Falls need tailored management, fractures risk management

Cameron and Kurrle strike a note of frustration in their editorial accompanying the paper on preventive strategies to minimise falls.^{1 2} Falls in older people are sensitive to several spheres of influence: the physical status of the individual; the mental state of the individual; the influence of environmental factors; the impact of medication, adverse or beneficial; and acts of violence and abuse.

For an individual a fall is generally a symptom of an underlying problem not an explicit diagnostic sign, and therefore multivariate analysis using falls as the index is unlikely to produce a robust understanding. In an audit of admissions to one district hospital we observed that in medical admissions from care homes falls were quite common but that conditions that predisposed to falls such as infection and poorly managed heart failure were ubiquitous.³

Institutional fall rates are probably an unreliable indicator. In reviewing fall data from care homes, occasionally a report of dramatic fall rates is seen and these are often attributable to individual residents with extremely high fall rates but are seldom accompanied by injury. Investigation often reveals that these are not so much accidental episodes related to gravitational forces but acts that reflect “frustration” even “defiance.” Falls may, to a degree that needs definition, be accepted as part of the risk taking associated with individual choice and autonomy; to do otherwise invites imposition of a regime of restraint, restricted movement and inevitable increase in dependency.

Fracture or injury rates have greater currency as they are less amenable to interpretation and may indicate that risk is inadequately being managed. Risk in this context may have dimensions amenable to change. Fracture rates may also allow more robust baselines from which new interventions can be assessed efficiently through statistical design.