Last reviewed 13 February 2018

Older people learn to fear falls. The attendant immobility is often a major step towards long-term dependence, declining health, even institutionalisation. Jef Smith investigates falls in care homes.

Homes which are looking after vulnerable elderly people take care that their residents fall as rarely as possible. Despite all of their best efforts, however, it has been estimated that around a half of all residents in care and nursing homes have a fall approximately once a year; some of course fall much more frequently.

It is also true that older people living in homes are three times more likely to fall than their contemporaries in the wider community. This is not, of course, because homes are intrinsically more dangerous places, far less that staff are generally unobservant or uncaring — indeed quite the opposite on both counts. It does, however, reflect the fact that residents are very frail generally, being older, less healthy and more disabled than older people who are still able to cope in their own homes, so staff need to be particularly aware of such vulnerability.

The first responsibility for staying upright rests of course with the individual, and steps and hard surfaces need to be taken especially seriously. For all the care I try to take, I did fall recently. I was leaving an art gallery and, as I was carrying both a shoulder bag and a heavy book, it would have been wise on reflection to hang onto the rail when going down the last short set of stairs. In the event, physically, I was pretty much OK — nothing broken, not even any bruises — and it was only my pride and a new pair of trousers which were seriously damaged.

Reflecting on the experience, however, has made me think about how older people generally feel about falling. I can’t work out why I slipped, but I remember in absurdly sharp detail my thoughts as I went down. There was embarrassment of course, especially when a gallery attendant promptly on the scene suggested calling for first aid, and I worried about how anxious my wife would be as she helplessly watched my downfall. A care worker responding to a resident who has fallen needs to be aware of similar reactions, but they will also be asking a rather wider range of cautionary questions.

Risk factors

What factors are associated with a person’s risk of falling? The first is pretty obvious — a history of falls. Anyone who falls is quite likely to fall again, so a single incident should lead at once to a review of the care plan in order to identify additional precautions which might be necessary. By and large the older people are the greater the likelihood of their falling, and of course certain medical conditions, notable dementia, stroke, Parkinson’s disease, epilepsy, arthritis and abnormally high- or low-blood pressure increase the risk. So a fall may be either the consequence of a health condition or evidence of something previously undiagnosed; both are important danger signals.

Certain medicines carry the warning that they may cause or contribute to falls by increasing, for example, dizziness, postural hypotension, unsteadiness or drowsiness. Multiple medications — certainly four or more, and many people in homes are taking many more drugs than that — heightens the risk of side effects. It may be wise to use a fall to request a review of a resident’s medication, particularly if different medicines have been prescribed by different practitioners in response to a variety of conditions.

There are numerous environmental factors which can contribute to falls, but most homes will be aware of these and have taken appropriate precautions. Older people living in their own homes are much more vulnerable in this respect, but the poor lighting, low temperatures, wet, slippery and uneven floors, clutter, unstable furniture, inappropriate walking frames and loose-fitting footwear which are often found on domestic premises, should rarely be present in a well-run home. Nevertheless, a resident’s fall should always prompt a review of where they were when they fell and whether there was anything in the immediate surroundings which could be removed or at least softened to mitigate further risks.

Those last few paragraphs have drawn substantially on Managing Falls and Fractures in Care Homes, an education pack published by the Care Inspectorate. The Care Inspectorate in Scotland carries out approximately the same functions as the Care Quality Commission in England in relation to social care, though their advice is clearly nationally relevant. The document uses the word “risk” liberally, but this is a concept which requires some unpacking; risk assessment is not a one-way process and guarding against all risks is impossible and would anyway be far from desirable.

Choosing to take risks

Risk taking, even for vulnerable older people in care, is a vital part of life and it is for residents themselves to decide what level of personal risk they are prepared to face. By and large, residents’ relatives tend to overestimate the risk their loved ones face and, therefore, to expect a home to take precautions beyond what the residents themselves find convenient or congenial. Homes may need to be reminded that they should take their instructions from their clients, not from their clients’ families!

This may mean that some residents will wish to live more dangerously than others might consider advisable; preserving their privacy, when, for example, going to the lavatory or undertaking other personal tasks, may be more important to them than guaranteeing absolute safety. Just as the rest of us exercise our right to place ourselves in all sorts of risky situations — from crossing roads to engaging in dangerous sports — residents should not be altogether deprived of life’s convenience or excitement. Fulfilment, not least in care homes, where there is often little opportunity for self-expression, involves taking whatever chances present themselves, even if there is some risk involved.

Risk aversion is not of course the exclusive preserve of overcautious homes, where staff fear criticism from relatives or inspectors. A resident’s perception of their likelihood of falling, perhaps based on recent experience, may make them unduly cautious. This can diminish their quality of life and may also, perversely, place them at higher risk by, for example, diminishing their willingness to take exercise. In such instances, the major emphasis may need to be on confidence building, even if being slightly more adventurous appears to be adding to the possibility of falling.

Certain conditions such as dementia, however, undermine a person’s capability to take sensible decisions for themselves and these cases present the biggest challenge of all for responsible risk assessment. They are by no means rare since a substantial proportion of people in homes now have at least early-stage dementia and many more are seriously confused. The importance of thorough care planning, with full coverage of why certain decisions were taken especially if they appear to conflict with a resident’s own wishes, cannot be overstressed.

Data on falls

It should be clear, therefore, that the incidence of falls in a home, rather like the number of complaints, should not be taken as a crude indicator of poor practice. The balances to be struck are complex, and eliminating all risks, even if that were possible, would certainly not be desirable. This point is endorsed, in a slightly different context, by the Department of Health (DH). In a recent publication on falls and fractures, the section on high-risk care environments, a category which certainly includes care homes, notes that the fact that “a trust with a high number of reported incidents has lower levels of patient safety and, conversely, a low number of reported incidents does not necessarily suggest better patient safety procedures are in place”. “While this may be the case,” it continues, “it could equally be that a trust with a high number of incidents may be better at identifying and reporting incidents.” This may be a useful reference for a manager to quote when their establishment is accused of being one which presents particular dangers for residents.

The DH nevertheless places a strong emphasis on scrupulous analysis of falls data. It commends as resources the practice guidance on the subject published by the College of Occupational Therapists in 2015 and the National Institute for Health and Care Excellence’s (NICE) 2013 guidelines on assessing risk and prevention. Every NHS area is required to have a formal group on falls reporting to the trust board and to assess its performance regularly. This is of course a natural area for work across different disciplines and agencies with varied purposes, almost a test case for effective collaboration between health and social care.

Finally, here is a definition of a fall which appeared in a research study as long ago as 1987 but which is still reckoned sufficiently appropriate to be quoted by the Care Inspectorate and others. It begins, “an unintentional event that results in a person coming to rest on the ground or another lower level …” An updated version set out by NICE reads, “A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level.” There is something about that quaintly precise wording, perhaps my own recent experience of “coming to rest” at a level rather lower than I had intended, which makes me smile. In reality of course, perhaps particularly for residents in care and nursing homes, falls are no laughing matter.