Falls prevention in older people

Jackie Riglin is clear what it takes to make a successful falls prevention service: multidisciplinary teams, joint working across agencies and having someone who isn't afraid to shout about it. 'Falls prevention needs local champions,' she says. 'You've got to have someone enthusiastic to fight the corner or it gets lost among all the other priorities. You need the 'keenies' to stand up and keep going on at people.'

The UK is at the forefront of falls prevention research and practice, leading Europe and much of the rest of the world in setting up consistent patient pathways. Physiotherapists like Ms Riglin have been the pioneers, although they have been helped by national policy and guidelines which have sought to make the issue a priority. Other agencies, such as charities, are pushing the agenda. 26 June sees this year's National Falls Awareness Day, which will be a focus for action across the country, organised by Help the Aged. Falls prevention coordinator Ms Riglin set up her admired service in Southern Cambridgeshire in September 2000. (It is now being developed across all of Cambridgeshire). This was the year before the DH published its national service framework for older people, with a standard on falls prevention, and well ahead of the National Institute for Health and Clinical Excellence guidelines published in 2004. The service puts into practice the ideas of Dawn Skelton, a renowned falls expert and scientific coordinator of the Prevention of Falls Network Europe (see panel: Connecting Europe). Research from Dr Skelton and others advocates an exercise continuum, which allows older people to move smoothly between specialist falls prevention rehabilitation and general classes in the community that can be used either for prevention or as exit routes when the specialist course is finished. 'We're trying to put into practice research showing exercise will only be effective if it's maintained,' says Ms Riglin. 'Research shows that if someone does a 12-week course, then is tested after a 12-week break, they don't retain the benefits. So the idea is we try to make sure they continue exercising.' Since the NSF for older people was published, many services have gone some way to setting up a falls prevention programme, including consultant-led specialist falls clinics. However, specialist falls clinics are expensive, and would be swamped if they had to see everyone referred for falls prevention. Having tiered services, including exercise programmes, is an effective way to reduce the pressure. According to Ms Riglin, making exercise in the community accessible and attractive is how to achieve this. 'We started out running classes in the local community hospital, using hospital transport, but that was very frustrating,' she says. 'So then we ran a pilot without transport which worked much better - people had to get there themselves, but we helped them to do that.' WORKING IN THE COMMUNITY Keeping people indefinitely on hospital-based exercise programmes is neither practical nor desirable, she says. So a huge amount of work has gone into providing general classes, aimed at reducing the risk of falling, in community settings. These settings include care homes, sheltered housing complexes, local authority-run exercise classes, independent gyms and even village halls. The Cambridgeshire programme has been innovative in solving one of the biggest challenges, which is access to classes. 'We've built relationships with organisations like Dial-a-Ride, a voluntary service run by a local charity, which has agreed to give our people priority,' says Ms Riglin. 'We also encourage people to use subsidised transport through schemes like Taxi Card, if they qualify. Family, friends and neighbours are also very good at getting people to classes, and there are usually a couple of people who drive and as the class goes on, are happy to give people lifts.' People are asked to pay a £1.50 contribution but the classes are subsidised. 'The local authority has been very good at accessing grants from the likes of Sport England,' says Ms Riglin. The sheer diversity of people leading exercise classes for older people is also impressive and again, that's down to good relationships with the local authority. 'We have a code of practice locally which says anyone leading falls prevention courses has to undergo postural stability training and, from this year, Otago training, and those running classes for older people have to have the Leicester College chair-based exercise qualification or equivalent.' 'Independent exercise instructors fund the courses themselves, while the PCT funds healthcare assistants and other NHS staff. The local authority provides funding for wardens of council-run sheltered housing.' Exercise physiologist Dr Skelton is passionate about falls prevention and was a moving force in introducing Otago to the UK. She is a leader in promoting proper training in falls prevention, both as an academic with Manchester and Glasgow Caledonian Universities and as director of Later Life Training, which trains physiotherapists and others to deliver falls prevention exercise. A WORLD LEADER As such, she has a good overview of services across the UK and, indeed, through her work with ProFaNE, in the rest of Europe as well. 'The UK is really in advance of elsewhere in Europe and the Americas. But there are obviously issues with resources. It's also the case that some of the guidelines can be open to interpretation. But falls prevention is so rewarding. It helps people retain their independence, gives them the confidence to go out and use public transport again, helps them get rid of their sticks and, in the long term, will save the NHS money.' Dr Lewis Morrison, a consultant geriatrician in Edinburgh, estimates falls make up around half of his caseload. For him, it's a hugely important clinical area. 'If we're saying that everywhere should have a stroke unit, then equally everyone should have a proper falls programme and it has to be truly multidisciplinary. All the evidence shows you can't pick and choose bits of a falls prevention service, you have to have the whole lot, including specialist falls clinics and thorough medical assessments.' Despite the UK's leading position, Dr Skelton is frustrated that more resources are not directed towards exercise programmes, which research by her and others have shown to work. 'Correctly tailored and progressed exercise can significantly reduce risk of falls even in those with a history of frequent falls,' she wrote in the British Medical Journal in 2005. 'With all this evidence, why is it that even those services in the UK which claim to be comprehensive and integrated often have no exercise provision in their care pathways?'All the statistics show falls is a huge issue, both for health and social services and for society as a whole. With the population ageing -16 per cent of people in the UK are over 65 and this is set to increase - it's a field that can't be ignored. However, with firm foundations in place, the hope is that the only way is up for falls prevention. FURTHER INFOwww.profane.eu.orgwww.laterlifetraining.co.uk Skelton D et al. (2005) 'Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT)', Age and Ageing, 34 (6):636Close, J.  (2005) 'Prevention of falls in older people', Disability and Rehabilitation, 27(18-19):1061 Top tips
  • get local authority colleagues on board - they might be able to access funding from different agencies such as Sport England or other national bodies. Multi-agency working also means more clout
  • think laterally. Be aware of other pots of money that NHS bodies might have available for specific projects, then find a way to build falls work into that don't be a shrinking violet - take every opportunity to let people know how important your service is
  • home visits give a fuller picture. Simply walking into someone's house can show why they are falling, for example because of the layout or because they are wearing loose slippers
  • make activities part of mainstream or general health services for older people as much as possible
Connecting Europe ProFaNE is the Prevention of Falls Network Europe, a four-year project, which launched in 2003 to focus on falls prevention and improving postural stability in elderly people. Funded by the European Commission, it brings together 25 workers in the field to take forward and share research and best practice. There are four main work streams: clinical assessment and management; assessment of balance function; the psychological aspects of falling, and taxonomy and classification. Professionals from across Europe are involved in each area, with activities including networking; workshops and job exchange programmes; setting up collaborative studies and sharing data in order to develop evidence-based protocols. In its four years, ProFaNE has been responsible for producing guidelines, research, and other publications, such as a consensus statement agreeing a core data set and methodology for researchers to use across the world, making it easier to compare and share. The networking enabled by ProFaNE, not only in workshops and in international conferences, but also online, is another of its strengths. The project's website has an active discussion forum where the 1,810 registered users can pose questions to falls practitioners and engage in online conversations about falls and prevention. ProFaNE is due to wind up in August, but arduous efforts are being made to keep it going, says coordinator Dawn Skelton. 'The feedback we get shows ProFaNE is valued. We're pursuing a number of avenues, but if anyone has any ideas we'd love to hear them.'

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