Risk Factors and Fall Prevention in the Elderly

Introduction

According to Van Beurdenn et al (1998) estimated one-third of all U.S. adults less than 65 years of age fall each year. In addition, falls have become the leading cause of injury-related hospitalization as well as deaths for elderly Americans. Injured and fatalities comprise about 13% of the overall population but account for 73% of all fall-related deaths. More than 10,000 seniors died as a result of falls in 1999 and 61% of these were 75 years old or older. By 2000 about 1.6 million hospitalizations were caused by falls.

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Among the elderly, bone fractures related to falls are frequent and are often linked with physical decline, negative impact on quality of life, and reduced survival (Bloem et al, 2003). The impact of falls on the elderly population and health care system is big. This is translated into debilitating injuries, loss of independence, death, or transfer to an institution. It was also suggested that about 1 in 3 elderly in the community experience at least one fall a year. Van Beurden et al (1998) added that many countries populated by aging baby boomers already experience and anticipate an increased number of injuries from falls. This, however, is anticipated through the development of comprehensive prevention strategies to reduce the burden (Van Beurden et al, 1998).

Discussion

Location of Falls

The greatest number of hospitalizations due to falls among the elderly is caused by slipping, tripping, or stumbling at an estimated 40%. The more common locations include stairs or steps (4%), beds (4%), ladders (2%), chairs (2%), and wheelchairs (1%). What may be alarming is that women were three times more likely than men to fall from chairs and two times more likely to fall from beds but men were four times more likely than women to fall from ladders (Bloem et al, 2003).

Risk Factors

Many falls are multi-factorial in nature, while some have single, apparent causes. Tinetti (2003) enumerated the following factors that increase the risk of falling: demographics, medical conditions, medications, and environmental factors. An increase in age also increases the risk of serious fall-related injury and hospitalization. Individuals 85 years of age are 11.55 more likely to be hospitalized than those aged 65 to 69 years.

It was suggested that falls are the result of a complex combination of medical and lifestyle factors, alone or in conjunction with precipitating environmental factors. The more common modifiable risk factors are muscle weakness, problems with balance, gait or stability, multiple drug therapy, postural hypotension, and cardiac disorders (Tinetti, 2003).

Likewise, fall risk was also related to other factors like history of falls, muscle weakness, gait deficit, balance deficit, use of the assistive device, visual impairment, mobility impairment, fear of falling, cognitive impairment, depression, sedentary behavior, age, number of medications, psychotropic/cardiovascular medications, nutritional deficits, urinary incontinence, arthritis, home hazards and footwear (AGS, 2001). Shumway-Cook et al (2001) added that the natural aging process that leads to inactivity gradually results in decreased physical performance of many elderly who are at increased risk of falling.

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Clinical Management

Health care practitioners or professionals can play a major role in identifying elderly patients at risk of falling. It was proposed that during routine medical visits, they should ask every older patient about the occurrence of falls and any gait or balance problems.

Health care practitioners or professionals should encourage older patients to adopt a lifestyle to help maintain balance through regular exercise, healthy eating, and responsible drinking. Appropriate and timely referrals to allied health care workers such as physiotherapists to assist with footwear and mobility aids are also important.

Prevention

It is necessary to address concerns about falls of the elderly through directed assessment and modification of environmental hazards such as problems with building design, handrails, surfaces, changes in elevation and lighting. Patients with history must also be doubly provided with this. Occupational therapists or public health agencies are available in many communities to complete these assessments. Reduction of hazards at home will also reduce the risk of falls, especially when combined with strategies to improve elderly people’s physical condition. Their confidence must also be increased to address their fear of falling through exercise programs to improve balance and muscle strength.

Aside from identifying people at risk of falls, prevention also involves modifying their risk factors where possible. Tinetti (2003) suggested multifaceted strategies that address a variety of risk factors may help reduce the incidence of falls among people at high risk, aside from being a good investment. Within the health service community, interventions may include the development of policies to prevent falls. Public places must be assessed and modified, implementation of community-based strategies, and combining these with exercise programs to improve balance and muscle strength as well as education sessions on fall prevention. In addition, patients and people at risk of falling must be referred to local programs or resources.

Gillespie (2001) suggested that interventions reduce the fall rate in an elderly population. Interventions range from initiatives to ensure a safer environment to specific methods of training of the individual (Close et al, 1999). Part of the deterioration in physiological capacity may be caused in part by a lack of stimulation and training and this can be addressed by exercise. Robertson et al (2002) pointed out that exercises comprised of balance training and strength training proved to be the most effective in the reduction of fall incidents.

Moreland et al (2003) went extreme as to suggest that even the very old and fragile elderly specifically all people over 80 years of age should be offered exercise training regardless of risk factor status.

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Patients with a history of falls are a risk factor for repeat falls. This is called the fall risk cycle resulting from being injured or traumatized by a fall. The individuals enter an emotionally draining cycle that begins with the fear of repeat falling and leads to decreased activity, and changes in gait patterns and balance. These lead to an increased risk of repeat falling. Health care providers and caregivers must understand and realize that the elderly patient who has been injured in a fall needs emotional support as much as medical attention.

In predicting fall risk, a major problem presented has been the multi-factorial mechanisms of falls. Brauer (2000) stressed that the influence of environmental factors and the difficulty in daily tasks performed must be considered with the individual physiological factors. To be able to cope well in daily-life situations, the elderly must be able to balance demands in the environment and in the tasks performed.

Complications of Falls

Fractures of the pelvis, hip, femur, vertebrae, humerus, hand, forearm, leg, and ankle are the most serious complication associated with falls (Close et al, 1999). Hip fractures are the most serious that leads to the greatest number of health problems and death. Hip fracture rates also increase with age as those aged 85 and older are seventeen times higher rate than those aged 65 to 69, specifically 3,357.1 against 197.3 per 100,000. Evidence-based studies also found that the physical toll is harsher for women than for men, as approximately 20% of women who experience a hip fracture die within a year after the fracture and another 20% lose the ability to walk independently (Moreland et al, 2003).

Conclusion

Falling is a complex phenomenon of multi-factor origin with the crucial fall risk of redundancy. In settings where there is an elderly, an approach to fall risk assessment in which the physiological performance is evaluated in relation to the activity profile of the individual must be undertaken.

The high frequency and fatal nature of falls in the elderly must be a major concern as 65-year-olds are the fastest-growing segment of the population. More efforts should address education and prevention of fall-related injuries. Health care providers, public health workers, family, friends, and caregivers must be proactive and play an important role in ensuring that seniors and the elderly are healthy and that fall risks are minimized.

Reference

American Geriatric Society (2001). “Prevention AGSPF: Guideline for the prevention of falls in older persons.” American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Journal of American Geriatric Society, 49, pp 664-672.

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Bloem BR, Steijns JA, Smits-Engelsman BC (2003): An update on falls. Curr Opin Neurol, 16:15-26.

Brauer SG, Burns YR, Galley P (2000). “A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers.” Journal Gerontology A Biological Science Medicine Science, 55, pp M469-M476.

Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C (1999). “Prevention of falls in the elderly trial (PROFET): a randomised controlled trial.” Lancet, 353, pp 93-97.

Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH (2001). “Interventions for preventing falls in elderly people.” Cochrane Database System Rev, CD000340

Moreland J, Richardson J, Chan DH, O’Neill J, Bellissimo A, Grum RM, Shanks L (2003). “Evidence-based guidelines for the secondary prevention of falls in older adults.” Gerontology, 49 pp 93-116.

Robertson MC, Campbell AJ, Gardner MM, Devlin N: Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc 2002, 50:905-911

Shumway-Cook A, Woollacott MH (2001) Motor Control: Theory and Practical Applications. Philadelphia, Williams, and Wilkins.

Tinetti, ME. (2003). “Preventing falls in elderly persons.” New England Journal of Medicine 348 (1), pp 42-9.

Van Beurden E, Kempton A, Sladden T, Garner E. (1998). “Designing an evaluation for a multiple-strategy community intervention: the North Coast Stay on Your Feet program.” Australia New Zealand Journal Public Health 22, pp 115-9.

Appendix

Prevention

Below are some strategies physicians, older persons and their care-givers can do to reduce the risks of falling:

  • Provide information on gait training and advise patients on the appropriate use of assistive devices such as walkers and canes.
  • Participate in regular exercise programs that emphasize balance and strength training.
  • Routinely review medications to check for side effects and possible drug interactions.
  • Screen for osteoporosis, postural hypotension, and other cardiovascular disorders, including cardiac arrhythmia. Treat diagnosed conditions.
  • Consider bone strengthening medications such as hormone replacement therapy, calcium, vitamin D, and antiresorptive agents (e.g., raloxifene, alendronate, risedronate, or calcitonin) to reduce risk of fallrelated fractures.
  • Examine home environment for hazards. Remove clutter and small rugs from floors. Keep frequently used items in low, reachable cabinets; use handrails and lights on stairs; install grab bars next to toilets and in showers, and improve overall lighting throughout the home.
  • Recommend shoes that are supportive, thin, and have non-slip soles.
  • Anatomically-designed external hip protectors may reduce the risk of hip fracture in frail elderly adults (Kannus P. et al, 2000).

Fall death rates, age _65 years, Oregon, 1990–2001

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