By Jane Teasdale
The impact of a fall on an older person’s life expectancy, physical and mental health, independence and ability to remain at home has been well documented. But what is a falls risk assessment, and how do we mitigate, intervene and management risks? What should it mean to be truly falls risk aware?
To better understand falls risks, we need to understand the various domains and environments involved, as well as their scope, interactions and dependencies.
Clinical domains differ significantly from those in the home and community, where an individual or their family takes responsibility for the person’s environment and routines. Acute care’s primary scope in the rehab or hospital domain may be acceptable for short-duration recovery and treatment, but is not preferred by most people for longer periods. Providing support in a private home has a wider scope and involves more than just “the physical space and circumstances”— it has to take into account the person’s lifestyle, preferences, capabilities, social, emotional and physical needs, and spiritual engagements. The opportunity to provide empathic, person-centred care also differentiates private care from acute care’s more task-focused approach.
In support of empathetic care
For care providers, it is important to consider how each person interacts with their environment when trying to determine falls risks and possible interventions. This is particularly true as a person’s intrinsic capacity declines and we move toward providing supports or a more “institutional” environment.
Today, the focus of falls risk assessments still appears very much centred within the clinical domain and its assessment protocols. However, a new body of thought suggests widening the scope and range of potential interventions along a continuum of identity, and across a variety of environments and range of capabilities.
Beyond one-way clinical processing
At the furthest reach of the continuum lies the full scope of mind and place. Once falls risk assessment engages with a person’s day-to-day life, it should arguably move away from a stand-alone, one-way clinical processing and recording of dependencies and inabilities to introduce a parallel approach that prioritises preferences, intrinsic capacity and identity, and a clear interaction with where and with whom the person is living. This type of “empathic processing” acknowledges the dominance of the individual’s expertise and their preferences with respect to themself and their day-to-day environment.
Falls risks are primarily physiological and secondarily behavioural. The person doing the assessment must consider strong identities, behaviour that is at odds with changing capacities and active versus sedentary lifestyles. Third, location is a factor—the environmental situation, including the social and physical habitats, must be recognized. And fourth, consideration should be given to the potential for random and uncertain circumstances given an unknown confluence of events (including a person’s medications) that make fall prediction more complex.
The literature and clinical experience have shown that risk factors have deep roots and may well develop earlier than is often believed. Risk awareness also has an intergenerational profile.
Providing support in a private home involves more than just ‘the physical space and circumstances.
Review of a person’s potential domains
Four domains should be considered:
1) The clinical domain is required for accurate diagnosis, treatment and intervention. Clinical inputs (physiological profile and interventions) should feed into and support non-clinical personal supports and assessment processes (home care).
2) The personal domain of the individual as an agent in the process includes individual preferences, personal growth and autonomy. This domain is impacted by intrinsic capacity and cognitive, financial, social and emotional resources supportive of social and physical engagement.
3) The non-clinical domain of personal supports includes their facilitation of intrinsic social, emotional, physical and spiritual engagement with place. Offering appropriate home care, for instance, as a “falls risk intervention” can help delay declines in capacity, provide a sensitive response to falls risks and facilitate engagement with mind and place. Non-clinical considerations sit atop of the clinical, and are sensitive to and directly impacted by physiology.
4) The wider social and community domain, both institutional and asset-based, facilitates opportunities for social, emotional, physical and spiritual engagement. Compassionate communities are a key facet of this domain.
Lacking time and tools
Unfortunately, implementing falls risks protocols within the community still appears to be constrained by a number of factors, including resources, complexity of process and perceived institutional insensitivity to the needs of the individual.
A 2019 UK study noted that few family doctors use recognized clinical guidelines and lack the time to engage in assessments of falls risks.1 The authors noted that their findings were consistent with others from the US and Australia. Of note: A 2011 US-based study noted that only eight per cent of responding physicians based their fall-prevention practices on clinical guidelines, with physicians reporting barriers to prevention strategies that included a lack of time during visits and the need to address more pressing medical issues.
Also, a systematic review of the literature published in 2012 noted conflicts between identity of the individual and the clinical process.3 The authors described how older people are not considered experts, and that clinical advice they are given often appears insulting and dictatorial. A 2017 Canadian report titled “Falls Prevention in Primary Care” also noted that multifactorial risk assessments can be difficult to complete, and that primary care providers do not systematically assess for falls risks or provide links to community-based interventions.4 And yet another Canadian study from 2018 noted “significant multi-level barriers to fall prevention within and across organizations and settings,” including insufficient knowledge and skills and limited resources,5 confirming the concerns of earlier studies.
A call for a more robust physiological profile
Within the clinical domain, an initial screen is often used to prioritize those who require a more comprehensive assessment and interventions or to identify the need for higher levels of attention. Guidelines from the UK’s National Institute for Health and Care Excellence (NICE) recommend against the use of short-form screening tools, and instead suggest that clinical judgement is better. There is also a wide base of literature supporting concerns regarding the limited ability of short-form screening tools to forecast and specify a falls risk probability.
A full multifactorial falls risk assessment based on guidelines from the American Geriatrics Society and the British Geriatrics Society would perhaps be a more appropriate tool for the Canadian system. This would not only provide a more robust physiological profile, but also go a long way to informing better care in the community.
Effective, empathic assessment and management of falls risks for those with high support needs is dependent on a number of existing and potentially new processes and domains working together. Primary intelligence on capacities and sensitivity to physiology resides in the community and yet it is rarely, if ever, input into falls risks assessment. To be more successful, the following points should be considered:
• Falls risk assessment needs to consider a more holistic approach that emphasizes the individual’s agency, expertise and care preferences.
• Within the care in the community domain, an iterative feedback loop can be provided by both the caregiver and person interaction to obtain a dynamic informed response to preferences, capacities and abilities.
As WHO has noted in its Clinical Consortium on Healthy Ageing: “Healthy ageing depends upon an individual’s intrinsic capacity, their environment and the interactions between the two.” Falls risk assessment and management within this wider domain should not and cannot remain a stand-alone assessment of risk and constraint, but a higher level of supportive awareness in a collaborative, multi-dimensional, empathetic person-centred relationship.
Jane Teasdale is the business development director and principal of Mosaic Home Care & Community Resource Centres. mosaichomecare.com.