One Sunday morning about a year ago my 85-year-old mother-in-law rang from her home in Dorset to say she’d had a fall. “A peculiar thing happened last night,” she said. “I fell over in the kitchen and couldn’t get up.” She’d lain on the floor for more than an hour, making periodic efforts to stand, before eventually shuffling out into the hall and using the stairs to push herself up.
Within days she was in hospital with pneumonia where, determined to avoid the indignity of a bedpan, she set off to the toilet by herself and fell again, this time cracking a rib, which pierced her lung. And so it went on — a cascade of misfortune, one complication leading to another, keeping her bedridden throughout the spring and summer and culminating in a bout of MRSA.
Old people don’t do well in hospital, and she was no exception: she was uncharacteristically depressed and querulous, and too weak to sit up or wash herself. She said she wanted to die; we often thought she would. Eventually, she rallied, took up the Times crossword again and went home; but the redoubtable woman who had not so long ago played 18 holes of golf, tramped the hills with her grandchildren and sailed the Atlantic in a four-masted schooner was now much diminished. Instability and failing eyesight meant that she needed regular daily attendance; she fell again. “You just start tipping and you can’t do anything to save yourself,” she explained. In November, reluctantly, she put her house on the market and moved into a residential care home.
Falls are the most common and the most serious accidents imperilling older people: in Milton Keynes in Buckinghamshire all accidental deaths in women aged 65 or over had the underlying cause of death recorded as a fall. If falls don’t kill you, they destroy confidence, increase isolation and reduce independence. The statistics make bleak reading: according to the Royal Society for the Prevention of Accidents, more than 600,000 people aged 65 and over ended up in hospital as a result of falls in 2002. Of those, 48,000 had fractures of the hip; up to a third of hip-fracture patients die within a year of their accident; half lose the ability to live independently.
In Milton Keynes more older people (over-65s) die from falls than almost anywhere else in the country — 30 per cent more than the national average. There is no obvious reason: the big general hospital scores well in league tables for swiftness of treatment and of the two areas with the highest number of cases, one is relatively poor and the other relatively wealthy.
“We are determined to bring the numbers down,” says the city’s director of health, Dr Nicholas Hicks. As well as investigating the cause of falls “much more closely”, the city is running a falls prevention service aimed at all old people at risk.
In an airy, sunlit room at the city’s Fraser Day Hospital, 86-year-old Vera Rigby is taking cautious steps along a course of uneven rubber matting; a physiotherapist and a nurse walk on either side of her. Vera has had “lots of little falls” in the past two years and hopes that this eight-week course of muscle-strengthening and confidence-building will help to keep her on her feet. The first time she fell, in the sitting room of her sheltered accommodation, she was baffled: “I found myself on the floor and thought, how the heck did I get here?” she says.
People often assume that they have tripped on a bit of loose carpet or a step. “But,” says Dr John Keet, a gerontologist, “that loose carpet or step has been there for years without causing trouble. There is another reason for the fall which needs looking at because once you’ve had one fall, the chances are you’ll have another.”
Falls often happen soon after an older person has got out of bed or stood up from a chair because of a drop in blood pressure. “When we stand up, a certain head of pressure is required to supply the brain with blood,” says Keet. “If this system is impaired in an old person, the blood doesn’t get there fast enough.
“Exercise is the best treatment: waving arms around and making cycling movements to get the heart rate geared up for standing. But even if the pressure does lift, it may not remain regular, which is why many old people find it hard to stand sentry-still. “They feel fatigued,” Keet explains, “and may fidget or move around to get their heart rate up. This is an unconscious response to a failure in their autonomic system.”
Like my mother-in-law, many old people find they can’t do anything either to stop themselves falling or even to mitigate the damage. “Ah,” says Keet, “that could be vertebro-basilar insufficiency. As the neck gets crickety or arthritic, the arteries which snake up the spine to the back of the brain may be nipped or go into spasm, compromising the normal responses. ”
Partially blind people fall more often and many elderly people are on a cocktail of medicines, including psychotropic drugs — antidepressants and sleeping pills, for example — which may interact and contribute to falls. The National Institute for Health and Clinical Excellence recommends that older people at risk of falling should ideally be restricted to a maximum of four medications.
And then there is fear. According to Professor Jonathan Howland, of Boston University’s School of Public Health, fear of falling exceeds other anxieties that older people are prey to, such as being mugged or losing their mem-ory. Fear makes you timid; you’re scared of falling so you stop going out, stop doing housework, stop life. As you do less, so your physical condition deteriorates, making you more prone to falling.
“Confidence — or lack of it — is a huge factor,” says Julie Uglow, newly appointed co-ordinator of the fall prevention service in Milton Keynes. “We will be getting clients to do things that they are scared of doing at home on their own — such as reaching up to get something off a shelf — as well as working on their muscle strength.”
In an ideal world everyone over 65 would have what Dr Keet calls a 100,000-mile MOT: a full physical examination and a detailed history taken, 24-hour blood pressure monitoring and electrocardiogram. “For every major cause of falls in an older person, there will be several other contributing causes,” he says. “Falls clinics in the NHS are a welcome advance, but full investigation is often unrealistic.”
We spend £1.8 billion a year in the UK on hip fractures alone and, because we are all destined to live longer, these costs are likely to increase, so health authorities around the world are anxious to minimise falls.
Joan Williams, a 75-year-old elegant redhead, has completed the eight sessions of the Milton Keynes course and feels stronger and safer for it. The key will be keeping up her exercises at home. She and Vera Rigby are neighbours and discuss the possibility of setting up regular sessions for other members of their community in the big communal sitting room. “There’s lots legless like us,” nods Vera cheerfully, “I dare say they’d benefit too.”
The Cornwall health authority has produced a helpful guide to preventing falls: www.fallsprevention.co.uk
To obtain a copy of Help the Aged’s video, Be Strong, Be Steady telephone 0870 7700441, quoting N-26-01 or visit www.helptheaged.org.uk/health/healthyageing/fall
