Fall prevention

Fall prevention is a variety of actions to help reduce the number of accidental falls suffered by older people.

This article is about prevention of domestic falls in older adults. For fall protection in the workplace, see Fall protection.

Falls and fall related injuries are among the most serious and common medical problems experienced by older adults. Nearly one-third of older persons fall each year, and half of them fall more than once.[1] Over 3 million American over the age of 65 visited hospital emergency departments in 2015 due to fall related injuries with over 1.6 million being admitted.[2] Because of underlying osteoporosis and decreased mobility and reflexes, falls often result in hip fractures and other fractures, head injuries, and even death in older adults. Accidental injuries are the fifth most common cause of death in older adults.[1] In around 75% of hip fracture patients, recovery is incomplete and overall health deteriorates.[1]

The most consistently proven predictors of fall risk are history of a fall during the past year and gait and balance abnormalities.[3] Some studies (but not others) indicated that impaired vision, certain medications (especially psychotropic drugs),[4] decreased activities of daily living and impaired cognition are associated with a higher risk of falls. Furthermore, some interventions that have been shown to be effective in one country are not necessarily generalized to other populations.[5] The contribution of orthostatic hypotension to fall risk remains uncertain.[3]

Risk factors of falls

Various kinds of individuals of different ages and conditions are at constant risk of falling.

Fall of falling (Basophobia)

Basophobia is a term used in many circumstances such as fear of falling on either normal or special situations. This concept refers to the uncomfortable situation older people might suffer in this case. They could feel week lower-body strength or unstable balance, and that creates them the feeling and fear of falling, which could get them exposed to injuries and pains that could be potentially fatal sometimes.[6]

Healthy young individuals

The most common cause of falls in healthy adults is due to accidents. It may be by slipping or tripping from stable surfaces or stairs, improper footwear, dark surroundings, uneven ground, or lack of exercise. Studies suggest that women are more prone to falling than men in all age groups.[7] The most common injuries in the young population due to falls occur at the wrist/hand, knees and ankles.[7]

Older adults

Studies have shown that old adults above the age of 65 years are more prone to falls than young healthy adults.[8][9] The most falls in older adults are due to:[10]

  • Gait Deviations - These are the main changes that occur in the gait patterns of older adults, which may contribute to the incidence of falls. There may be a 10-20% reduction in gait velocity and reduction in stride length; an increase in stance width and double support phase; and bent posture.[11][12][13] Studies show that a wider stride does not necessarily increase stability but instead seems to predict an increased likelihood of experiencing falls.[14]
  • Limitations in mobility - People that suffer it are not able to move as normal and that increases their chances to fall unexpectedly on a situation that, under normal circumstances, should be easily passed by people (like walking up/down stairs or walk up/down a hill)[15]
  • Reduced muscle strength: Especially in their legs; this is going to make them get and stand up.[16]
  • Poor reaction time: Sometimes it all comes to physical abilities like reactions and awareness. A poor physical condition with a lack of reactions (frequently common in the elderly) is a common neurological problem in older people due to age.[17]
  • Accidents/Environmental factors – a fall may be from stable or unstable surfaces - slipping or tripping on wet surfaces or ice, from stairs or rugs, and/or due to improper footwear.
  • Balance disorders – vertigo, Syncope, unsteadiness
  • Visual, sensory, motor, and cognitive impairment - affected reflexes
  • Medications and alcohol consumption - taking medications for a long time can make one feel dizzy, confused, and slow. Alcohol consumption causes a delay in reflexes and hampers balance.
  • Acute and chronic infections
  • Dehydration

Stroke

High fall rates in individuals with stroke are reported. Approximately 30% fall at least once a year and 15% fall twice or more.[18] Risk factors for falls in stroke survivor’s are:[19]

  • Gait Deviations - Disturbance of gait is a common problem post-stroke and a common contributor of falls, predicting a continuing functional decline. Velocity, cadence, stride time, stride length, and temporal symmetry index were reduced and resulted in significant gait deterioration.[20] Reduced propulsion at push-off, decreased leg flexion during the swing phase, reduced stability during the stance phase, and reduced automaticity of walking occur.[18]
  • reduced muscle tone and weakness
  • side effects of drugs (hypoglycemic, antihypertensive, neuroleptic drugs)
  • hypoglycemia
  • hypotension
  • communication disorders
  • hemianopia
  • visuospatial agnosia

Parkinson's disease

Most people with Parkinson’s disease (PD) fall and many experience recurrent falls.[21] A study reported that over 50% of persons with PD fell recurrently.[22] Direct and indirect causes of falls in Patients with Parkinson's disease:[23]

  • Gait Deviations - Decreased gait velocity and stride length due to Hypokinetic movement, decreased cadence due to Bradykinetic movements. Increased double-limb support.[24] They also exhibit Flat foot strike.
  • Sudden falls - these can be sudden and unpredictable
  • Freezing and festination episodes
  • Postural instability
  • Intensified dyskinesia
  • Autonomic system disorders - orthostatic hypotension, neurocardiogenic syncope, postural orthostatic tachycardia syndrome
  • Neurological and sensory disturbances - muscle weakness of lower limbs, deep sensibility impairment, epileptic seizure, cognitive impairment, visual impairment, balance impairment
  • Cardiovascular disease
  • Drugs - Levodopa-induced dyskinesia

Multiple sclerosis

Evidence shows that there is a high prevalence of falls among people with multiple sclerosis (MS), with approximately 50% reporting a fall in their past 6 months.[25] About 30% of those individuals report falling multiple times.

  • Gait Deviations – Gait variability is elevated in individuals with MS.[26] Stride length, Cadence, and Velocity decreased. Stance duration and cycle duration increased.[27]
  • Drop foot - may cause the person to stumble on flat surfaces
  • Ataxia - loss of motor skills. Vestibular ataxia results in loss of balance. Symptoms exacerbated when eyes closed and base of support reduced.
  • Reduced proprioception – no sense of body position and surrounding
  • Improper or reduced use of assistive devices[28]
  • Vision – blurred vision, double vision, loss of peripheral vision
  • Cognitive Changes – Approximately 50% experience difficulty with their cognition over the course of the disease. This affects planning, organizing, problem-solving, and one's ability to accurately perceive their environment. When these problems interfere with walking, it may result in a fall.
  • Neurological medications – causes fatigue,[29] weakness, dizziness

Dementia

Studies suggest that men are twice at the risk of falling than women.[30] Common causes of falls in dementia include:

  • Gait deviations - Slower walking speed, reduced cadence, and step length, increased postural flexion, increased double support time[31]
  • Postural instability - gait changes and impaired balance. People with balance deficits are three times more at risk of falling than those with a normal gait and intact balance
  • Lack of physical exercise
  • Memory impairment
  • Visual impairment
  • Fatigue
  • Medications – psychotropic drugs have effects on balance, reaction time and other sensorimotor functions, orthostatic hypotension, and extrapyramidal symptoms

Strategies and interventions

Recent clinical studies indicate that most successful approach to fall prevention uses a multimodal, motor-cognitive training approach.[32] The scientific basis of this approach is an understanding of how leveraging the dual-task paradigm induces neuroplasticity in the brain, especially in aging populations.[33] Specifically, functional MRI identified changes in brain activity patterns for those patients that were exposed to combined motor-cognitive training, as opposed to exclusively physical training.[34] One approach to motor-cognitive therapy, which involves the use of a semi-immersive virtual reality simulation with physical and cognitive challenges, was found to reduce falls by 50% in clinical trials and up to 80% with practitioners in the field over a period of 15 sessions or 5 to 7 weeks.[35] This compares favorably to the gold standard of fall prevention, tai chi, which reduces falls by 35% over 52 weeks.

Other preventative measures with positive effect include strength and balance training, home risk assessment,[36] withdrawing psychotropic medication, cardiac pacing for those with carotid sinus hypersensitivity, and tai chi. Resistance exercise 2 or 3 times a week with ankle weights or elastic bands has been proven in tests to rebuild loss muscle mass and reduce falls in adults of all ages. This was first tested and proven in New Zealand by the Otago Medical School in 4 controlled trials in which close to 1000 older adults, average age 84, participated. Falls among a test group that did the Otago routines 3 times a week for 12 months were 35% less than a control group that did not use the routines.[37] Two similar 12-month tests were conducted in the US using residents of assisted and skilled nursing facilities with one group showing a 54% reduction in falls.[38] After the age of 50, adults experience a decrease in muscle mass, a condition known as sarcopenia, by approximately 2% every year.[39] A systematic review concluded that resistance training can slow down the rate of loss in muscle mass and strength. It has been recommended that older adults participate in resistance training 2-3 times a week to weaken the effects of sarcopenia.[39] Assistive technology can also be applied, although it is mostly reactive in case of a fall.[5] Exercise as a single intervention has been shown to prevent falls in community dwelling older adults. A systematic review suggests that having an exercise regimen that includes challenging balance workouts for three or more hours per week results in a lesser chance of falling.[39] Resistance training has been shown to be beneficial beyond fall prevention, as it also helps improve functional mobility and activities of daily living such as walking endurance, gait speed, and stair climbing.[39] Research explains that this significant increase in performance can be accomplished after the age of 90. In order for older adults to gain confidence in resistance training, which may ultimately lead to fall prevention effects, they need to obtain the recommended amount of daily activity.[39]

The aim of medical management is to identify factors that can contribute to falls and fracture risk such as osteoporosis, multiple medications, balance and gait problems, loss of vision and a history of falls. Beers Criteria is a list of medications that are potentially inappropriate for use in the elderly and some of them increase the risk of falls.[40]

Assessment of every fall should be aimed at identifying the inciting cause so that it can be avoided in the future. If the fall is clearly without loss of consciousness, a "Timed Get up and Go" or "TUG" test should be performed to assess the mobility and a thorough examination of the musculoskeletal system should be performed to identify any contributory factors.

Falls are well known amongst community-dwelling individuals ages 65 and older.[41] The risk of fall-related incidents nearly doubles when individuals are institutionalized.[42] The impact on different falls in certain situation of fall prevention programs on the rate differences of falls in elderly population has not been reported. According to the study, annual 60% of older people with cognitive impairment and dementia are highly likely at risk of having a fall-related incident. Most falls that are experienced are by older people over the age of 65 with acute problems that can come from chronic diseases. These falls may occur by intrinsic risk factors as well as precipitating causes. In order to prevent falls that could lead to serious injury or death health facilities need to know how to solve the problems and explore alternatives that can lead to a patient fall. As well as cognitive impairment, functional impairment, gait, and balance disorders, certain medications can all increase fall risk factors for patients. By advanced age, these risk factors are double and more likely to occur. It’s important to identify the risk factors that increase the likelihood of injurious falls. State-level fall prevention strategies can also mitigate fall risk for community-dwelling older adults.[41]

Environmental modification
Grab rails on a longer-distance commuter train catering for mainly seated passengers
A staircase with metal handrails
Front-wheeled walker.
Grab bar mounted in a bathroom
Forearm crutch/cane

The home environment can present many hazards. Common places for injurious falls are the bathtub and steps. Changes to the home environment are aimed at reducing hazards and help support a person in daily activities. Changes could include minimizing clutter, installing grab bars in the shower or tub or near the toilet, and installing non-slip decals to slippery surfaces.[43] Stairs can be improved by providing handrails on both sides, improving lighting, and adding colour contrast between steps. Improvement in lighting and luminance levels can aid elderly people in assessing and negotiating hazards. Currently, there is insufficient scientific evidence to ensure the effectiveness of modification of the home environment to reduce injuries.[44] It appears that changes to the environment are not easily implemented because of low uptake by study participants.[44] Nevertheless, evidence suggests that pre-discharge home assessments are associated with a reduced risk of falling.[36]

Safety technology

Important improvements to prevent falls at home or indeed, anywhere, include the provision of handrails and grab bars, which should be easy to grip or grasp and should be near any stairs, or change in floor level. Floors should always be flat and level, with no exposed corners or edges to trip the unwary. Patterned floors can be dangerous if they create misleading or distorted images of the floor surface, so should be avoided.[45]

There are special handles and closed handgrips available in bathrooms and lavatories to assist users when bending down or over, for example. Extra support for users when moving include walking sticks, crutches, and support frames, such as the Zimmer frame. Flexible handles such as hanging straps can also be useful supports.[46]

This kind of solution is really helpful for our elderly. But there is still a time when people do not use these protections and cause unintentional injuries from falling and hits that could have been prevented by the use of these items.[47]

Eyeglasses selection and usage

Bi-focal spectacles and tri-focal eyeglasses are commonly ground to provide refractory correction ideal for reading, that is, 12 to 24  inches (30 to 60  cm), when the wearer is looking downward through them. These glasses, used for reading, are therefore not ideal for safe walking, where correction for 4½ to 5 feet (137 to 152  cm) would be far more appropriate. Some countries with universal health care recommend separate reading and walking glasses, a rather rare practice in the U.S. in the early 21st Century.

Occupational and physical therapy

Studies show that balance, flexibility, strength, and motor-cognitive training not only improve mobility but also reduce the risk of falling. This may be achieved through group and home-based exercise programs or engagement with physical therapy clinics with the appropriate equipment. The majority of older adults do not exercise regularly and 35% of people over the age of 65 do not participate in any leisurely physical activities.

Older adults

In older adults, physical training and perturbation therapy is directed to improving balance recovery responses and preventing falls.[48] Gait related changes in the elderly provide a greater chance of stability during walking due to slow speed and greater base of support, but they also increase the chance of slipping or tripping and falling.[49] Appropriate joint moment generation is required to create sufficient push-off for balance recovery. Age-related changes in muscles, tendons, and neural structures may contribute to slower reactive responses. Interventions involving resistance training along with perturbation training may prove to be beneficial in improving muscle strength and balance recovery.[50]

Stroke recovery

Stroke exercises help patients regain mobility and strength in their bodies. These exercises must be done regularly in order to regain the muscle tone that gives people what it needs not to fall. Nowadays it is very easy to keep up with the different exercises due to the big amount of apps that we can download on our devices. These apps like Aachen Fall Prevention App (AFPA) explains to you everything about strokes, how they occur, and what exercises you need to do in order to recover muscle tone and so lower your risk of falling. These apps state a personalized plan based on your experiences and needs. Moreover, you can have a 24/7 live chat with people that can help you with any concerns, and it also has a forum where users post their concerns so other people can give them answers.[51]

Some of the most common exercises applied to stroke recovery are the following:

Stroke exercises for legs
  • Knee extensions - While sitting on a chair, do10 repetitions on each leg
  • Seated marching - Seated position, then lift your leg up into your chest and then place it back to the floor (10 repetitions each)

Stroke exercises for balance and core
  • Trunk rotation - From the seating position, place one hand on your legs' opposite side' and gently twist your torso to a side. (15 times)
  • Toe tap exercise - Lying down on your back, lift your leg up, and bend your knees at 90 degrees angle. Then bring your leg down and repeat 10 times each leg

Stroke exercises for arms
  • Tabletop circle - Lace your fingers together and while holding a water bottle or such, make circular movements around any flat surface.
  • Open arms exercise - Hold a water bottle on one side and keep your elbows next to your sides. Then, with your shoulders at 90 degrees, open your arms (forearms facing coming out to your sides)


Exercises for prevention

One of the most important things for elderly people is to stay healthy, and the senior's park is a good place to keep them in shape and improve their physical condition. These places are fully equipped with different stations where people can exercise. The parks usually have an extended amount of space and different stages for all the body exercises. By doing their regularly and doing some daily exercise they can improve their weaknesses as lack of balance, strength, vision, and reactions. There are many different exercises that include spinning wheels, trunk rotation, knee bending, shoulder movement, calves stretchers, etc. It is highly recommendable for the elderly to assist to these parks and get some stations done in order to maintain or improve their health.[52]

Long term care facilities and hospitals

Vitamin D supplementation probably reduces the rates of falls (not the risk of falls) among people in long-term care facilities.[53]

Although multifactorial interventions and exercise interventions in care facilities seem to be beneficial; more robust evidence is needed to support them.[53]

There's uncertainty on the effectiveness of exercise interventions in subacute hospital settings at reducing falls in older adults, the same holds true for multifactorial interventions in hospitals.[53]

Support from close people

Family and friends become a really important source of energy and motivation to the elderly. They support them and help them so they can get adapted to this new stage and so that they can be aware of the risks they are taking by not doing things right. They would discuss the elderly person's health conditions, medications, and any concerns that the person might have. Not having support such as family or a close friend usually leads to bad consequences like falls, hits, injuries, and in some cases death. This is due to the fact that the person is not being supervised or check frequently and just a small move or decision can cause big problems. So it is important for the elderly to always have someone to contact that is aware all the time of the patient's situation.[54]

See also

References
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Further reading
  • Lord, Stephen R.; Sherrington, Catherine; Menz, Hylton B.; Close, Jacqueline C. T. (March 2007). Falls in Older People: Risk Factors and Strategies for Prevention. Cambridge University Press. ISBN 978-0-521-68099-8.
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