Guidance

Preventing falls in people with learning disabilities: making reasonable adjustments

Published 19 August 2019

1. Summary

People with learning disabilities have a similar risk of falls throughout their lives as older people in the general population. Around one-third of falls by people with learning disabilities result in injury and the rate of fractures is higher than in the rest of the population. This may be due to increased risk of osteoporosis. Falls and injuries are avoidable causes of frailty and reduced wellbeing, in addition to significant costs caused to health and social care.

Falls risks are usually multi-factorial; accordingly, risk assessments and the resulting actions to prevent falls must address the wide range of factors that may be involved for an individual. Some factors may be intrinsic to the person (such as sensory impairments), some linked to behaviour and lifestyle, and some environmental.

Policy and guidance on preventing falls focuses on older people; the growing body of evidence relating to people with learning disabilities suggests that much of the policy and guidance may be equally applicable, while taking account of some specific considerations.

These should include:

• providing accessible information for people with learning disabilities and information for family members and paid support staff
• ensuring that risk assessments cover risks known to be associated with having a learning disability (for example, epilepsy, impaired vision, multiple medications)
• making reasonable adjustments to enable full assessment of bone density
• tailoring interventions to the individual, their lifestyle and the support available to them
• providing adapted interventions (such as strength and balance exercise programmes)

2. Introduction

This guide contains information to help staff in public health, health services and social care to prevent falls in people with learning disabilities. It is also intended to help falls prevention services to provide support that is accessible to people with learning disabilities. The guide aims to be of use to family carers, friends and paid support staff to help them think about what risks may contribute to falls and how to reduce such risks.

This guide is one in a series of guidance looking at reasonable adjustments in a specific service area to enable public sector organisations to fulfil their duties to disabled people under the Equality Act 2010. The aim is to share information, ideas and good practice in relation to the provision of reasonable adjustments.

A search was conducted for policy, guidelines, research and resources that relate to people with learning disabilities and falls prevention. A request was put out through a range of networks for practical examples of work to prevent falls.

This guidance sets out the findings of the research and includes case studies and examples of reasonable adjustments. It also describes the online resources found and where they can be accessed.

Thank you to everyone who shared their expertise, resources and examples from practice support this guidance. Names and some details have been changed about individuals in case study examples to anonymise them.

3. Falls in people with learning disabilities

3.1 Impact

Research in the UK and elsewhere^{[footnote 1]} shows that people with learning disabilities are at risk of falls throughout their lives with 25-40% experiencing at least one fall per year. This is similar to the rate reported for older people in the general population (30%).^{[footnote 2]} Falls are the leading cause of injury, including fractures, in people with learning disabilities.

Around one-third of falls are reported to result in injury; the rate of fractures is higher than in the general population and fractures can occur in younger people.^{[footnote 1]} Fear of falling can result in avoidance of activities, social isolation and increasing frailty; reduced physical activity resulting from fear can in itself increase the risk of falls.^{[footnote 3]} While there is limited literature on the psychological impact of falls on people with learning disabilities, family carers of people who have fallen report constant fear and anxiety.^{[footnote 1]}

Falls and the related injuries to older people in the general population result in significant costs to health and social care, in addition to the impact on the individual’s quality of life. In 2014/15 more than 250,000 people aged over 65 were admitted to hospital in England as a result of falls and UK costs to health and social care of hip fractures were estimated at £2 billion.^{[footnote 2]}

3.2 Risk factors

The risks of falling are usually multi-factorial^{[footnote 4] [footnote 5]} and risk assessment should accordingly be individual and consider a range of possible contributors, including:

• internal factors (such as the person’s health, vision and fitness)
• behaviour and lifestyle
• external factors (such as the environment at home and out and about)

Different studies^{[footnote 4] [footnote 6] [footnote 7]} have yielded long lists of factors associated with falls in people with learning disabilities. There is more substantial evidence on risk factors for older people in the general population^{[footnote 5]} and many of these may be relevant to people with learning disabilities who share similar characteristics, such as:

• visual impairment
• foot problems and unsuitable footwear
• sedentary lifestyle
• cognitive impairment, including decline linked to dementia
• multiple medications

The association between sight loss and falls is particularly important, given that people with learning disabilities are 10 times more likely to have a serious sight problem.^{[footnote 7]} The prevalence of sight problems increases with severity of learning disability and also with age. Older people with learning disabilities, like other older people, become more likely to need spectacles and may also develop more serious sight-threatening conditions, such as glaucoma, macular degeneration, or cataracts.

Many sight-threatening changes are gradual and not immediately obvious to another person, so supporters need to be aware that a change in behaviour could in fact be due to a vision problem.^{[footnote 8]} For example, a sight problem can cause difficulties with depth perception, so a person might become wary of kerbs and stairs; impaired field of vision might mean the person bumps into obstacles more frequently, or finds light/dark contrasts more difficult to decipher.^{[footnote 7]}

People with learning disabilities are more likely than other people to develop dementia and to develop it at a younger age than in the general population. Sensory processing can be affected, making it more difficult for a person with dementia to make sense of the environment and perhaps increasing the risk of falls as a result.^{[footnote 9]}

Common findings^{[footnote 1]} from longitudinal studies highlight the following factors for injuries resulting from falls:

• epilepsy (not only related to seizures)
• urinary incontinence (though it is unclear why)
• problems with balance and gait
• a history of falls

People with learning disabilities are at increased risk of osteoporosis compared to the general population^{[footnote 10] [footnote 11]} and this may contribute to the incidence of fractures resulting from falls. Osteoporosis risk is related to:

• taking epilepsy medication (prevalence of epilepsy is at least 20 times higher in people with learning disabilities than in the general population)
• lack of weight-bearing activity (people with learning disabilities engage in much lower levels of physical activity than the general population)
• vitamin D deficiency (over half of adults with learning disabilities in one study^{[footnote 11]} had low or very low levels and this can also be linked to taking epilepsy medication)
• hypothyroidism and early menopause, both of which are more common in people with Down’s syndrome than in the general population
• Down’s syndrome, shown in one study^{[footnote 12]} to be an independent risk factor due to low bone formation and low accrual of bone mass, with no significant differences in bone resorption
• taking anti-psychotic medication

4. Policy and guidance

4.1 Preventing and responding to falls

Policy and guidance on preventing and responding to falls is focused on older people, as there is substantial evidence of the risks and the impact on individuals and on health and social care.^{[footnote 5]} As noted in the section on impact, people with learning disabilities are also at high risk of falls: the level of risk is similar to that for older people, but extends throughout their lives. The evidence base specific to people with learning disabilities is growing;^{[footnote 1]} in the meantime policy developed from work with the general population can be applied, with consideration of any factors specific to people with learning disabilities.^{[footnote 3]}

Evidence-based interventions in relation to older people were described in 2013 guidance and updated in 2016,^{[footnote 5]} but subsequent audits showed variation in implementation.^{[footnote 14]} PHE led work to develop a consensus statement that set out a collaborative, whole system approach to prevention, responses and treatment.^{[footnote 2]} Underpinned by strategic leadership and governance, the recommended approach included:

• promoting healthy ageing
• optimising evidence-based case finding and risk assessment

• commissioning services that provide:

  • appropriate responses to people who have fallen, including secondary prevention
  • multi-factorial risk assessment and interventions for those at high risk
  • evidence-based strength and balance programmes for those at low to medium risk
  • home hazard assessment and improvement programmes
  • fracture liaison services, including falls interventions
  • providing interdisciplinary care for people with serious injuries resulting from falls
• promoting healthy ageing and falls prevention through housing improvements
• acting to reduce risks in hospitals and residential care

The consensus statement was supported by a comprehensive resource pack^{[footnote 14]} containing more detailed guidance, tools, research evidence, information resources, example indicators and a commissioning checklist.

Throughout the consensus statement and linked resources, the partner agencies emphasised that older people responded more positively to terms such as ‘staying steady’ rather than ‘falls and fragility’. The language used in public information should therefore reflect this.

Additional guidance for the NHS^{[footnote 15]} set out a falls and fragility fractures pathway. Reinforcing the consensus statement recommendations, this added evidence about impact and potential savings to the NHS from implementing falls prevention, case finding and evidence-based responses to falls and fragility fractures. There was a specific emphasis on reducing falls in hospitals. System enablers and practice examples were included.

4.2 What we mean by learning disabilities

A person with learning disabilities has:

• a significantly reduced ability to understand new or complex information and to learn new skills
• a reduced ability to cope independently

These will have started before adulthood, with a lasting effect on development.

This does not include people with conditions such as dyslexia, in which they have a difficulty with one type of skill but not a wider intellectual impairment.

Public Health England (PHE) estimated that there were 1,087,100 people with learning disabilities, including 930,400 adults, in England in 2015. The number of people with learning disabilities recorded in health and welfare systems is much lower. For example, in the same year, GPs identified 252,446 children and adults as having learning disabilities on their practice-based registers.^{[footnote 16]} Those on the registers are likely to be the people who have more severe learning disabilities or more obvious conditions causing it (for example, Down’s syndrome).

4.3 What we mean by reasonable adjustments

Under the Equality Act 2010 public sector organisations must make reasonable changes in their approach or provision to ensure that services are accessible to disabled people as well as everybody else. Reasonable adjustments can mean alterations to buildings by providing lifts, wide doors, ramps and tactile signage, but may also mean changes to policies, procedures and staff training to ensure that services work equally well for people with learning disabilities. For example, people with learning disabilities may require clear, simple and possibly repeated explanations of what is happening, and of treatments to be followed, help with appointments and help with managing issues of consent in line with the Mental Capacity Act. Public sector organisations should not simply wait and respond to difficulties as they emerge: the duty on them is ‘anticipatory’, meaning they have to think out what is likely to be needed in advance.

All organisations that provide NHS or adult social care must follow the accessible information standard by law. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand with support, so they can communicate effectively with health and social care services.

5. What we know about what works in preventing falls in people with learning disabilities

5.1 Prevention

Given the high risk of falls in people with learning disabilities, and the associated risk of injury, proactive primary prevention will be useful as part of person-centred health action planning. Promotion of healthy lifestyles will normally include encouraging physical activity^{[footnote 17]} (accompanied by individual risk assessment and management where appropriate). Regular health checks^{[footnote 18]} should include vision, hearing and medication; balance and gait problems are sometimes overlooked.^{[footnote 4]} The implications of health check results (for example, in relation to visual impairment) then need to be related to the person’s individual circumstances – such as their environment and activities – in order to consider the individual’s risk of falls and how to mitigate the risks, while supporting people to live full and active lives. A simple example would be supporting a person to wear their spectacles or use a low vision aid that had been recommended.^{[footnote 8]} Medication review may also highlight fracture risks linked to osteoporosis,^{[footnote 4] [footnote 11]} prompting consideration of needs for:

• specific attention to promoting bone health through diet and weight-bearing exercise
• formal assessment of bone density

MacIntyre is a national charity providing support for people who have learning disabilities. They gave an example of a staff ‘round table’ learning event on falls prevention (part of the organisation’s health and wellbeing work supported by charitable funds). The objectives for the session included:

• factors that contribute to falls for people with learning disabilities
• how falls affect the person, and particularly a person with dementia
• how to reduce the risk of falls, including environmental factors
• how to support general health to help prevent falls
• supporting a person after a fall

Participants used MacIntyre’s e-book ‘Reducing the risk of falls’ to understand the prevalence of falls and factors that could contribute, with a focus on prevention. Although the total number of falls recorded was very low, staff had been proactive in looking for ways to reduce the risks.

Anonymised real-life examples were used, including a man with learning disabilities and dementia: discussion focused on the links between his medications, an increase in the number of falls he was having and how his risk of falls might be reduced. This touched on topics such as his environment, hearing, eyesight, joint problems, staffing numbers and staff training. Another example involved a person on blood-thinning medication who had a fall, and why staff would need to be particularly aware of the consequences of falling for a person in that situation.

Participants were given handouts including MacIntyre’s resources on relevant topics. The event also covered how falls should be recorded. Participants discussed and took away lots of practical ideas. Co-facilitator Nicola Payne said:

A wide range of staff attended this round table event, which was just great to see. Polypharmacy was also discussed; being able to discuss that medicines can affect a person’s balance (which could lead to a fall) was an important learning point. I know from feedback that staff left feeling more confident and skilled, ready to share what they learned with their colleagues.

For further information, contact Sarah Ormston, Health, Dementia and Wellbeing Manager, MacIntyre: sarah.ormston@macintyrecharity.org

5.2 Prevention and support after a fall or ‘near miss’

Following a fall or a ‘near miss’, a more structured approach should be adopted to multi-factorial risk assessment and management, tailored to the individual and their circumstances. This should be led by a health professional with appropriate skills and experience, normally as part of a specialist falls service.^{[footnote 5]} Some risks identified through this process may be rectified easily (for example, removing a trip hazard such as a loose rug, or supporting the person to get new spectacles). Some risks may require more sustained action, such as supporting the person to increase their physical activity.

Recording the circumstances of ‘near misses’ and actual falls can help the person and their supporters to understand more about their individual risk factors: where and when they may fall, and what may be happening that could be connected. A falls chart can assist with this; an example is available in the guide from Glasgow Caledonian University.

An individualised risk assessment might include any or all of the following elements, depending on what is relevant to the individual:^{[footnote 4] [footnote 19]}

• general health and fitness, including levels of physical activity
• balance and gait
• the individual’s environment and how they interact with it, to identify hazards
• use and appropriateness of any existing mobility aids and adaptations
• bone health^{[footnote 11]}
• vision and visual processing^{[footnote 8]}
• hearing and any ear problems that may affect balance
• changes in cognitive capacity
• medication review

An individualised prevention and risk management programme can be devised based on the multi-factorial risk assessment. This might include:

• promotion of physical activity
• attention to balance and gait, with advice and interventions tailored to the individual, ideally as part of a falls pathway service led by qualified therapists^{[footnote 4] [footnote 19]}
• addressing hazards in the individual’s environment
• provision of mobility aids and adaptations
• advice from a pharmacist about medication
• promotion of bone health
• attention to low vision and visual processing difficulties

Physical activity and exercise programmes:

Promotion of physical activity can help to improve general health and wellbeing; physical activity meaningful to the person can be incorporated into daily routines and occupation.^{[footnote 19]} Evidence from work with older people^{[footnote 20]} shows that more structured strength and balance exercise programmes are required to make a difference to falls risks related to balance and gait, ranging from group exercise for people with lower risks, through tai chi to home-based programmes for people with higher risks. There is some evidence from studies with people with learning disabilities to support this.^{[footnote 21] [footnote 4]}

For example, a falls pathway service was set up within a community learning disabilities physiotherapy team in Glasgow and evaluated. Over 18 months 50 people with learning disabilities were referred: 35 were prescribed exercise and 27 completed the 12-week home-based exercise programme. Completion of the exercise programme led to significant improvement in balance and mobility, and a decrease in the number of falls.

The programme involves individuals with learning disabilities completing two or three exercises every day from each category of:

• warm up exercises
• general/strengthening exercises
• balance exercises

plus two or three aerobic exercises per week, for 12 weeks.

The physiotherapist selects exercises appropriate to the individual’s needs, from a choice under each of the headings listed above and provides a written exercise programme in photo format for the individual to complete. Supporters (family or paid) are encouraged to complete the exercises with the person, to help motivate and support them, and it is recommended that the exercises are incorporated into the person’s everyday life once the 12-week programme is completed.

The falls pathway service also provides free information leaflets on the following:

• Education leaflet incorporating a falls chart
• Mobility and safe use of walking aids
• Don’t fall: Tips for your safety
• Getting up from the floor following a fall
• Exercise plan for bone health (osteoporosis)

For further information, or to request leaflets, contact Jennifer Crockett, Professional Lead for Physiotherapy, Glasgow learning disability services: Jennifer.Crockett@ggc.scot.nhs.uk

In another area the learning disability service received multiple referrals for input following falls for people with learning disabilities aged under 65, as the mainstream falls services were for people aged 65 or over. Physiotherapy and occupational therapy staff from the learning disability service visited the mainstream falls group to gather information and noted that the group would not meet the needs of people with learning disabilities due to communication methods, length of sessions and lack of carer support.

In response to this gap the multi-disciplinary team set up a pilot group for people with learning disabilities, described in the following example aims to:

• reduce risk from falling
• promote exercise
• improve balance and strength
• physically reduce the risk of falls
• provide education on factors that affect falls, to increase confidence and awareness about why people fall
• reduce environmental risks and medical reasons that cause falls

The group was held in a local learning disability day service over an 8 week period. Each session of one and a half hours was split into 3 parts: exercises, educational talk and a game (with a break after the exercises). The short talks were presented by members of the team and included: environmental risks; healthy eating; medication; anxiety about falling; vision and hearing. Participants also had the opportunity to try using an ‘ELK’ lifting cushion (as used by the emergency services) to assist them in getting up from the floor. All information was in an easy-read form with folders including the exercises for the participants to take home. The team delivering the sessions consisted of staff from the learning disability team (physiotherapy, occupational therapy, nursing, vision and hearing specialists) and a therapy technician from the mainstream service.

Eight people were invited to participate and 5 attended consistently. Outcome measures were completed at the start, at the end, and 3 months after completion of the programme. The results indicated that all the participants benefited from attending the group: their risks of falling reduced as their strength and balance improved, and their worries about falling during ordinary daily activities were lowered. However, the team found at the 3 month review that these benefits had not been sustained. Support to continue exercises at home had been variable and sometimes information had not been shared. Commitment from supporters is now being sought at the time of referral to continue following the exercises and guidance at home. A resource to enable other teams to run groups has been compiled and shared across the Kent learning disability teams; groups are being set up in each area.

For further information contact Karin West, Occupational Therapist, Dartford, Gravesend, Swanley and Swale Learning Disabilities Team, Kent Community Health NHS Foundation Trust karin.west@nhs.net

Environment and mobility:

A formal assessment of environmental hazards (both at home and out and about) and of the ways the individual interacts with their environment may be appropriate based on the individual’s falls risks.^{[footnote 19]} An example can be found in the guide from Glasgow Caledonian University. Occupational therapy or physiotherapy assessment and advice may also include consideration of needs for:

• adaptations to the person’s home
• mobility aids
• assistive technology such as a personal alarm

Professional advice and regular checks are important to ensure safe use and appropriate maintenance of aids and adaptations, to avoid unintentionally increasing the risks of injury.^{[footnote 4]}

A thorough, person-centred approach achieved very positive outcomes for one person, according to her mother and her mother’s advocate (names have been changed):

Sarah is in her 60s; she has lived near her mother, Teresa, for over 15 years. She has strong connections in her local community and excellent support from her GP. She is happy and settled in her supported living, shared with two friends.

Sarah’s balance became less good as she aged; she hit her head several times and sustained a significant injury on the last occasion. Her social worker was concerned and proposed moving Sarah into a residential care home some miles away. Teresa was very distressed about how she would maintain contact with her daughter and was also concerned about Sarah losing her settled home and all her social connections.

Sarah’s support provider was keen to work with the community learning disability team to enable Sarah to stay at home. A local family carer support service provided an advocate who worked with Teresa and Sarah’s siblings to prepare a report expressing their concerns: they were all very clear that they wanted Sarah to stay where she was currently living, based on their detailed knowledge of her and her needs. A mental capacity assessment established that Sarah had capacity to understand what was being proposed; an advocate was appointed to support her. Sarah did not wish to move home. Following a series of meetings involving advocates, social work, the support provider and therapists, with reports from others such as Sarah’s GP, it was agreed that Sarah should be supported to stay in her settled home.

The community learning disability occupational therapist assessed Sarah’s needs and environment. Changes were made the layout of her room, including putting up grab rails. The bedside cabinet was moved so that she could not hit her head on it. Sarah’s epilepsy monitor was serviced and the alarm on the pressure mat by her bed was changed to reduce the disturbance to others when she got up in the night. Her support was increased to 1:1. Sarah’s seizure activity was monitored and her epilepsy medication reviewed.

A referral was made to the physiotherapist and Sarah began a series of daily exercises to help her balance and retain strength; she continues to do these every day. She uses a wheelchair more now if she has to walk any distance when out and about. She also has a Zimmer frame she uses at home, though staff still need to support her as she has poor grip in one hand.

Two years later Sarah remains at her home and it has been agreed that she will remain there after her mother, who is in her 80s, passes away.

Bone health:

Any concerns about a person’s bone health should be raised with their GP. The osteoporosis risk assessment tools in common use may not take account of the additional risk factors for a person with learning disabilities,^{[footnote 11]} so care may be needed to add these. A dual-energy X-ray absorptiometry (DXA) scan may be recommended to assess bone density. This would normally entail a hip and spine scan taking 10-15 minutes, requiring the person to lie still. A feasibility study of reasonable adjustments^{[footnote 11]} found that 29 out of 30 adults referred were able to have a complete scan and that the adjustments were acceptable both to the participants and the health professionals involved. Adjustments included:

• provision of accessible information in a variety of formats
• longer appointment times
• appointments at quiet times
• having a supporter present
• the offer of refreshments
• ensuring a hoist or sling was available for transfer from a wheelchair

One person in the study had a scan of the wrist and forearm instead, but this was not found to be very helpful.^{[footnote 11]}

Dietary supplements may also be prescribed (the advice for the general population is not to take vitamin D or calcium supplements without these being prescribed).^{[footnote 5]} A small recent study^{[footnote 22]} suggested some bone density benefit for people with learning disabilities, previously diagnosed with vitamin D deficiency, from long term vitamin D supplements. The results indicated that vitamin D supplementation might help to counteract the negative effects of anti-epileptic medication on bone.

Attend to sight problems/low vision:

The first step should always be action to correct or mitigate sight problems wherever possible. In some cases, a person may still only have limited useful sight, even after treatment or when wearing spectacles. It may be necessary to ensure that the person is certified or registered as having low vision in order to obtain services provided by the NHS or local authority. Local low vision services vary but should be able to provide advice and aids. Local optical practices will have optometrists and dispensing opticians who can provide expert advice around low vision aids and support. Vision rehabilitation workers are experts in supporting people with sight loss, assessing how a person’s environment can be adapted to help them make the most of their vision as well as minimise falls, and providing training on guiding by sighted supporters.

Supporters may also benefit from advice about how to keep the person’s environment safe (for example, not leaving cupboard doors open) and how to avoid interactions that might cause a person to lose their balance.^{[footnote 8]}

SeeAbility provides specialist support, accommodation and eye care help for people with learning disabilities, autism and sight loss. The charity employs its own vision rehabilitation workers. One of them, Jenny, explains how her day to day work can help reduce falls:

Recently I worked with an individual around colour contrast, putting brightly coloured tape onto the handles of her walking frame, which has enabled her to instantly locate the correct place to hold onto. Falls can be a huge problem for some people with reduced vision, as people may under- or over-reach for their walking frame and go off balance. I have also completed some similar work by increasing the contrast of an individual’s bedroom door frame so she could independently and safely exit without bumping into one side.

Lighting is also a major aspect to consider by ensuring a person can maximise and use their vision to orientate themselves, and lighting levels need to be right for the person. Some care services may look to dim the lights at night, but if a person has a visual impairment, they may experience night blindness, which creates a huge risk of falls. Just small adjustments to lighting can have a major impact on independence too. One person’s posture changed dramatically when I introduced a task light while she was having a cup of tea. Prior to this inadequate lighting meant she was not using her vision effectively, causing her to drop her head.

SeeAbility provides lots of free easy-read resources on having an eye test and wearing glasses, as well as advice for supporters such as a ‘functional vision tool’ that can be used to look out for signs of sight problems, and a database of opticians that offer experience in testing people with learning disabilities.

6. Resources

The tables that follow list all the information and resources we have found in relation to preventing falls in people with learning disabilities:

• Table 1 lists websites and resources that may be of use to family members and paid supporters who want more information
• Table 2 lists resources that may be of use to health and social care professionals
• Table 3 lists the easy-read resources we have found. This is where you can find information to use with people with learning disabilities

Some resources may be available from more than one site, but there is only one link. Included are resources that are free to download, although some of the websites may also include resources which can be bought.

Table 1: Resources about falls prevention for family carers and paid supporters

Theme	Description	Provider
Injury and fall prevention for people with learning disabilities	Resource guide for people who care for or support people with learning disabilities. Includes a range of useful illustrations and tools.	Glasgow Caledonian University
Reducing the risk of falls	E-book for supporters and health professionals working with people with learning disabilities.	MacIntyre
Learning disability and sight loss	Booklet for supporters with a checklist and tips, including falls risks.	RNIB Scotland
Looking after your eyes	Advice and resources on noticing and responding to sight problems in people with learning disabilities.	SeeAbility
What accidents happen and how to prevent them: falls	Web pages on preventing falls, aimed at older people and their supporters but widely applicable. Resources include short videos and tips on safety.	The Royal Society for the Prevention of Accidents
Prevention: falls	Advice and links aimed at the general public.	NHS
Are you at risk of falling?	Self-assessment and linked resources aimed at the general public.	NHS
Falls prevention	Advice and links on falls prevention, aimed at the general public, and downloadable guide to staying steady.	AgeUK
Get up and go – a guide to staying steady	Video and guide on falls prevention, aimed at the general public.	The Chartered Society of Physiotherapy/Saga/PHE
Falls prevention in hospital: a guide for patients, their families and carers	Advice and checklist aimed at the general public.	Royal College of Physicians
Preventing falls in the home	Tips and resources aimed at the general public.	PeopleFirst Hammersmith & Fulham, Kensington & Chelsea, Westminster
AskSARA	Online self-help guide providing advice and information on products and equipment for daily living for older and disabled adults and children.	Shaw Trust

Table 2: Resources about falls prevention for health and social care professionals

Theme	Description	Provider
Injury and fall prevention for people with learning disabilities	Resource guide for people who care for or support people with learning disabilities. Includes a range of useful illustrations and tools.	Glasgow Caledonian University
Policy to practice: falls in adults with intellectual disabilities	Webinar presentations covering evidence on risk factors and interventions.	Association of University Centers on Disabilities (USA)
Occupational therapy in the prevention and management of falls in adults	Practice guideline. Includes advice on working with people with learning disabilities.	Royal College of Occupational Therapists
Falls and fractures: consensus statement and resources pack	Guidance aimed at local commissioning and strategic leads in England with a remit for falls, bone health and healthy ageing. Comprehensive resource pack includes further summaries of research, detailed guidance, tools, example standards and indicators, and a commissioning checklist.	PHE/National Falls Prevention Coordination Group
Falls Prevention Network	Network delivering the ‘Stand up, stay up’ campaign: raising awareness, sharing best practice and information.	Hosted by the Royal Society for the Prevention of Accidents
Falls in older people: assessing risk and prevention	Clinical guideline and accompanying flowchart, quality standard, tools and other resources.	National Institute for Health and Care Excellence
NICE falls and fragility fractures impact report	Report on how evidence-based guidance (see above) contributes to improvements in the prevention and management of falls and fragility fractures. Includes examples.	National Institute for Health and Care Excellence
Local health and care planning: menu of preventative interventions	Chapter 7 covers interventions to prevent and respond to falls and fractures.	PHE
Falls and fragility fractures pathway	Pathway defining core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures. Includes examples.	NHS England
Falls and fragility fracture audit programme	National clinical audit to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives.	Royal College of Physicians

Table 3: Easy-read and accessible resources about preventing falls

Theme	Description	Provider
Don’t fall!	Easy-read leaflet with tips about staying safe.	South Staffordshire and Shropshire Healthcare NHS Foundation Trust
Prevent falls	Easy-read leaflet about avoiding falls in hospital.	James Paget University Hospitals NHS Foundation Trust
Osteoporosis	Easy-read leaflet about osteoporosis.	Easyhealth and Women’s Health Concern
Looking after your eyes	Advice and easy-read resources on noticing and responding to sight problems.	SeeAbility

References

1. Finlayson J. Fall prevention for people with learning disabilities: key points and recommendations for practitioners and researchers. Tizard Learning Disability Review. 2018;23:91-99.d ↩ ↩² ↩³ ↩⁴ ↩⁵

2. Public Health England with the National Falls Prevention Coordination Group member organisations. Falls and fracture consensus statement: Supporting commissioning for prevention. London: Public Health England; 2017. ↩ ↩² ↩³

3. Freiberger E. Commentary on “Fall prevention for people with learning disabilities: key points and recommendations for practitioners and researchers”. Tizard Learning Disability Review. 2018;23:100-102. ↩ ↩²

4. Finlayson J. Injury and fall prevention for people with learning disabilities. A resource guide for people who care for or support people with learning disabilities. Glasgow: Glasgow Caledonian University; 2016. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

5. National Institute for Health and Care Excellence. Falls in older people: assessing risk and prevention. Clinical guideline CG161. London: National Institute for Health and Care Excellence; 2013, updated 2016. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

6. Hsieh K, Rimmer J, Heller T. (2012). Prevalence of falls and risk factors in adults with intellectual disability. American Journal on Intellectual and Developmental Disabilities. 2012;117:442-454. ↩

7. RNIB UK Visual Impairment and Learning Disability Services. Learning disability and sight loss. Glasgow: RNIB Scotland; 2013. ↩ ↩² ↩³

8. seeability.org [Internet]. Epsom: SeeAbility; c2019 [cited 2019 Feb 26]. Available from: https://www.seeability.org/Pages/Site/looking-after-your-eyes/ . ↩ ↩² ↩³ ↩⁴

9. Giraud-Saunders A, Marriott A. Dementia and people with learning disabilities: making reasonable adjustments. London: Public Health England; 2018. ↩

10. Emerson E, Baines S, Allerton L, Welch V. Health inequalities and people with learning disabilities in the UK: 2012. London: Public Health England; 2012. ↩

11. Finlayson J, De Amicis L, Gallacher S, Munro R, Crockett J, Godwin J, Feeney W, Skelton DA. Reasonable adjustments to provide equitable and inclusive assessment, screening and treatment of osteoporosis for adults with intellectual disabilities: A feasibility study. Journal of Applied Research in Intellectual Disabilities. 2018;1-13. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

12. McKelvey KD, Fowler TW, Akel NS, Kelsay JA, Gaddy D, Wenger GR, Suva, LJ. Low bone turnover and low bone density in a cohort of adults with Down syndrome. Osteoporosis International. 2013;24(4):1333-1338. ↩

13. Public Health England. Falls and fracture consensus statement: resource pack. London: Public Health England; 2017. ↩ ↩²

14. NHS England, Public Health England, National Osteoporosis Society. RightCare pathway: falls and fragility fractures. Leeds: NHS England; 2017. ↩

15. Hatton C, Glover G, Emerson E, Brown I. People with learning disabilities in England 2015. London: Public Health England; 2016. ↩

16. Giraud-Saunders A, Marriott A. Making reasonable adjustments to obesity and weight management services for people with learning disabilities. London: Public Health England; 2016. ↩

17. Giraud-Saunders A, Marriott A, Turner S. Health checks for people with learning disabilities: including young people aged 14 and over, and producing health action plans. London: Public Health England; 2015. ↩

18. College of Occupational Therapists. Occupational therapy in the prevention and management of falls in adults. London: Royal College of Occupational Therapists; 2015. ↩ ↩² ↩³ ↩⁴

19. Public Health England. A structured literature review to identify cost-effective interventions to prevent falls in older people living in the community. London: Public Health England; 2018. ↩

20. Crockett J, Finlayson J, Skelton DA, Miller G. Promoting exercise as part of a physiotherapy-led falls pathway service for adults with intellectual disabilities: A service evaluation. Journal of Applied Research in Intellectual Disabilities. 2015;28:257-264. ↩

21. Frighi V, Morovat A, Andrews TM, Rana F, Stephenson MT, White SJ, Fower M, Roast J, Goodwin GM. Vitamin D, bone mineral density and risk of fracture in people with intellectual disabilities. Journal of Intellectual Disability Research. 2019;63:357-367. ↩