falls in the elderly

A Three-Tier Strategy to Avoid Falls in the Elderly:

If you or an elderly relative have suffered a fall, you are not alone. In fact, the numbers associated with old people falls may surprise you. Each year, over two million senior citizens are treated in emergency rooms for injuries caused by a fall. More than 800,000 seniors are hospitalized for those injuries; most commonly are head injuries and hip fractures[i]. With medical costs for fall injuries skyrocketing to over $30 billion every year[ii] and falls being classified as the leading cause of death[iii] due to injury among seniors, there is little wonder that there is a great deal of psychological and emotional trauma associated with a fall.

We can add to this that when a senior citizen has a fall, there is a certain amount of disruption to their family’s routine and life. Since falls among old people seems to a widespread occurrence, it is up to families and medical professionals to develop and then implement the appropriate strategies to help avoid old people from falling.

Here’s how we’ll examine the subject in this article:

 

Falls – A Few Fast Facts[iv]

Whether you have already had experience with an elderly family member falling, or you have suffered a fall, it is important to realize you are not alone. Look at these statistics:

  • Almost all hip fractures in seniors are the result of a fall, often from falling sideways.
  • Every one in five falls result in a serious injury, such as a head injury or broken bones.
  • At least 300,000 older people are hospitalized for hip fractures annually.
  • More than 800,000 senior citizens are hospitalized every year because of a fall injury.
  • Falls are the leading cause of traumatic brain injuries (TBI).
  • Nearly 3 million elderly people are treated for fall-related injuries in emergency departments yearly.
  • Of those 3 million seniors, an older adult is treated in the emergency room for a fall every 11 seconds, and a senior citizen dies from a fall every 19 minutes.
  • Fall injuries are costly. The direct medical costs rack up to approximately $31 billion per year, and hospital expenses account for a major two-thirds of the total amount.
  • Older adults who suffer a fall can expect a hefty financial increase. It has been reported that as the population ages, that toll could reach around $67.7 billion by 2020.

 

Why Are Seniors Prone to Falling?

According to definitions[v], a fall occurs when someone comes to rest on the ground or any other lower level. Sometimes, a body part may strike against an object which breaks their fall. It is important to understand that falls are not random, and people do not fall just because they get older. Often, there is an underlying cause, or even a risk factor, that contributes to the fall.

A risk factor, in this instance, is considered something that increases the person’s risk of a fall or their susceptibility to a disease or medical issue. The more risk factors that are present in a situation, the greater the risk of falling. Often, elderly falls are linked to a medical problem or a physical condition, like a chronic disease or muscle atrophy. There are many other causes, too, such as safety hazards around the home or within their community environment. Loose gravel on the sidewalks and clutter among stairwells are also typical examples of risk factors.

Typically, falls are caused by a complex interaction of three factors; intrinsic factors, extrinsic factors, and situational factors.

  • Intrinsic Factors – These factors include age-related impairments, acute and chronic disorders, and the adverse side effects of certain medications. Intrinsic or natural factors can affect a wide area of a senior person’s functions, including the ability to maintain the stability and balance, their depth perception, the ability to recover their balance, and their muscle power and velocity. Two common contributors to falls in the elderly are unsteadiness or dizziness when walking or standing up from sitting or lying down position.
  • Extrinsic Factors – These are environmental factors, such as uneven or slippery surfaces and unfamiliar surroundings or terrain. When combined with natural factors, external factors can contribute significantly to elderly falls. For instance, if a senior person is unsteady with his or her balance, the attempt to navigate an uneven surface increases the likelihood of them falling and getting injured.
  • Situational Factors – Situational factors include activities or decisions that could enhance the risk of a fall with injuries. These factors include not noticing a hazard to movement, talking while walking, rushing movements, or multitasking. For example, when someone talks on their phone while walking, their focus becomes impaired. That, coupled with an already unsteady posture can substantially increase the likelihood of a fall.

 

Common Places Where Seniors Fall:

It is not surprising that over half of all falls occur in a person’s own home[vi]. The majority of falls tend to occur either inside or close to the home, and it is reported that more injuries from falls are caused by falling either from a standing height or on the same level. As a result, statistics show that as many as 53% of senior citizens who are discharged from the hospital with a fall-related hip fracture are likely to have another fall within six months[vii].

So, why do old people falling tend to do so in their own homes? That’s because we are accustomed to moving about in our homes with little to no concern for our own safety. We are familiar with the environment. Yet, this careless familiarity is a top contributing factor to falls and fall-related injuries.

Here is another interesting statistic: according to a study conducted by the National Institutes of Health[viii], accidental falls are the most reported incidents in hospitals. In U.S. hospitals, the rate of falls tends to range from 3.3 to 11.5 falls per 1,000 patients. Fall rates within hospitals can vary considerably according to the unit. For instance, neurology, medicine, and neurosurgery units tend to report the highest fall rates whereas intensive care and surgical units report lower fall rates than other hospital units.

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How to Avoid Falls in the Elderly?

1. Minimize the Risks:

The most important first step towards preventing elderly falls is to become educated about contributing risk factors. Does your loved one have any risk factors? Are there any present circumstances that could mitigate or aggravate those factors? While a senior person may not be aware of or even want to admit to, factors being present, it is up to those around them to observe their movements and take note of any irregularities. To minimize the risks of a fall, you may have to intervene with your loved one and take the appropriate action to prevent them from falling.

Some of the most prominent risk factors for falls include:

  • Aging
  • Depression
  • Alcohol abuse
  • A low weight
  • Weak muscles, particularly the legs
  • A history of falling or a fall within the last 6 – 12 months
  • Diabetes
  • Distorted vision
  • Cognitive impairment and confusion
  • Posture disorders
  • The wrong shoes
  • Urinary incontinence
  • Distorted or limited depth perception
  • Disturbed coordination or balance
  • Certain medications, especially when multiple drugs react with one another. A study has found that there is a 14% increase in the risk of falls with every medication taken beyond a four-medication regime[ix].
  • Orthostatic hypotension – one study was conducted where it was found that there is a 69% increase in the risk of a serious fall during the first 45 days after antihypertensive treatment[x].

Home hazards that contribute to falls include:

  • Unsteady furniture
  • Loose rugs
  • Uneven surfaces
  • Poor lightening, particularly in stairwells
  • Unsecured electrical cords
  • Clutter in and around common walkways in the home
  • Furniture that is placed too close together that prevent ease of movement
  • Items places higher than where an elderly person can easily reach them
  • Lack of handles to assist with entering and exiting a bathtub

Environmental factors outside the home that can contribute to a fall include:

  • Uneven surfaces
  • Loose gravel
  • Moving hazards
  • Wet or loose leaves
  • Slippery or wet surfaces
  • Uneven and high steps
  • Cluttered and crowded walkways

While this list is not exhaustive, it does provide a reasonable overview of the common risk factors that can be avoided or corrected. It is important to regularly examine your loved one’s surroundings so that you can minimize the danger of a fall and fall-related injuries.

3.Manage Medical Conditions and Medications:

What is the elderly person’s current medical condition? Physiological factors tend to contribute significantly to a person’s high or low-risk factor for a fall or fall-related injury. A thorough physical examination can help determine physiological factors that may contribute to the risk of a fall, including:

  • Hearing impairment
  • Visual acuity[xii]
  • Any deformities
  • Standing and resting blood pressure
  • Any limitations in their range of motion
  • Heart rate and rhythm
  • Muscle weakness, particularly in the legs
  • Pain in the spine, neck, or extremities

A thorough neurological examination will include:

  • Coordination
  • Posture
  • Sensation
  • Muscle atrophy
  • Dizziness
  • Balance

As we have already discussed, the scope for interactions along with the effects of multiple medications can contribute significantly to falls. Drugs that increase the likelihood of a fall should be eliminated from the patient’s medical regime, or at a minimum, the dosage should be modified to a lower amount. Interestingly, Vitamin D, especially when taken in conjunction with calcium, can significantly reduce the risk of a fall, especially for patients who are deficient in vitamin D[xiii].

It has been noted that different medications can contribute to falls in various ways[xiv]. Sedative medications tend to impair coordination and result in stumbling even if there is not an obstacle in the way. Diuretics can lead to dehydration, causing the urge to rush to the bathroom, resulting in a fall. Some medications are known to cause a sudden drop in blood pressure when standing or getting up, and this can cause dizziness.

How to Maximize Prevention?

Once you have educated yourself about falls and how to minimize them in old people, efforts should be made to maximize appropriate methods and strategies of prevention. These procedures may include:

1. Performance Testing:

According to the National Institute for Health and Care Excellence (NICE)[xv], the following reasonable tests can be used in any situation, and there is no need for special equipment:

  • Turn 180° Test – Have the patient stand up and step around to face the opposite direction. If they require more than four steps to turn around, further assessment may be needed.
  • Times Up and Go Test – Have a patient rise from a chair without using their arms for support. Then, have them walk three meters, ask them to turn around, and then sit down again. Patients may use a walking aid if needed. The patient should be able to complete this test without difficulty and while steady, which indicated a low risk of falling.
  • The Berg Balance Scale – The Balance Scale comprises 14 tasks that the patient will need to complete: turning 360 degrees, looking over their shoulders, sitting-to-standing, transferring bed to chair, standing-to-sitting, sitting and standing without support, tandem standing, standing feet together, single limb standing, standing with eyes closed, pick something up from the floor, reaching, alternating foot on stool.
  • Tinetti Performance-Oriented Mobility Assessment (POMA) – This is an easily administered task-oriented test that is aimed at measuring the patience’s balance abilities and posture. There is a checklist of instructions to go over with the patient to ascertain their likelihood of a fall[xvi].

2. Using Assistive Devices When Needed:

Patients often benefit from the help of assistive devices such as a walker or cane. In fact, some 6.8 million Americans make use of assistive devices to aid their mobility. Included in this figure are 6.1 million users of various mobility devices like walkers, canes, and crutches, and 1.7 million scooter or wheelchair riders[xvii].

It has been found that canes, especially the multi-legged varieties, offer the needed assistance for senior citizens who have minimal joint or unilateral muscle impairment. But, those seniors who experience weakness in both legs or who suffer from impaired coordination tend to be better served by a walker, particularly ones with wheels. It is worth noting that wheeled walkers can be dangerous for some patients who are unable to control them properly. It is a good idea to seek the assistance of a physical therapist that can help with fitting and sizing the walker, and then teaching the elderly person the correct and safe way to use the device[xviii].

3. Participate in Evidence-Based Fall Prevention Programs:

There has been a myriad of evidence-based fall prevention programs developed that have been proven to reduce the risk of old people falling[xix]. Some suggestions include:

  • Falls Talk – This program has been designed for individuals who have already suffered a fall or who tend to lose their balance on a regular basis, regardless of any present medical conditions, walking ability, fitness level, or mobility. Falls Talk begins with a one-on-one interview and subsequent interviews with a trained program facilitator. There are daily personal reflection exercises as well as weekly and monthly follow-up calls.
  • A Matter of Balance – This group intervention has been designed to last 8 weeks and places much emphasis on practical strategies aimed at reducing an elderly person’s fear of falling while also increasing their activity levels. Seniors learn to control their fear of falling while also being guided to set attainable goals designed to increase their activity, modifying their environment to reduce and eliminate fall risk factors, and taking up exercise to improve their balance and strength[xx].
  • Stay Active and Independent for Life (SAIL) – This program is aimed at seniors who are 65 and older. During the program, participants are required to perform exercises that will improve their fitness, balance, and strength. The program is typically offered three times per week for one hour at a time and can accommodate people who have a mild level of difficulty with mobility. The exercises are designed in a way that they can be done either sitting or standing[xxi].
  • Fall Scape – This customized program is aimed at anyone who regularly loses their balance, no matter their medical condition, fitness level, mobility, or walking ability. It is also aimed at assisting those who have already suffered a fall. The program consists of a couple of training sessions and a few brief multimedia sessions that are specially selected for each participant to help them prevent falls in their own situation and environment. The program is usually offered either in a community setting or at the patient’s home and runs in conjunction with Falls Talk.
  • Tai Ji Quan: Moving for Better Balance – This program comprises two one-hour sessions each week for a total of 24 weeks. Every session begins with warm-up movements, core exercises, therapeutic movements, and then a few cool-down exercises[xxii].
  • The Otago Exercise Program – The Otago Exercise Program[xxiii] is made up of 17 exercises that concentrate on balance and strength. The activities are facilitated by a physical therapist in the patient’s own home, and the therapist works to assess and coach patients for six months to a year.
  • Tai Chi for Arthritis – Tai Chi has proven to be one of the most practical exercises for arthritis sufferers[xxiv], and it helps with preventing falls by improving stamina, muscular strength, balance, and flexibility. It is also extremely relaxing and can quickly become a part of one’s daily routine.
  • Stepping On: Did you know that about 30% of older people who fall tend to go out less often and lose their self-confidence? A lack of activity results in social isolation and loss of muscle strength as well as balance, and this significantly increases the risk of elderly falls. The Stepping On program[xxv] has been designed to break that cycle and engage the elderly in a range of proper fall prevention strategies.

Fall prevention programs prove to be most successful when different components work together. These programs provide the tools that help to prevent falls in the elderly and reduce the likelihood of hospitalization. Successful fall prevention programs usually include:

  • Patient and staff education
  • Assessments to capture relevant data
  • Documentation to identify fall risks and related trends in the outcome of elderly falls
  • Marketing and community outreach activities aimed at increasing community awareness

Even if a person does not sustain an injury when they fall, they are prone to becoming scared of falling. In return, this fear compels them to reduce, or eliminate, their usual daily activities. When a person becomes less active, they become weaker, and this increases their risk of falling. That’s why fall prevention programs are an essential part of any prevention strategy.

Getting the Family Involved:

Anyone who has elderly relatives at risk for falls can, and should be involved in preventative measures.

1. Fall-Proof the Home:

While falls can and do happen anywhere, the majority do occur at home[xxvi]. Humans are creatures of habit, and we tend to spend lots of time in familiar surroundings, moving around easily with little concern for our safety. Falls at home usually happen while we are going about our daily activities, but some are caused by factors such as slippery surfaces, poor lighting, and clutter. A few things you can do to fall-proof your or your loved one’s home include:

  • Arrange furniture so that there is enough room to walk freely.
  • Place non-slip strips on steps and floors, and put the same, or a rubber mat, on the floor of showers and bathtubs.
  • Remove anything that may cause someone to slip or trip when walking.
  • Make sure carpets are adequately secured to steps and floors. Remove any loose rugs, or attach them to the floor using double-sided tape.
  • Remove clutter and lose items from walking paths and floors.
  • Avoid walking on wet floors and clean up spills immediately. Install handrails on either side of walkways and stairs.
  • Install grab bars to use when getting in and out of the shower or bathtub.
  • Make sure there is adequate lighting in all rooms, entrances, and outdoor walkways.
  • Rearrange items that are often used to make them accessible without climbing or reaching.
  • Place a lamp within easy reach of beds and use night lights in hallways, the kitchen, and bathroom. Keep a flashlight next to the bed in case the power goes out.
  • Make sure there are light switches at the top and bottom of stairwells.
  • Be careful when walking outside and avoid going outdoors alone in snowy or icy conditions.
  • Get someone to spread salt or sand on slippery surfaces in the winter and wear boots with adequate traction if you must go out in the snow.

 

2. Provide Information and Education[xxvii]:

Family, along with their elderly loved ones, should be involved in decisions about the senior person’s care and determine how much change is required to prevent old people from falling. Aim to educate everyone concerned to determine how they can contribute to prevention. Both written and spoken information should be provided to seniors and their caregivers, including:

  • How to call for help in the event of a fall
  • Measures that should be taken to prevent falls in the elderly
  • Symptoms that indicate someone is susceptible to a fall
  • The psychological and physical benefits of modifying the risk of falls
  • The importance of fall prevention strategies

 

3.Use Technology:

  • GPS Location Devices[xxviii] – GPS trackers are ideal for attaching to clothes or wearing on a wrist. The device will let caregivers and family know where an elderly relative is and some can be set to alert individuals by email, text, or phone when the relative ventures beyond a particular geographical area.
  • Wearable Emergency Response Devices[xxix] – Medical alert devices reduce the risks associated with falls in the elderly with devices that connect patients with help. This enables seniors to live an independent life and gives their family member’s peace of mind. These devices are ideal for older adults who live alone or with a spouse or partner that is unable to provide physical assistance in an emergency. The patient presses a button that is connected to a call center.
  • Activity Monitors – Physiological monitors help to alert caregivers of an emergency. For instance, of the elderly person has not left the bathroom for a long time, it could mean they have fallen. Sensors can be placed throughout their home to detect falls and extended periods of inactivity, too. Wearable devices are handy for monitoring essential functions like weight, blood pressure, and heart rate, also.

 

What to Do in the Event of a fall?

Unfortunately, we are all prone to falling. As we get older, the likelihood of a fall and the risk of associated injuries increase. That is why it is important to know what to do and what not to do should you have a fall or need to help someone who has fallen.

1. After the fall – for the Fall Victim

If you have fallen and you can get up:

  • Pause for a moment and breathe naturally
  • Check for injuries
  • Do not rush

To get up:

  • Lie on one side and bend the top leg. Lift yourself onto your hands or elbows.
  • Pull yourself towards a sturdy object that won’t move easily.
  • Kneel while placing both hands on the object.
  • Put the stronger leg in front with the foot flat on the floor.
  • Hold onto the object and stand up.

Sit down carefully and take the time to check for any other injuries. If you struggle with walking or standing, it is a good idea to practice these steps regularly so that you know what to do should you fall.

If you have fallen and you can’t get up:

  • If you feel pain or cannot get up or move, try to get help by calling out.
  • If you have an emergency device or there is a phone nearby, use it to get help.
  • If you do not have a phone or emergency device, gently move towards one or to a place where someone may hear you.
  • Use an object that is within reach to make a noise and attract attention.
  • Try to get into a comfortable position to wait for help.
  • If you can, arrange your neck and head in the most comfortable position.
  • Try to move your joints periodically to increase circulation and avoid stiffness.

 

2. If You Witness a fall

  • Do not try to get the person up right away. Check for injuries first and whether or not the person is conscious.
  • Reassure the person that you are going to help them and will not leave them.
  • If the individual is unable to get up, call for help and, if you can, administer first aid. While you wait for emergency services, assist the person to get into a comfortable position and keep them warm.
  • If the individual seems to be able to get up and they want to, carefully execute the following steps:
  • Bring a chair closer to the person
  • Help them turn to one side and bend their upper leg. Assist the person into a seated position
  • Place yourself behind the person firmly hold onto their hips to support them up to kneel. Have them place their hands on the chair in front of them.
  • While they hold onto the object, get them to put their stronger leg in front with the foot flat on the floor. You may need to guide their leg.
  • Grip their hips firmly and help them stand up, turn, and sit.
  • Whether you witness a fall or are a victim of one, do not underestimate how serious it can be. Even if you can’t see any injuries, they may surface later, or there may be internal injuries. If the person, who fell lost consciousness before or after the fall, is dizzy, drowsy, has vision problems, or complains of a lingering or strong pain, they should seek immediate medical assistance.

 

Conclusion:

With falls in the elderly increasing all the time, an elderly person has a one in four chance of falling. However, not many will report the fall to their doctor. Falling once can double your chances of having another fall. While many falls won’t result in an injury, one in five falls will cause a serious injury[xxx] such as head trauma or broken bones. These injuries make it difficult for the person to move or perform their daily activities.

Considering the tragic effects of falls in the elderly, and the increased responsibility of their family members and caregivers, screening and assessment for fall risks should be a priority. Screening can be performed in a hospital setting, and resulting interventions can be produced to prevent the risk of old people falling. In the home environment, family members and patients need to be aware of risk factors and take the appropriate actions to minimize them. When we prevent elderly falls, everyone benefits – the patient, their family, and the healthcare system.

 

References:

[i] Web–based Injury Statistics Query and Reporting System (WISQARS)
[ii] Burns EB, Stevens JA, Lee RL. The direct costs of fatal and non-fatal falls among older adults—United States. J Safety Res 2016:58. Quoted on http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.
[iii] http://www.learnnottofall.com/content/fall-facts/how-often.jsp
[iv] http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
[v] http://www.merckmanuals.com/professional/geriatrics/falls-in-the-elderly/falls-in-the-elderly
[vi] http://homeability.com/us-fall-statistics/
[vii] http://www.learnnottofall.com/content/fall-facts/how-often.jsp
[viii] Morse JM. Enhancing the safety of hospitalization by reducing patient falls. Am J Infect Control.2002; 30:376–380. Reported on https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572247/
[ix] Freeland KN, Thompson AN, Zhao Y, et al; Medication use and associated risk of falling in a geriatric outpatient population. Ann Pharmacother. 2012 Sep; 46(9):1188-92. doi: 10.1345/aph.1Q689. Reported on http://patient.info/doctor/prevention-of-falls-in-the-elderly-pro
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[xi] http://www.uth.tmc.edu/hgec/GemsAndPearls/geriatricSyndromes_Falls.html
[xii] https://en.wikipedia.org/wiki/Visual_acuity
[xiii] https://www.ncbi.nlm.nih.gov/pubmed/20796001
[xiv] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125318/
[xv] http://cks.nice.org.uk/falls-risk-assessment
[xvi] http://www.sgim.org/TinettiTool.Pdf
[xvii] https://www.disabled-world.com/assistivedevices/
[xviii] http://www.aafp.org/afp/2011/0815/p405.html
[xix] https://www.ncoa.org/resources/select-evidence-based-falls-prevention-programs/
[xx] http://www.mainehealth.org/mob
[xxi] http://www.synapticseminars.com/
[xxii] http://tjqmbb.org/
[xxiii] http://www.med.unc.edu/aging/cgec/exercise-program
[xxiv] http://taichiforhealthinstitute.org/why-tai-chi-for-arthritis/
[xxv] https://wihealthyaging.org/stepping-on
[xxvi] http://www.learnnottofall.com/content/home-environment.jsp
[xxvii] http://www.nice.org.uk/guidance/CG161/chapter/introduction
[xxviii] http://www.alzheimers.net/8-8-14-location-devices-dementia/
[xxix] http://www.livescience.com/43016-best-medical-alert-systems.html
[xxx] http://erwinehealthcare.com/healthnews-facts.html