Editorial

With health and social care services striving to address the challenge of demographic change and rising demands on public services, it is worth taking time to consider the scale and nature of falls among older people. The November edition of SMJ provided an estimate of the cost to health and social care services in Scotland of managing the sequelae of falls: in excess of £470 million and set to rise over the next decade as our population ages and the proportion with multimorbidity and polypharmacy grows. ¹ Less easy to quantify is the impact of falls on an older person's independence and quality of life, and the repercussions for family and friends.

Falls are considered to be one of a number of ‘geriatric syndromes’ – clinical conditions in older people that do not fit into a discrete disease category but are highly prevalent, multifactorial and associated with multimorbidities and poor outcomes such as disability and decreased quality of life. ² A fall is a symptom rather than a diagnosis and may flag-up multiple interacting risk factors spanning a range of physical, cognitive, behavioral and environmental domains. The multifactorial nature of falls necessitates a multi-professional, multi-agency approach to both prevention and management. This is explicit in Scotland's Allied Health Professions' National Delivery Plan, which calls for integrated working to reduce falls-related emergency admissions. ³

The evidence for falls reduction interventions for older people living in the community has been summarised in a recent Cochrane review ⁴ and is reflected in the recommendations presented in the joint American Geriatrics Society and British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. ⁵

The Guideline recommends that multifactorial risk assessment linked to interventions should be offered to older people who have recurrent falls, and/or seek medical attention because of a fall and report difficulties with gait and balance.

Recommended interventions include:

An exercise programme incorporating balance, gait and strength training.

The 2012 report, Up and About or Falling Short, ⁶ presents the findings of a survey in Scotland which aimed to identify the extent to which these recommended practices were embedded in systems of care for older people. The report suggested that although in recent years there has been progress in the implementation of local care pathways for older people who have fallen, there remains variation in service provision and quality in Scotland. An older person's likelihood of being offered evidence-based care depends on where and to whom he or she presents following a fall or with a fall-related injury.

Opportunities for prevention of falls and fractures are being missed. In 2011, David Oliver, former National Director for Older People Services in England and a practising Consultant Physician wrote

The very occurrence of a fall or fracture should be seen as an opportunity to case-find, detect underlying risk factors, and intervene to prevent the next fall or fracture (and accumulative disability). Ensuring the patient is sufficiently rehabilitated, with the right services and equipment to maintain safe, sustainable independence and activity, should be the ultimate goal. All too often, these opportunities are missed – in a way that would be considered wholly unacceptable in conditions such as stroke, TIA or ischaemic heart disease. ⁷

For the many older people whose falls risk is lower, prevention and early intervention is not falls-specific. As health and social care professionals, we can actively support and encourage regular physical activity, healthy eating, good foot care, regular eye checks and medication reviews; all are likely to contribute to reducing falls risk. Reducing sedentary behaviour amongst older people is a key component of a population approach. Guidance is provided in the four home countries’ Physical Activity Guidelines for Older Adults, ⁸ which include recommendations for undertaking physical activity specifically for muscle strength and balance on at least two days a week.

In conclusion, the Scottish Government's Reshaping Care for Older People Programme for Change ⁹ states, ‘Providing high quality care and support for older people is a fundamental principle of social justice and is an important hallmark of a caring and compassionate society’. Effective falls and fracture prevention can make a real difference to the lives of older people and has a significant contribution to make to enacting these principles.