Understanding carers’ fall concern and their management of fall risk among older people at home

The perception of fall and fall risk varied among carers regardless of whether their care recipients had fallen previously. Many carers were constantly worried about the possibility of their care recipients falling again. For example, one older male carer whose wife had fallen more than three times over the past year commented that ‘You spend a lot of time worrying about where she is, if she is going to fall down the stairs, or fall in the shower…’ (C3). Another female carer also expressed concerns for her mother’s fall risk even though she had not fallen: ‘I guess I am always worried. She is always careful. I guess I am a bit worried that she may trip over a shoe or a floor mat’ (C17).

A few carers were concerned about the consequences of the fall causing additional harm to their care recipients and bringing an end to their independent living. This concern was illustrated by one female carer looking after her husband: ‘…if he does fall, like you say like causing more damage to himself, with arthritis and everything like that, breaking bones, or making them worst, and making them pain’ (C15).

In contrast, few carers were unconcerned about their care recipients sustaining minor injuries such as bruises and abrasions from the fall. When asked about the care recipient’s fall injuries, one female carer looking after her mother, who had sustained more than three falls in the past 1 year, replied that: ‘…just a few bruises and scraped knees. There was nothing major, so we were fine’ (C14). Many carers believed that their care recipients had a low risk of falling because they had employed paid home carers to assist them in their daily activities or with the household chores. The majority of carers highlighted that the presence of assistive devices such as walkers, shower chairs, and grab bars gave them confidence in helping with their care recipients’ balance. For instance, one older female spouse carer said that: ‘I don’t worry much now because in the house he is using the walker and he walks around he uses that all the time now. And when we go out shopping, he has another walker that he uses. So, I feel that he’s got more stability’ (C4). Another female spouse carer (81 years old) said that: ‘When he (her husband) is walking with his walker, he is very good. But if he holds onto the furniture and tries to walk, he could fall over then’ (C5).

Theme 2 describes carers’ perception of their care recipients’ fall risk including actions which may increase carers’ fall concern. Carers, especially those looking after their parents said they had difficulty communicating fall risk to their care recipients. Several carers were concerned about the care recipients not listening to their fall prevention advice. This often resulted in feelings of frustration, stress, and helplessness. For example, one female carer, whose mother had sustained a fracture from her recent fall, commented that: ‘She should look after herself. If she wants to use it (the walker), she uses it. But I have told her if she had another fall, she will be going into care (institutional care) or I won’t be caring for her shoulder. She will hopefully use the walker’ (C7). Another female carer said that her parents refused to seek help when needed and continued with activities against advice, which put them at increased risk of falling: ‘The biggest challenge is getting through to both, they shouldn’t be lifting heavy weights. Mum chops wood sometimes and getting up on ladders’ (C9). Only one female spouse carer (C10) discussed about the difficulty of communicating fall risk to her husband. Instead, the majority of carers of spouses had concerns related to their care recipients’ health and functional status, and environmental risk factors.

In some cases when the care recipients were repeatedly reminded about their fall risk, they became upset and felt that their carers were trying to control them. One female carer looking after her mother (85 years old) said that: ‘So if I say things too often to her, oh what about doing this? What about doing that? Then she gets cranky and says stop pushing her in doing things’ (C16). There were several reasons suggested by carers about why the care recipients would not adhere to their fall prevention advice. Some carers believed that the care recipients were aware of their fall risk but resisted acknowledging their physical limitations by being dependent. This was explained by the previous carer that: ‘I think it’s the dignity thing that they still want their independence but it’s disappearing on them because of age and some of them can’t accept it where others their age accept it’ (C16). Another female carer felt her mother (79 years old) was unaware of her fall risk and therefore did not take any measures to protect herself: ‘…my biggest concern is her not realising that she is getting older. I must keep reminding her she is getting older. She can’t do things like she used to be able to do then’ (C7).

The care recipients’ cognitive and functional decline leading to an increased risk of falling was highlighted when carers discussed fall concern. This was often associated with issues of ageing, or other pre-medical conditions, such as dementia and Parkinson’s disease. For example, one older female carer (C13) noticed that her husband (84 years old) had started to ‘get a bit slower’ in his actions and memory due to his Parkinson’s disease. A younger female carer (C16), was extremely concerned about her mother (85 years old) falling, as she realised that her mother was starting to lose her memory and would forget what she was saying, or supposed to be doing. One female carer, looking after her mother (99 years old), described the issue of cognitive decline as unavoidable and likely to worsen over time: ‘I think that will pretty go on for as long as she lives because she just forgets, forgets more with some things’ (C14).

Impaired gait and poor balance were emphasised by several carers when talking about their care recipients’ fall risk. In some instances, it was also the main reason for the fall. One female carer, who was looking after her mother (92 years old), described an event that: ‘She turned quickly and her knees kind of didn’t because she has arthritis in her knees and when she turns quickly her knees didn’t sort of go with her and she fell broke her hip’ (C20).

Furthermore, a few daily activities such as showering, getting up from bed, or a chair, and using the stairs, were highlighted by carers as potential risks in causing a fall. This prompted carers to try to supervise and assist their care recipients in these activities. There were also concerns that the care recipients rushed to do things, or forgot to use their walking aid, especially when carers were not around to remind them, resulting in a fall. One male participant caring for his mother commented that: ‘She is very good using her walker, which is, you know is great. Only that if she just gets up to answer the phone, or something and is a little quick, that’s all, that she might fall in her unit’ (C21).

Besides increasing carers’ fall concern, the issue of the care recipients’ health and function may affect the overall caregiving process and level of support required. This was illustrated in one female carer’s account: ‘Since mum has dementia, I have become more involved with her care. I don’t just think of her risk of falling, but I actually think of everything else and that she’s safe’ (C18).

Several carers discussed concern regarding their care recipients using stairs and falling at home. This concern was often associated with the care recipients’ health issues such as syncope or functional decline. One female carer mentioned that: ‘if she (her mother) is going to have another one of these episodes where she blacks out a little bit, if she is going to be going down the stairs, that’s a big risk and there is no hand rails’ (C16). A few carers also expressed relief that there were no stairs at home, especially after their care recipients had sustained an injury from a fall. One older male carer whose wife had broken her hip from a fall said that: ‘But our house is very flat now. Used to have a 2-storey house but luckily, we sold it last year. So, it’s all flat’ (C19). Other concerns expressed by carers included tripping over uneven floors, or objects, walking on a slope, or a wet surface. This was highlighted in one female carer’s account: ‘my bathroom is lower than the floor. About a good 6 inches lower than the floor. So, you’re not only stepping into a bath, you step into a drop (C10)’.

The concerns about care recipients falling outside the home were similar to those in the home. Nevertheless, these outdoor concerns were often considered inevitable and difficult to control. For example, one female carer whose mother (92 years old) was living alone said that: ‘we have taken all the precaution we need to, like removing mats and making the house as safe as possible. But there’s probably not a lot we can do especially when she is going out of the house and unless she avoids using the steps at all’ (C20). A few carers were even reluctant to let their care recipients to go out alone. For instance, one female carer whose husband had fallen twice last year added that: ‘I won’t put him alone no, and I won’t let him go anywhere on his own, no. Like if he wants to go. He likes to just go out the street to get out of the house, I can’t let him go on his own’ (C10).

Many carers expressed concern about their care recipients falling when alone at home. A few carers would only leave their care recipients alone for a short period of time or get someone else to look after them. Others could not leave their care recipients alone at all. For carers who were not living with their care recipients, many were reassured that they are living near to them, or their care recipients have had neighbours to look out for them. This was highlighted by one female carer who was looking after her mother: ‘Knowing that there is a close neighbour, it is very helpful because I think there’s always another person around’ (C9).

Carers identified various strategies to prevent their care recipients from falling which included increasing supervision, assisting with daily activities, providing support during mobility, or encouraging physical activity. Close monitoring of the care recipients was the most commonly used method in situations such as making sure that they use their walking aid and being around when they shower. For example, one female carer chose to spend more time with her mother who was suffering from dementia because of the lack of fall prevention knowledge: ‘Maybe I don’t know everything that could be done, to prevent. That’s why I like to be around a lot more’ (C18).

Most carers regularly called to check on their care recipients if they were not living with them. For example, one female carer said that: ‘I do telephone. Checking on her (her mother) most of the days. I visit maybe three times a week and that will generally include an outing, we go out like the social occasion, coffee or lunch’ (C17). Another female carer looking after her father with mobility impairment also said that: ‘I ring him several times a day to make sure he’s okay’ (C22). Additionally, one female carer (C16) had encouraged her mother with an impaired gait to carry a phone with her at home, just in case she fell and needed to call someone. A majority of carers also mentioned helping out with the difficult chores such as preparing meals, doing grocery shopping, cleaning the house, and doing laundry in an effort to reduce the fall risk of their care recipients.

Several carers, who were looking after their spouses, were at risk of falling themselves. This group described strategies such as looking out for each other’s risk, planning and doing things together. For instance, one older female spouse carer said that: ‘…we really don’t go out much and leave each other. We do go shopping together, we prepare the meals together, and we do the dishes together. So, we were 85% of the time we were in our own home’ (C11). However, regardless of the caring relationship, the majority of carers discussed about making changes to the environment to prevent their care recipients from falling. This included installing handrails, replacing the bathtub with a shower, levelling the floor, and removing of carpets or mats. This was highlighted in one female spouse carer’s account: ‘…we have got railings outside the house for the steps to prevent falling. In the house we had modifications to the shower and railings in the shower’ (C4).

When asked about the risks of preventing their care recipients from falling, only one carer (C1) mentioned sustaining an injury (i.e. sprain) while trying to assist her husband get up from the fall. Most carers claimed they had not encountered this problem. For example, one younger male spouse carer mentioned that: ‘It happened so quickly. Out of the sudden she fell. It happened so quickly that you didn’t have time to support her or anything like that’ (C2). A few carers were aware of their physical limitation and the risk of sustaining an injury when assisting their care recipients during the fall. For instance, one older female spouse carer said that: ‘I don’t think he would be able to get up on his own. I don’t try to assist because I could be injured as well. You should just let them fall, if they are going to fall’ (C4). Another female carer who was looking after her mother when the fall occurred said that: ‘I can’t hold her if she falls. I think there was one fall which I was holding onto her arm. I had to let go because when she fell, it was dead weight and I would have landed on top of her’ (C14).

Several carers received support from their family and friends in fall prevention, which included assistance in activities requiring manual handling, monitoring of care recipients, and home modification. As previously mentioned, some older spouse carers were also at risk of falling due to functional decline and increasing age. Support in undertaking complex activities may help these older carers better manage their care, minimise the risk of falling for both carers and their care recipients, and alleviate their fall concern. For example, one female spouse carer said that: ‘My daughter and some of the grandchildren, they help out at times. Especially with the yard and the bigger jobs’ (C8). Another female carer looking after her mother mentioned that: ‘Since the fall, I visit my mother every day, my sister does some nights, my niece does some nights, and another niece does some nights’ (C14). One female spouse carer (C15) said that her friends came to install hand rails and modify the stairs (made smaller steps) in her house. This support helped mitigate her disappointment with the delay in professional help from the hospital and community disability services.

In contrast, some carers expressed frustration with the lack of support from their family members in the general provision of care and activities which may be beyond the physical limitation of carers and were potential falling risks. For example, one female spouse carer (67 years old) said that: ‘It’s very tiring for me. So, it’s a bit of everything. He doesn’t listen, we have the kids always promising to come in and help, mow the lawn, and things like that, and they got their own life’ (C10). Similarly, another younger female carer looking after her mother also said that: ‘My sister and her children sometimes visit. But they just go and have a chit chat and leave, while I used to spend the whole day there and do stuff’ (C16).

The majority of carers did not receive any fall prevention information from healthcare professionals. Among those who had received advice on the management of their care recipients’ fall risks, information was delivered in the form of brochures provided by nurses in the hospital. For example, one older female spouse carer said: ‘When he had his first operation, the nurse in the emergency took me into a quiet room and she gave me a piece of paper with what to do if he falls over and what to do if he’s disoriented. That was very helpful’ (C5). A few carers also reported that their care recipients had received services from occupational therapists for home assessment and modification, and physiotherapists for body strengthening exercises to prevent falls. For instance, one male spouse carer said that: ‘As part of the rehabilitation, there was physiotherapist instruction on what to do and how to look after yourself and what muscles to build up to make sure you don’t fall’ (C6).

While the majority of carers who had received advice and support on fall prevention from healthcare professionals were satisfied with these services, one male carer whose wife had sustained multiple fractures from a fall felt that this advice had come too late: ‘We were advised by the hospital about how to break the fall if things like that were to happen again, like if it is possible. Anyway, these were only after the fall’ (C2). He added that: ‘My wife, prior the hospitalisation only had two falls. She had talked to the doctor about it. The doctor said well that happens when you get old. That wasn’t very good advice’. Another female carer (C17) wanted to know more about fall prevention but did not know who to seek advice from since her mother has not fallen.