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An Ounce of Prevention — Fall-Proofing Elders
By Diane A. Klein, PhD, and Sandra L. McGuire, EdD

As we age, both the risk and incidence of falls increase. But taking steps to assess risk and foster prevention can diminish the potential for devastating falls.

For older adults, falls are common and often life-altering events. Each year in the United States, more than one third of community-dwelling adults aged 65 and older experience falls, according to the Centers for Disease Control and Prevention (CDC). More than one half of those who fall have multiple fall episodes. Approximately 20% to 30% of falls result in moderate to severe injuries, including fractures, soft tissue and internal organ injury, dislocations, traumatic brain injury (TBI), and spinal injury. Many of these injuries impair elders’ mobility, reduce their ability to maintain independence, and frequently lead to early death. In more than 90% of elders whose hip fractures have been caused by falls, 25% die within six months to one year after the fall. It is estimated that each year nearly 16,000 older adults aged 65 and older die from fall-related injuries, with more than one half of those deaths due to TBI. Adults aged 75 and older account for nearly 85% of fall fatalities.

Every year, more than 1.6 million older adults visit emergency departments for treatment of fall-related injuries. The direct costs of fall injuries in older adults exceed $19 billion per year, and they are expected to increase to $54.9 billion by 2020. These costs don’t include the long-term effects from fall injuries leading to disability, loss of independence, lost time from activities at work and home, and reduced quality of life. TBI and injuries to hips, legs, and feet account for 78% of fall fatalities and 79% of the costs.

Women are more likely to fall—both fatal and nonfatal—and costs from falls in women are two to three times higher than those in men. According to the CDC, men have a 49% higher fall fatality rate than women, and women have a 67% higher nonfatal fall injury rate than men. In addition, those aged 75 and older are four to five times more likely to be admitted to long-term care for one year or longer following hospitalization due to a fall.

A 1995 study determined the likelihood of various settings contributing to injurious falls. These included standing or walking (63%), standing up and/or just standing after standing up (7%), sitting down (9%), risky tasks (4%), other known causes (15%), and unknown circumstances (2%). Among the other known causes are medications, chronic illnesses (Parkinson’s disease, diabetes mellitus, arthritis, previous myocardial infarction, stroke, or cancer), issues with activities of daily living, as well as vision, hearing, blood pressure, balance, and body mass.

Evaluating Risk
Falls don’t occur simply due to aging. However, the risk of falls increases with age. Individuals aged 75 and older, white non-Hispanic, housebound, and living alone are at greatest risk. Contributing factors include personal medical history and physical deficiencies, as well as environmental risks. 

Personal aspects placing an older adult at greater risk for falls are the use of a cane or walker, a history of previous falls, acute illness (e.g., pneumonia and urinary tract infection), and certain chronic conditions. Pain and neuromuscular disorders also play a role. Medications are a factor too, particularly if the individual is using four or more prescription drugs where the risk of side effects and interactions increases. Cognitive impairment, reduced vision and vision changes, difficulty rising from a chair, foot problems, neurological changes (including postural stability, reaction time, and sensory awareness), gait and balance changes, and hearing and speech impairments are all fall risks. Those with poor balance or walking difficulty are more likely to fall. Further contributing to fall risk is the fear of falling. Individuals who have a history of falls and/or fall-related injury have a higher rate of repeat fall episodes. This occurs because older adults with a fear of falling may limit their activities, reducing mobility and physical capability, leading to an increased risk for falling.

Assessing for Falls
Regardless of whether an individual has a fall history, assessing fall risk is essential. Individuals who have fallen repeatedly or have had near-fall episodes may be reluctant to share the details. They may be embarrassed by the circumstances surrounding the fall or may be concerned about loss of independence. Among the many assessment techniques available, some of the more useful ones are: POEMS, SPLATT, the “up-and-go” test, and the Tinetti Gait and Balance Assessment.

In addition to evaluating medical history, the POEMS assessment should include evaluating a Performance-Oriented Environmental Mobility Screening, and a clinical evaluation. The individual’s living environment needs to be assessed for fall risks. Evaluation focuses on visual impairments, postural hypotension, reduced lower extremity strength, impaired gait and balance, impaired mobility, use of ambulation devices, bladder dysfunction, altered cognition, polypharmacy, and the use of sedatives, psychotropics, hypnotics, and antihypertensive drugs.  POEMS assesses balance maintained in sitting and rising from a bed, chair, and toilet; standing balance; ability to bend down from a standing position; and ability to ambulate in the bedroom and bathroom. Transfers and ambulation maneuvers should be tested with and without assistive devices. By testing capacity in various locations, POEMS accounts for the dissimilarity of space limitations, ground surfaces, and illumination of space, and the differences in risk.

When reviewing fall history, employ the SPLATT acronym for evaluation. Consider Symptoms experienced at the time of the fall(s); number of Previous falls; Location of the fall(s); Activity at the time of the fall(s); Time of day the fall(s) occurred; and physical or psychological Trauma associated with the fall(s). This evaluation helps determine how falls might be prevented and what interventions are appropriate.

The modified up-and-go test, a quick and easy method of determining fall risk, examines dynamic balance through a performance-oriented test. Directions for scoring and setup of this test can be found in Section 10 at here.

Another relatively easy set of tests for fall risk is the Tinetti Gait and Balance Assessment. Assessment sheets, directions, and safe administration protocols can be found at here and here.  Using the gait and balance assessment sheets provides a means of recording observations and scoring the results.  The assessment sheet guides the scoring for each component for gait and balance. Higher scores indicate less fall risk.

Reducing Risk
Regular exercise is one of the most important ways to reduce fall risk because it builds strength and helps elders feel better, both physically and mentally. Tai chi and other exercises focused on improving balance and coordination are most helpful, but any exercise increasing strength, endurance, and flexibility provides improved physical function for balance and coordination. The use of a cane or walker may be necessary for balance and security. Elders should use handrails on stairs for guidance and support. Wearing rubber soled, low-heeled shoes that support feet and are not slippery adds to the security of walking with reduced fall risk.

Reviewing prescription and over-the-counter medications enables identification of potential interactions and adverse effects. As individuals age, the way their bodies metabolize medications changes, affecting medications’ impact. Side effects of medications can affect coordination and balance. Check blood pressure in both lying down and standing positions to detect orthostatic hypotension, which can make a person dizzy and prone to falls.

Vision changes occur over time for everyone. Annual eye examinations may prevent wearing the wrong eyeglasses or detect conditions such as glaucoma or cataracts that limit visual acuity. Poor vision contributes to balance problems and increases the likelihood of falls.

Since more than 60% of all falls occur in the home, a home safety assessment can limit falls due to obstacles, loose carpet or rugs, slipping on slick surfaces, or falling from step ladders or stools. It’s important to ensure proper lighting, provide grab bars, and remove cords and wires from traffic areas. Also, chairs with arms are much easier for elders to use.

Osteoporosis increases an elder’s risk for falls and fractures. Keeping bones healthy is an important part of fall prevention. Osteoporosis makes bones thin and more porous, diminishing bone mineral density and creating microarchitectural deterioration of bone. Spontaneous fractures due to osteoporosis may actually cause a fall or bone thinning from osteoporosis may increase the fracture outcome after a fall. DEXA and ultrasound exams can diagnose osteoporosis and its precursor, osteopenia. An estimated 28 million Americans are affected by osteopenia or osteoporosis. Current medications for osteoporosis can help to rebuild and maintain bone mineral density, making bones stronger and preventing bone fractures. Mild weight-bearing exercise and supplemental calcium intake can aid in slowing bone loss due to osteoporosis.

Proactive Professionals
Numerous resources exist for healthcare professionals’ evaluations and interventions related to falls. The Falls Free Coalition includes more than 455 organizations using a collective approach to promote a national fall-prevention action plan. The Fall Prevention Center for Excellence works to identify best practices in fall prevention and help communities offer fall-prevention programs to older adults who are at risk of falling. Local health departments and Area Agencies on Aging may participate in fall-prevention activities or know of additional resources that can be helpful to your clients.

Health professionals can explore locally available programs or become the lynchpin for developing such programs. The CDC offers grants, and working with other stakeholders to create community programs presents the opportunity to become an active advocate.

— Diane A. Klein, PhD, is a gerontological health education and exercise program consultant for Klein Consulting in Knoxville, TN. She previously taught and coordinated the interdisciplinary programs in gerontology at the University of Tennessee in Knoxville.

— Sandra L. McGuire, EdD, is a gerontological nurse practitioner and a professor and the chair of the Master of Science in Nursing Program at the University of Tennessee in Knoxville, where she teaches in the interdisciplinary gerontology minors.