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Clinical Articles, Lead Article


The NHS provides inadequate services for preventing falls and fractures in older patients, according to a national clinical audit1 published recently. There is a gap between what NHS organisations claim to provide, in terms of commissioning, protocols or structure, and the actual care provided, it claims.

Data on the clinical care of 9,567 patients, who suffered from a fragility fracture after a fall during 2010, were gathered from all NHS Acute Trusts, or equivalent, in England, Wales and Northern Ireland, as well as Primary Care Organisations, Mental Health Trusts and a sample of care homes.

Cardiac arrhythmias poorly documented

Amongst other indications of sub-optimal care, researchers found that most patients did not receive adequate assessment for cardiovascular disease (CVD), emphasising that postural hypotension and arrhythmias in particular are common treatable causes for falls in older people.  17% of hip fracture patients surveyed had no documented examination for heart murmurs, and 23% no evidence of analysis of an ECG, despite cardiac arrhythmias being a common complication of hip fracture surgery, the authors claim.

Only 38% of non-hip fracture patients were found to have been examined for murmurs, and only 29% had evidence of ECG analysis. Only 15% of non-hip fracture and 38% of hip fracture patients are documented as having lying and standing blood pressure assessed. An improvement since 2007, when the equivalent figures were 13% and 23% respectively, these results remain unacceptably poor, say the authors.

Despite 10% of all patients having cardiovascular abnormalities identified, there was no evidence of onward referral or assessment in a quarter of cases analysed. The authors recommend that either falls service staffing should include access to a specialist in elderly patients, or that falls nurses/allied health professionals should be trained in cardiac examination, including measurement of lying and standing blood pressure, and ECG analysis.

Dr Jonathan Potter, Clinical Director at the Royal College of Physicians’ Clinical Effectiveness and Evaluation Unit, commented: “This report is welcomed in providing a clear indication of the care received by people who fall. Once again it is starkly apparent that what organisations say they provide is not matched by what people receive. There is real urgency to ensure effective assessment and management for people who fall and in the very least to ensure evidence based fracture liaison services are established in all Trusts”.

T’ai chi in falls prevention…..

Preventing falls and improving mental wellbeing amongst older people are two potential benefits of t’ai chi, according to an overview published recently in the British Journal of Sports Medicine.2

Researchers from the Korea Institute of Oriental Medicine in South Korea and the University of Exeter in the UK assessed 35 studies into possible benefits of the Chinese martial art to numerous disease areas, including CVD and hypertension.  Although contradictory results were found regarding benefit to CVD and its risk factors, the authors assert that t’ai chi is effective for fall prevention and improving psychological health and was associated with general health benefits for older people.

…and heart failure

A further study3 found recently that t’ai chi may improve quality-of-life, mood-disturbance and self-confidence regarding exercise in patients with systolic heart failure (New York Heart Association class I-III, left ventricular ejection fraction (LVEF) ≤40%).  The study randomised 100 patients to take a 12-week series of t’ai chi classes (n=50) or attend, on exactly the same schedule, classes based on the HFSA patient-education modules covering diet, exercise, medications, and other aspects of self-management (n=50) – both were given educational materials for use at home.

After three months of twice-weekly classes, although the t’ai chi group showed no significant improvements over the class-based patients in exercise capacity, patients in the t’ai chi group had greater improvements in disease-specific quality of life (Minnesota Living With Heart Failure Questionnaire, p = .02). Improvements with t’ai chi were also seen in exercise self-efficacy (Cardiac Exercise Self-efficacy Instrument, p < .001) and mood (Profile of Mood States total mood disturbance, p = .01).


1 Treml J, Husk J, Lowe D, Vasilakis N.  Falling standards, broken promises: Report of the national audit of falls and bone health in older people 2010.  Royal College of Physicians 2011.

Full audit available from:

2 Lee MS, Ernst E.  Systematic reviews of t’ai chi: an overview. Br J Sports Med 2011. doi:10.1136/bjsm.2010.080622.

3 Yeh GY, McCarthy EP, Wayne PM, et al.  Tai Chi Exercise in Patients With Chronic Heart Failure: A Randomized Clinical Trial. Arch Intern Med 2011;171:750-7.

Published on: June 8, 2011

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