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Age and Ageing 2002; 31: 203 210 2002, British Geriatrics Society
Evaluation of a nurse-led falls
prevention programme versus usual
care: a randomized controlled trial
2 2 2 1 3
ELIZABETH LIGHTBODY , CAROLINE WATKINS , MICHAEL LEATHLEY , ANIL SHARMA , MICHAEL LYE
1
Department of Medicine for the Elderly, University Hospital Aintree, Liverpool, UK
2
Department of Nursing, University of Central Lancashire, Preston PR1 2HE, UK
3
University Clinical Departments, The Duncan Building, Liverpool, UK
Address correspondence to: E. Lightbody. Fax: (q44) 1772 894968. Email: [e-mail]
Abstract
Objective: to evaluate a nurse-led management plan and care pathway for older people discharged from an Accident
and Emergency Department after a fall.
Design: randomized controlled trial.
Setting: a large teaching hospital.
Subjects: 348 consecutive patients aged 65 or over attending the Accident and Emergency Department with a fall.
Interventions: we randomized patients to falls nurse intervention or usual care. Within 4 weeks, the intervention
group received a home assessment to address easily modifiable risk factors for falls. This included assessments of
medication, ECG, blood pressure, cognition, visual acuity, hearing, vestibular dysfunction, balance, mobility, feet and
footwear. All patients were given advice and education about general safety in the home.
Main outcome measures: Further falls, functional ability, re-attendance at the Accident and Emergency Department
and admission to hospital.
Results: at 6 months post-Index fall, 36 patients in the intervention group and 39 patients in the control group had
had 89 and 145 falls respectively. Although the intervention group had less falls, this was not significant (P)0.05).
Similarly, the intervention group had fewer fall-related admissions and bed days (8 and 69 respectively) than the
control group (10 and 233 respectively). The intervention group scored significantly higher in indicators of function
(P-0.05) and mobility within the community (P-0.02).
Conclusions: although the differences were not significant, patients in the intervention group had fewer falls, less
hospital attendances and spent less time in hospital. Moreover, patients in the intervention group were more
functionally independent at 6 months post-Index fall.
Keywords: older people, fall prevention
The multifactorial aetiology of falls and heterogeneity
Introduction
of those at risk make assessment and treatment
Falls are common and debilitating, affecting about a difficult. Knowledge of risk factors [16 22] has led to
third of those aged 65 and over [1 4], in whom they are development of community falls prevention pro-
a leading cause of mortality and morbidity [4  8]. In grammes [23 35]. Study results conflict and use a
Britain, over 300 000 older people attend Accident and variety of interventions including exercise and postural
Emergency Departments after falling at home, and of control [23 27], education programmes [28, 29] and
these 1500 die as a direct result of falling. multifactorial assessment [19, 30 34].
Falls in older people cause major injuries,   long lie  Few studies have significantly reduced falls [23, 25, 28,
complications, functional decline and fear of falling 30, 33], despite using complex intervention programs.
[9 14]. Costs are substantial in terms of functional loss Reasons for previous negative studies may include
and use of healthcare services. Hip fractures cost an differences in intensity and duration of interventions,
estimated Ł160 million a year and account for 20% of length of follow-up and, most critically, the definition
orthopaedic bed occupancy [15]. and measurement of a fall. Even the populations studied
203
E. Lightbody et al.
have shown great variability in terms of sex, age group noted falls in the previous year and severity of Index fall.
and risk factors [23]. Index falls were coded a priori (to allow post hoc testing
In Tinetti s study [30], subjects were assessed by a of randomization) using a simple classification: mild, no
nurse and a physiotherapist. Intervention subjects were treatment; moderate, required simple dressing; severe,
visited on average eight times in 3 months. A 6-month required X-ray, sutures or sustained a fracture; or head
maintenance phase followed. At one year, 35% of the injury.
intervention group fell compared with 47% of controls.
Interventions using existing resources and mechan-
Intervention
isms are likely to be implemented and be sustainable.
This study assessed a nurse-led intervention for older Following some basic training, therapists and clinicians
people discharged from the Accident and Emergency agreed about the nurse s initial assessment and criteria
Department, requiring a single visit, where action on falls for onward referral, as some areas require specialist
risk factor modification could be taken through usual assessment, e.g. provision of aids and adaptations. The
channels. intervention group was assessed for risk factors for falls
[2, 9, 14, 16 21, 42, 43] at home by the falls nurse 2 4
weeks following the Index fall. Medication, ECG, blood
pressure, cognition, visual acuity, hearing, vestibular
Methods
dysfunction, balance, mobility, feet and footwear were
assessed using adapted versions of the falls checklist
(Appendix 2) and   s  test [44, 45]. The environmental
Design
assessment identified inadequate lighting, tripping
A randomized controlled trial of usual care versus a falls hazards and unsuitable furniture. Patients were given
nurse intervention. Patients were block-randomized advice and education about safety in the home, and
consecutively to groups. simple modifications were made with consent (e.g. mat
We obtained ethical approval from the appropriate removal).
ethics committees. Risk factors requiring further action were referred to
relatives, community therapy services, social services
and/or the primary care team. Direct referrals were not
Setting and subjects
made to hospital outpatients or day hospital.
University Hospital Aintree, Liverpool is a teaching At randomization, patients were given a diary to
hospital with a catchment population of 250 000. complete daily for up to 6 months after the Index
Between July and December 1997, we recorded con- fall. Further falls, consequent injury and subsequent
secutive patients aged 65 or over attending the Accident place of treatment (i.e. GP, hospital) were recorded.
and Emergency Department with a primary diagnosis of At 6 months, postal questionnaires asked about the
  fall  . Patients were excluded if they were admitted to number of falls, functional ability, mood and social
hospital as a result of the Index fall (see below), lived support. GP records were reviewed and hospital
in institutional care, if they refused or were unable to databases interrogated for attendances and admissions.
consent, or were out of the area.
Definition of a fall: Patient failing to maintain a
Sample size and analysis
stable position and inadvertently coming to rest on the
ground or lower level, with or without loss of con- The power calculation estimated that 168 patients per
sciousness, but not as the result of acute medical events group were required to detect a 35% reduction in
(e.g. stroke) or extraordinary environmental factors number of falls by 6 months after the Index fall (a=5%,
(e.g. traffic accident). Coming to rest against furniture or 90% power, chi-square).
a wall was not deemed a fall [3]. The current fall was We compared frequency data using chi-square
termed the Index fall. or Fisher s exact test, ordinal using the Mann
Whitney U-test, interval using Student s t-test (for all
tests a=0.05).
Baseline measurement
Eligible patients were identified, gave consent and were
randomized. We collected baseline data in the Accident
Results
and Emergency Departments, including demographic
details, pre-fall independence (Barthel [36]) and pre-fall
handicap (Rankin [37]). We developed a scaled version
Patient demographics
of the Life Space Diameter [38, 39], indicating the area
through which people habitually move (Appendix 1). We Of 863 patients who matched the inclusion criteria, 348
recorded current cognitive function (Abbreviated Mental (40.3%) were recruited, 171 to falls nurse intervention
Test Score [40]), mood (Yale [41]) and medication. We and 177 to usual care (Figure 1). There was no difference
204
Efficacy of a falls nurse intervention in preventing falls
Table 2. Baseline data
Intervention Control P value
N 171 177 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Demographics
Median age (IQR) 75 (70 82) 75 (70 81) 0.85
Women 131 (77%) 128 (72%) 0.43
Lived alone 79 (46%) 74 (42%) 0.47
Fall-related variables
Falls in previous 12 months 72 (42%) 74 (42%) 0.96
Falls outside 107 (63%) 101 (57%) 0.34
Injuries sustained in index fall
Mild no treatment 21 (12%) 21 (12%) ns
Moderate dressing 17 (10%) 25 (14%) ns
Severe medical treatment 112 (66%) 117 (66%) ns
Head injury head injury 21 (12%) 14 (8%) ns
Mean Barthel Index (SD) 19 (2.0) 19 (2.3) 0.42
Rankin)1 66 (39%) 77 (44%) 0.41
Median Life Space Diameter 6 (5 7) 6 (5 7) 0.08
(IQR)
Positive response to Yale 37 (21%) 38 (22%) 0.83
Medications
Number of daily 612 723 0.04
medications
Patients on more than 3 69 (40%) 101 (59%) 0.53
Number on target 123 (72%) 126 (71%) 0.97
medications
IQR = Inter quartile range.
Figure 1. Trial profile.
Intervention by Falls Nurse
Of those in the intervention group, 170 had a home visit.
Problem areas identified (not mutually exclusive) are
Table 1. Sex and age of patients aged 65 and over
shown in Table 3.
attending the Accident and Emergency Department with
Referrals to community services are shown in Table 4.
a fall
The falls nurse referred target medications for GP
Age
review in 125 (74%) patients and thirteen (8%)
n Women Men (median, IQR)
orthopaedic footwear referrals. Twenty-three (14%)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
patients had Social Services referrals for assessment for
Included 348 259 (74.4%) 89 (25.6%) 75 (70 81)
Refused 185 132 (71.4%) 53 (28.6%) 75.5 (70 80.5)a
aids or adaptations.
Retrospective 222 139 (62.6%) 82 (36.9%)b 74 (69 80.5)c
Other not 92 51 (55.4%) 41 (44.6%) 75.5 (68.5 82.5)d
included
Outcome data
Withdrew 16 11 (68.8%) 5 (31.3%) 77 (71.5 83)
Admitted 393 272 (69.2%) 121 (30.8%) 80 (74  86)a
At 6 months, 314 patients remained in the study, 155 in
Institution 203 160 (78.8%) 43 (21.2%) 84.5 (77 90)
the intervention group and 159 in usual care. Eighteen
patients had died (11 intervention, 7 usual care), 12 had
a
For 4 patients, no age or date of birth recorded.
withdrawn (2 intervention, 10 usual care) and 4 were lost
b
For 1 patient, no name or sex recorded.
to follow up (3 intervention, 1 usual care). There were no
c
For 2 patients, no age or date of birth recorded.
significant group differences in mortality or withdrawal
d
For 3 patients, no age or date of birth recorded.
rates.
IQR = Inter quartile range.
A review of the falls diaries revealed that in the
intervention group, 43 patients fell a total of 141 times
and with usual care, 44 patients fell a total of 171 times.
in age (P)0.05) between those recruited and those not These differences were not significant.
(retrospectively identified and refused consent) (Table 1). Table 5 shows the main outcomes. From postal
There were no differences between intervention and questionnaires: 35 (23%) patients in the intervention
usual care groups in baseline characteristics, except total group fell a total of 89 times, with usual care, 39 (25%)
number of medications (Table 2). patients fell a total of 145 times. Although there were
205
E. Lightbody et al.
Table 3. Problems identified by the falls nurse during these, 2 were lost to follow-up, 12 (57%) had been
the home visit contacted, 10 (48%) had been assessed and 5 (24%) had
received an aid or adaptation by 6 months (data not in
Problem areas N % affected
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
table).
Target medication 125 74
There was little overall difference between interven-
Abnormal ECG 83 50
tion and usual care patients in terms of target
Postural hypotension 1 -1
medications at 6 months, compared with baseline.
Cognition 25 15
However, the numbers of patients in the intervention
Visual acuity 85 51
Hearing 52 31
group taking anti-hypertensives and diuretics were
Dizziness 78 46
markedly reduced. Conversely, there were increases in
Balance 62 37
the number of patients on benzodiazepines, vasodilators,
Mobility 80 47
anti-convulsants and anti-Parkinsonian drugs.
Foot and footwear 63 37
When comparing target medication at baseline
Environment 130 77
(Table 2) with subsequent falls by 6 months, patients
on more than three target medications were significantly
See Appendix 2 for definitions of abnormalities.
more likely to fall than those on three or less (P-0.005,
odds ratio 3.31, 95% confidence intervals 1.34 8.20).
Table 4. Referrals by the falls nurse
Occupational
Discussion
Chiropody Physiotherapy therapy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This study demonstrates the effectiveness of a nurse-led
Directly Referred 30 10 7
Seen 20 (74%) 5 (56%) 2 (33%) intervention in reducing dependence and maintaining
Not seen 7 (26%) 4 (44%) 4 (67%)
mobility in the community by 6 months after the Index
Died/lost 3 1 1
fall. The numbers of subsequent falls were lower in the
Primary care Referred 8 50 
intervention group and there were less falls-related
Seen 1 (17%) 9 (20%) 
hospital admissions and bed days in the intervention
Not seen 5 (83%) 35 (80%) 
group.
Died/lost 2 6 
The intervention group were significantly more
independent in activities of daily living and were more
mobile within the community than the control group.
more falls in the usual care group, this was not These findings reinforce those of Close and colleagues
significant. There was no significant difference in the [33] where there was a significant difference in Barthel
number of falls recorded in diaries compared with postal scores between groups at 12 months (though patients in
questionnaires. both groups had deteriorated). Despite finding that more
Although the Barthel index was lower in both groups, of the intervention group were able to go out alone at
there was no apparent deterioration in Life Space 12 months, this effect was not apparent after adjust-
Diameter. Table 5 shows that at 6 months the ment for initial Barthel score and ability to go out alone
intervention group were significantly more independent at baseline [33].
(P-0.04) and more mobile in the community (P-0.02). In this study, there were fewer falls (non-significant)
In the 6 months after their Index fall, 39 (13%) patients in the intervention group. Previous studies suggest that
not previously requiring support were now receiving it, increasing activity results in more falls and injuries [46,
24 (62%) in the usual care group and 15 (38%) in the 47]. In maintaining activity, our intervention may have
intervention group. increased opportunities for falling. When considering the
Fewer patients (trend only) in the intervention group overall faller rate in the 6 month follow-up period (23%
re-attended the Accident and Emergency Department or of the intervention and 25% of the control) the study
were admitted with a new fall or a falls-related problem in retrospect was under-powered; the sample size was
(Table 5). The intervention group presented with fewer based on previous studies with an estimated proportion
major injuries (2 head injuries and 1 fractured femur) of fallers of up to 52% [19, 23, 30, 33] and aimed to
than the usual care group (2 head injuries, 2 fractured reduce the number of fallers by 35%.
femurs and 2 wrists) and had fewer falls-related days in For other outcome indicators, the intervention group
hospital. re-attended the Accident and Emergency Department
More of the patients (P-0.05) directly referred for less often, had fewer hospital admissions and bed days,
community services by the falls nurse received treatment and were less likely to require additional social support.
(physiotherapy 5/10 : chiropody 20/30) than those Our results reflect those of Close et al. [33] and Tinetti
referred via the primary care team (physiotherapy et al. [30] who found that subjects in the intervention
9/50 : chiropody 1/8) (Table 5). In addition, 23 patients group required fewer hospital admissions. It is beyond
were referred to Social Services by the falls nurse and of the remit of this paper to present detailed cost analyses.
206
Efficacy of a falls nurse intervention in preventing falls
Table 5. Outcome data at 6 months
Intervention Control P value
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of fallersa 36 (23%) 39 (25%) 0.89
Number of fallsa 89 145 0.65
Number of fallersb 39 (25%) 41 (26%) 1.00
Number of fallsb 141 171 0.89
Mean Barthel Index (SD)a 18.5 (2.37) 17.8 (3.6) -0.04
Median Life Space Diameter (IQR)a 7 (5 7) 6 (4  7) -0.02
Resource use
AED new fall or problemc 43 58 0.82
Falls-related GP attendanced 91 67 0.14
Falls-related Hospital admissionsc 8 10 0.87
Total number of bed days with a fall or
fall related problemc 69 233 0.56
Total number of bed days 470 590 0.91
Medications
Number of daily medications 608 684 0.41
Patients on more than 3 79 (49%) 94 (57%) 0.21
Number on target medications 130 (81%) 132 (80%) 0.88
Source of information:
a
Questionnaire.
b
Diary.
c
Hospital database.
d
GP questionnaire.
However, if we consider falls-related bed days, it is with positive outcomes have used a year follow-up
apparent that cost savings could be made (total cost of period [30, 33].
bed days Ł11 719 and Ł37 951 in the intervention and The efficacy of this intervention has been demon-
usual care groups respectively). This suggests that the strated and the intervention s acceptability to patients is
falls nurse intervention might lessen the need for formal evidenced by low withdrawal rates. It has proved feasible
care and reduce the economic burden of falls. with this nurse-led intervention to effect positive
The intervention aimed to use existing resources and changes in function and mobility, number of falls-related
referral mechanisms. Where the falls nurse could take hospital bed days, Accident and Emergency Department
action on interventions directly, e.g. by removing mats or attendances and new falls.
social service referrals, risk factors were modified by 6
months in most cases. However, where interventions
had to be taken indirectly, risk factors were less likely to Key points
.
have been addressed. For example, as polypharmacy A fifth of those aged 65 and over attending Accident
increases falls liability [6, 16, 20, 48 53], it was imperative and Emergency Departments, do so with a fall.
.
for the falls nurse to facilitate modification of target A single assessment of risk factors for falls
medications. However, this could only be achieved with appropriate intervention increased long term
indirectly through primary care. Unfortunately, the independence.
.
proportion of those on three or more medications Effective mechanisms for actioning interventions
actually increased, despite this risk factor being easily through primary care should be agreed.
.
modifiable. Falls prevention programmes should focus not only
The falls nurse in this study was unknown to many on falls but also on independence.
GPs and contact was generally by letter. The interven-
tion may be improved if the falls nurse worked directly
with a primary care trust and had close liaison with
Accident and Emergency Departments and older
peoples services e.g. geriatricians, and existing falls
Acknowledgements
clinics. Successful implementation of such a service
depends on developing acute and primary care-based
This study was grant funded by North West Region
multidisciplinary pathways.
NHS Executive and supported by Liverpool and Wirral
Non-intervention by a second party in this study may
Research and Development Liaison Group. We wish to
also have been compounded by the short timeframe to
thank Kevin McDonald for the design of the database
identify, implement and effect change. Other studies
and cleaning the data.
207
E. Lightbody et al.
21. Robbins AS, Rubenstein LZ, Josephson KR et al.
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I am able to travel outside town/city including daytrips/
the risk of falling in a community-dwelling elderly cohort. Arch
Int Med 1988; 148: 2441 4. holidays
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E. Lightbody et al.
Appendix 2. Patient assessment checklist
Risk factor Test If abnormality/problem intervention/action Action taken by
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Target medication Psychoactive Discussed side effects Nurse
Anti-depressants, -hypertensives, Letter to GP requesting review GP
-arrhythmics, -convulsants,
-Parkinsonian, -histamines
Vasodilators
Diuretics
Hypoglycaemics
ECG abnormalities 5 minutes supine ECG Rate, rhythm & conduction abnormalities Physician
Letter to GP GP
Postural hypotension 5 minutes supine BP done Advised on symptom management, rise Nurse GP
2 minutes standing BP repeated slowly, exercises before getting up, caution
3
Drop 20 mm Hg systolic after meals, avoid prolonged standing
=postural hypotension Letter to GP to review target medication
Postural/positional symptoms
Cognition Abbreviated Mental Test Score Letter to GP GP
Cognitively impaired -7
Visual acuity 3 metre Snellen chart, with & Advised to see optician Nurse/Patient
without glasses, lowest line Advised on home safety, lighting &
correctly read (2 attempts) obstructions
Vision impaired if (3/18
Visual field assessment
Hearing Patient reported Hearing aid training Nurse
Nurse s subjective assessment Letter to GP re audiological evaluation GP
Dizziness Questioned regarding Letter to GP to review target medication GP
unsteadiness, spinning Advised on symptom management Nurse
Balance & or mobility Positional & displacement stress Housebound, referred to physiotherapy Nurse
Romberg s & S-test Not housebound, letter to GP GP
Advised on simple exercises Nurse
Feet Foot pathology, corns, calluses, Not housebound, referred to chiropody Nurse
bunions & deformities Housebound, letter to GP re chiropody GP
Vascular, neurological & nail Deformities, letter to GP GP
assessment
Footwear Footwear appraisal, type, fit, grip, Advised on footwear Nurse/Patient
heels, support Deformities, letter to GP re Appliances GP
Inappropriate prosthetic footwear, referred Nurse
back to Appliances
210