Insight: Stop a fall becoming a death sentence

Falls lead to more than 40 per cent of care home admissions. Photograph: John Devlin

The OTAGO programme – run, in this instance, by the Paisley-based charity Roar Connections for Life – is a series of low-impact exercises, specifically designed to improve balance, increase muscle strength and prevent the falls that so often act as a catalyst to decline in elderly people.

Ramsay, a twinkly-eyed dynamo, a few weeks off her 85th birthday, has already fallen twice. The second time – back in 2014 – she tripped crossing the road while visiting her son in Bournemouth. She blacked out and awoke to see paramedics tending her broken wrist. Her angina meant it could not be operated on so, two years on, it is still visibly bent, although, thanks to rigorous physiotherapy, it has returned to full strength.

Now Ramsay, who moved into the village 15 years ago after her husband died, is doing her damnedest to make sure she doesn’t fall again. Her commitment to the OTAGO programme means she has excellent balance and mobility as well as the stamina to enjoy a social life so hectic it would leave the stars of Made In Chelsea begging for mercy.

Two nights a week, she attends an ordinary keep fit class, where she is affectionately known as “auntie” and she will soon be off on a cruise of the West Indies .

“I love disco dancing,” she says. “The young men always get me up. They shout: ‘Come on, Gran’ and they pull me around all over the place. I was at my grandson’s wedding and I asked: ‘Am I embarrassing everyone?’ He said: ‘Of course not. We’re proud of you.’ ”

When it comes to our ageing population, falls don’t attract the same level of attention or sympathy as heart attacks or cancer, yet they affect a larger number of people and their impact on health and quality of life can be just as damaging.

In the past few weeks, three Scottish pensioners have been found frozen to death outside their homes in Stornoway and Glasgow in incidents that seem almost certain to have involved a fall. Leonard Cohen, too, is said to have suffered a fall shortly before he died at his Los Angeles home on 7 November.

According to Dawn Skelton, professor in ageing and health at Caledonian University, a third of people over 60 can expect to have at least one fall a year, while half of those over 80 will have two. And the problem is self-perpetuating; a bad fall means a period of immobilisation, and a further loss in muscle strength, making more falls likely.

For elderly people, a fall can be devastating. Even a small one can dent an individual’s confidence so much it acts as a tipping point, while more than half of those who suffer a hip fracture in a fall never regain their full mobility.

“A hip fracture is a really bad outcome,” says Skelton. “The person involved may end up wheelchair-bound or in a care home. There are often complications; their immobility means they are more likely to contract pneumonia or infections and 20 per cent will die within the year.” Recent surveys have found fear of falling is greater even than fear of crime amongst the elderly, though fear of crime is more likely to be openly acknowledged.

Falls also take a massive toll on our overburdened National Health Service. In 2012, they were said to be responsible for 18,000 unscheduled hospital admissions and 390,500 bed days. Falls cost the NHS in Scotland in excess of £470m a year and have increased by 47 per cent in the past decade.

In addition, falls in the over-65s account for 35,000 call-outs a year to the Scottish Ambulance Service, are one of the leading reasons for A&E attendance, and are implicated in more than 40 per cent of care home admissions.

Over the past few years, much has been written about bed-blocking through delayed discharge, and initiatives have been put in place to address the problem. But, given 30-40 per cent of falls are avoidable, shouldn’t more be done to prevent people from ending up in hospital in the first place?

This is what Roar is attempting to do. It has introduced a variety of interconnected initiatives aimed at preventing first falls and keeping people out of the health system.

The exercise classes represent one strand of the charity’s work. Roar has eight qualified trainers delivering ten weekly OTAGO classes and two weekly strength and balance circuits. The exercise is so low-impact it is suitable for almost everyone, although club co-ordinators like Morgan have “spotters” on hand to watch out for anyone who is struggling. Those who take part are encouraged to keep on doing the exercises at home. Many of them can be performed while watching TV or standing at the kitchen sink.

Roar has also teamed up with the Scottish Fire Service, and fire officers in Renfrewshire and Inverclyde now carry out falls risk assessments on over-65s in the course of conducting fire safety visits.

Those identified as at risk of falling will be referred to the charity, which will then come out and check for physical hazards such as loose carpets or rugs and explore the possibility of fitting safety measures such as LED sensor lights and non-slip surfaces.

In addition, Roar will assess the individual’s eyesight, hearing, strength and balance and give advice about how to move around more safely. “If people are scared and walking tensely, they are more likely to fall and, if they do fall, they are more likely to break something,” says Skelton. “Some try to sit down too early because they are so worried about falling, others walk round holding on to the furniture, but if that bit of furniture moves they are left lying in a heap on the floor.”

Roar’s tie-up with the Scottish Fire Service recently won the Innovative Partnership Idea of the Year at the Health and Social Care Alliance  Scotland Self Management Awards. Station master Michael Jaffrey has  been involved in introducing similar pilot schemes in Midlothian, East Lothian and the Borders. “We visit thousands of homes every year, so we are in an ideal position to target the elderly in relation to slips trips and falls,” he says.

Another strand of Roar’s work involves providing footcare services for those unable to access toenail cutting on the NHS due to budget cuts. It is hard to imagine when you are young, but elderly people are often unable to cut their own toenails. If they have no-one to do it for them, they will eventually find it impossible to put their shoes on properly and so be at greater risk of tripping.

Finally, Roar works to raise public awareness of the need to keep an eye on our ability to balance throughout our lives. With this in mind, it has come up with the one-legged wobble challenge. If you cannot stand on one leg with your eyes closed for ten seconds, the charity says, you need to start practising or accept that you’ll be at risking of falling in the future.

“We focus on trying to prevent first falls because the health system is already overloaded,” says Roar general manager Nicola Hanssen. “If you wait until something bad happens, then that person’s life has already been devastated, it is already costing society money and an expensive chain of events has been set in motion.”

Roar works within the Scottish Government-sponsored National Falls Programme, which has run since 2010 and is now part of the active and independent living improvement programme.

From 2014 to 2016, it has focused on preventing recurrent falls. “What we are saying is, if any older person presents to health or social care services as a result of a fall, that’s an opportunity to have a conversation about falls, and people who need further assessment and support and care can then be offered it,” says programme manager Ann Murray. “It’s about a more systematic approach so whenever a fall is reported we act on it, because even if they haven’t hurt themselves, a fall can be a tipping point in an older person’s life.”

Murray has just launched a new action plan which encourages paramedics called out to a fall to consider whether the patient could be dealt with by community-based rapid response teams instead of being taken to A&E.

Next year, the emphasis of the National Falls Programme will shift towards earlier prevention and initiatives such as those delivered by Roar and the Positive Steps awareness-raising programme in Ayrshire and Arran.

Skelton, however, believes too much emphasis is still being placed on reacting to incidents that could have been avoided. This despite the many reports, including the 2011 Christie Commission on the future delivery of public services, which have called for a move towards prevention.

“The focus has been on trying to deal with the swell of people who are arriving at hospital. If they come in with a hip fracture, they are already frail. That doesn’t mean you can’t help them, it’s just harder and the NHS is not equipped to give a big enough dose of rehabilitation to make a big difference,” she says.

“Sadly, falls prevention has been neglected. We have got hung up on smoking cessation and reducing alcohol consumption though actually the numbers of people who end up in hospital due to heart attack or cancer are less than a quarter of those who go in as a result of a bad fall.”

Skelton says hospitals – which are short-staffed and risk-averse – do not encourage patients to move around enough. “The [staff] don’t want people to fall in hospital, so they aren’t mobilised, so it becomes normal for them not to move. When they go home, they still don’t move, they lose even more muscle strength, then the hospital wonders why they are back in a few months’ time.”

Most importantly, perhaps, Skelton believes we need a cultural shift in the way we perceive old people: from isolated and frail, à la last year’s John Lewis advert, to potentially active and socially engaged.

“We see veteran athletes in their 90s still running and winning medals.  The body is capable of doing more than we allow it do,” she says. “We  live in a society where we are taught to give up our seats to people on trains, older people are sitting on average  for 12 to 16 hours of their waking day.

“We pull heartstrings about how lonely old people are, but if we ensured they understood the value of movement , they would be more able to get out and meet people.”

The old people who go to Roar’s various OTAGO classes can testify to that. Iris McGrath, 89, who lives alone, has suffered a stroke and several falls in the past few years. She still needs a stick and finds it hard to walk long distances but the exercises have helped her build up her strength, her balance and her confidence so she is able to leave the house and join her friends for a St Andrew’s Day lunch at St Mark’s Church in Ralston.

After his wife died five years ago, Stan Kerr “turned in on himself”. He stopped going out, and allowed everything – the house, the garden and his physical state – to deteriorate to the point where he spent his days “talking to the wall” and he could hardly get himself out of a chair. Eventually, his son encouraged him to move to Lochwinnoch where he started taking exercise classes.

“I found it painful, but I persevered and got my physical fitness back to a reasonable state where I could go walks. Through Roar, I learned not to fall over, which we are all prone to do.”

And then there’s the irrepressible Ramsay. “There are some nights when it’s cold and I don’t feel like going out,” she says. “I could quite easily sit and watch TV but you just have to tell yourself off. I have made a good life for myself. And I want it to last at least another ten years.”