Older people's experience of falls: understanding, interpretation and autonomy

Older people’s experience of falls: understanding, interpretation and

autonomy

Brenda Roe, Fiona Howell, Konstantinos Riniotis, Roger Beech, Peter Crome & Bie Nio Ong

Accepted for publication 7 May 2008

Correspondence to B. Roe:

e-mail: [email protected]

Brenda Roe PhD RN RHV

Professor of Health Research

Evidence-based Practice Research Centre,

Faculty of Health, Edge Hill University,

Ormskirk, UK

Fiona Howell MA RN RHV

Lecturer in Nursing

School of Nursing and Midwifery,

Keele University, UK

Konstantinos Riniotis MSc

Consultant Physician in Medicine

Inverclyde Royal Hospital, Greenock, UK

Roger Beech BSc PhD

Reader Health Services Research

Centre for Health Planning and

Management, Keele University, UK;

Academic Lead for Research

Central and Eastern Cheshire Primary Care

Trust, UK

Peter Crome PhD MD FRCP FFPM

Professor of Geriatric Medicine

School of Medicine, Keele University, UK;

President of the British Geriatrics Society UK

Bie Nio Ong BA BEd MA PhD

Professor of Health Services Research

Institute of Primary Care and Health

Sciences, Keele University, UK;

Chair of Central and Eastern Cheshire

Primary Care Trust UK

ROE BROE B., HOWELL F. , RINIOTIS K. , BEECH R., CROME P. & ONG B.N. (2008)HOWELL F. , RINIOTIS K. , BEECH R., CROME P. & ONG B.N. (2008)

Older people’s experience of falls: understanding, interpretation and autonomy.

Journal of Advanced Nursing 63(6), 586–596

doi: 10.1111/j.1365-2648.2008.04735.x

AbstractTitle. Older people’s experience of falls: understanding, interpretation and autonomy.

Aim. This paper is a report of a study to explore the experiences of older people who

suffered a recent fall and identify possible factors that could contribute to service

development.

Background. Falls in older people are prevalent and are associated with morbidity,

hospitalization and mortality, personal costs to individuals and financial costs to

health services.

Method. A convenience sample of 27 older people (mean age 84 years; range 65–98)

participated in semi-structured taped interviews. Follow-up interviews during 2003–

2004 were undertaken to detect changes over time. Data were collected about expe-

rience of the fall, use of services, health and well-being, activities of daily living,

informal care, support networks and prevention. Thematic content analysis was

undertaken.

Findings. Twenty-seven initial interviews and 18 follow-up interviews were con-

ducted. The majority of people fell indoors (n = 23) and were alone (n = 15). The

majority of falls were repeat falls (n = 22) and five were a first-ever fall. People who

reflected on their fall and sought to understand why and how it occurred developed

strategies to prevent future falls, face their fear, maintain control and choice and

continue with activities of daily living. Those who did not reflect on their fall and did

not know why it occurred restricted their activities and environments and remained in

fear of falling.

Conclusion. Assisting people to reflect on their falls and to understand why they

happened could help with preventing future falls, allay fear, boost confidence and aid

rehabilitation relating to their activities of daily living.

Keywords: autonomy, experiences, falls, interviews, nursing, older people, social

perspectives, understanding

Introduction

Falls and falling are common occurrences with increasing age

(Tinetti et al. 1998). Older people are particularly likely to

fall, and this can result in severe cases in injury, fractures,

hospitalization and premature death (Rawsky 1998, Cryer &

Patel 2001). Other consequences are repeat falls, fear of

falling, impaired mobility, loss of independence, social

ORIGINAL RESEARCHJAN

586 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd

isolation and significant costs to individuals, their families

and public services (Gryfe et al. 1977, Morse et al. 1987,

O’Loughlin et al. 1993, Rawsky 1998, Cryer & Patel 2001,

Tinetti 2003). Awareness of the costs and implications of falls

in recent years has made falls prevention an important policy

internationally for health and social services to address

supported by initiatives in the voluntary sector (DH 2003,

2004, Todd & Skelton 2004). There has been little research

investigating the consequences of falls from the perspectives

of older people and their families. In this paper, we report the

findings from qualitative research investigating older people’s

experiences of recent falls to analyse their understanding of

thee falls, and their autonomy. These findings could serve as

the basis for service and practice development.

Background

Up to a third of older people aged 65 years and above living

in the community in the USA will fall each year resulting in

injury, hospitalization or death (Tinetti et al. 1998, Tinetti

2003). Falls are associated with chronic conditions (Lee et al.

2006) and the likelihood of falling increases with age with

one in two people aged 80 years and over likely to have a fall

(Blake et al. 1988, O’Loughlin et al. 1993, Tinetti et al.

1998). Women are more likely than men to fall (O’Loughlin

et al. 1993, Yasamura et al. 1994) and, having fallen, one in

three older people will fall again within the following year

(Gryfe et al. 1977, O’Loughlin et al. 1993, Luukinen et al.

1994, Tinetti et al. 1998). Attendance at accident and

emergency departments, hospitalization, admission to long-

term care and death are consequences of falls in people aged

65 years and over (Morse et al. 1987, Rawsky 1998, Cryer &

Patel 2001, Tinetti 2003, Todd & Skelton 2004). In the

United Kingdom (UK), the costs of falls to health and social

services are estimated at £908Æ9 m (NICE 2004), while in the

United States of America (USA) the estimate in 1994 was as

high as $20Æ2 bn (Englander et al. 1996).

Systematic reviews of randomized controlled trials of

interventions to prevent falls conclude that multi-factorial

risk assessment and individualized home-based exercises

targeted at those most at risk are effective in fall prevention

(Gillespie et al. 2003, Chang et al. 2004). Loss of confidence

and fear of falling are notable consequences of having fallen

(Tinetti 2003).

Studies of older people’s views and experience of falls are

limited (Salkeld et al. 2000, HEBS 2001, Horton 2002).

Kingston (2000) investigated falls in older people and

discussed them in the context of metaphor, status passage

and preferred identities. Little qualitative research has been

undertaken to investigate the social perspectives, meaning and

impact of falls in older people. Horton (2007) has undertaken

a grounded theory study of falls in older men and women and

concluded that the social construction of the risk of falling and

actions were gendered. Parrticipants had gendered ways of

talking about risk and identifying risk factors for falling. Men

viewed themselves as ‘responsible’ and ‘rational’ and expected

to reduce their own risk of falling, while older women had a

tendency to blame themselves or others for falls. These

differing perceptions influenced their actions to prevent future

falls. Horton (2002) also found that the gender of the older

person and their key family member influenced actions, with a

power imbalance between men and women resulting in

younger male family members undertaking protective and

coercive actions with older female relatives who fell. When

younger female family members with older males fell, this

resulted in daughters undertaking negotiating and engaging

actions, and this was similar with younger female relatives

and older women that fell.

The study

Aim

The aim of this study was to explore the experiences of older

people who had a recent fall and identify possible factors that

contribute to future service development.

Design

A qualitative research using semi-structured interviews with

prompts was conducted in two primary care trusts (PCTs –

primary care provider organizations) during 2003–2004.

Initial interviews were followed up with a second interview

within 3–4 months. A recent fall was defined as being within

the last 10 days and classified as a new (first ever) or repeat

fall (having experienced a previous fall or falls) in people aged

65 years and above.

Settings

The settings were two primary care trusts in the North-west

of England. One was rural, with a spread of towns and

urban locations and having an established falls prevention

programme and community hospital clinic (PCT 1). The

other was in an urban setting, with merged towns and rural

areas radiating outward and having a less-established falls

prevention service and a falls clinic in a hospital setting

(PCT 2). Selection and categorization of these PCTs was

based on previous research findings, documentation on

structure and configuration of services and dates of

JAN: ORIGINAL RESEARCH Older people’s experience of falls

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd 587

establishment to reflect a range of falls services and

geographical settings.

Participants

The sample was one of convenience and comprised 27 older

people who had had a recent fall (n = 26 within the last

10 days, n = 1 within 16 days) being interviewed (12 PCT 1;

15 PCT 2). A 100% and 94% response rates were achieved

for PCT 1 and PCT 2, respectively; in the latter a man was

going to stay with his brother and was reluctant to partic-

ipate. More women than men were interviewed (22 vs. 5;

PCT – 1 0 men, 12 women; mean age 87 years, age range 65–

98 years; PCT 2–5 men, 10 women; mean age 81 years age

71–94 years). Across the sample their ages ranged from 65 to

98 years of age with the mean age of those in PCT 1 being

older (mean age 87 years) than those interviewed in PCT 2

(mean age 81 years).

Data collection

Participants were recruited via accident and emergency

departments, ambulance services, community health services,

intermediate care services and day centres. Interviews were

conducted either at home, in hospital, or nursing home in a

place that ensured privacy (by KR PCT 1 and FH PCT 2) and

were tape recorded. Data were collected on participants’

experiences of the fall, use of services, health and well-being,

activities of daily living, informal care and support networks

and prevention using an indicative interview guide and

prompts. A follow-up interview was undertaken 3–4 months

later and to collect information on similar themes to detect

any differences or changes over time and the occurrence of

repeat falls.

The first three interviews in each location were classed as

pilot work to test the feasibility of recruitment and opera-

tional definitions. Recruiting participants within 7 days of a

fall proved difficult and so the operational definition was

modified to become within 10 days of having fall. No

changes were made to the methods of recruitment or the

semi-structured interview schedule and so the data were

retained in the main data set.

Data analysis

Tapes were transcribed following each interview and ‘edited’

as a true record with line identification for interviewers and

participants. All transcripts were anonymous. Content anal-

ysis was undertaken and themes and categories arising from

the data reaching saturation identified independently by three

members of the team (one member for transcripts from each

PCT, KR and FH, and one member across all transcripts) and

agreed by discussion and consensus.

Rigour

Reliability checks were undertaken on the themes and cate-

gories derived within a selection of complete interviews and

across themes by two members of the team with a high level of

agreement; minor differences were eliminated by discussion to

reach consensus. The validity of information was verified and

clarified with each participant during interview.

Ethical considerations

This study was approved by the appropriate health service

ethics committee. Informed consent was obtained prior to

initial interviews. Assurance was given that data would

anonymized and kept confidential.

Findings

Participants

Twenty-seven people were interviewed following their recent

fall, with those from PCT 1 all women and having a higher

mean age than participants interviewed in PCT 2 (Table 1).

Eighteen follow-up interviews were conducted 3–4 months

later (PCT 1 n = 8; PCT n = 10) and the mean age difference

remained, with those from PCT 1 being slightly older than

those in PCT 2. Participants were lost to follow-up because of

being unwell (n = 5), having died (n = 2) or being lost to

contact, suggesting re-location (n = 2). Initial interviews were

undertaken with more than half of the participants in PCT 1

in hospital (n = 7), three in nursing homes and two at home.

In PCT 2 all initial interviews were undertaken at home,

except for one in a day centre. All follow-up interviews were

undertaken at home in both PCTs.

The majority of participants lived in their own homes

(houses n = 17, with one person living downstairs; bunga-

lows n = 2; apartment in extra care housing n = 1; sheltered

housing n = 4), with slightly more than half of interviewees

living alone (n = 13).

All participants in PCT 1 had falls involving fractures

requiring treatment as inpatients (neck of femur, pubic rami,

pelvis, humerus, shoulder) while those in PCT 2 had minor

injuries, such as soft tissue injury, bumps, skinned elbow and

bruises, although one man had fractured a wrist that went

undetected (Table 1). For five participants this was a first-ever

fall, but for the majority (n = 22) it was a repeat fall, with

B. Roe et al.


participants in PCT 2 having more frequent falls within the

previous days, weeks, month or year, but with less injurious

consequences than those in PCT 1. Four participants had a

repeat fall between the initial and follow-up interview

(Table 1).

Location of falls

The majority of falls occurred indoors (n = 23), with nearly

half in the morning (n = 12, one in the shower and two on

the ground floor), fewer in the afternoon (n = 7) and five

participants falling at night while getting up to go to the

toilet, using a commode or getting ready for bed (Table 1).

The majority of participants were alone when they fell

(n = 15); eight were able to get up by crawling to furniture

and raising themselves up, while the remainder relied on

carers, spouses, neighbours, workmen or ambulance crews

to help them, having lain on the floor for 15–30 minutes.

Reflection, understanding and interpretation

On exploring their experience of the fall, a theme of

‘reflection’ arose, where the majority of people who reflected

on their fall to understand why it happened and its cause to

prevent a future fall (PCT 1, n = 10; PCT 2, n = 9). Few

people did not know why they fell or what caused it, and they

did not attempt to reflect on the reasons (n = 5).

Key features of falls were the suddenness and feeling alone.

One woman described the suddenness of not being able to

stop herself from falling:

Suddenly – I don’t know what happened but I just fell backwards,

caught my arm on the bannister and landed on the floor. (Mrs D,

aged 85 years with a fractured pubic rami)

Another stated:

I was in the living room walking along the carpet and all of a sudden I

was on the floor. I just simply went down, I couldn’t get back up. I

think one fall upsets the apple cart. This is what I have been afraid of.

Well, it came as a shock to me. (Mrs F, aged 87 years with a

fractured neck of femur).

Fourteen participants lived alone and the majority (n = 15)

were alone when they fell. Feeling alone was a feature of falls

for these people, as they were alone when they fell and unable

to get up:

I was alone. Well, I lay there for a bit and I banged my

head…eventually I got up – I was alone. With great trouble I got

myself up and stood up. Nobody, nobody (helped me). I was alone,

entirely alone. (Mrs A, aged 89 years with a fractured pubic rami)

Another woman stated:

I can remember being on the floor and I couldn’t get to the phone. I

hadn’t got (personal body-worn safety alarm) on. So I got told off for

that, but I wouldn’t have been able to use it as I wasn’t ‘with it’. I lay

for 3 hours… (Mrs V, aged 81 years)

Prior to their initial fall only three people had a personal

body-worn alarm, but only one was wearing the alarm at the

time of the fall and used it to get help, while two participants

crawled to theirs and used them. Participants in sheltered

accommodation could not access their call buttons as these

were in other rooms from where they fell; one woman who

had previously had a personal body-worn alarm at home

discontinued renting it when she moved into sheltered

accommodation. Eight participants obtained a personal

alarm following their initial fall, with half not being worn

at the follow-up interview. Two participants wore theirs but

had no need to use them, and a further two wore theirs but

only one pressed the alarm when they subsequently fell.

Table 1 Demography and falls characteristics of participants

according to primary care provider organization (primary care trust –

PCT)

Participants

PCT 1 PCT 2

n = 12 n = 15

Gender

Female 12 10

Male 0 5

Age (years)

Mean age 87 81

Age range 65–98 71–94

Type of interview

Initial 12 15

Follow up 8 10

Type of fall

First ever 3 2

Repeat 9 13

Location of fall

Indoors 10 13

Outdoors 2 2

Time of fall

Morning 5 7

Afternoon 4 3

Night time 1 4

Alone when fell 6 9

Injuries

Fractures 12 1

Soft tissue 0 14

Residence

Own home 8 14

Sheltered accommodation 4 0

Retirement community 0 1



Loss of confidence and fear of falls appeared to relate to

the severity of the fall and the injuries sustained. The

majority of people, and those in PCT 1 who had suffered

serious injury as a consequence of their fall, reported loss

of confidence and fear of further falls, as illustrated by this

woman who was aged 90 years and sustained a fractured

neck of femur:

I just fell. I am afraid of falling…it’s just shattering. I feel nothing but

a nuisance. (Mrs G)

Another woman, aged 87 years, who also fractured her neck

of femur said:

The only worry is when I get home. I don’t want to go into a home. I

want to be independent. It did make me fear another fall – yes, it did

make me feel like that. It has made me feel like that, but I’m sure that

I will fight it. (Mrs F)

Fear of falling outside of the home was also a concern, as this

woman aged 82 years stated:

I’m a bit frightened go out. About falling again. I’ve fell in here and

fell at my son’s. Well, I’m frightened go out now through the door.

Yes, I was, ‘cause I went a real fall’. A real bang and cut my head.

(Mrs M)

Loss of confidence was also a concern, as typified by this man

aged 79 years:

But I’ve applied for one of them things around your neck. It’ll give me

more confidence, I should think. I’ve lost my confidence some while

ago. Just can’t walk, that’s the thing. Can’t get about. If I could get

out and walk, I’d be all right. (Mr O)

A minority of people, particularly those in PCT 2 who did

not have serious injury as a consequence of their fall,

reported fear of fall or loss of confidence, as evidenced by a

woman aged 81 years in PCT 2 who did not hurt herself

when she fell. She reported that her first fall had been about

3 years ago, when she said she started losing her balance.

She had fallen in the street and indoors and had been

helped. She had also fallen when alone and had managed to

get up by herself. She said that she now fell about twice a

month, with two falls in the last week. She was frightened

when she fell but said that she had not hurt herself and that

she managed to get herself up. Falls had restricted her life

and she would only go out accompanied, as she feared that

no-one would know who she was, and she had lost

confidence:

They’ve (falls) gone gradually worse, duck. Yea. But this last week or

two it’s gone sudden. Well, I can’t get about. I could get about before

but, you know, I’ve got be taken everywhere. I’ve got no confidence.

Lost all my confidence. Just come this has. I don’t know. It’s ‘cause I

can’t walk properly. (Mrs V, aged 81 years)

Personal strategies to overcome fear and boost confidence

included reflecting on the fall to understand why it had

happened; obtaining a personal body-worn alarm; being

cautious and taking things more slowly; minimizing environ-

mental factors; and using home adaptations and equipment,

e.g. hand rails, stair lifts, trolleys and walking frames. Some

participants restricted going outdoors unless accompanied

and there was a greater fear of falls outdoors than indoors,

because of their consequences. For one woman the fear was

that ‘Nobody knows who you are’, while another man

considered that people thought that ‘you might be drunk’.

One man had stopped driving because of his fear of falls and

had stopped his hobby of fishing as ‘I could fall in the lake’.

Participants who had fallen retained more control indoors

and felt safer.

Ageing and the life course

Falls were perceived as a consequence of ageing and part of

the life course. A woman aged 78 years who fell down stairs

in her home stated:

Well I could fall anytime It’s a thing old people do is fall or stumble

don’t they old people? It’s always these cracked bones and soft bones

and hip replacements with older people. Well I suppose they could go

a bit giddy couldn’t they? You know, well when you’re up (town) you

see more old people on walking sticks than any men and some

are…well they look old ‘cause they’re bent…I mean you could fall

anywhere, anytime couldn’t you? Anybody could fall. (Mrs S)

A man aged 76 years who is a carer for his wife, fell in the

shower in the morning and hurt his back reported:

The ‘60 (age) one was the worse one, (more) than this one. It was just

a nasty fall, very painful at the time because there’s age. You’ve got to

look at somebody at 20 and somebody at 70 odd, you see. (Age is a

factor) It is. It is, yea. You see, you begin to lose your strength a bit,

you know, although I’ve still got good strength. You know, in my

hands. (Mr Z)

Another woman aged 72 years observed:

I’ve not fallen before, that’s the first time. Only, you know, when

you’re younger, when you fall in the snow and bad weather and

things like that, but no. It really…it unsteadied me. Really, it did

unsteady me. (Mrs R)

She was attended by paramedics in her home as part of the

local health services response via general practitioners (GP) in

PCT 2, who confirmed that ageing was a factor to consider:

B. Roe et al.


He said, you know, how you are when you’re children, he says, you

don’t think as much about being stiff next day as you are when you’re

older. (Mrs R)

Preventive approaches, such as fitting safety hand rails in the

home, were also a feature of having a fall for some people,

but also as a consequence of age, as illustrated by a woman

aged 94 years who stated that ‘Social services had fitted rails

in my home, not because of falls but because of age’ (Mrs W).

For these older people who did reflect on age as a factor in

falls, it would appear that the older they were the greater the

severity or consequence of the fall. However, in contrast to

this finding, the impact and injury of a fall for a woman aged

65 years was as severe as for some of the older people

interviewed.

Maintaining control, choice and autonomy

Reflection, interpretation and understanding why and how

falls occurred related to maintaining control, choice and

autonomy. Participants who did not know why they fell nor

tried to understand it were a minority. They restricted or

curtailed their lives, e.g. one woman stayed indoors and only

moved between her bed and her sofa.

In relation to reflection and fear of falls, it would appear

that people who reflected on their falls confronted their

fear in one of two ways in order to maintain control,

choice and autonomy. They acknowledged their fear, faced

it, took steps to minimize falls but accepted the risk. For

example, Mrs B aged 86 years, who had a fractured neck

of femur, stated:

I’ve been trying to think about that and I don’t know…it sounds

stupid, but I felt as if my leg was broken before I fell. I just don’t

know how it happened. I just…I’ve tried to think how could it

happen. Because there was nothing in front of me, I didn’t fall over

anything. Just went down…

This woman had now returned to her own home from

hospital and had retained her independence. She has paid for

a second-hand stair-lift to be installed as she had initially used

crutches and found them difficult on stairs. She now used a

walking stick. She had adapted her life and used taxis instead

of buses but when going to do her shopping or friends would

drive her. She continued to use and pay for a personal body

alarm but did not wear the alarm around her neck. As her last

fall she had had another fall but did not injure herself. The

difference between the impact of both falls was that the

previous one caused injury requiring hospitalization while in

this most recent one she did not injure herself.

Another example are the words of a woman Mrs J, aged

76 years, who had a fractured neck of femur:

So I couldn’t get me (walking frame)…so I held onto the door and…I

got in the shop all right, but it’s coming out of the shop, because the

door was stiff see. If I hadn’t have been so clumsy, let’s put it that

way, I could have prevented it. I mean, it’s my fault, nobody else’s,

that I fell, you know. It was my fault entirely. Well, I just fell over this

little step. So, yea, I mustn’t have been concentrating.

And after the fall she said:

Well, as I am now I’m not active, but I don’t know how I’m going

to be later on, do I? You know, once I get home and get myself

going it’s going to take a time…so I don’t know really yet…it’s

knocked me, if you like, out of focus so I’ll have to take it slowly

and, with his help and that, I’ll have to take it slowly…I’m not one

for sitting on my bum, so I’ll have to remember to sit longer and

take it easy. Because I don’t like sitting down, but I’m going to have

to learn to sit down and take it easy. Then I’ll do little bits at a

time, yea. No, it will change my life. Yes, because I’ve got to learn

to slow down. (Mrs J)

However, others who reflected on their falls stated that they

were not frightened or worried as there was no point because

fear is a wasted emotion, and they accepted the risk.

A man aged 83 years who lived with his wife stated:

So I was rushing a little bit and that’s it. I didn’t pay due care and

attention. (I was disgusted) because I expected it…there was a risk it

(falling)would happen because…it’s happened I should say five times

in the last 3 years…I was just disgusted with myself because I can’t

stand fools, you know, and I’d been foolish (by rushing). I don’t

really worry. I mean, the only thing I worry about is James Gartside

coming up and measuring me. He’s the local funeral director. At my

age for God’s sake! The grim reaper gets daily nearer. No, I don’t

think about the future. I reminisce about the past, I must be honest. I

take it as it comes. Obviously…I try to avoid anything that I can. But

I don’t really think about it. (Mr N)

A woman who fell at home ‘suddenly’ while getting up to

answer the door to her carer said that she had not hurt

herself. She reflected on the cause of her fall and also said she

did not worry:

I’m never very ill, you know. Never have a cold or a headache. So I

can’t grumble. Yes, I am in good health. I never worry. I don’t believe

in it. Don’t believe in worrying. It doesn’t help does it? (Mrs Y, aged

83 years)

A further example was a man who had reflected on the cause

of his recent fall and compared it to a previous one and did

not fear a further fall:

No, I don’t…I don’t worry about that at all, you know. I’ve always

lived in danger. (Mr Z, aged 89 years)



A minority of people did not reflect on the cause of their fall;

those who also did not know why they had fallen appeared to

live in fear, restricting their environment and activities.

Mrs C aged 98 years, with a fractured humerus stated:

I don’t know. Well…I can’t think of anything really, unless I had my

stick with me and whether I didn’t put it far enough away from me

and I caught my stick and went down, I just don’t know. Because I

was holding the handrail as well. Well, my eyes are not good, I can’t

see, I’ve got damaged retinas. Well, I don’t really know ‘cause, I

mean, I’ve always taken care. I’ve had so many falls that I’m wary of

falls. I don’t like them and I’m always so careful.

Mrs M aged 82 years, who lived alone and spent her day

going between her bed and the settee, stated:

I’ve got vertigo. No, I don’t know really. The doctor give me tablets

for it and then after a while he took them off me ‘cause he said they

were no good.

I just went to lock my door and I just stepped backwards and fell,

yea. It just happened…I’m a bit frightened go out. About falling

again. I’ve fell in here and fell at my son’s. Well, I’m frightened to go

out now through the door. Yes I was, ‘cause I went a real fall. A real

bang and cut my head.

For the majority this was a repeat fall, and as a consequence

of falls they slowed down, were more cautious and were

fearful of another fall, typified by the following woman aged

98 years who fractured her pubic ramus:

I don’t think I’d be very keen to walk out, for instance, by myself. I’m

a bit scared by this. I’ve had other falls you see. I had one

only…10 years ago. (Mrs H)

Another woman stated:

It’s just through what I’ve done with falling, so it’s frightened me. I

mean, this was the second fall I’ve had. I fell on the market once,

just tripped up. So I’m like that when I’m walking down. I’ve got

my eyes on the floor, looking see if anything’s in my way all the

time. But it has taken a lot of me – what do you call it? –

confidence away because I can’t do things now because I’ve got to

have something to hold onto all the time. Because I’m frightened of

falling. After having that fall and I didn’t realize I could…as I’d fell

badly, I’m just frightened now. I either clutch onto my husband or I

have this buggy (walking frame), so it’s taken my confidence away,

yea. It was such a bad fall and come unexpected that I’m just

frightened of falling. (Mrs J, aged 76 years, fractured neck of

femur).

Emotions and feelings

A range of emotions were experienced by participants during

and after the fall, ranging from shock, pain, fear, feeling

alone, anger and blaming themselves for the fall. An 86-year

old woman who had fractured her neck of femur said:

Well, it’s…I feel very annoyed. I feel very annoyed and stupid about

it. At first it upset me because I thought, well, am I ever going to get

walking again. But it’s improving now and I know I’m going to get

moving soon, I assure you…at the moment because I can’t get about,

I feel frustrated because I can only walk on crutches at the moment

so… (Mrs B)

Other people felt shocked, as illustrated by these two women

aged 87 years and 65 years respectively:

Well, it came as a shock. It’s a shock to me, very much. I really didn’t

think anything like this would ever happen to me. Nothing ever has

of all the years…and it came as a terrible shock. I’ve not really got

over it yet. (Mrs F, with fractured neck of femur)

Shock. Thinking of going in hospital. A shock, yea, because I don’t

usually like hospitals, you know what I mean? Oh, I was ever so

nervous and that. I was like this (trembling, shaking). Well,

somebody sent for an ambulance. (Mrs I, with fractured hip)

Others described the pain they experienced, as illustrated by a

woman aged 94 years who had fallen 3 months previously

and still experienced continual pain on moving:

Oh, it’s been terrible my back has, been terrible. It’s 3 months since I

did it and it isn’t better yet, although I can suffer it now – it isn’t very

much but it still hurts. Yes, they did take X-rays but I’m wondering,

you know, it was right at the bottom of my back. What is that bone

called at the bottom of your back? The cockles or something, isn’t it?

Well, I think it’s that what I’ve hurt. And I don’t think they X-rayed

down there – I think they must have done the middle of my back.

Because I can’t understand why they didn’t find anything wrong.

Because I was in agony – I just sat in this chair. And sitting in this

chair I hadn’t got the pains. It starts again…starts when I get up.

(Mrs W)

Discussion

The majority of people interviewed were women living in

their own homes, with nearly half of participants living alone

and the majority of falls occurring indoors. Women in PCT 1

were older and had a higher mean age than those interviewed

in PCT 2 and also suffered more injurious falls. This may

have been due to their increasing age and the locations from

which they were recruited. Those interviewed in PCT 2,

although slightly younger and having less injurious falls, were

experiencing more frequent falls, which may be indicative of

deteriorating medical co-morbidity. These findings are in

keeping with existing evidence on falls in older people.

B. Roe et al.


Twenty to 30% of falls result in reduced mobility and

independence and an increased risk of mortality (Todd &

Skelton 2004). Not only do falls in older people have serious

consequences for their health and well-being and impact on

their families and carers, but also incur substantial costs for

the health services. In the UK, around 10% of ambulance

calls are to people over 65 years who have fallen, with

around 60% of those attending hospital. Hospitalization

rates are five times higher for falls than with any other injury,

with 20% of frequent fallers followed-up at 1 year being in

hospital, long-term care or having died (Todd & Skelton

2004). Common risk factors for falls include chronic diseases

(Nevitt et al. 1989, Luukinen et al. 1995, Tinetti et al. 1996,

Lawlor et al. 2003, Lee et al. 2006), impaired mobility

(Tinetti et al. 1998, American Geriatrics Society, British

Geriatrics Society, and the American Academy of Orthopae-

dic Surgeons Panel on Falls Prevention 2001), sedentary

lifestyle (Skelton 2001), nutritional deficiencies (Tinetti et al.

1996), impaired cognition and poly-pharmacy (Campbell

et al. 1989, Koski et al. 1996, 1998) and visual impairment

(Jack et al. 1995, Ivers et al. 1998).

Understanding and interpreting falls

Most research has looked at existing information on falls,

risk factors and causes with a view to risk assessment and

prevention (Todd & Skelton 2004, Yardley et al. 2005). Few

researchers have investigated falls from the perspectives of

the individual who has fallen, and the impact on them and

their families (Kingston 2000, Salkeld et al. 2000, HEBS

1999, Horton & Arber 2004, Yardley et al. 2006, Horton

2007). This study contributes to this developing literature on

the social perspectives, experiences and implications of falls

for older people and their families.

Reflections, emotions and feelings

The majority of people reflected on their fall to try and

understand how and why it had happened, and only a small

minority did not reflect and did not know why they fell. Key

features were the suddenness of the fall and feeling alone,

particularly if they could not get up. They also expressed

shock and annoyance. People who cannot explain why they

have fallen may have little basis for reflection. Similarly,

those who have fallen without a clear precipitating cause may

be hampered in reflection as they lack a focus. In the case of

people who expressed feelings of being alone, reflection may

be painful as the loneliness and associated fear dominate the

need to work out why they have fallen. The feeling of shock

may be associated with suddenness or realization that a fall

signals a transition into a different stage of life. Annoyance is

a different process, and may relate to the consequences of a

fall, such as pain and impairment.

Around 50% of people who fall need help to get up after at

least one fall, with only 10% of falls resulting in a lie of more

than 1 hour. Lying on the floor for longer than 12 hours can

result in pressure ulcers, hypothermia, dehydration, pneumo-

nia and death (Tinetti et al. 1994, Todd & Skelton 2004).

Even non-injurious falls in an older person unable to get up

can result in death (Todd & Skelton 2004). In our study, the

majority of people were alone when they fell were indoors

and had repeated falls; a minority had to crawl and use

furniture to get themselves up, and the remainder relied up

help from family members, carers, the public or ambulance

services. A small minority had access to personal body-worn

alarms to call for help, but only a few wore them or had used

them. It is generally acknowledged within care services that

older people’s access to and adherence to using personal

body-worn alarms is low and that there may be ‘resistance’ to

their changing identity and dependence on others. Assistive

technologies are emerging that rely of non-body-worn

sensors, computers and the internet within homes to alert

service providers to older people’s need for help (Sixsmith

2000, Sixsmith & Johnson 2004, McCreadie & Tinker

2005).

Ageing and the life course

While the prevalence of falls increases with age and

underlying co-morbidities are implicated, prevention strat-

egies aim to prevent falls by addressing external and

intrinsic risk factors and teaching people how to get up

(Todd & Skelton 2004). The older a person, is the more

likely they are to fall and, although it is not possible to

prevent falls in older people completely, it may be possible

to delay onset or serious consequences associated with a

fall. In our study, some older people commented that falls

were a consequence of ageing and the life course, a

normalizing tendency similar to that with osteoarthritis

(Sanders et al. 2002), and this was also confirmed by some

healthcare professionals attending them. Of note were some

older people’s views on the consequences and severity of

falling at different ages and their ability to recover, the

inference being that the older a person is, the more serious

the consequences. However, this was not always borne out

from the data, as evidenced by a woman of 65 years who

had a severe fall and subsequently died being a relatively

‘young’ older person but whose underlying medical condi-

tions may have been deteriorating and her fall was a

prelude to this.



Assistive equipment was used by a minority of people for

prevention and included frames, safety hand rails, shower

and bath seats. For some this was as a consequence of having

the fall, but for others it was to assist with maintaining

mobility and independence as they aged.

Fear of falls, loss of confidence

Older people in this study were frightened of having a further

fall and described a loss of confidence. Increased severity of

falls and their consequences appeared to be factors in their

feelings of fear. For some their confidence was returning as

they recuperated and they focused on regaining mobility and

confidence, whereas others accepted loss of confidence and

fear of falls as inevitable. Fear of falls has been reported in up

to 70% of people having a recent fall and up to 40% in those

not reporting a fall expressing a fear of falling (Tinetti et al.

1998, 1994). Psychological sequelae of falls continued to be

investigated, predominantly from a quantitative and risk

perspective, and have involved self-efficacy, self-esteem,

attribution and locus of control (Martin et al. 2005, Yardley

et al. 2005, Mann et al. 2006), although it is not clear which

came first – the fall or the fear of falling (Friedman et al.

2002). Chou and Chi (2007) studied the temporal relation-

ship between falls and fear of falling in older people in

primary care settings and found that falls and fear of falling

were not independent predictors. Rather, age was a common

independent predictor for falls and onset of fear of falls,

which lends some support to the argument that falls are part

of the ageing life course. They found no vicious cycle of falls

and fear of falls.

In our study, people who reflected on their falls and why they

occurred also appeared to handle their fear in one of two ways:

either acknowledging its existence, facing it and taking steps to

minimize future falls but accepting the risks involved as they

went about their daily lives or they stated they were not

frightened and that fear is a wasted emotion and accepted the

risk of falls in their daily lives. The minority of people who did

not reflect on their falls appeared to live in fear of future falls

and restricted their environments and daily activities, remain-

ing indoors. Reflection helps people to identify causes and

consequences; even when no apparent cause can be defined,

reflection plays a role in anticipation and adaptation to altered

identities from independent to dependent, from health to

frailty, or from outward facing to inward facing.

Control, choice and autonomy

Reflecting on, interpreting and understanding why and how

their falls occurred related to maintaining control, choice and

autonomy in daily lives and activities, facing the fear,

accepting the risk and getting on with life. Those who did

not reflect or did not know why they fell, albeit a minority,

curtailed and restricted their lives, which could result in

increasing isolation, withdrawal and loneliness. Maintaining

independence, social connectedness and choice in older age

remains a challenge (Cordingley & Webb 1997). Social

isolation and loneliness in older people continues to be

investigated. While social engagement with kin and social

networks benefits quality of life (Victor et al. 2005a),

loneliness as an attribute can vary over the life course and

may be a long-established trait, may be late in onset or may

even decrease with age (Victor et al. 2005b). Understanding is

needed of the experiences of older people who have had a fall

and the consequences from an individual perspective. Per-

ceived control can be a mediator between social support and

well-being in older people, as well as a feature of the life

course, self management and determination (Jacelon 2007).

Study limitations

As with all qualitative research, our findings cannot be

generalized to all populations. However, the study contrib-

utes to a small but developing body of research exploring the

consequence of falls from individuals’ perspectives and their

What is already known about this topic

• Falls are prevalent in older people and increase with

age, resulting in serious injury, hospitalization, mor-

bidity, long-term care needs and mortality.

• Falls risk assessment and falls prevention services fea-

ture as part of health policy and research.

• Little is known about individuals’ or families’ experi-

ences of falls.

What this paper adds

• The majority of older people reflected on their fall to

understand why it happened, adopted strategies to

prevent further falls, accepted the risk, faced the fear

and continued with their daily living activities.

• A minority of people who did not know why they had

fallen and did not reflect on their fall restricted their

daily activities and lived with a fear of falling.

• Assisting people to reflect on their falls and to under-

stand why they happened could help with preventing

future falls, allay fear, boost confidence and aid reha-

bilitation relating to their activities of daily living.

B. Roe et al.


families. Ideally we would have liked to interview older

people for whom it was their first-ever fall, but identifying

such people proved difficult as not all who fall, particularly

those who do not have an injurious fall, are reported to

healthcare professionals (Age Concern 1997). A pragmatic

approach to sampling was adopted and convenience samples

of people who had fallen within the previous 10 days were

recruited. Recruited location was related to severity of fall, its

consequences and age, which explained the differences

between PCT 1 and PCT 2. Thus, the two sub-samples

provided scope to explore the consequences of falls across age

cohorts in later life.

Conclusion

Helping people to reflect on their falls and understand why they

happen could help with prevention of future falls, reduce fear,

boost confidence and aid rehabilitation related to activities of

daily living. Further research into the social aspects of falls is

needed to improve understanding of the experiences older

people and their families and care networks. To inform falls

prevention policy and strategies, and to develop services and

care delivered by health and social care professionals.

Acknowledgements

This study was funded by an internal grant from The Medical

School, Keele University and data collected was included in

an MA Gerontology awarded to Fiona Howell and an MSc in

Geriatric Medicine awarded to Konstantinos Riniotis from

Keele University. Thanks to the staff of the primary care

provider organizations that facilitated the study and to the

older people who agreed to be interviewed. Thanks also to

Sue Humphries for transcribing the tapes and Frank Ward,

Age Concern Chester for his advice.

Author contributions

BR, RB, PC & BO were responsible for the study conception

and design. FH & KR performed the data collection. BR, FH

& KR performed the data analysis. BR was responsible for

the drafting of the manuscript. BR, FH, KR, RB, PC & BO

made critical revisions to the paper for important intellectual

content. BR, FH, KR, RB, PC & BO obtained funding. BR

supervised the study.

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