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Fall prevention

Dr.Ahmed M RashadPGY1 Family Medicine

+Objectives

To know the causes of fall in elderly population

To outline Fall risk assessment

To outline fall preventive measures

+Introduction

Each year, one out of three adults age 65 and older falls, according to the CDC.

In 2000, falls among older adults cost the U.S. healthcare system more than $19 billion

Falls are equally common between men and women, but were more likely to result in injury in women.

+Causes

Medical Risk factors

Impaired musculoskeletal function, gait abnormality and osteoporosis

Cardiac arrhythmias (irregular heartbeat), blood pressure fluctuation

Depression, Alzheimer's disease and senility

Arthritis, hip weakness and imbalance

Neurologic conditions, stroke, Parkinson's disease, multiple sclerosis

Vision or hearing loss

Side effects of medications

+ Personal Risk Factors

• Age. The risk for a fall increases with age. Normal aging affects our eyesight, balance, strength, and ability to quickly react to our environments.

• Activity. Lack of exercise leads to decreased balance, coordination, and bone and muscle strength.

• Habits. Excessive alcohol intake and smoking decrease bone strength. Alcohol use can also cause unsteadiness and slow reaction times.

• Diet. A poor diet and not getting enough water will deplete strength and energy, and can make it hard to move and do everyday activities.

Risk Factors at Home (e.g. Slippery floors)

+Prevention

Falls in older persons occur commonly and are a major factor threatening the independence of older individuals.

Falls often go without clinical attention for a variety of reasons:

①The patient never mentions the event to a health care provider;

②There is no injury at the time of the fall

③ The provider fails to ask the patient about a history of falls; or either provider or patient erroneously believes that falls are an inevitable part of the aging process

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+Evaluation of patients at risk History

a. Several studies report that the most important consideration in the history is a previous fall, which places the patient at increase risk of future falls

b.For patients presenting with a fall, important components of the history include the activity of the faller at the time of the incident, prodromal symptoms, and where and when the fall occurred.

Physical Examination

Comprehensive examination including vital signs, visual acuity, cardiovascular and examination of extremities.

+ Muscloskeletal function

• 'Get Up and Go' test — The test is performed by observing the subject rising from a standard arm chair, walking a fixed distance across the room, turning around, walking back to the chair, and sitting back down. Observation of the different components of this test may help to identify deficits in leg strength, balance, vestibular dysfunction, and gait.

Diagnostic testing

• Laboratory tests such as a hemoglobin concentration and serum urea nitrogen, creatinine, and glucose concentrations can help to rule out causes of falling such as anemia, dehydration, and dehydration and autonomic neuropathy related to diabetes. Serum 25-hydroxyvitamin D levels can identify individuals with vitamin D deficiency who will benefit from vitamin D supplementation.

+Exercise Multiple meta-analyses of randomized trials conducted in various populations find that general exercise reduces the risk of falls, and that exercise programs that include balance components are most effective.

Exercise interventions can be grouped into six categories:

• Gait and balance training

• Strength training

• Flexibility

• Movement (such as Tai Chi)

• General physical activity

• Endurance

+ Exercise classes incorporating multiple categories of exercise reduced the risk of falling (risk ratio, RR 0.85, 0.76-0.96)

Home-based exercises that included more than one type of exercise also decreased the fall rate and fall risk.

In one trial, a program that integrated balance and strength training into everyday home activities resulted in a 31 percent decrease in the rate of falls (RaR 0.69, 95% CI 0.48-0.99) and was more effective than a structured exercise program done three times a week.

+Medication modification

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.

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. (http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf)

+Vitamin D supplementation

Although the evidence is not definitive, because of low risk of harm, we suggest that older patients be given cholecalciferol (vitamin D3) supplements for fall prevention, which can be given daily, weekly, or monthly with the dose adjusted upward to achieve the dosing equivalence of at least 800 units daily.

Men and women over age 65 years with low serum 25-hydroxyvitamin D concentrations (<10 ng/mL [25 nmol/L]) are at greater risk for loss of muscle mass, strength, and hip fractures.

+Control 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.

It is useful to conduct a walk-through of the home to identify possible problems that may lead to falling. A home visit by occupational therapist might also be useful to identify risk factors and recommend appropriate actions.

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+Resources Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons

living in the community. N Engl J Med 1988; 319:1701.

Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328:680.

Centers for Disease Control and Prevention (CDC). Self-reported falls and fall-related injuries among persons aged > or =65 years--United States, 2006. MMWR Morb Mortal Wkly Rep 2008; 57:225.

Centers for Disease Control and Prevention (CDC). Public health and aging: nonfatal injuries among older adults treated in hospital emergency departments--United States, 2001. MMWR Morb Mortal Wkly Rep 2003; 52:1019.

Nachreiner NM, Findorff MJ, Wyman JF, McCarthy TC. Circumstances and consequences of falls in community-dwelling older women. J Womens Health (Larchmt) 2007; 16:1437.

Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am 2006; 90:807.

Nickens H. Intrinsic factors in falling among the elderly. Arch Intern Med 1985; 145:1089.

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.

Hartholt KA, van der Velde N, Looman CW, et al. Trends in fall-related hospital admissions in older persons in the Netherlands. Arch Intern Med 2010; 170:905

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