Various literature reviews on falls among the elderly population have been conducted and implement to effectively educate old people on preventive measures and methods of dealing with risks of falls such as exercises. Literature review we are going to look at in this chapter concentrates on incidence of fall, risk factors and strategies to prevent falls. Fall prevention is a community intervention designed for public health practitioners and community based-organizations intended to help address the fall problems among the elderly population. The community has designed strategies that provide relevant detailed interventions for organizations to implement so as to prevent fall among the elderly.
Fall cases in elderly population are among the most causes of accidental admissions in most hospitals. According to Center for Disease Control data, more than one-third admissions in 65 year and older is due to fall (CDC, 2008). Research indicated that one-half of fall incidences are recurrent and most falls risks results to serious health concerns such as hip fracture, other fracture, subdural hematoma and other soft tissue injury. Falls lead to inability to perform activities of daily livings such as dressing bathing and restricted activities or immobility that can eventual result in ulcers and other complications (Tinetti, 2003).
MacCulloch, Gardner &Bonner (2007) states that more than 300,000 hospitalizations cases among the elderly each year results from fall risks. The fall risks cause incidents such as hip fracture and other parts of the body injuries. MacCulloch et al (2007) indicate that the main reason for constructing Nursing Home was because of fall risks among the elderly population. Healthy people 2010 objective was to reduce hip fracture hospitalization rates among aged women of 879 per 100,000 people (Yannesa & Koceja, 2005, p.66).
Fall is defined as “a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force”, Feder, Cryer, Donovan and Carter (2000). Falls risks are divided into three categories, a). Accidental falls b). Un-anticipated physiologic falls and c). Anticipated physiologic falls. Accidental falls are caused by environmental circumstances such as slipping or tripping unexpectedly, whereas unanticipated physiologic is caused by unpredictable event such as fainting or seizure and anticipated falls are caused by the patient’s condition. There are varieties of strategy used in different setting to prevent falls in elderly including identifying risk factors and strategies to preventing fall based on identified risks. These prevention strategies can be individual, community based, multi-factorial or multidisciplinary approach (Rome, 2002).
A 2 year prospective study conducted on community-dwelling of older women, Nancheriener, Findorf, Wyman & McCarthy (2007) investigative reports founded that majority of the falls were caused by risk behaviors such as carrying objects with both hands, rushing, reaching for objects beyond their reach. Environmental hazards were also founded to be the major cause of falls risks, these includes; ice, cords, throw rugs and uneven surfaces and also among them were health- related problems.
Tinetti (2003) study on causes of fall risks among elderly population revealed that majority of falls resulted from “interactions between long-term or short term predisposing factors and short term precipitating factors”. In reviewing various literatures for these studies, Huang and Acton (2004) reported that falls were caused by both extrinsic and intrinsic factors. Environmental factors contribute to the major cause of falls in elderly people. These causes include; “decline in physiologic functions such as balance, muscle weakness, pathologic disease processes, psychological factors and the effects of medications” (p.248). Huang (2004) conducted a research to determine the risk of falls among the elderly using a checklist. Cross-sectional design was used and the sample was carried out elderly people who lived in three different sheltered housing projects. The subjects were grouped into two groups; fall group and non-fall group. Participants in the fall group were found to have more illnesses and took more medications. They had less social contacts from family and friends, they expressed fear of falling and were extremely careful in participating in activities of daily living. Reports also revealed that participants at a higher risk of falling used walker or a cane, had increased urinary incontinence, took longer time in a Get-up and Go test, poor lightning, clutter at the front door or backyard and had trouble getting out of bed as compared to other participants of the group.
A study conducted by Abdelhafiz &Austin (2003) on predictive visual acuity was compared with that of bone mineral density (BMD) of 775 women of 75 years and older with no history of hip fracture. Femoral neck BMD was assessed by dual photon X-ray absorptiometry and visual acuity by snellen chart. At 1.9 years follow up 154 women suffered a first hip fracture. After adjustment of femoral neck BMD poor vision remained significantly associated with increased risk of hip fracture.
Community-based study conducted a research of over 12 months to construct a risk model in order to identify elderly individuals at risk for frequent falling. A number of variable were evaluated and the result showed that polypharmacia was the most medical predictor with an odds ratio of 1.29 (p=0.005), poor visual acuity the best sensory predictor (OR= 0.84; P=0.009) and general fear of falling the most crucial psychological predictor (OR= 3.45; p<0.001). The best physical predictor was a low score on the physical performance test (OR4.15; p<0.001). They concluded that, the study confirms the multicausality of falls since medical, psychological, sensory, postural and physical variables provides a predictive value (Delbaere et al, (2006)
Another community-based cohort study was conducted using ten year data collection to estimate impact of benzodiazepine- associated injurious falls in elderly. Results indicated that benzodiazepine was the most contributing factor in causing fall injuries. The study was carried out on old people aged over 80 years and results revealed that majority of the patients were at a higher risk or 28.1% likely to incur injuries from falls related to benzodiazepine. This dy defines injurious fall as “fall resulting in hospitalization, fracture, head trauma or death” (Pariete et al, 2008, p.62).
Older people with dementia are considered to be at a higher risk of falling as compared to those without dementia. Interactions between the intrinsic and extrinsic factors fail on dementia people because of therapeutic cognitive impairment. Dementia pose danger to these old patients since it denies their frailty, overestimate their capability to deal with environmental hazard, causes communication impairment, forget that they cannot ambulate and need assistance with ambulation. The combination of visual and cognition of familiar places and inattentiveness to cues and details are also depicted as significant fall risk in this group. Another health factor such as anemia has been statistically reported to increases the risk of injurious falls in the elderly reported. Duh et al (2008) reports that anemia has been “a statistically significantly higher risk of injurious falls in elderly” (p.330) (Tideiksaar 2007).
Older adults, after falling once with or without injury will develop fear of falling. Patients who experiences falling fear are mostly women with advanced age. Risks of falling affect gait and balance and consequently the quality of life and willingness to participate in certain activities in lessened (Mitty and Flores, 2007, p. 4).
The risk associated with falls as portrayed by numerous literatures indicates that falls occur as a result of a single factor, or combination of factors. It is most often a result interaction between intrinsic and extrinsic factors. Identifying the predisposing and precipitating factors related to fall is critical in fall prevention because it helps to tailor interventions to prevent falls. Gillespie, Robertson, Lamb, Cumming, & Rowe (2003) conducted a review of 62 studies, of which 47 were conducted in the community to assess the effectiveness of interventions in reducing the incidence of falls in elderly people and found the following:
Untargeted exercise or home safety interventions were not effective in reducing the number of fallers (RR: 0.89 (95% CI, 0.78-1.01) or falls in the home (pooled RR: 1.03 [95% CI 0.75-1.41]). Individually tailored programs of exercise significantly reduced the number of falls over a year period (RR: 0.80 [95% CI, 0.66-0.98]). Interventions combining exercise, home hazard modification and management of reduced vision showed significant reductions in the number of falls. Multidisciplinary, multifactorial, risk screening and intervention programs were effective in reducing the proportion of fallers in untargeted population (RR: 0.73[95% CI, 0.63-0.85]), and for older people at high risk (RR: 0.86 [95% CI, 0.76-0.98]) (p.240).
Pynoos, Rose, Rubenstein, Choi & Sabata (2006) concluded that where important individual risk factors can be corrected; focused interventions will be effective in fall prevention than multi-factorial interventions. Single interventions programs such as environmental modifications, staff training or fall prevention for the elderly are less effective than multi-factorial interventions. With regard to home safety programs, Gillipie et al (2006, p.240) commented that “what appears to be a single intervention, targeting a single risk factor, may instead be a multi-factorial intervention by trained professional”. However, Tinetti (2003) reported that multi-factorial intervention not linked to targeted intervention is not effective.
Huang and Acton (2004) conducted a two group pretest-post-test experimental and randomly assigned the subjects to experimental or comparison group. The purpose was to examine the multi-factorial interventions to prevent falls by increasing self efficacy to prevent falls. The intervention was delivered to the experimental group. The experimental subjects improved their fall self efficacy and knowledge of medication safety significantly more than the comparison group. However, both group improved in the post-test than the pre-test score.
Hart-Hughes, Quigley, Bulat, Palacios & Scott (2004) reported a 2 year nationally funded evidenced- based fall prevention programs for veterans at high risk for fall. The program instituted a fall clinic and staffed by Multi-disciplinary teams. The goals of the clinics were to assess fall risk etiology and develop a treatment plan. Over a 2 year period, data from 571 participating patients indicated a three- fold reduction in falls following the initial fall clinic visit when compare to preclinical values. “The patients were identified as repeat fallers at initial evaluation and over 50% of the patients seen in the clinic were not previously or currently enrolled in any form of rehabilitation”( Hart-Hughes et al, 2004, p.49).
Tinetti (2003) in her studies suggested that the most consistent approach to prevention of fall has been multi-factorial assessment followed by interventions targeting identified risk factors. This approach showed reduced rates in the occurrence of falling by 20- 39%. Successful targeted interventions include review and possible reduction of medications, balance and gait training, muscle strengthening exercise, evaluation of postural blood pressure and strategies to reduce it, home hazards modifications and medical and cardiovascular assessment and treatment.
Hossini & Hossini (2008) designed a community model in preventing fall among the elderly in the communities. The community based model was to; first raise public awareness of fall injuries among the elderly. They wrote a booklet on fall prevention and distributed it among the elderly, family members and other member of the society. Secondly, to organize and start community education that include exercise classes with potential to improve the motor skills of the elderly and that this can be done by training nurses and other community members as fall prevention advisors, medication workshop leaders and home safety advisor. Thirdly, emphasize local health officials to identify and rectify fall hazards through this community programs. The community model should be comprehensive enough as to address the home safety checklist to include information on available home safety products in the local hardware store and to educate hardware store owners and employees about the programs.
Another study conducted by Shumway-Cook, Silver, Lemier, York, and Koepsell (2007) to evaluate the effectiveness of a community based multifaceted intervention to prevent fall in community dwelling elders. A one year follow up shows that there was 25% lower falls rate in the intervention group than the control group 1.33 vs 1.77 falls/ person. The participants in the study had three times a week exercise, six hour fall prevention education, comprehension fall risk assessment with the result sent to their Primary care providers for follow up. They concluded that this community based multi-factorial interventions was successful in improving modifiable risk factors such as strength, balance and mobility but no significant effect on the incidence rate of falls.
Improved self efficacy through exercise can “provide psychological benefits since self efficacy could mediate relationship between exercise and fear of falling” and fear of falling is a major fall risk in elderly (Fukukawa, Kozakai, Niino, Nishita, Ando &Shimokata, 2008, p.19) which a major fall risk in older adult. They concluded in their study that not every participant’s fall efficacy improved with exercise rather their study analysis indicated that participants with “less social support experienced greater benefit of exercise in improving self efficacy” (Fukukawa et al, 2008 p.23). Yannessa & Koceja (2005) conducted a cross sectiontional comparative study to examine the relationship between a community based balance measure and perception of balance ability among individuals from different elderly living in group housing and those in the community centers who live independently. The research shows no differences in their physical balance ability and the belief about their diminished physical ability based on their physical limitation. However, there was a significant difference by living environment. Those who live in the community independently perform the activity of daily living without fear of falling whereas group dwellers believe that they cannot perform activities of daily living as well as independent dwellers, they felt that they were at risk of falling but their fall efficacy was lower. The researchers recommend that educators who are working with the older adult should focus more attention to improving fall efficacy in a group living instead of primarily focusing on increasing physical ability (Yanesssa & Koceja, 2005).
A study revealed that similar fall prevention strategies used in different setting may not yield similar result. For example, a group of Dutch researchers adapted a British multidisciplinary fall prevention program; they conducted a feasibility study to see if such program can be feasible in the Netherlands. They employed multidisciplinary team, similar intervention protocol, however, due to the different in the healthcare system of the two countries, the adjustment in settings and the referral services and they concluded that this program was feasible in the Dutch setting but only if implementation was modified to fit the their healthcare system (Hendrcks, Bleijlievens,Haastregt, Bruijn, Diederiks, Mulder, Ruijgrok, Stalenhoef, Crebolder& Eijk, 2008).
Contrary to other studies of multidisciplinary interventions that showed reduction in falls, Hendriks, Bleijlerens, Haastregt & Gebolder (2008), another study of two-group randomized survey with a controlled trial of 12 months and follow up reported 300 community dwelling elderly that visited emergency department after a fall. One group underwent a detailed occupational therapy assessment and evaluation and addressed risk factors for fall followed by a recommendation and a referral for treatment. The controlled group received usual care. The result of the study shows no statistical significant on fall.
Medications such as anti-anxiety, anti-hypertensives, anti-convulsants, anti-arrhythmic agents, some antidepressants and anti-psychotic have been sited by researchers as major risk factors for falls in elderly (Tinetti 2003; MacCulloh et al , 2007), Katz, Kozma, (2004)). Medication discontinuation has been mentioned in addition to professional supervised exercise and home modification as a single-intervention strategy that has been proved effective. Tinetti (2003) sited an earlier study by (Campbell, 1999) in which withdrawal of psychotropic medications over 14 weeks brought about 39 % fall reduction. Medications as fall prevention strategy is often include as part of multi-factorial intervention approach to reduce fall, (Tinetti, 2003; Shumway-Cook et al, 2007; Hossini et al, 2008). As concluded by the previous study, Van der Velde, Meerding, Looman, Pols, & Cammnen (2008) conducted a study with a geriatric population in Netherlands with a history of falls. They assessed 139 elders with history of falls for fall risk and fall risk drugs were withdrawn appropriately in 75 of them. The other 64 fallers’ withdrawal was not possible. The outcome for the group with drug withdrawal was 0.8 (SD 2.4) and 3.1 (SD11.5) for the group without withdrawal. The mean number of withdrawn drug was 1.2 (SD0.8). After all adjustment drug withdrawal significantly reduced the number of falls by 0.89. The total number of falls prevented was 3.4 per person in the second and third month. This resulted in 491 euro per prevented fall. When injurious falls was reduced by 50% the cost saving per patient remained significant at 804 Euro. Pariete et al (2008) in their research of impact of benzodiazepine and injurious fall recommended limited use of this group of medication in elderly population. Practitioners have to be certain that the benefits of these drugs outweigh the risk of the condition being treated.
With advancing age, muscle and joints reduce mobility and balance problems (Haung, 2004). Regular exercises that include gait and balanced training concentrate on muscle strengthening and reduce risks of fall. (Laurence & weintraub, 200; Faber, Bosscher & Chin, 2006; Marcus, Graybill & Lastayo, (2007). According to the study conducted by Liu-Ambrose Khan, Donaldson, Eng (2006) mobility and gait is independent of Balance and mobility in women with low bone mass. Exercise is found to improve bone mass in women who are diagnosed with osteoporosis, minimizes fall risk and incurring injury. Li, Harmer, Glasgow, Mack Fisher, Melvin (2007) employed Tai Chi exercise intervention. After 12 week, the participant significant improvement in functional reach and a Get up and Go test.
Environmental modification is also considered one of the targeted single-intervention that may effective in reducing the number of falls in the elderly. Haung (2004) discussed in his study that:
A checklist could be completed… to avoid extrinsic risk factors, and to protect from intrinsic risk factors for falls among the elderly, for examples eliminating dimly lit kitchen and clutter at the front or backdoor, keeping a regular exercise routine to strengthen the balance of steps, watching to see if elderly are afraid to move from beds (138).
Social support is incorporated in environmental intervention exercises to help patients with high risks of falling. He mentioned that families helping to remove hazards will lower the risk for fall and that less visits by sons may indicate neglect and may be linked to fall. Home modification include use of non- slip bath mats, safe foot wear, removal of rugs, installation of grab rails and raise toilet seats (Hussein et al ,2008; Tideiksaar (2007). Both studies further recommended involvement of community leaders to fall proof sidewalks eliminating pot holes and other hazards.
Prevention and proper management of medical conditions which are major risk factors such as visual disorders, osteoporosis, MI, arrhythmias, diabetes, arthritis and others have been shown in studies ( Tinetti, 2003; Duh et al 2008; Huang , 2004), to reduce falls in elders in a significant rate. Duh et al (2008) suggested that correcting anemia by treating its causes is a strategy for preventing falls prevention.
Education of fall risk factors in emphasized by health professionals raising awareness (Hosseini et al, 2008; Pynoos et al 2006). Education activities include counseling about fall risk, how to change modifiable risks and how to seek professional help (Casteel, Peek-Asa, Lacsamana, Vasquez & Kraus, (2004). The main purpose of fall preventive education is to increase the awareness of falls, risk factors, and strategies to reduce risks. Education should focus activities and behaviors aimed at risk reduction and health promotion. Periodical medical visits should be administered to encourage patients to report falls and episodes of instability. Patients should be encouraged to exercise regularly and home safety inspection and improvement should be improvised (Tideiksaar, 2003, p.201).
Older patients should be provided with educational materials on risk factors and falls prevention strategies. Most fall prevention strategies need education to succeed in all settings. Educational materials include advice to sit on some kind of protective clothing such as slacks, avoiding carrying objects in both hands, avoiding rushing to answer telephone that would make them stumble on something and injure themselves (Nachreiner et al, 2007).
In conclusion rehabilitation centers need to assess devices that will help reduce risks of fall in old patients (McCulloh et al, 2007). Hip protectors have been proven to reduce fall injury in institutionalized patients. Technological solutions need to further investigation ways to optimize safety (Hart-Hughes, 2004 p.50). Physical therapist , occupational therapists, medical staff, nurses and other care givers need to assess, evaluate and educate elderly in proper use of assistive equipment and behavior changes that would help them reduce risks of fall and take care of themselves ( Hart-Hughes,2004; Pynoos et al )
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