4.3 The Clinical Basis of Falls
4.4 The Pattern of Falls, Their Predictability and Prevention
Introduction
4.2.1 There are certain disabilities which place the affected person at risk of falling. The nature of the disability and the person's age will have an effect on the amount of supervision they will need. In some cases, reasonable precautions can be taken which may avoid the risk of falling, or reduce the risk of injuries resulting from a fall.
4.2.2 There are six factors which are most important in determining the likelihood of falls occurring and influencing the risks of danger posed should one occur. These are:-
(i) the clinical basis for the falls;
(ii) the pattern of their occurrence;
(iii) the person's ability to take reasonable precautions to avoid them;
(iv) the age of the person;
(v) the ability of the person to get up unaided after a fall; and
(vi) the existence of another medical condition which would make falls more dangerous, such as osteogenesis imperfecta [see Chapter 46] or osteoporosis [see Chapter 6].
4.3 The Clinical Basis of Falls
4.3.1 A history of falls must have an adequate clinical basis. This is often provided by medical conditions which cause weakness, spasticity, or rigidity in the lower limbs or trunk, ataxia (incoordination of movements), involuntary movements, visual impairment [see Chapters 10 and 39], and confusion or disorientation [see also Chapter 21]. Without a clinical basis it is difficult to establish the cause of the falls.
4.3.2 In some cases there is no history of falls but a claim is made on the basis that, because of the clinical condition, the person might fall. Generalisations about risk of falling in certain clinical conditions are insufficient to establish need; it is the risk in the individual person that has to be assessed.
4.3.3 In the case of elderly people, falls may occur without there being any readily classifiable clinical disorder though the elderly person often exhibits an unsteady or shuffling, short-stepped gait. Moreover, there are a wide range of conditions, which in elderly people may lead to a risk of falling even when only relatively trivial physical signs are detected on examination eg. osteoarthritis of the knees. Many elderly people may have great difficulty getting up after a fall without the help of another person and consequently find themselves at risk of developing hypothermia or dehydration. All these factors may influence the liability to fall and the occurrence of any dangers thereby arising. [See also Chapter 3]
4.3.4 The age of the claimant is also relevant in that falls in younger people, even those with disabilities, are less likely to result in significant injury than is the case in older people. Quicker reaction time may often enable a younger disabled person to take some protective action to minimise injury from a fall. Each case should be judged on an individual basis.
4.4 The Pattern of Falls and Their Predictability
4.4.1 The pattern of falls is important. If there is a history of one or two falls more than a year previously, there is unlikely to be an ongoing risk of substantial danger. Likewise, if falls only occur when the person first rises from bed or from a chair (commonly due to a transient fall in blood pressure), pausing for a few moments may remove the danger. But if falls are currently occurring unpredictably, the question of danger does arise.
4.4.2 Some practical precautions may have been taken to remove the risk of falling. Whilst it is reasonable to expect a disabled person not to undertake activities such as reaching for objects from high shelves, it is unreasonable to expect him/her to spend the whole day sitting in a chair. In addition many practical measures may reduce the risk of falling. If a mentally competent person is experiencing falls for which there is a clinical basis and reasonable precautions have not removed the risk of danger, then they are likely to need supervision and/or attention by day. Moreover the nature, pattern and frequency of falls in this circumstance will have an effect on the person's walking ability.
4.4.3 If the mental state is such that the person is unaware of potential danger and hence cannot take reasonable precautions; and the person is currently experiencing falls for which there is a clinical basis, there may well be a need for supervision during day-time.
4.5 Falls at Night
4.5.1 A risk of falling at night can only occur if the person gets out of bed and moves around. The necessity for this may have been avoided by use of a urinal in bed or a commode beside the bed. Falls at night are most unlikely in these circumstances. However, the very elderly person may find it difficult to use a urinal in bed or may get out of bed for other reasons.
4.6 Further Evidence
4.6.1 In many cases a report provided by a GP or an examining medical practitioner (EMP) will assist in determining the risks arising from falls. This report should include a detailed description of the clinical condition and mental state of the person, a description of the pattern of the falls including the time and circumstances of their occurrence and a record of the severity of any injuries which may have been sustained.
It may also help to determine what precautions have been taken to avoid falls. Simple statements such as "danger of falling" do not help in identifying the precise risks in any particular case.