FALLS

FALLS

Falls and near-falls occur in more than 30% of people aged 65 years or older. Every year, 50% of people in the community older than 80 years have a fall, and approximately 60% of nursing home residents fall each year.

The incidence of falls in the elderly is growing every year, reflecting the growth of the elderly population. By the year 2050, the projected proportion of people older than 65 years will be 23%.

Women experience a greater proportion of falls because they make up the majority of the total population as they age, a difference mostly due to the earlier mortality of men.

Injuries occur in 10-20% of falls, and 3-5% of injuries result in fractures. About 10% of all falls have consequential injuries that are deemed serious; examples include fractures, joint dislocations, and severe head injuries.

Approximately 90% of fractures in the hips, pelvis, and forearms result from falls. The mortality rate for a patient in the year after a fall resulting in a hip fracture is 14-36%. Of those experiencing hip fractures after a fall, 25-75% have lingering functional impairments. In 1994, approximately $10 billion in acute healthcare costs were spent on fall-related fractures.

Falls in the geriatric population can be associated with substantial morbidity. Falling is the most common cause of traumatic brain injury in those older than 65 years. About 14-50% of patients who fall are unable to rise after a fall. As a result, they may lie on the ground for a long time before they are found or before they can manage to contact help. This delay can result in catastrophic events, eg, the development of a pulmonary embolism or the onset of hypoglycemia in a diabetic patient.

Falls are the primary etiology of accidental deaths in those older than 65 years, and falls are responsible for 70% of accidental deaths in people older than 75 years. However, the highest rate of death after a fall is in white men older than 85 years. These findings support an overwhelming need for fall prevention and education to optimize rehabilitation management in the geriatric population.

RISK FACTORS FOR FALLING

Those most susceptible to falling are older white women with a low body mass index (BMI), greater height, lower bone mineral density (BMD), and history of a cerebrovascular accident (CVA).

Alcohol-related falls are more common in men than in women. Surprisingly, 14% of elderly patients who go to the emergency department are alcohol dependent. Women fall on their hips or buttocks more often than men do. However, incidence of head injuries is substantially more in men than women.

Many intrinsic factors can contribute to falls in the elderly. The most predictive is a history of a previous fall. Individuals prone to falling are known to have increased hip flexion, decreased knee flexion in pre-swing, and decrease in knee power in pre-swing. Stride-to-stride variability increases the likelihood of falling by 5 times. Those who tend to fall are also noted to have a slow gait. Patients with more risk factors are more likely to fall.

Age-related physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP] <20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls.

Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction.

The potential energy of a fall is determined by the height of the fall, the person's body mass, and the velocity with which the center of mass is displaced. Identifying the severity of injury after falls has been reviewed.

Risk factors for minor injuries after a fall include a slow reaction time and decreased grip strength in the hands. Risk factors for major injuries after a fall include older age, female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension.

Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls.

Results of studies suggest that the risk of falls and fractures in elderly patients taking selective serotonin reuptake inhibitors (SSRIs) is not different from that of patients taking tricyclic antidepressants. The use of 4 or more medications of any type also increases the risk of falls.

Fatigue induced by radiation therapy or chemotherapy also creates a risk of falls in an elderly patient with cancer. Environmental barriers include stairs, uneven footpaths, polished floors, thick mats or carpeting, and poor footwear choices (eg, wearing of high-heeled shoes).

CONSEQUENCES OF FALLS

Walking disability affects the older patient's autonomy and well-being. Sustaining a fall can damage self-esteem and threaten the independence of a geriatric patient because falls are associated with the placement of the patient in a long-term care facility.

An elderly patient with a gait dysfunction has an increasing risk of falls; a fear of falling; and functional decline, with subsequent immobility, decreased activity, weakness, and isolation. Falls and the fear of falling share predictors, which include the following: those with perceived poor general health, older age, and the use of more than 4 medications.

Older people who restrict their activity are physically deconditioned and have more depressive symptoms than those who have a fear of falling without these other conditions. Differences in patients' risk factors may help in refining the clinical intervention and preventive program for an individual patient.

Falls are associated with pain, a decline in function, and a loss of stamina. More than 40% of people with an injury from a fall report continued pain or restriction in activity 2 months after the fall.

Documentation of the patient's level of pain (with the visual analogue scale) and of any nonpharmacologic treatments is important in determining the appropriate rehabilitation to help the patient regain full mobility and functional activity.

REHABILITATION AFTER A FALL

Rehabilitation physicians should develop a standard evaluation for targeted groups of patients to increase participation in rehabilitation programs after a fall.

The patient's history should include information about the individual's history of falls, the circumstances of the falls, the associated symptoms, and the known comorbidities (eg, sensory impairment, depression, CVA, incontinence) that may lead to falls.

Physical examination should include an assessment of the following   :

vital signs with orthostatic blood pressure measurements, visual and hearing impairments, arrhythmias, bruits, postural instability, joint limitations, podiatric problems, gait dysfunction, lower-extremity weakness, and changes in mental status.

Any adaptive equipment and the patient's FIM score should be reviewed. The get-up-and-go test is a useful clinical tool for follow-up assessments of balance or gait dysfunction.

For geriatric patient at risk for falling, access to rehabilitation is important.

Clinicians should aid their patients in finding opportunities for exercise (eg, swimming, yoga, tai chi) in their community, beyond formal physical and occupational therapy, and in overcoming barriers to obtaining needed services.

Goals for the practitioner include educating patients and their caregivers and supportive family members about fall prevention and the risk factors for falls in older people. Patients with previous falls tend to accept the risk of falling; however, those with an active lifestyle tend to minimize their personal risk and the relevance of fall-prevention measures.

Strategies for successful rehabilitation include education about falls, modification of the environment, implementation of exercise programs, supplying and repairing aids, and reviewing drug regimens. A thorough approach to rehabilitation can improve the quality of life of a patient after a fall.

During rehabilitation, physical impairments should be addressed first. Interventions aimed at decreasing the incidence of falls should include an assessment of the patient's visual acuity and cataract status. If functional impairment is evident, the patient should be referred for treatment. Decreased visual acuity, visual-field defects, and cataracts are risk factors for hip fracture due to a fall. Good visual acuity facilitates head stabilization, which in turn aids dynamic balance.

Ensuring that older people have access to regular eye examinations and timely treatment for eye diseases (eg, cataracts) may substantially reduce the incidence of falls and subsequent hip fractures. The identification of risk factors in patients with known vestibular dysfunction is also important because it affects their care.

Compared with the general geriatric population (>65 y), patients with bilateral vestibular loss have a greater incidence of falls. Patients may wear hip protectors, which help prevent hip injury caused by a direct fall from a standing position.

If the etiology of the fall is postural, the following measures may be beneficial: use of ankle pumps and pressure stockings, elevating the head of the bed, sitting upright, ingesting caffeine, and modifying medications.

Periodic review of the patient's prescription and over-the-counter (OTC) medications is imperative. Medications should be minimized or discontinued is appropriate. Polypharmacy should be avoided if possible.

Falls are a major factor contributing to symptomatic fractures in postmenopausal women, which add to the risk attributable to age and osteoporosis.

The prevention of osteoporosis with hormone replacement therapy (HRT) and calcium and vitamin D supplementation, as well as decreased caffeine intake, may decrease the risk of fracture after a low-velocity fall. A nutritional review and the supplementation of micronutrients, such as selenium, may also be warranted.

PREVENTION OF FALLS

Clinical practice guidelines for general safety and fall prevention are important components of patient care in the acute medical, surgical and rehabilitation wards.

The Fall Risk Assessment is a tool used by the nursing staff on a daily basis to monitor the change in the level of fall prevention necessary for each patient.

This tool helps in determining the risk of falling and in identifying relevant interventions, for example, keeping the bathroom light on at all times, keeping the commode near the bed, keeping the patient in the lobby of the unit to provide constant supervision when one-to-one coverage is unavailable, using a wrap-around belt when the patient is seated in a wheelchair, using bed exit alarms, and keeping side rails of the bed up.

General safety standards should also be implemented, and examples of these include locking the breaks on the wheels of hospital bed, keeping the bed in a low position; keeping the patient's room and environment free from clutter; keeping the call light within the patient's reach; keeping at least 2 of 4 side rails up at all times; keeping wheelchairs locked during all transfers; and keeping the table, telephone, and bed controls within the patient's reach at all times.

The prevention of falls or a reduction in the number of falls can also reduce a patient's functional decline. The use of proper transfer techniques and moderate exercise (20-min sessions 5 d/wk) to maintain mobility are vital parts of a comprehensive rehabilitation program.

The incorporation of resistance training 2-3 times per week into the patient's rehabilitation program increases his or her overall strength. Resistance can be increased when the patient is able to complete 10 repetitions of an exercise with full range of motion (ROM). Maintenance programs are important. A home-based program that targets the patient's underlying physical impairments can reduce the progression of functional decline.

One of the challenges that older people face is decreased postural stability, which also increases the risk of falls.

Maintaining balance during dynamic activities is essential for preventing falls in older adults.

Even head stabilization contributes to dynamic balance, especially during the functional task of walking.

Tai chi quan, or tai chi chuan, is a physical exercise that enhances balance and body awareness. In the rehabilitation community, the practice of tai chi is known to reduce falls. Over the last decade, interest has grown in the use of tai chi to improve postural balance and prevent falls in older people.

This ancient Chinese art emphasizes low-velocity, low-impact exercise in harmony with deep breathing and concentration. Tai chi promotes strength, flexibility, balance, and postural stability (even in patients with simultaneous disturbances of vision and proprioception). Tai chi also benefits the cardiovascular system by reducing the patient's blood pressure, decreasing fat composition, and fear of falling.

Falls are further reduced with the addition of home-hazard management.

Home visits by occupational therapists can help to preserve the patient's autonomy.

Modifications to the patient's home environment may consist of smoothing out uneven surfaces, using ramps instead of stairs, applying non-skid and colored tape on the outer edges of steps, installing rails on stairs, eliminating throw rugs, removing thick carpet, repairing unstable furniture, and installing good lighting. A well-lit pathway to the bathroom that is clear of clutter must be emphasized.

Large touch-lights or automatic sensory lights, which do not require dexterity, can be placed at the patient's bedside or in other areas to help decrease the risk of falls, especially at night. Motion-detector lights are helpful in providing illumination (eg, to the bathroom) at night.

Falls in the shower and bathtub are the third leading cause of accidental death, and more than half can be prevented with environmental modifications.

Examples include the installation of tub mats, tub benches or seats, raised toilet seats, and grab bars in the shower and bathroom. Walkie-talkies, cell phones attached to waist clips, and lifelines are all excellent communication devices for the elderly, and these can be valuable in the event of a fall. Medical-alert bracelets can be useful to rescuers.

In addition to these environmental modifications, outpatient therapy can help the patient to learn how to address barriers that may be present in the community.

For instance, the patient can practice on obstacle courses designed with low technology and simulated functional tasks that they may face in real life. One group notes that performance on such an obstacle course is not a predictor of future falls, but the findings can be used as short-term indicators of the patient's response to a rehabilitation program for balance and mobility.

CONCLUSION

Overall, falls in the elderly are a tremendous concern because of the growing geriatric population.

Today's practitioners should focus on the use of screening tools in the clinic, risk assessments, programs for fall prevention, and rehabilitation after a fall.

The goal is to prevent falls in the geriatric population and thus decrease morbidity and mortality rates and improve the patient's mobility, outlook, and function in society.