Guidelines for the Physiotherapy management of older people at risk of falling

©AGILE: Chartered Physiotherapists working with Older People
Produced by the AGILE Falls guidelines working group:
Victoria Goodwin & Louise Briggs
August 2012

Since the publication of the ‘Guidelines for the rehabilitative management of elderly people who have fallen’1  there has been a wealth of new research evidence,  national and  international guidelines relating to the prevention of falls in older people. 

This update to the guidelines is intended to provide a physiotherapy focussed summary of  the current evidence and to supplement Chartered Society of Physiotherapy and AGILE  Standards of Practice.  

Evidence supports the provision of physiotherapy interventions, such as exercise, as part of  a uni-professional service, or, as part of a multi-disciplinary team, undertaking multifactorial assessments and tailored interventions.  

Practice points to consider:

• Establish the extent to which older people and their carers are able to participate in  a falls prevention programme. 

• Establish baselines of appropriate outcome measures as part of a pre-intervention  assessment, against which ongoing or post-interventions outcome scores can be  compared. This will enable an evaluation of the impact of any interventions, taking  into account other plausible explanations for observed changes over time. 

  

• Patient goal setting (as opposed to therapy goals)  should form part of any rehabilitation programme. Short and longer term SMART goals should be identified  (Specific, Measurable, Achievable, Realistic, Timed). 

• Physiotherapists should employ strategies for  o motivating older people to actively participate in rehabilitation programmes, and  o promoting adherence, whilst taking into consideration patient beliefs, 

attitudes and preferences 2

. 

• When planning falls prevention programmes, supplementary interventions for bone  health should also be considered for those older people at risk of fragility fracture, such as bone loading exercises, nutrition and medication. This may involve other members of the multi-disciplinary team or fracture liaison service.  

• The provision of mobility aids should not be undertaken in isolation and should always form part of a broader rehabilitation programme including strength and balance training.  

• Where current evidence for the effectiveness of interventions is inconclusive or absent, physiotherapists should make clinical decisions relating to the care of an individual patient based upon the best available evidence, in conjunction with contextual factors and information obtained during  subjective and objective assessment of the individual.

Aim 1: To prevent falls

Assessment including outcome measurement 

Older people should be routinely asked whether they have fallen in the past year and asked 

about the frequency, context and characteristics of any falls 2.

  

Management 

In a Cochrane systematic review, multi-component exercise programmes (home and group delivered) and Tai Chi have been found to reduce falls among community-dwelling older people 3.

 Exercise programmes may be delivered as a single  intervention or as part of a multi-factorial intervention. Programmes should be  delivered by qualified health  professionals or exercise professionals, tailored to the individual, and, should include  regular review, progression and adjustment of the exercise prescription as appropriate 4.  

Systematic reviews by Sherrington and colleagues regarding exercise interventions to  reduce falls reported the most effective programmes included a high balance challenge,  used a higher dose of exercise (50 hours- roughly twice a week for six months) and did not  include a walking programme 5;6. 

The effectiveness of exercise interventions for preventing falls among people with stroke 7 and Parkinson’s disease 8 is inconclusive. Neither exercise nor multi-factorial interventions appear to be effective at reducing falls among people with cognitive impairment 4.

In nursing care facilities, the effectiveness of exercise interventions is uncertain although supervised  exercise programmes are effective in sub-acute hospital settings 9. 

Multi-factorial interventions (which may include exercise) appear to be effective at reducing hospital falls and may be effective with people in nursing homes 9

Key messages

• Assess falls history over the past year 

• Exercise interventions can be delivered as a single intervention or as part of a multifactorial intervention 

• Exercise programmes to reduce falls should be high dose (> 50 hours over 6  months) 

• Exercise programmes to reduce falls should have a high balance challenge  component 

.  

Aim 2: To improve the older person’s ability to withstand threats to  their balance

Balance impairment is a major risk factor for falls among older people and those with long 

term conditions, such as stroke or Parkinson’s disease 10;11. 

Assessment including outcome measurement 

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance 4.

 Assessment should identify risk factors relating  to balance and mobility limitations, such as muscle strength and gait, and establish which factors are  modifiable with exercise or rehabilitation interventions.

There are a wide range of outcome measures for assessing balance. When selecting an  outcome measure, consideration should be taken in relation to the properties of the measure (reliability, validity, sensitivity to change).  

Measures you may consider include: 

• Berg Balance Scale 

• Timed Up and Go Test 

• Performance-Orientated Mobility Assessment  

• 180 degree turn 

• Four-square step test  

Management  

A recent Cochrane systematic review 12 examining exercise interventions to improve balance among older people reported exercise interventions  that included: (a) gait, balance, coordination and function training; (b) strength training; (c) three dimensional training e.g. 

dance, tai chi; and (d) mixed training were beneficial in relation to balance outcomes. The 

most effective programmes involved dynamic exercise programmes that ran three times 

weekly training for three months.  

Key messages

• Use appropriate reliable and valid outcome measures

• Include exercise components for gait, balance, coordination and function 

• Include strength training and three dimensional activities 

• Ensure balance training is sufficiently dynamic 

Aim 3: To prevent the consequences of a long lie 

Up to half of non-injured fallers are unable to get up again 13;14. The inability to get up from  the floor independently following a fall is associated with subsequent serious fall-related injury 15;16 and increased mortality 14. The consequences of a long lie on the floor (> 1 hour)  include pressure sores, hypothermia and dehydration and increased risk of admission to  hospital with a subsequent fall, or moving into long term care 17. In a national UK audit only  4% of fallers were taught how to get up again 18

. 

Assessment including outcome measurement 

Older people and their carers should be asked: 

• If they are able to get up from the floor following a fall; 

• How they move around on the floor, and keep warm; 

• How they are able to get help. 

Those that report they are able to get up should be observed doing so. 

Management with supporting evidence (including quality of evidence) 

There is some evidence that teaching and practicing how to get up from the floor is  acceptable to older people and can be successful 19;20.

Key messages

• Ask all older people if they are able to get up from the floor following a fall 

• Check that older people have a strategy to get help if they fall and are unable to rise 

• Teach and practice how to get up from the floor, when possible   

Aim 4: To optimise confidence and reduce fear of falling

Fear of falling affects many older people, including those that have not experienced a fall.  This can lead to activity avoidance, loss of independence and reduced quality of life, and is  associated with an increased risk of falling. These psychological factors can be more disabling and have a greater impact on function than the fall itself and should therefore be an important consideration in rehabilitation programmes.   

Assessment including outcome measurement 

Assessment should identify fall-related psychological factors that impact on confidence, activity restriction and participation. An appropriate outcome measure should be used such as the Falls Efficacy Scale (FES), FES - International (FES-I) or the Short FES-I. Each of these has been found to be a valid and reliable measure with cognitively intact older people and those with mild to moderate cognitive impairment. These measures are also responsive to change following interventions.  

Considerations when selecting a measure should include: 

• How the measure will be administered (self-completed or by interview) as this will  impact upon response rates.   

• Also, both the FES and the Short FES-I have been reported to have ceiling effects with more active older people. 

Management with supporting evidence (including quality of evidence) 

There is high quality evidence from two systematic  reviews supporting the benefits of 

interventions to improve confidence and reduce fear of falling

21;22. Effective interventions are: exercise (including Tai Chi), hip protectors and multi-factorial falls prevention programmes.  

Key messages

• Assess for fall-related psychological factors 

• Use an appropriate outcome measures such as the FES-I 

• Consider interventions such as exercise and Tai Chi  

Reference List 

 (1)  Simpson JM, Harrington R, Marsh N. Managing falls among elderly people. Physiotherapy 1998; 84:173-177. 

 (2)  National Institute for Health and Clinical Excellence. Falls: The assessment and  prevention of falls in older people. CG21. 2004. London, Royal College of Nursing.  

 (3)  Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG et al. 

Interventions for preventing falls in older people living in the community (Review).  Cochrane Database of Systematic Reviews 2009;(2). 

 (4)  American Geriatrics Society and the British Geriatrics Society. Clinical practice  guideline: Prevention of falls in older persons. American Geriatrics Society [ 2010  [cited 2010 Apr. 8]; Available from: 

URL:www.americangeriatrics.org/education/prevention_of_falls.shtml

 (5)  Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JCT. Effective  exercise for the prevention of falls: a systematic review and meta-analysis. Journal of  the American Geriatrics Society 2008; 56:2234-2243.

 (6)  Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to prevent falls in  older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull 2011; 22(4):78-83. 

 (7)  Batchelor F, Hill K, Mackintosh S, Said C. What works in falls prevention after stroke? 

Stroke 2010; 41(8):1715-1722. 

 (8)  Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL. The effectiveness of  exercise interventions for people with Parkinson's disease: a systematic review and meta-analysis. Movement Disorders 2008; 23:631-640.

 (9)  Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG et al.  Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database of Systematic Reviews 2010;(1). 

 (10)  Ashburn A, Stack E, Ballinger C, Fazakarley L, Fitton C. The circumstances of falls among people with Parkinson's disease and the use of falls diaries to facilitate reporting. Disability and Rehabilitation 2008; 30:1205-1212. 

 (11)  Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM. Risk factors for falling in homedwelling older women with stroke. Stroke 2003; 34:494-501. 

 (12)  Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance  in older people. The Cochrane Database of Systematic Reviews 2011;(11). 

(13)  Skelton D, Dinan SM, Campbell M, Rutherford OM. Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34(6):636-639. 

 (14)  Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls  among elderly persons. Journal of the American Medical Association 1993; 269:65-70. 

 (15)  Bergland A, Wyller FB. Risk factors for serious fall-related injury in elderly women living at home. Injury Prevention 2004; 10:308-313.

 (16)  Bergland A, Laake K. Concurrent and predictive validity of "getting up from lying on the floor". Aging Clinical and Experimental Research 2005; 17:181-185. 

 (17)  Fleming J, Brayne C. Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. BMJ 2008; 337. 

 (18)  Goodwin V, Martin FC, Husk J, Lowe D, Grant R, Potter J. The national clinical audit of falls and bone health - secondary prevention of falls and fractures: a physiotherapy perspective. Physiotherapy 2010; 96(1):38-43. 

 (19)  Hofmeyer MR, Alexander NB, Nyquist LV, Medell JL, Koreishi A. Floor-Rise Strategy Training in Older Adults. Journal of the American Geriatrics Society 2002; 50(10):1702-1706. 

 (20)  Reece AC, Simpson JM. Preparing older people to cope after a fall. Physiotherapy 1996; 82:227-235. 

 (21)  Rand D, Miller WC, Yiu J, Eng JJ. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40(3):297-306. 

 (22)  Zijlstra GAR, van Haastregt JCM, van Rossum E, van Eijk JTM, Yardley L, Kempen GIJM. Interventions to reduce fear of falling in community-living older people: a systematic review. Journal of the American Geriatrics Society 2007; 55:603-615.