Falls and hip fracture older people

Falls and fracture are a major public and personal health issue for older people especially in residential care. It has proved difficult to prevent falls and fracture in residential care, perhaps because the population is very frail, the staff reportedly overstressed and the resources for pragmatic change scarce.

This is a randomised trial testing best practice falls prevention in a large number of residential care facilities in Australia. The intervention was one specialist nurse delivering the ‘Green Box’ guidelines for falls prevention to 46 residential facilities with 2802 persons. There were training sessions for the ‘link’ nurses in groups and exercise therapists, and ongoing ‘network meetings’ three monthly. There were 215 hip fractures and 33% of residents with hip fracture died within 3 months! Vitamin D use increased in all facilities, hip protector use was low and stayed low. There was no difference in the number of falls, hip fractures, hospitalisations after a fall or any measured outcome between the intervention and control group facilities. This was a very pragmatic attempt at preventing falls, a nurse in charge of several facilities (46) using evidence-based resources and standard training/implementation type strategies.

A robust trial

This is a well-designed and conducted cluster randomised trial where the whole facility was randomised to receive the intervention or not. Out of 92 facilities, 88 facilities (5391 residents) took part, the randomisation was stratified for bed type, and the outcomes were gathered by staff in all facilities (unblinded outcome assessment) and by hospitalisation data (blinded outcome assessment). The sample size was pragmatic, that is all available facilities. It is debatable whether a reduction in hip fracture would have been detectable, as perhaps one might need up to 10 000 participants to be sure, but one would have expected an impact of the intervention on specific aspects of the guideline (eg, vitamin D and hip protectors) and some suggestion of an impact on falls with this large number of enroled facilities. I believe the result is true and the interpretation is correct that this strategy did not work. The main possible reasons for this are either the one nurse was not enough resource to effect change (this is very likely), or the strategy of best practice does not work.

Not all interventions are helpful

Previously a trial showed that intervening to prevent falls is not helpful and may have increased falls1; the intervention in that trial was nurse led, of low intensity, and emphasised best practice, that is there were few resources added on as part of the intervention. The most successful falls prevention interventions in residential care have been multifaceted and multidisciplinary2 and have involved considerable additional resources including physiotherapists, specialist nurses and medical staff. The successful trials were also carried out in Europe where the registered nurse staffing levels in residential care are somewhat higher than Australasia.

What to do next

This is quite problematic as the resources for this intervention were developed using the evidence base, and it can only be assumed that the facilities were either already using most of the strategies or were unable to change usual practice without more energy, support and resources being funnelled into the change process. Or of course that the evidence-based strategies are ineffective on delivery; this is an unpopular view but quite possible.

The recent Cochrane review3 (41 trials with 25 422 participants) suggests that in nursing-care facilities multifaceted interventions delivered by a multidisciplinary team may reduce the rate of falls by 40%, and that vitamin D reduced the rate of falls by 30%. Hip fractures were reduced in some trials.

This current trial reinforces the need for real resources to be delivered to aged care facilities to allow change in practice. It also reinforces that falls and hip fracture are hard to prevent. For those working in aged care, keep working and look out for innovative ways to increase resources and change practice but always measure the outcome you hope to impact as you go.