Elderly Falls

Elderly Falls are common & may lead to injuries and decline in function. Evaluation should included risk factor assessment, gait assessment, and home assessment. Exercise can improve outcomes.

Falls are an important cause of morbidity and mortality in elderly. Most often the cause of fall is multifactorial. Falls and their sequelae are potentially preventable and hence it is of importance to know the risk factors for fall in the elderly.

Elderly Fall is an event caused by age associated diseases like Parkinson’s disease, cognitive decline and musculoskeletal problems in association with physiological changes like impairment of sensory system, impairment of righting reflex and decrease in lean body mass. The incidence of falls increases with advancing age. It is one of the leading cause of death in elderly. The morbidity due to falls includes serious injuries and fractures, restricted mobility and loss of independence leading to functional decline, psychological fear of falling (post fall syndrome) and permanent disability.

Prevalence Of Elderly Falls

Several epidemiological studies have looked at the rate of falls in the elderly at home, in outpatient settings and institutions. 30% of those over 65 years fall annually. Half are repeat fallers. Falls go up with each decade of life. Over half of those in nursing homes and hospitals will fall each year. It appears that for the elderly living at home one-third to one-half tend to fall or do fall.Those who are more aged, female, single, divorced or widowed have an increased rate of falling.

One major impact of fall is hip fracture. More than 90% of hip fractures are associated with falls in persons above 70 years of age and are associated with greater mortality. Falls are potentially preventable. Much interest is being shown in the evaluation of elderly falls and identification of the risk factors, which would help in elderly falls prevention programs. There are many studies on evaluation of falls in various populations. These studies suggest recurrent falls are more common with multiple, often interacting risk factors. Some studies reveal that risk of elderly falls appears to rise as the number of risk factors increases.

The associated risk factors or causes of falls in elderly include:

  • older age.
  • history of past falls.
  • cognitive impairment.
  • impairments of activities of daily living.
  • lower extremity weakness or other disability.
  • impaired balance and gait.
  • dizziness.
  • arthritis.
  • history of stroke.
  • poor visual acuity.
  • low body mass index.
  • increased number of medications and use of psychotropic medications.

Complications of Elderly Falls

The complications of Elderly falls are numerous and significant.

  • Fear of falling can be a very real reason for loss of mobility in the elderly. After a few falls, some people become so frightened and anxious that they will not attempt to stand even when there is adequate help and support. Fractures of the hip or forearm are common results of falling.
  • Hip fractures carry high morbidity (health problems related to a disease or condition) because of prolonged immobility, surgical risks and functional disability, possibly related to hospitalization.
  • Hypothermia, dehydration, bronchial pneumonia and pressure damage to the skin are all possible complications resulting from exposure in patients who are unable to get up once they have fallen.

Evaluation of Elderly Falls

History

  • Location & circumstances of Fall.
  • Associated symptoms.
  • Other falls or near falls.
  • Medications (including nonprescription) and alcohol.
  • Injury & ability to get up.

Physical Examination

  • Supine and standing BP - always.
  • Routine physical examination.
  • Focus on cardiovascular, MS, neuro, feet.
  • Vision and hearing evaluation.
  • Consider acute medical illness & delirium.
  • Formal gait and balance assessment.

Home Evaluation

  • Can be performed by nurse, OT, PT, others.
  • Stairs.
  • Lighting.
  • Clutter.
  • Bathroom.
  • Specific hazards: cords, throw rugs.

Risk Factors for Injury

  • Osteoporosis assessment.
  • Anti coagulation: Usual benefits outweigh risks unless repeat or high risk faller.
  • Can the person get up from fall?
  • Is there a way to notify others in case of falling?

Formal Gait Evaluation

  • Get up and Go Test.
  • Tinetti Gait and Balance Evaluation (POMA).

POMA: Gait Component

  • Initiation.
  • Step length and height.
  • Step symmetry & continuity.
  • Path.
  • Stance.
  • Ability to pick up speed.

Elderly Fall Prevention & Care

  • Treat acute injury & underlying medical conditions.
  • Remove unnecessary medications.
  • Rehab.
  • exercises.
  • assistive devices.
  • Correct sensory impairments.
  • Environmental modifications & safety.
  • Evaluate for osteoporosis treatment

Elderly Fall Prevention Tips

Causes and Prevention

The causes of elderly falls are known as risk factors. Although no single risk factor causes all elderly falls, the greater the number of risk factors to which an individual is exposed, the greater the probability of a fall and the more likely the results of the fall will threaten the person's independence.

Many of these risk factors are preventable. As obvious as it may sound, a lack of knowledge about risk factors and how to prevent them contributes to many falls. Some people believe that falls are a normal part of aging, and as such are not preventable. Lack of knowledge leads to lack of preventive action, resulting in falls.

Discussed below are five key risk factors of falls among older adults. Preventive measures for each factor are briefly listed.

Factor #1: Osteoporosis

Osteoporosis is a condition wherein bones become more porous, less resistant to stress, and more prone to fractures. Caused by hormonal changes, calcium and vitamin D deficiency, and a decrease in physical activity, osteoporosis is a chief cause of fractures in older adults, especially among women.

What is debatable is whether brittle bones break after a fall, or break when stressed and in turn cause a fall. In either event, a decrease in bone density contributes to falls and resultant injuries.

Prevention Tips

  • Eat or drink sufficient calcium. Postmenopausal women need 1,500 mg of calcium daily. Calcium-rich foods include milk, yogurt, cheese, fish and shellfish, selected vegetables such as broccoli, soybeans, collards and turnip greens, tofu and almonds.
  • Get sufficient vitamin D in order to enhance the absorption of calcium into the bloodstream. Vitamin D is formed naturally in the body after exposure to sunlight, but some older adults may need a supplement.
  • Regularly do weight-bearing exercises.

Factor #2: Lack of Physical Activity

Failure to exercise regularly results in poor muscle tone, decreased strength, and loss of bone mass and flexibility. All contribute to falls and the severity of injury due to falls.

Prevention Tips

  • Engage regularly (e.g., every other day for about 15 minutes daily) in exercise designed to increase muscle and bone strength, and to improve balance and flexibility. Many people enjoy walking and swimming.
  • Undertake daily activities in a safe manner, such as reaching and bending properly, taking time to recover balance when rising from a chair or bed, learning the proper way to fall, and learning how to recover after a fall.
  • Wear proper fitting, supportive shoes with low heels or rubber soles.

Factor #3: Impaired Vision

Age-related vision diseases can increase the risk of falling. Cataracts and glaucoma alter older people's depth perception, visual acuity, peripheral vision and susceptibility to glare. These limitations hinder their ability to safely negotiate their environment, whether it be in their own home or in a shopping mall. Young people use visual cues to perceive an imminent fall and take corrective action. Older adults with visual impairments do not have this advantage to the same extent.

Prevention Tips

  • Have regular checkups by an ophthalmologist to discern the extent of age-related eye diseases such as cataracts and glaucoma.
  • Use color and contrast to define balance-aiding objects in the home (e.g., grab bars and handrails).
  • Add contrasting color strips to first and last steps to identify change of level.
  • Clean eye glasses often to improve visibility.

Factor #4: Medications

Sedatives, anti-depressants, and anti-psychotic drugs can contribute to falls by reducing mental alertness, worsening balance and gait, and causing drops in systolic blood pressure while standing. Additionally, people taking multiple medications are at greater risk of falling.

Prevention Tips

  • Know the common side effects of all medications taken.
  • Talk with your physician or pharmacist about ways to reduce your chances of falling by using the lowest effective dosage, regularly assessing the need for continued medication, and the need for walking aids while taking medications that affect balance.
  • Remove all out-of-date medications and those no longer in use.
  • Have a physician or pharmacist conduct a "brown bag" medicine review of all current medications.
  • Limit intake of alcohol as it may interact with medications.

Factor #5: Environmental Hazards

At least one-third of all falls in the elderly involve environmental hazards in the home. The most common hazard for falls is tripping over objects on the floor. Other factors include poor lighting, loose rugs, lack of grab bars or poorly located/mounted grab bars, and unsturdy furniture.

Prevention Tips

It is useful to conduct a walk-through of your home to identify possible problems that may lead to falling. A home visit by an interior designer or occupational therapist might also be useful in that they are trained to identify risk factors and recommend appropriate actions.

Outdoors

  • Repair cracks and abrupt edges of sidewalks and driveways.
  • Install handrails on stairs and steps.
  • Remove high doorway thresholds Trim shrubbery along the pathway to the home.
  • Keep walk areas clear of clutter, rocks and tools.
  • Keep walk areas clear of snow and ice.
  • Install adequate lighting by doorways and along walkways leading to doors.

All Living Spaces

  • Use a change in color to denote changes in surface types or levels.
  • Secure rugs with nonskid tape as well as carpet edges.
  • Avoid throw rugs.
  • Remove oversized furniture and objects.
  • Have at least one phone extension in each level of the home and post. emergency numbers at each phone.
  • Add electrical outlets.
  • Reduce clutter.
  • Check lighting for adequate illumination and glare control.
  • Maintain nightlights or motion-sensitive lighting throughout home.
  • Use contrast in paint, furniture and carpet colors.
  • Install electronic emergency response system if needed.

Bathrooms

  • Install grab bars on walls around the tub and beside the toilet, strong enough to hold your weight.
  • Add nonskid mats or appliques to bathtubs.
  • Mount liquid soap dispenser on the bathtub-wall.
  • Add a padded bath or shower seat.
  • Install a raised toilet seat if needed.
  • Install a portable, hand-held shower head.
  • Use nonskid mats or carpet on floor surfaces that may get wet.

Kitchen

  • Use a sturdy step stool when you need something from a high shelf.
  • Make sure appliance cords are out of the way.
  • Keep commonly used items within easy reach.
  • Avoid using floor polish or wax in order to reduce slick surfaces.

Living, Dining and Family Rooms

  • Keep electrical and telephone cords out of the way.
  • Arrange furniture so that you can easily move around it (especially low coffee tables).
  • Make sure chairs and couches are easy to get in and out of.
  • Remove caster wheels from furniture.
  • Use television remote control and cordless phone.

Bedroom

  • Put in a bedside light with a switch that is easy to turn on and off (or a touch lamp).
  • Have a nightlight.
  • Locate telephone within reach of bed.
  • Adjust height of bed to make it easy to get in and out of.
  • Have a firm chair, with arms, to sit and dress.

Stairways, Hallways and Pathways

  • Keep free of clutter.
  • Make sure carpet is secured and get rid of throw rugs.
  • Install tightly fastened hand rails running the entire length and along both sides of stairs.
  • Handrails should be 34 inches high and have a diameter of about 1.5 inches.
  • Apply brightly colored tape to the face of the steps to make them more visible.
  • Optimal stair dimensions are 7.2 inch riser heights with either an 11 or 12 inch tread width.
  • Have adequate lighting in stairways, hallways and pathways, with light switches placed at each end.

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Further Reading

  • Falls Among Older Adults: An Overview. Home & Recreational Safety
  • Prevention of Falls in the Elderly. Patient.co.uk
  • Falls and Older Adults. NIH Senior Health
  • Falls. Medline plus
  • Falls in older adults. Wikipedia
  • Tinetti, ME; Baker DI; Garrett PA; Gottschalk M; Koch ML; Horwitz RI (March 1993). "Yale FICSIT: risk factor abatement strategy for fall prevention". J Am Geriatr Soc 41 (3): 315–20.

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