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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 152-156

Prevent falls in older adults


1 Department of Geriatrics, Indraprastha Apollo Hospitals, New Delhi, India
2 Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission26-Jun-2019
Date of Acceptance08-Aug-2019
Date of Web Publication11-Sep-2019

Correspondence Address:
Raju Vaishya
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_42_19

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  Abstract 


Falls are common in the elderly and may lead to serious injuries. Recurrent falls are also frequent and are responsible for significant morbidity and mortality in older adults. The most serious injuries due to these falls are head injury and the fractures. The effect of a fall on an older person can be a devastating event, resulting in chronic pain, loss of independence, and reduced quality of life. Hence, the prevention of fall is better than the treatment of the injuries resulting from it.

Keywords: Falls, fractures, geriatric, head injury, older adults, osteoporosis


How to cite this article:
Sharma O P, Vaishya R. Prevent falls in older adults. Apollo Med 2019;16:152-6

How to cite this URL:
Sharma O P, Vaishya R. Prevent falls in older adults. Apollo Med [serial online] 2019 [cited 2019 Sep 20];16:152-6. Available from: http://www.apollomedicine.org/text.asp?2019/16/3/152/266779




  Introduction Top


Falls are common in the elderly and may lead to serious injuries. Recurrent falls are also frequent and are responsible for significant morbidity and mortality in older adults. It points toward an overall poor physical and cognitive status of the individual. The most serious injuries due to these falls are head injury and the fractures. It is estimated that >80% of hip fractures in the elderly are due to falls. The elderly are more susceptible to fall-related injuries and fractures, and >30% need hospitalization, following a fall. In addition to physical injury, recurrent falls may result in fear and psychological trauma (“postfall syndrome”), where an elderly refuse to move for fear of recurrent falls and injury. An exact incidence of fall in older adults is difficult to determine as many events are unreported. It is estimated that its annual incidence is about 300 per 1000 and one-third of the elderly fall in a year. This incidence is even higher in the institutionalized elderly, probably due to poor health of the elderly and higher reporting rates.


  Causes Top


The balanced and upright posture in human beings is maintained by the central nervous system which coordinate the sensory inputs from visual, vestibular and proprioceptive organs, and muscular activity (especially of the lower limbs). In older adults, there occur the age-related changes in the nervous system, for example, impairment of vision and hearing, reduction of proprioceptive and vibratory sensation, increased sway, altered gait, and poor positional control. These changes alone are not responsible for a fall but significantly contribute to it.

The fall is a symptom and not a disease and is often multifactorial and often interrelated. Problems such as a physical ailment, cognitive decline, medications, and environmental hazards may be responsible factors for it. Falls are reported to be more common in women and advancing age. Both intrinsic and extrinsic factors are responsible for falls in older adults. [Table 1] highlights some of the major intrinsic causes of falls, and [Table 2] lists the extrinsic causes of falls in the elderly. Increasing age, female sex, cognitive impairment, polypharmacy, sensory impairment, and poor psychosocial and environmental factors are associated with the increased incidence of falls.
Table 1: Intrinsic causes of falls

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Table 2: Extrinsic causes of falls

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  Injuries Related to Falls Top


A fall in the elderly may lead to minor or major injuries. Many of the falls in the community-dwelling elderly are unreported because of their noninjurious nature. Around 50% of falls are associated with injury, of which 10% may result in major injuries such as fractures, dislocations, and lacerated wounds requiring suturing. Patients may present with minor injuries such as contusion and abrasions and soft tissue injuries. The major injuries are head injuries (e.g., subdural hematoma [SDH]) and fractures (e.g., hip, and spine). Head injury may present acutely or delayed, as headache and altered sensorium with or without seizures and minimal focal neurological deficits. Chronic SDH may also present with progressive dementia. The fractures sustained due to these falls may be serious, especially of the hip and spine and may require surgical intervention.


  Assessment of Falls Top


A detailed history should be followed by a targeted physical examination, functional assessment, and appropriate diagnostic tests (if required).

History

History to recall the circumstances leading to a fall, must be elicited. Pneumonic “SPLATT” is useful for recalling fall circumstances.[1]

S: Symptoms that occurred immediately before fall or with the fall episode (lightheadedness, dizziness, vertigo, palpitations, chest pain, dyspnea, focal defects, aura, syncope, urinary, and fecal incontinence

P: History of previous fall

L: Location of fall

A: Activity at the time of fall

T: Timing of fall

T: Trauma or injury resulting from fall.

History should include assessment of individuals' fear of falling. Two self-efficacy tests are available to assess the fear of falling. These are (a) falls efficacy scale and (b) activities-specific balance confidence scale.[2],[3],[4],[5]

History of medications that increase the risk of falls should be elicited. Particular attention should be given to newly started drugs or those for which the dose has been increased recently. History regarding acute or chronic medical conditions related to fall should be obtained. Acute conditions they may precipitate falls include metabolic disturbances, vertigo, delirium, postural hypotension, syncope, seizures, and alcoholic intoxication. Chronic conditions associated with falls include sensory impairment, cognitive impairment, sleep problems, cardiovascular conditions, muscular and skeletal problems, and depression.[6],[7],[8],[9] History about all these should be elicited. Depression is assessed with geriatric depression scale [10] and functional status with activities of daily living score.[11]

Physical examination

Physical examination includes assessment of vision, gait, and balance, and lower extremity joint function. Detailed neurological examination should include assessment of muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal, and cerebella function. Cardiovascular assessment includes evaluation of heart rate, rhythm, postural pulse, and blood pressure, especially in syncopal fall. Cognitive screening using the Mini-Mental State Examination [12] should be conducted. Emergency evaluation of an old person with injurious falls warrants X-ray and other imaging studies. For falls that occur at home with no apparent reasons, home safety evaluation should be considered.

Functional assessment

Test for clinical assessments of gait and balance

Functional reach

Measures the distance in inches that a standing individual can reach or lean forward without stepping. A score of 6 inches or less in 70 years old is strongly correlated with high fall risks. This test is easy to perform and requires minimum equipment, time, and space.

Timed up and test (TUG)

Time in seconds for an individual to stand up from a chair, walk 10 feet, turn around, come back, and sit down. A score of 30 s or higher indicates impaired mobility, and assistance is required.

Berg balance scale

Functional activity test that rates performance from 0 (unable to perform) to 4 (average performance) on 14 tasks. The time required is 15 min. Tasks include the ability to sit, stand, walk, turn in a complete circle, reach, lean over, turn, and look over each shoulder and step. The maximum score of 56 indicates excellent balance; <45 predicts multiple fallers.

In addition to an assessment of function and observation of gait and balance on physical examination, peripheral sensory inputs can be measured with low technology clinical tests such as visual acuity, visual field and depth perception, tactile sensation, proprioception, and vestibulocochlear reflexes.

Central sensory organization measures include selection and combination of appropriate inputs and the determination of orientation to self and environment. Two tests are used for the measurement of central sensory organization. They are.

  1. Sensory organization test (SOT) in computerized dynamic posturography (DP)
  2. 2. A clinical test of sensory interaction and balance (CTSIB).


CTSIB is a low technology test based on the same six sensory conditions of high technology SOT [Table 3].
Table 3: Tests used for the measurement of central sensory organization

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  Motor Coordination Test Top


Impairment in the central adjustment of movements can be measured qualitatively by a motor coordination test. The peripheral components of movements result from appropriate interaction of muscle, bone, and joints of the skeletal muscle systems. Some muscle skeletal risk factors for fall observed in adults are decreased knee and ankle strength, inability to extend the back, and decreased range of motion in the ankle dorsiflexion and neck motion.


  Evaluation of Recurrent Falls Top


Recurrent falls have to be differentiated from syncope and seizures. Some investigators include this also as a cause of fall. A good history from the patient or witness will help differentiate these problems. A clear history of a trip may point to an environmental hazard or a new medical problem in the lower limb [Figure 1].
Figure 1: Evaluation of recurrent falls

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Evaluation of an elderly with recurrent falls should be individualized. A good history and thorough physical examination will decide the need for further investigation. A complete blood count, serum electrolytes, plasma glucose, and renal function, chest X-ray, and resting electrocardiography are indicated in all cases of falls. Further investigation should be individualized and can include Holter monitoring for arrhythmias and electroencephalogram for seizures.


  Management Top


The treatment of an elderly presenting with falls in an emergency room includes managing the injury and any associated illness present. Once the patient is stabilized, the treatment of the cause of the fall should be assessed and addressed.


  Interventions to Prevent/reduce Falls Top


The prevention of fall is an important clinical and public health issue since the frequency of falls and their complications are increasing enormously. The following interventions may be adopted in fall prevention:

  1. Fall-related education
  2. Environmental assessment and modification
  3. Modification of medication regimens
  4. Interventions to improve strength, balance, and endurance.


Fall-related education

This is included as a part of a multifaceted intervention. Education alone was not found to be beneficial for any measure of fall incidence.

Environmental assessment and modification

Home visits to be made by health care workers and individualized recommendation to be given to reduce environmental fall hazards (e.g., removal of mats and rigs, installation of stair railing and night light). Intervention group appeared to be nearly 20% less likely to experience a fall.

Modification of medication regimens

In a multivariate analysis of the history of falls and number of mediation, individuals assigned to medication withdrawal group were 66% less likely to experience a fall during the 44-week follow-up, which is a statistically significant reduction in falls compared to control group.

Interventions to improve strength, balance, and endurance

Results from metanalysis from FICSIT trial indicate that balance intervention delays the onset of fall more than strength and endurance intervention.


  Machine-based Intervention Top


Motor-driven balance platform has been used to evaluate and train balance. The platform has several force transducers embedded within, and the motor allows the platform/visual surround to move in an angular or linear plane. As an evaluation tool, the clinician can distinguish the relative contribution of the visual, vestibular, and somatosensory systems to postural control and use this information to develop specific treatment recommendation. Limitations to this approach are its expense and lack of controlled trials to prove that this form of treatment does reduce the incidence of falls.


  Taichi Top


It is an oriental martial art form of China. The slow and direct rhythmicity of movements contributes to the development of movement strategies to prevent fall in real-life situation. Modest program delays the onset of falls and improves cardiovascular status.


  Strengthening Exercises Top


High-intensity muscle-specific lower extremity exercise improves strength, walking speed, and other physical measures. A definite relationship between existing diagnosis, health status, and strength training exercises in delaying the onset of falls in old individuals requires further evaluation.


  Endurance Top


Endurance training can be done on an individual or group basis. Increasing the number of repetitions or speed for sit to stand, perimeter, or outdoor walking distances are essential ways to improve endurance. This form of exercise is useful for patients with less endurance and who develop fatigue fast during repetitive contractions.

No definitive evidence currently exists to support one type of physical activity more than another.[13] This is largely because the effectiveness of different forms of physical activity has not been directly compared across the different levels of fall risk. It, therefore, remains unknown whether one form of exercise is better than another for older adults at different levels of fall risk. What can be inferred from the research published to date is that physical activity programs aimed at reducing falls should include a combination of gait, balance, coordination, resistance (strength), and aerobic endurance activities. Moreover, as the level of fall risk increases, both the type and intensity of physical activities selected must specifically address the impairments identified, be carefully tailored to the individual's physical capabilities, and progressed accordingly. Whether tailored physical activity programs are implemented in group-based community settings or the individual's own home does not appear to affect the outcomes relative to lowering fall risk. Some evidence also exists for the use of alternative forms of exercise such as tai chi for more sedentary community-residing older adults who are relatively healthy.

At the community level, distribution of manuals on physical activity, balanced training, and other activities like Yoga, an ancient system of exercises originating in India, can be provided. It is aimed at integrating mind, body, and spirit to enhance health and well-being. Much emphasis has been stressed on the role of culturally acceptable physical activity worldwide.

The effect of a fall on an older person can be a devastating event, resulting in chronic pain, loss of independence, and reduced quality of life. The cumulative effect of falls and resulting injuries among the growing number of older persons in most countries has the potential to reach epidemic proportions that consume a disproportionate amount of health care resources. Immediate action is needed to implement sound public policies through a sustained commitment to financial and human resources to address this important issue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tideiksaar R. Preventing falls: How to identify risk factors, reduce complications. Geriatrics 1996;51:43-6, 49-53.  Back to cited text no. 1
    
2.
Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol 1990;45:P239-43.  Back to cited text no. 2
    
3.
Powell LE, Myers AM. The activities-specific balance confidence (ABC) scale. J Gerontol A Biol Sci Med Sci 1995;50A:M28-34.  Back to cited text no. 3
    
4.
Rai GS, Kiniorns M, Wientjes H. Falls handicap inventory (FHI) – An instrument to measure handicaps associated with repeated falls. J Am Geriatr Soc 1995;43:723-4.  Back to cited text no. 4
    
5.
Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW, et al. Fear of falling and activity restriction: The survey of activities and fear of falling in the elderly (SAFE). J Gerontol B Psychol Sci Soc Sci 1998;53:P43-50.  Back to cited text no. 5
    
6.
Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J Am Geriatr Soc 1994;42:269-74.  Back to cited text no. 6
    
7.
Brown JS, Vittinghoff E, Wyman JF, Stone KL, Nevitt MC, Ensrud KE, et al. Urinary incontinence: Does it increase risk for falls and fractures? Study of osteoporotic fractures research group. J Am Geriatr Soc 2000;48:721-5.  Back to cited text no. 7
    
8.
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. J Am Geriatr Soc 2001;49:664-72.  Back to cited text no. 8
    
9.
Brassington GS, King AC, Bliwise DL. Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years. J Am Geriatr Soc 2000;48:1234-40.  Back to cited text no. 9
    
10.
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: A preliminary report. J Psychiatr Res 1982;17:37-49.  Back to cited text no. 10
    
11.
Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv 1976;6:493-508.  Back to cited text no. 11
    
12.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.  Back to cited text no. 12
    
13.
Paper on the Role of Physical Activity in the Prevention of Falls in Older Age, Presented at WHO Technical Seminar on Falls. Canada; Feb, 2007.  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
Abstract
Introduction
Causes
Injuries Related...
Assessment of Falls
Motor Coordinati...
Evaluation of Re...
Management
Interventions to...
Machine-based In...
Taichi
Strengthening Ex...
Endurance
References
Article Figures
Article Tables

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