The Mounting Costs of Falls

'Then I became quite dizzy at the window and felt a sort of twitching in my limbs, like my joints wanted to fold over me. I lifted my arms and tried to balance myself against the wall.' Sebastian Barry - from The Secret Scripture: a story told from the perspective of a 100-year-old woman.

Falling is not just an aged care issue. It is a major problem in hospitals and the community at large. The cost of falls is high ($566 million per annum for acute cases and rising an up to one billion dollars for lifetime costs) and the number of hospital entries as a result of falls is large (66,800 per annum in 2006 and rising).

Research on falls prevention is being carried out in many major hospitals around the world in an attempt to reduce the incidence of falling and the associated costs. The Princess Alexandra Hospital (PAH) in Brisbane invited me to participate in their Falls hPrevention Collaborative where I learnt that the 'fall-out'from falls is massive enough to have many PhD students, doctors, occupational therapists and physiotherapists studying the issues in the hope that the problem can be reduced.

Walking Across Space

The causes of falls are complex with the physical environment being only one of the many contributing factors. It is here that my interest lies. As an architect, I need to know that we are not adding to the fall statistics.

The main information sources for architects fall into these categories:

• Direct discussion from clients, CEOs, directors of nursing, boards and maintenance managers.
• Research derived from journals, conference attendance and specialised internet searches.
• Site visits and feedback from other users of other projects.
• Stored knowledge accumulated from years of our own experience in aged care design.
• Regulations, standards and guidelines.

Strangely however, talking directly with elderly residents is rare, yet their perspective on the matter is crucial and other overlooked. I remember my first encounter with a 102-year old woman. I was in awe of her and wanted to ask her a million questions abouit her life. The idea of delving into a resident's past is fascinating, but more important for my work is how he or she sees their life today. As you age, your circumstance and mobility change, although you still remain 'you' and your relationship with the world is at once the same and different.

Imagine my delight when an elderly gentleman pulled me aside one day, in an aged care facility we were researching, and told me just how he feels, walking 'across space'. The idea that space had to be navigated had never occurred to me. Sure, we make sure we include handrails, but the idea that the journey from one side of the room to the other was something 'to be navigated' was novel to me. He said he liked the narrow room he was in, as it meant he was close to the walls and that reduced his fear of falling. This first-hand information is very enlightening for architects.

He commented on how he hated the 'disabled toilets' that were in the facility, as he had to get from the door to the toilet without any support. He much preferred the usual 900mm x 1500mm toilet he had inhis own house, where he had the wall to support him. When he is in a larger space alone without any support he experiences fear. This demonstrates the all too often repeated scenario that well-intentioed legislation can cause more problems than it fixes.

Similarly the Australian Standard for Disabled Access, which is meant to make toileting easier for wheelchair users, actually makes it harder for old people. Often legislative changes are not thoroughly thought through and negatively affect the elderly.

With regard to the adverse effects of building code requirements, it is best taken up with sympathetic certifiers, who may be able to offer advice on ways to achieve compliance without jeopardising safety.

Behind the Issue

Recent changes to the building code include many measures that are meant to improve safety, such as the introduction of tactile indicators for the vision impaired where there are impending level changes. These tactile indicators have been actually causing falls as the raised indicators are just high enough to trigger imbalance.

Falls have a complex variety of causes including medication, poor balamce, disorientation, weakness, illness, poor vision, incontinence and lack of supervision. In fact, most falls occur at home, with the second highest category of falls occuring in residential aged care facilities. Falls occur mostly in the bedroom (and mostly beside the bed) and in the bathroom. Most falls are unwitnessed, and more females fall than males.

Some current falls prevention strategies include:

• Investigation into non-slip socks.
• Vitamin D with calcium supplements.
• Tai Chi (for better muscle control).
• Better continence management (regular toileting so that residents don't need to rush to the toilet).
• Impact absorbing flooring to reduce injury.
• Better lighting at changes of level (stairs, ramps).
• Better supervision.
• The use of high/low beds.

For the influence of the physical environment on falls, there are several determinants:

• Flooring - non-slip in wet areas.
• Good lighting, particularly where there are changes in levels.
• Attention to the use of colour (for example. using the same wall and floor colour can make space seem like walking in a cloud).
• Attention to the positioning of power points, switches and call bells.
• Making storage easily accessible and easily reachable.
• Including storage for equipment so that trip hazards are reduced.
• Having a clear line of vision from the bed to the bathroom.
• Handrails positioned properly.
• Making windows easy to open and close.
• Having taps that are easy to operate.
• Minimising clutter.
• No changes of flooring surface and no thresholds.
• Having recesses in corridors where residents can rest.
• Clear signage and way-finding tools.
• Glare control.

Falls management programs are also recommended, which may include orientation for new residents and demonstrations on everyday activities, immediate mopping of spills and better supervision.

Another area of interest is single-bed wards versus two-bed wards. There is some preliminary concern that more falls occur in single rooms although further research needs to be done in the area.

The PAH has a Falls Injury Prevention Collaborative Research Working Party and is continually active in its research, although no studies on the physical environment are currently being undertaken. The collaborative is headed by Dr Paul Varghese, who is a gerontologist at the PAH.

If you have any contribution to make on this important subject please contact me. It is through your concern and your feedback that improvements is fall prevention can be made.

Catherine Baudet is a Fellow of the Royal Australian Institute of Architects and director of Ferrier Baudet Architects. She can be contacted at catherine@ferrierbaudet.com.au

Report for Australian Architecture Association (November - December 2011)
www.architecture.org.au