Physiotherapy works: Falls and frailty

As we age, we begin to notice changes, small at first, a little joint stiffness maybe, hips and knees or shoulders can be culprits. Or our balance starts to become less reliable. It may be time to consult your Chartered Physiotherapist. Physiotherapy treatment and rehabilitation reduces falls, addresses frailty and restores independence. It helps maintain our strength, flexibility, balance and function if we are ageing well and want to stay active and independent for our life time.

Risks of a fall:

Half of people who have a fall will fall again within the next 12 months

A fall is an event that results in a person coming to rest unintentionally on the ground or floor or other lower level.⁽¹⁾ Over 400 risk factors leading to falling have been identified including
lack of physical activity resulting in loss of muscle tone, decreased bone mass, poor balance, and reduced flexibility; impaired vision, medications, disease including Parkinson’s, dementia, stroke and arthritis, surgery, and environmental hazards. The risk of falls and associated complications rise steadily with age and can be a marker of increasing frailty. Frailty is not clearly defined but is widely accepted to include a combination of weight loss, fatigue, reduced grip strength, diminished physical activity or slowed gait associated with increased risk of falls, hospitalisation, loss of mobility and independence, increasing disability and death.⁽²⁾

Size of the problem

Cost of the problem:
Cost to the NHS of falls is estimated at £2.3 billion per year.⁽¹⁴⁾

• 1 in 3 people aged over 65 will fall every year⁽¹⁰⁾ equating to more than 3 million falls per year.The rate increases to nearly 1 in 2 for community dwelling adults over 80⁽¹¹⁾
• Half of people who fall will fall again in the next 12 months^{(12, 13)}
• 10-25% of fallers will sustain a serious injury
• Injury due to falls is leading cause of mortality in people aged over 75 in UK
• Recurrent falls are associated with increased mortality, increased hospitalisation and higher rates of long term care.

Physiotherapy:

The cost of falls

Falls cost the NHS £4.6 million every day yet every £1 spent on physiotherapy could save £1.50 across the whole pathway

Find and share the figures  for your locality

Physiotherapists work with older adults in interdisciplinary teams and with other agencies in community, hospital and care settings often as an integral part of local falls care pathways. They have specialist skills in assessment and re-ablement and provide evidence based exercise, education and advice programmes aimed to prevent falls, improve balance, increase self confidence, reduce fear of falling and promote active and healthy lifestyles. Physiotherapy led group exercise programmes have been shown to be effective and to reduce falls by 29% and the risk of falling by 15% and individual exercise programmes by 32% and 22% respectively.⁽³⁾ Community based falls prevention programmes targeting older adults particularly older women, can be highly cost effective with the value of benefits from reduced hospital admission significantly exceeding cost of intervention.⁽⁴⁾ For community living older adults tailored exercise programmes delivered as part of a multidisciplinary co-ordinated intervention reduced the rate of falls by 31% and the risk of falling by 27%.⁽⁵⁾

More on falls, fractures and physiotherapy:

Falls and fragility fractures information aimed at patients and carers

Programmes delivering 50+ hours of exercise have been shown to be more effective (23% reduction in rate of falls) than those with less than 50 hours (7% reduction) and programmes of 2 hours per week for 6 months are recommended.^{(3, 6)} Up to half of non-injured fallers are unable to get up following a fall; physiotherapists teach people how to get up from the ground safely, reducing the risks associated with long lies including pressure sores, hospital admission and moving into long term care.⁽⁷⁾ Physiotherapists lead falls clinics providing comprehensive assessment, identifying underlying pathologies (such as osteoporosis), signposting to other specialist services and offering individual advice and support.

There is a need for more research into frailty but two systematic reviews suggested that physiotherapy had a positive effect sustained for 12 months in reducing disability in older adults with moderate frailty.^{(8, 9)}

Case study

The Westminster Falls Service offers multifactorial risks assessment and targeted intervention for clients referred following a fall or who are at risk of falling. After assessment clients are stratified to receive either 1:1 physiotherapy and/or attend a 12 week strength and balance programme designed to increase physical capability and confidence, improve balance, and reduce fear of falling. On completion of the programme clients continue evidence based falls prevention exercise via ‘Steady and Stable’ classes in partnership with a voluntary organisation. The falls pathway enables clients to reach the recommended 50+ hours of strength and balance required to prevent falls in the long term. High risk clients are also reviewed by telephone.

Clients followed up a year post discharge reported a 60% reduction of falls, 55% fewer fractures, 92% fewer A&E admissions, and a 80% reduction in GP appointments compared to the year prior to intervention.

References

World Health Organisation. WHO Global Report on Falls Prevention in Older Age. Geneva: World Health Organisation; 2007. http://www.who.int/ageing/publications/Falls_prevention7March.pdf?
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

Gillespie Lesley D, Robertson MC, Gillespie William J, et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2012(9) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007146.pub3/abstract

Hektoen LF, Aas E, Luras H. Cost-effectiveness in fall prevention for older women. Scand J Public Health. 2009;37(6):584-9.

Cameron Ian D, Gillespie Lesley D, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews. 2012(12) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005465.pub3/abstract

Sherrington C, Tiedemann A, Fairhall N, et al. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. NSW Public Health Bull. 2011;22(3-4):78-83. http://www.publish.csiro.au/?paper=NB10056

Goodwin V, Briggs L. Guidelines for the physiotherapy management of older people at risk of falling. London: AGILE: Chartered Physiotherapists working with Older People; 2012. http://agile.csp.org.uk/documents/guidelines-physiotherapy-management-ol…

Arantes PMM, Alencar MA, Dias RC, et al. Physical therapy treatment on frailty syndrome: systematic review. Brazilian Journal of Physical Therapy. 2009;13(5):365-75. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-35552009000…

Clegg AP, Barber SE, Young JB, et al. Do home-based exercise interventions improve outcomes for frail older people? Findings from a systematic review. Reviews in Clinical Gerontology. 2012;22 (1):68­78.

Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7.

American Geriatrics Society British Geriatrics Society American Association of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49(5):664-72.

Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med. 1989;320(16):1055-9.

Nevitt MC, Cummings SR, Kidd S, et al. Risk factors for recurrent nonsyncopal falls. A prospective study. JAMA. 1989;261(18):2663-8.

National Institute for Health and Care Excellence. Falls the assessment and revention of fall in older people (CG 161). London: National Institute for Health and Care Excellence; 2013. http://guidance.nice.org.uk/CG161