Are you ready for the autumn and winter? Key questions for people providing and planning local falls prevention services during the time of COVID-19

This blog was jointly written by: Sarah De Biase, Chair of AGILE (professional network for physiotherapists working with older people), Chartered Society of Physiotherapy; Dr Celia L Gregson, Consultant Senior Lecturer in Musculoskeletal Medicine & Honorary Consultant Geriatrician, University of Bristol; Daniel MacIntyre, Consultant in Public Health, West Sussex County Council; Dawn A Skelton, Professor of Ageing and Health, Glasgow Caledonian University; and Julie Whitney, Consultant Practitioner in Gerontology & Gerontology RDU Lead, NIHR CRN Ageing Lead (South London), Kings College Hospital. The authors are all members of the National Falls Prevention Coordination Group.

Local areas need to plan for the expected increase in falls amongst older people this coming autumn and winter. Below are some questions to help you do this. We would also like to share examples of local good practice and there is a comment box at the bottom of the page where you can share information. The British Geriatrics Society wants to hear what you are doing, so please do get in touch.  

The COVID-19 pandemic is likely to have led to a significant increase in the risk of falls amongst older people in the UK. During the pandemic, community falls services have largely been put on hold. Social distancing guidance has meant that group exercise classes have no longer been possible. The ‘lockdown’ has led to a situation in which falls prevention activities and services have ceased, both for people already under the care of falls services and for those newly referred.  At the same time, many older people have spent much more time at home. These reductions in activity levels lead to loss of muscle strength and postural stability, which both increase falls risk.

All of these factors taken together suggest that it is likely that there will be a significant increase in demand for falls prevention services over the coming autumn and winter. However, the provision of care will continue to be constrained by ongoing infection control requirements. In addition, the situation is likely to be exacerbated by further COVID-19 outbreaks, although their extent is hard to predict at this stage.   

It is really important that local falls services are prepared – hoping for the best but planning for the worst. Everybody involved in providing, commissioning, and planning falls-related services at a local level should be asking themselves the following key questions:   

1. What additional provision do we need in order to meet the expected increased demand on falls services over autumn and winter this year?

Local areas will need to estimate the likely increases in demand and consider how they might resource this. This will need to include:

• All patients who were under the care of the community falls service and all those participating in strength and balance programmes prior to ‘lockdown’.
• All those who would have newly required these services following the start of ‘lockdown’ on March 23rd, but who have been unable or unwilling to access services.
• All those who require services going forward, which is likely to be greater than usual due to deconditioning related to reduced activity levels and worsening of chronic conditions.   

2. Which parts of our local services can be delivered remotely using technology and which need to be delivered face to face?

COVID-19 constraints mean that traditional models of care entirely provided face-to-face are currently not possible. Local areas will have to make decisions about the way in which care is provided, with the ongoing aim of keeping person contact to a minimum, especially for the most vulnerable.

Telephone triage could be used initially to determine those who require a clinically-led comprehensive assessment (i.e. those with unexplained falls, and multiple and complex risk factors), as opposed to those who can be referred directly to evidence-based falls prevention exercise programmes. Both the clinical assessment and the first session with the falls prevention exercise programme will require an initial face-to-face assessment, resulting in a recommended set of individualised interventions and/or exercise prescription. These face-to-face assessments should take place in line with infection prevention and control guidance and using Personal Protective Equipment where necessary.

Subsequent interactions may be able to take place remotely by video, using laptops or tablets. Older people may require support from the service, or families or carers to use these, and this needs to be planned. Telephone follow-up may be possible for people not able to use video. It is likely to be difficult for therapists to progress exercises to effectively challenge balance over the telephone, as they cannot observe stability and level of challenge orensure safety. However, any exercise/ physical activity as opposed to none, is likely to be of benefit and therapists will potentially need to be more cautious about exercise prescription and progression provided remotely.

Local areas should consider working more closely with voluntary and community sector organisations, who may be able to offer further motivational support through phone calls, as we know this is a necessary part of adherence to strength and balance exercise. Engagement with families and carers to help motivate people to do their home-based exercises is also key.

The evidence around the use of digital tools, such as apps, suggests engagement with health and fitness professionals increases adherence, but evidence is still lacking on safety and efficacy of progression in challenge exercise. There are a number of apps which allow a physiotherapist/specialist exercise instructor to see how many exercises, or how much time people spend on their exercises. These apps allow for direct contact using motivational messages; however, the requirement for an initial assessment remains, and other types of support mentioned above will be necessary.   

Many older people still do not have access to technology or have problems using it, often due to sensory impairments. However, just sending a leaflet or booklet is highly unlikely to change behaviour, so phone calls to increase uptake and adherence are vital.

3. How are we going to continue to deliver falls prevention interventions during further waves of COVID-19?

It is highly likely that the UK will experience further waves of COVID-19 infection, although their extent is unknown. Falls services need to develop resilience. All local services should have plans in place which will outline how service delivery can respond to the impact of staff redeployment, and resumed social distancing regulations. There will be a need to engage with older people whose COVID-19-related anxiety makes them less likely to seek help. How can you ensure that people know you are ‘open for business’ and that you can help them reduce their risk of further falls? Who are the local champions for falls services in your area and how can you stay in touch?

There is a need to make use of all available communication channels, including via local authorities, voluntary and community sector organisations, who are likely to still be in contact with vulnerable older people at home. It is important to work with local communications teams to agree key messages and make sure that all relevant channels are being used.

4. How are you going to maintain or increase physical activity levels amongst all older people in your area? 

As well as planning for falls services, local areas should consider how they can maintain or increase physical activity levels amongst all older people to ensure that they are able to maintain and develop their muscle strength and balance and reduce their risk of falls. There are a lot of available resources to support this:

- University of Manchester and the Greater Manchester Ageing Hub have produced a Keeping Well at Home printed booklet containing information on home exercise and other areas of healthy living specifically targeted at those who are currently unable to go outside or have limited or no access to online resources. It can be downloaded here.

- Leaflets have been developed by University of Sheffield to support people remaining ‘Active at Home’ by providing practical guidance to older adults on home-based activities that will help to maintain their strength and balance. It is on the PHE Campaign Resource Hub here

Local authorities and other organisations can download print ready and digital versions of Active at Home or order physical copies by completing an order from here (please note the link to the order form can be found on the PHE resource hub).

- Later Life Training Promotes physical activity amongst older people by providing 10-minute online movement classes called Make Movement Your Mission, three times a day, for older people or those who have been very sedentary and want to ease back into movement and activity. Also archived (available as videos)

- The Chartered Society of Physiotherapists (CSP) Get up and go – a guide to staying steady is a 32-page guide for the public and patients on how to prevent falls, produced by Saga in partnership with the CSP and Public Health England.

- Keeping Well at Home with Gateshead Older People’s Assembly (OPA).

For the 140,000+ older people in the region who aren't online, a new daily TV programme, Keeping Well at Home with Gateshead OPA started with Episode 1 on 30th June 2020

The National Falls Prevention Coordination Group (NFPCG) is made up of over 35 organisations involved in the prevention of falls, care for fall-related injuries and the promotion of healthy ageing. It is hosted and facilitated by Public Health England. It has supported the development of a number of resources to address falls and fracture issues related to the COVID-19 pandemic.

The BGS would like to hear about and share examples of how local areas and falls services respond to the issues discussed in this blog - please send any examples of good practice to communications [at] bgs [dot] org [dot] uk or leave a comment in the form below.