End of Life Care in Frailty: Falls

Frailty is associated with an increased risk of falls.¹ The incidence of falls in frail adults is between 6.7 and 44%,² and over half of frail adults are reported to have fallen in the previous year.³ Frailty-induced falls are associated with a greater risk of fractures, hospitalisation and institutionalisation.⁴ As the severity of frailty increases, the risk of future falls increases.^5,6

The Comprehensive Geriatric Assessment (CGA) is an approach to assessment of an older person which prompts the formulation of a personalised management plan. This process of multifactorial assessment, with interventions targeted to an individual’s risk factors, has been shown to reduce falls in frail adults,⁷ including those in nursing homes,⁸ and this approach is recommended by the National Institute for Health and Care Excellence (NICE) in their guidance on falls in older people.⁹ This guideline selects the interventions which are most relevant to frail patients approaching the end of life.      

Modifiable risk factors

Assessment of home hazards, footwear and vision is relevant to all patients experiencing falls and can be undertaken without unnecessary burden to the patient.

The process of deprescribing requires a balance of risk and benefit. The benefits of preventative medication in frail patients approaching the end of life is likely reduced and many drug groups are implicated in falls risk. These include agents aiming for stringent glycaemic and blood pressure control. Reducing the morbidity from falls by stopping anticoagulants should be considered in patients falling frequently. Likewise, bone protection (anti-resorptive agents, calcium supplementation) is unlikely to be of any short-term benefit in patients at the end of life.¹⁰ Conversely, it may be appropriate to accept the falls risk associated with some medication, such as opioid analgesia, where it is necessary to manage troublesome symptoms at the end of life.  

Reducing falls-related harm

Hip protectors have been advocated as a way to reduce falls-related morbidity due to hip fracture. When provided to residential and nursing home residents, there is evidence for a small reduction in hip fracture risk, but adherence is often poor.¹¹  

Patient choice

Among institutionalised older people, exercise programmes have been shown to reduce falls risk, however this benefit seems to be limited to pre-frail adults; indeed frail adults who participate in group exercise may risk becoming a ‘faller’.¹² Given the unclear benefit of physical exercise in the very frail, decision-making regarding physical activity should reflect patients’ wishes and be kept under regular review. Towards the end of life, it may be appropriate to accept the risk associated with attempts to maintain mobility, where this promotes dignity and quality of life, but also to accept that some patients with advanced frailty may wish to be less mobile.

Summary

The overriding themes when managing falls in this patient group are to address any modifiable risk factors, while acknowledging that we may not be able to mitigate against falls risk entirely, and prioritising patient choice. 

In circumstances where the patient cannot be part of the discussion, it is paramount to involve those who know the patient well (relatives, carers, friends) to understand the patient’s wishes in respect to their health and wellbeing at the end of life. 

References

1. Clegg A, Young J, Iliffe S, Rikkert M O, Rockwood K. Frailty in elderly people. Lancet 2013; 381: 752-62. 
2. Fhon J R, Rodrigues R A, Neira W F, Huayta V M, Robazzi M L. Fall and its association with the frailty syndrome in the elderly: systematic review with meta-analysis. Rev Esc Enfern USP. 2016; 50: 1005-1013. 
3. Bandeen-Roche K, Seplaki C L, Huang J, Buta B, Kalyani R R, Varadhan R, Xue Q L, Walston J D, Kasper J D. Frailty in Older Adults: A Nationally Representative Profile in the United States. J Gerontol A Biol Sci Med Sci. 2015; 70(11): 1427-34. 
4. Joseph B, Pandit V, Khalil M, Kulvatunyoi N, Zangbar B, Friese R S, Mohler M J, Fain M J, Rhee P. Managing older adults with ground-level falls admitted to a trauma service: the effect of frailty. J Am Geriatr Soc. 2015; 63(4): 745-9.
5. Fried LP, Tangen C M, Walston J, Newman A B, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop W K, Burke G, McBurnie M A. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology: Series A. 2001; 56(3): 146-157. 
6. Kojima G, Kendrick D, Skelton D, Morris R, Gawler S, Iliffe S. Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015; 15:155.
7. Gates S, Cooke M W, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ. 2008; 336:130.
8. Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Falls among frail older people in residential care. Scandinavian Jounral of Public Health. 2002; 30:54-61. 
9. National Institute for Health and Care Excellence (NICE). CG161.  Assessment and prevention of falls in older people. 2013. 
10. Lavan A H, Gallagher P, Parsons C, O’Mahony D. STOPPFrail (Screening Tool of Older Persons Prescription in Frail adults with limited life expectancy): consensus validation. Age and Ageing. 2017; 46: 600-607. 
11. Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people (Review). 2014 (3).  
12. Faber M J, Bosscher RJ, Chin A Paw M J, van Wieringen PC. Effects of Exercise Programs on Falls and Mobility in Frail and Pre-Frail Older Adults: A Multicenter Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2006; 87(7): 885-896.