Interventions to reduce falls risk
Falls are an important independent contributor to fracture risk and most non-vertebral fractures are associated with a fall. While some falls interventions have been shown to reduce falls, there is no good evidence for any impact on fracture rates or health care resource utilisation. The benefits of falls interventions are also the indirect costs associated with fear of falling and consequent reduced health-related quality of life. Ask older people about their falls history opportunistically and at least annually. Those at highest risk are:
- Individuals with two or more falls in the previous 12 months
- A fall resulting in injury
- A fall associated with a disorder of gait and/or balance
The principal role of the GP is to case-find the high-risk faller and offer referral to a falls service. Individuals unwilling to attend falls services may best be managed pragmatically within the primary care team, focusing on obvious risk factors.
Which falls interventions are effective?
The best-evidenced interventions to reduce falls risk and/or rate of falling are:
- Multi-factorial, multi-professional falls assessments and interventions
- Tailored strength and balance training of adequate duration, frequency and amplitude and home-based exercise programmes
- Other unifactorial interventions with limited evidence of efficacy include vitamin D3 supplementation in those who are inadequately replete, home safety interventions in those with poor eyesight, first cataract surgery and prescribing modification programmes.
The relevant guidance is to be found in NICE Clinical Guideline 161 and the Department of Health's Falls and fractures: consensus statement and resources pack.
What steps should I take with someone who is a repeat faller?
- Obtain a relevant medical history and make a cognitive and functional assessment
- Check whether the patient is taking any medications that increase falls risk which can be safely withdrawn
- Check for remedial abnormalities of gait and balance; a 'sit to stand test', 'get up and go' test or abnormal body sway may be indicators
- Check for remedial disorders of visual acuity
- Check for evidence of an underlying physical, cardiac or neurological cause requiring further investigations or interventions
- Check for evidence of postural hypotension
- Investigate whether there are modifiable environmental hazards, including footwear
- Check whether there are risk factors for osteoporosis or a prior fragility fracture indicating that a DXA scan or osteoporosis treatment may be necessary
- Check whether vitamin D insufficiency is likely
- Offer education and written information whenever possible
- Offer referral for a multi-factorial assessment and intervention through the local falls service
- If unwilling, the patient may be suitable for exercise and balance training or a home exercise programme if available through trained physiotherapists or an 'active balance' class;
- If this is inappropriate or the patient is unwilling, offer specific advice, guidance and interventions to the patient and carer to modify or minimise the impact of identified risk factors for falls
- Recruit other members of the primary health care team, such as district nurses, to follow up
Frailty is reduced resilience and increased vulnerability to decompensation after a stressor event.
Identifying frailty in an older person can help us predict who is likely to have a fall, become dependent on other people to help with basic care tasks, experience an unplanned admission to hospital or a care home, or die within the next year. Frailty is also associated with anxiety, depression and a poorer quality of life.
NHS England’s ‘updated guidance on supporting routine frailty identification and frailty care through the GP Contract 2017/18 requires that GP Practice use an appropriate evidence based tool to identify patients aged 65 and over who may be living with moderate or severe frailty and deliver a series of interventions for those patients confirmed through clinical judgement as to be living with severe frailty.
NHS England has developed some useful resources for GP Practice to help in managing frailty all of which are available at the NHS England website.
Complementary and alternative therapies
At present there is no evidence that complementary and alternative therapies (CATs) increase bone density or reduce the risk of fractures. However, for those people who have sustained fractures as a result of osteoporosis, a range of CATs may offer additional relief from pain and other symptoms.
In all situations, it is important that the therapist is made fully aware of an individual's medical history before commencing treatment. Patients with an interest in CATs should be advised to explain to their therapist that they have osteoporosis and may be at higher risk of fracture. Some of the most commonly used therapies are acupuncture, osteopathy, herbal medicine, the Alexander Technique, aromatherapy, chiropractic and reflexology. Pilates, tai chi and yoga are exercise methods that can help to improve posture and develop muscle strength. For some people they may also help to alleviate pain resulting from vertebral fractures.
The National Osteoporosis Society's fact sheets ‘Complementary therapies, bone health and osteoporosis’ and ‘Complementary therapies for pain and symptoms after fractures’ provide more detail.
Also refer to What advice should GPs give patients about nutrition and exercise section of this resource.
More information for you and your patients
Download our leaflets, posters and factsheets to share with your patients. Including 'Healthy living for healthy bones', 'Complementary therapies, bone health and osteoporosis' and 'Complementary therapies for pain and symptoms after fractures'.