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Falls in Palliative Care.

Dear Editor: People with advanced disease will experience functional decline as disease progresses and many will have physical falls. Sequelae of falls can be catastrophic and fractures are not uncommon. Patients can also experience decreased confidence and anxiety if they have experienced a fall. Such anxiety often extends to family and health professionals. Risk aversive responses by health professionals and carers that demand patients reduce physical activity can have the negative consequence of hastening deconditioning and, perversely, increasing risk of falling. Falls etiology is underresearched in people with advanced disease and frailty, especially in younger patients. One prospective study of 185 patients with advanced cancer found 50% of patients fell, irrespective of age. Strong falls predictors in palliative care include previous history of falls; use of psychoactive medications; and difficulties with balance, strength, or ambulation. Factors associated with falls in a group of 200 cognitively intact hospice inpatients (age range 45 to 94) included reluctance to or decision not to ask for assistance and a higher functional ability as measured by the Palliative Performance Scale and the activities of daily living (ADL) Index. Preliminary analysis of an ethics-approved retrospective case series of 100 community-dwelling hospice patients found 32% had recorded falls (see Fig. 1), yet only 4% had a falls risk identified in routine risk assessment. Of those who fell, 13% sustained lacerations and bruising, 5% fractures, and 5% other injuries. Eight percent were admitted to hospital after their fall. No stated action about the fall was recorded for 30% of patients. We need to ask, if only 4% had an identified falls risk yet 32% experienced falls, why was this risk not detected? Further, 72% of patients were noted to have mobility issues known to contribute to falls. Yet none were referred to physiotherapy for gait and balance assessment and only 3% were referred to occupational therapy for home assessment and environmental modification. The drive to be active for as long as possible remains strong for people at the end of life, irrespective of functional decline. Given that evidence suggests people who fall are reluctant to ask for help but are the more physically active of the patients we serve, our remit as health clinicians, is not to discourage activity, which hastens deconditioning, but rather enable people with life-limiting illnesses to be active in the safest possible way. However, it is imperative we know who is falling and why. What informs our decision about when to assess falls risk, and if identified, what actions do we take? The most effective falls intervention strategies include a combination of systematic risk screening, medication reviews, and follow-up on identified risks. What are the most effective interventions that will best optimize function for people with worsening frailty and those who care for them? Interventions that will