falls and/or balance and gait deficits should be offered a muscle strengthening and balance programme. ■■ Multifactorial interventions with an exercise component for those in extended care settings.

Not discussed, recommend following community advice. Consider intervention on discharge.

Home hazard and safety intervention

Those who have received treatment in hospital after a fall should be offered a home hazard assessment and safety intervention/modifications. This is only effective in conjunction with follow up and intervention, not in isolation.

Ensure aspects of inpatient environment that could affect risk of falls are systematically identified and addressed. ■■ Those who have had hospital treatment after a fall should be offered a home hazard assessment and safety intervention/ modification. Normally part of discharge planning. ■■ Home hazard assessment shown to be effective only in conjunction with follow up and intervention, not in isolation.

Psychotropic medication

Medication reviewed and discontinued if possible.

Medication reviewed and discontinued if possible.

Cardiac pacing

Should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls.

Not discussed, recommend following community advice.

Participation in falls prevention programmes

■■ Discuss what changes a person is willing to make to prevent falls. ■■ Information should be relevant and available in languages other than English. ■■ Address potential barriers such as low self-efficacy, fear of falling and encourage activity change as negotiated with the participant. ■■ Ensure programmes are flexible to accommodate different needs and preferences and promote the social value of such programmes.

Not discussed, recommend following community advice. Consider intervention on discharge.

Exercise

Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falls.

Not discussed, recommend following community advice. Consider intervention on discharge.

Education

All healthcare professionals dealing with patients known to be at risk of falls should develop and maintain basic professional competence in falls assessment and prevention.

Not discussed, recommend following community advice.

Information giving

Individuals at risk of falling and their carers should be offered information orally and in writing about: ■■ What measures they can take to prevent falls. ■■ How to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components. ■■ The preventable nature of some falls. ■■ The physical and psychological benefits of modifying falls risk. ■■ Where they can seek further advice and assistance. ■■ How to cope if they fall, including how to summon help and how to avoid a long lie.

Provide relevant oral and written information and support for patients and their family and carers if the patient agrees. Take into account the patient’s ability to retain information. ■■ Explain a patient’s individual risk factors for falling in hospital. ■■ Show how to use the nurse call system. ■■ Inform family members and carers about when and how to raise and lower bed rails. ■■ Provide consistent messages about when a patient should ask for help before getting up or moving about. ■■ Help patients to engage in any multifactorial intervention aimed at addressing their individual risk factors. ■■ Ensure that relevant information is shared across services.

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Art & science | guidance is the same inconsistency in care provision across sectors. The focus of commissioning cannot always be about prioritising short-term gains. At some point investment must be made for long-term commitment to reduce falls (NHS Confederation 2012). The reasons why patients fall are complex and influenced by physical illness, mental health, medication and age-related issues, as well as the environment. In falls prevention the multidisciplinary team approach cannot be underestimated. Efforts to reduce falls and injury need to involve a wide range of individuals and agencies across health (secondary, primary and community) and social care (statutory, private, independent and voluntary). Implementation of the revised recommendations will require effective working relationships with people who

fall or who are at risk of falling to strike the right balance between preventing falls and maintaining independence, privacy, dignity and rehabilitation. Targeted prevention and intervention are important because they will enhance self-care, improve confidence and promote choice and self-control. In supporting people to reduce their falls risk, clinicians need to ensure that the falls prevention intervention promptly addresses the person’s identified individual risks for falling and takes into account whether the risk factors can be treated, improved or managed.

Online archive For related information visit our online archive and search using the keywords.

Conflict of interest None declared

References Age UK (2012) Stop Falling: Start Saving Lives and Money. Age UK, London. Cameron I, Gillespie L, Robertson M et al (2012) Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews. Issue 12. Fleming J, Brayne C (2008) Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. BMJ 2008; 337:a2227. Gillespie L, Robertson M, Gillespie W et al (2012) Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. Issue 9. Grant L, McEnerney J, Proctor T (2013) Making time for nurses to reduce patient falls. Nursing Times. 109, 37, 21-23. Murray G, Cameron I, Cumming R (2007) The consequences of falls in acute and sub-acute hospitals in Australia that cause proximal femoral fractures. Journal of the American Geriatrics Society. 55, 4, 577-582.

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NHS Confederation (2012) Falls Prevention: New Approaches to Integrated Falls Prevention Services. www.nhsconfed.org/publications/ briefings/pages/fallspreventionnewapproaches. aspx (Last accessed: May 27 2014.) National Institute for Health and Care Excellence (2004) The Assessment and Prevention of Falls in Older People. Clinical guideline 21. NICE, London. National Institute for Health and Care Excellence (2011) Centre for Clinical Practice: NICE Clinical Guideline and Quality Standard: Falls Final Scope December 2011. NICE, London. National Institute for Health and Care Excellence (2012) Osteoporosis: Assessing the Risk of Fragility Fracture. Clinical guideline 146. NICE, London. National Institute for Health and Care Excellence (2013a) Falls: Assessment and Prevention of Falls in Older People. Clinical guideline 161. NICE, Manchester.

National Institute for Health and Care Excellence (2013b) Costing Statement: Falls: Assessment and Prevention of Falls in Older People. www.nice.org.uk/nicemedia/ live/14181/64103/64103.pdf (Last accessed: May 27 2014.) National Institute for Health and Care Excellence (2014) Falls in Older People Overview: NICE Pathways. http://pathways.nice. org.uk/pathways/falls-in-older-people (Last accessed: May 27 2014.) National Patient Safety Agency (2007) Slips, Trips and Falls in Hospitals. www.nrls.npsa.nhs. uk/resources/?entryid45=59821 (Last accessed: May 27 2014.) National Patient Safety Agency (2011) Rapid Response Report NPSA/2011/RRR001 – Essential Care After an Inpatient Fall. www. nrls.npsa.nhs.uk/EasySiteWeb/getresource. axd?AssetID=94054& (Last accessed: May 27 2014.)

Perell K, Nelson A, Goldman R et al (2001) Falls risk assessment measures: an analytic review. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 56, 12, M761-766. Royal College of Nursing (2004) Clinical Practice Guideline for the Assessment and Prevention of Falls in Older People. RCN, London. Royal College of Physicians (2011) Falling Standards, Broken Promises: Report of the National Audit of Falls and Bone Health in Older People 2010. RCP, London. Royal College of Physicians (2012) Report of the 2011 Inpatient Falls Pilot Audit. RCP, London. World Health Organization (2007) WHO Global Report on Falls Prevention in Older Age. WHO, Geneva.

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Assessment and prevention of falls in older people.

In June 2013 the National Institute for Health and Care Excellence updated and replaced its 2004 clinical guideline 21 (CG21) on falls with clinical g...
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