Supporting quality of life as part of healthy and active ageing: prevention of falls and fractures in later life
Comprehensive risk assessments can reduce the risk of falls, minimise fragility fractures and prolong quality of life in older populations.
Five things you need to know
- People who are older experience the most severe consequences of fragility fractures, including reduced independence, immobility and ultimately transition into long-term care.1-3
- Maintaining quality of life and supporting mobility and independence in older people must be a priority for care planning and health promotion.
- Falls prevention services must be coordinated with multidisciplinary fracture prevention services and should consider people’s complex needs and personal risk factors, such as balance and potential trip hazards in the home.4
- Modifications in the home or long-term care setting can help prevent falls and reduce risk of fractures5 – but such needs are too seldom identified or addressed.
- Innovative falls prevention programmes should be made available to all older people at risk of falls and fragility fractures.5
What is it and why is it important?
Particularly for very old people, an osteoporotic fracture can be the straw that breaks the camel’s back. A fracture may lead to loss of independence through loss of function, pain or simply through loss of confidence. Even good rehabilitation may fail. Positive preventive action to at-risk individuals must be a priority.CLIVE BOWMAN, SCHOOL OF HEALTH SCIENCES, CITY, UNIVERSITY OF LONDON
Falls are a major risk factor for fractures in the older population, often marking a watershed moment in rapid deterioration of health and functioning.1 2 Among women, 80% of fractures occur at over 70 years of age – and 90% of these are the result of falls.3 After their first fall, people may become afraid of falling again, leading to reduced strength and mobility, which further raises the risk of subsequent falls.
For older people, major fragility fractures can result in rapid physical decline, even with best-practice care in hospital. The risk of dying in the first year after a hip fracture can be as high as 28% for people aged 60 years and over.6-8 In many cases, a major fragility fracture marks the end of independent living: 1 in 4 hip fracture patients who were previously independent are discharged to a care home.3
Health and social care services that integrate falls prevention and promotion of bone health could help older people maintain their independence and enhance their quality of life.4 9 Given the high costs of falls and care for associated fractures, prevention provides an opportunity to save costs for health and social care.10
Services must undertake a comprehensive assessment that includes the risk of falls and interventions to adequately respond to a person’s care needs.9 11 12 Key preventive measures include multimodal exercise, such as strength resistance training, a critical review of current medication, and initiation of treatment for osteoporosis and other conditions that may increase the risk of falls.4 The assessment should also include an analysis of behavioural and environmental factors and the removal of potential hazards that could cause falls, such as inadequate handrails, poor lighting and inappropriate footwear.4
Fragility fractures are often just as life-changing for the close family member or friend who must become a carer – they often feel unprepared for the role and may struggle to access information and support. In most cases, they are also older adults who may have health concerns and care needs themselves.
NADIA KAMEL, EUROCARERS
How do we know it works?
Multidisciplinary care is fundamental to prevent future falls. This includes early comprehensive rehabilitation, adaptation of the living environment and ongoing support to promote active and independent living. Support should encompass strengthening muscles and improving balance, reducing the impact of using multiple medications and antipsychotics,13-15 addressing psychological factors such as depression15 and improving safety in the living environment. A large study in German care homes found that targeted strength and balance training reduced the likelihood of falls by 20% and the number of hip fractures by 18%.5 A safer living environment, including the use of supportive devices such as hip protectors, further contributes to reducing the risk of fractures.16
What is the current situation?
Falls prevention has received increasing attention in recent years as part of European healthy ageing policy.17-19 The European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) was launched in 2012 to respond to the demographic challenges Europe is facing.20 Several programmes have been launched as part of its Action Group on personalised health management and prevention of falls, such as ProFouND, an initiative promoting exercise and adaptation of the physical environment.21 ADVANTAGE, a European Joint Action of 22 member states and more than 33 organisations, is developing a common approach to managing frailty in health and social care in the member states. Its activities include the use of technology to enable the detection of frailty-related symptoms and events such as falls.22 Similarly, the European long-term study FrailSafe is assessing the use of wearables, sensors and telemedicine to foster self-management and prevent falls.19
Some countries have been spearheading services and tools to help healthcare professionals and patients manage frailty and prevent falls, but access is often limited.23 24 Best-practice examples include the use of smartphone-based CGA and falls prevention programmes in Germany,25 though they are not yet widely implemented.26 In Scotland, an action plan to improve bone health in care homes improved outcomes significantly where it was used and, in some cases, falls were reduced by around 36%.24 The ongoing Dutch Nijmegen Falls Prevention Program, a five-week exercise programme for people at high risk of falls, has reduced falls by 46%.27
What needs to be done?
Comprehensive falls risk assessment and management must be widely available and easily accessible to people at risk and to healthcare professionals. The complex health status of older people often requires a range of care needs to be addressed. Tools to assess mobility along with other health needs should be integrated into clinical practice and can also be used by older people for self-assessment, freeing up healthcare resources and extending access to more people.
Policymakers must adequately fund collaboration between health and social care services. Falls and fracture prevention requires an integrated and person-centred model supported by a multidisciplinary team, involving each member as and when necessary. Geriatricians and specialist nurses must coordinate with physiotherapists and occupational therapists to improve the person’s mobility through exercise programmes and assistive devices, with primary care professionals and pharmacists for medication review and continuous monitoring, and with social care to adapt the physical environment. Patients and their informal carers should be considered equal partners in this multi-component approach. Public awareness of falls must be increased to encourage engagement with preventive measures before the first fall.
- Prevention of Falls Network for Dissemination. 2016. Falls Prevention Intervention Factsheets. Manchester: ProFouND
- Cameron ID, Dyer SM, Panagoda CE, et al. 2018. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 9: Cd005465
- Tarazona-Santabalbina FJ, Belenguer-Varea A, Rovira E, et al. 2016. Orthogeriatric care: improving patient outcomes. Clin Interv Aging 11: 843-56
- World Health Organization. 2017. Integrated care for older people (ICOPE). Guidelines on community-level interventions to manage declines in capacity. Geneva: WHO
- Bundesministerium für bildung und forschung. 2011. Training statt Bettruhe verhindert Oberschenkelhalsbrüche. Präventionsmaßnahmen in Pflegeheimen könnten bis zu 40 Millionen Euro sparen. Available from: https://www.gesundheitsforschung-bmbf.de/de/training-statt-bettruhe.php [Accessed 20/09/19]
- Katsoulis M, Benetou V, Karapetyan T, et al. 2017. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. J Intern Med 281(3): 300-10
- Roche JJW, Wenn RT, Sahota O, et al. 2005. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331(7529): 1374
- Becker C. 2017. Prävention von Stürzen und sturzbedingten Verletzungen. Z Gerontol Geriatr 50(8): 672-75
- Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. 2017. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis 76(5): 802-10
- Heinrich S, Rapp K, Rissmann U, et al. 2010. Cost of falls in old age: a systematic review. Osteoporos Int 21(6): 891-902
- Bruce J, Lall R, Withers EJ, et al. 2016. A cluster randomised controlled trial of advice, exercise or multifactorial assessment to prevent falls and fractures in community-dwelling older adults: protocol for the prevention of falls injury trial (PreFIT). BMJ Open 6(1): e009362
- European Innovation Partnership on Active and Healthy Ageing. 2013. Action Plan A2. ‘Personalized health management, starting with a Falls Prevention Initiative’. Brussels: EIP-AHA.
- Baranzini F, Poloni N, Diurni M, et al. 2009. [Polypharmacy and psychotropic drugs as risk factors for falls in long-term care setting for elderly patients in Lombardy]. Recenti Prog Med 100(1): 9-16
- Kamińska MS, Brodowski J, Karakiewicz B. 2016. The incidence of falls among geriatric outpatients in relation to the number and types of drugs taken. Family Medicine & Primary Care Review 18(2): 123-27
- Kamińska MS, Brodowski J, Karakiewicz B. 2015. Fall Risk Factors in Community-Dwelling Elderly Depending on Their Physical Function, Cognitive Status and Symptoms of Depression. Int J Environ Res Public Health 12(4): 3406-16
- Kannus P, Parkkari J, Niemi S, et al. 2000. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 343(21): 1506-13
- EU Falls Festival. 2019. European Falls Festival. Available from: http://www.eufallsfest.eu/ [Accessed 25/09/19]
- Joint Action European Union. 2019. ADVANTAGE JA -A comprehensive approach to promote a disability-free Advanced age in Europe: the ADVANTAGE initiative. Available from: https://advantageja.eu/index.php/about-us/what-is-ja [Accessed 09/08/19]
- FrailSafe. 2019. FrailSafe project. Available from: https://frailsafe-project.eu/ [Accessed 09/08/19]
- European Innovation Partnership on Active and Healthy Ageing. Welcome to the EIP on AHA portal. Available from:
https://ec.europa.eu/eip/ageing/home_en [Accessed 06/10/20]
- ProFouND. Home page. Available from: https://profound.eu.com/ [Accessed 06/10/20]
- Rodríguez-Laso Á, Mora MÁC, Sánchez IG, et al. State of the art report on the prevention and management of frailty. Available from: https://www.advantageja.eu/images/SoAR-AdvantageJA_Fulltext.pdf
- Alonso C. 2019. The ADVANTAGE initiative. A comprehensive approach to promote a disability-free advanced age in Europe. FrailSafe Final Conference; 03/04/19; Brussels
- Cooper R. 2017. Reducing falls in a care home. BMJ Quality Improvement Reports 6(1): u214186.w5626
- Lindera. 2019. Lindera. Available from: https://www.lindera.de/ [Accessed 09/08/19]
- Rapp K, Kampe K, Roigk P, et al. 2016. The osteoporotic fracture prevention program in rural areas (OFRA): a protocol for a cluster-randomized health care fund driven intervention in a routine health care setting. BMC Musculoskelet Disord 17(1): 458-58
- Weerdesteyn V, Rijken H, Geurts ACH, et al. 2006. A Five-Week Exercise Program Can Reduce Falls and Improve Obstacle Avoidance in the Elderly. Gerontology 52(3): 131-41