The risk of accidental falls increases with age and frequently results in injury. Injurious falls often result in admission to hospital and can be a prompt for admission into long-term care. With an increasing population aged over 60 years, pressure on hospital beds and a declining number of long-term care facilities, the health and economic impact of falls in older people is a matter of great concern to public health practitioners and planners.

In 1999 there were 647,721 attendances at accident and emergency and 204,424 admissions to hospital for fall-related injuries in people aged 60 years and over (see table). Compared with people aged 60-64 years, those aged 75 years and over were 3.5 times more likely to attend A&E, 11 times more likely to be admitted to hospital, and 14 times more likely to die following a fall. Of those aged 75 years and over, more than 27 per cent were admitted to long-term care following a fall.

The direct costs of falls are enormous; in 1999 these falls cost the National Health Service and Personal Social Services (PSS) £981 million. Approximately 50 per cent of these costs were attributed to hospital inpatient treatment, and 41 per cent for long-term care. The remaining nine per cent were attributed to ambulance journeys, A&E, outpatient care, and GP consultations. Overall, NHS expenditure on falls in those aged 60 years and over totalled £581 million in 1999. In addition to these costs there are out-of-pocket costs to patients (and their families), but the intangible personal costs of trauma, pain and suffering, a subsequent lack of confidence and a greatly heightened fear of falling can be more devastating.

These injuries from falls and/or the fear of falling can lead to older people tending to stay inside their home, and hence, become socially more isolated. The fear of a subsequent fall can be as debilitating as the initial fall. Many of these people tend to avoid risks and may avoid physical activity. This lack of activity weakens the strength of their bones and muscles, and reduces the sense of balance, thereby compounding the problem. Therefore, the risk of a subsequent fall is increased and injuries from a fall are likely to be more serious.

These falls place unnecessary strain on health care resources. For example, following a fall, people awaiting admission to long-term care may stay in hospital until a long-term placement becomes available ? "bed blockers". I emphasise "unnecessary" because these falls are not inevitable events but, with the right interventions, are preventable. Over the last decade there have been many trials of a wide range of different interventions to reduce the risk of falling. These have included balance and exercise training in older people, home modifications ? such as the removal of loose mats and installation of grab rails ? assessment of mobility and footwear, reviews of medication regimes such as reducing the prescribing and use of sedatives, the use of hip protectors, and assessment and correction of impaired vision.

Fall prevention guidelines based on the most reliable evidence of effective interventions have been developed through international collaborations (including the American Geriatrics Society and the British Geriatric Society) as well as by the Department of Health. These guidelines specify who, when and where risk assessment is needed, the factors that should be assessed, and the appropriate interventions. Current guidelines were developed three years ago and, since then, more evidence has been produced. In line with the development of the National Service Framework for Older People 2001, the National Institute for Clinical Excellence (NICE) has commissioned the National Collaborating Centre for Nursing and Supportive Care to develop guidelines on the assessment and prevention of falls in older people. This guideline will include methods to identify persons at a high risk of falling. The draft of the NICE guideline is expected to be available for consultation early in 2004.

Having guidelines is one thing, but providing services to implement guidelines is another. This requires appropriate levels of funding to be made available, as well as resources such as health care staff, and staff training. Therefore the guidelines may take some time before they are fully implemented. Nevertheless investing in fall prevention programmes will reduce the burden to the NHS and the personal burden to individuals.