Introduction

In section 1.3.2 we discussed the burden of fall related attendances in older people on the Emergency Department (E.D.), with an emphasis on the Australian population. Bell et al. reported that accidental falls and their consequences accounted for approximately 20% of E.D. attendances in a large university teaching hospital based in Sydney. (31) Over half of these attendances required overnight admission for further management. Larger population based studies using linked data have indicated that hospitalisations due to fall injuries constitute a significant proportion of the reasons for hospitalisation in people aged 65 years and older. (30, 37) Bradley et al. reported that fall injury hospitalisations of people aged 65 years and older accounted for 1,353,710 patient days in 2010-11 across all hospitals in Australia. (37) This figure represents 11% of all patient days for this age group and the data suggested an upward trend in hospitalisations between 1999 and 2011. This trend to increased fall related E.D. attendances and hospitalisations are also reported in North American populations. (130, 131) Orces et al. reported on projected figures for fall related injury E.D. up to 2030. Based on E.D. attendance rates and hospitalisation rates from 2001 to 2012 they deduced that there could be an increase in fall-related injuries of 43% by 2020 and 137% by 2030. (130) With the potential to cause such a significant burden on the healthcare system, it is important to understand more about the risk factors associated with these E.D. attendances and factors that are associated with increased propensity to further fall-related E.D. attendances.

Section 1.3.2 also discussed some of the characteristics of older people who have attended the E.D. with a fall in terms of the injuries sustained and the numbers requiring hospitalisation. Further discussion on the characteristics of and the risk factors for attendance

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at the E.D. with a fall-related injury is detailed in section 1.5.2. Davies and Kenny described the characteristics of 200 older people who attended an Accident and Emergency Department in the North of England with a fall. (66) The authors reported that 26% had cognitive impairment and that simple slip, trip and environmental causes for falls were common (29% of presentations). Further cross-sectional studies examined the circumstances of falls in terms of the mechanism of the fall (67) and how characteristics of the fall might determine functional decline in the short term. (132) Fewer studies however have examined outcomes following attendance at the E.D. with a fall. Close et al. reported that in an Australian cohort of older people aged 65 years and older who had attended the E.D. with a fall, a significant proportion had one or more E.D. presentations (35.4%) or one or more hospitalisations (20.3%) in the previous 12 months. (133) In a U.S. population of older people who attended a trauma centre E.D. with a fall or fall-related injury, 25.1% were found to have re-attended the E.D. for any reason over the following 12 months. (77) This study also reported a 1-year mortality rate of 15% in this cohort. These findings highlight the importance of developing strategies to predict those more likely to re-attend the E.D. with a fall.

Prospective cohort studies permit the examination of risk factors which might predict further falls in older people who have presented to the E.D. with a fall. A study of the non- intervention cohort of the PROFET trial (n = 213) found that an inability to get up after a fall and history of previous falls predicted falls in the future, when followed over 12 months. (69) A history of falls in the previous 12 months was also a significant risk factor for further falls in a study by Carpenter et al. (70) Similarly, Tiedemann et al. reported that recurrent falls in the previous 12 months was significantly associated with further falls in an E.D. population. (71) This study looked at a risk prediction model to identify those at greater risk of recurrent falls. These studies only examined the risk of further falls, rather than further falls-related

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E.D. attendance. We argue that it is important to understand the risk factors associated with fall-related E.D. attendances, as this may highlight a cohort of older people who require more focussed attention in terms of falls prevention strategies. All of the above studies followed their respective cohorts for a maximum of 12 months. A community based study has reported that older people who have recurrent falls are at greater risk of mortality at 3 years following a fall (73), which suggests that outcome follow-up should be longer than 12 months. We hypothesise that risk for further falls-related E.D. presentations exists past 12 months of follow-up. Understanding the factors that predict further falls-related E.D. presentations past 12 months may alter the focus of interventions to target these risks.

A group of people aged 65 years and older who have presented to the Emergency Department with a fall or fall-related problem were identified with similar methodology to the studies discussed above and in section 1.5.2. Given the strong association between previous history of falls and future falls shown in the prospective cohort studies, we hypothesized that a proportion of this cohort of older people would indeed re-present to the E.D. with a fall or fall-related problem. In addition, we hypothesized that certain characteristics recorded at their index fall presentation might predict these re-presentations. The objectives of this study were to determine the proportion of this cohort who re-presented to the E.D. with a fall or fall- related problem over a 5-year period, and to examine the association between risk factors examined at the index fall and further E.D. attendance with a fall.

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