News


2006-06_04-1

After the Fall

Falls can have devastating consequences, including fractures and limited mobility. The statistics related to falls are quite alarming, especially when they are applied to the elderly population. According to the Centers for Disease Control and Prevention (CDC), more than 33% of adults aged 65 or older fall each year. The majority of fractures seen in this vulnerable population are caused by falls.1 In addition, it is estimated that many falls are under-reported due to ignorance and fear. Many older adults may assume that falling is a natural occurrence during the aging process. Others may fear that telling their family or health care providers may lead to loss of independence or placement in a nursing home.2 As many physical therapists work with an older population, knowledge concerning falls is essential for providing optimal care and treatment.

Due to reimbursement issues and lack of awareness of both patients and health care providers, PTs usually see an individual following the fall. In this common scenario, the patient has fallen and sustained some type of trauma injury. In the case of a fracture, the treatment priority would evolve around mobility issues during the healing process. Attention would be given to any associated soft tissue injuries. As the PT assesses the acute problems, he or she must also investigate potential causes of the fall.

ASSESSMENT

A thorough patient assessment includes many components. One critical component is the fall history. Investigating the fall and its unique characteristics can greatly help the PT develop a comprehensive treatment plan. PTs must try to determine the factors that facilitated the falling event. Important details to consider include the fall’s location and the time of day when it occurred. Many questions will need to be answered. Was the fall associated with a particular activity or set of symptoms? Was there any precipitating event prior to the fall, such as an episode of vertigo? Can any trends be identified for individuals experiencing multiple falls? Are any witnesses available to add information to the fall history? Is there any evidence of substance abuse or domestic violence? The particular circumstances surrounding the fall can provide clues to the subsequent treatment and prevention of future falls.2

The PT should then collect data on any prior or current medical conditions. Many medical conditions, including cardiovascular, neurological, and orthopedic diseases, may predispose a patient to experience falls. All prescription and over-the-counter medications should be noted. Special attention should be given to the number of medications, their side effects, and their potential interactions. The patient should be referred back to the physician if medication is suspected of contributing to the fall.

The physical examination would include range-of-motion, sensation, and strength tests. Vital-sign monitoring is necessary to identify such conditions as postural hypotension, which could promote falling. Mobility testing would include such activities as bed mobility and transfers. Integrity of the balance response should be assessed, including the visual, vestibular, and somatosensory systems. Use of functional balance testing can provide baseline data and also help determine the continued fall risk. The patient’s cognitive state and overall mood should be assessed, as depression or dementia may be a contributing factor to fall events.2 In the ideal situation, a home assessment would be included in the initial examination visit, during which environmental hazards could be identified.

TREATMENT

Once all of the patient data has been collected, comprehensive treatment plans and rehabilitation goals can be established. Patient and family education related to safety awareness and fall-prevention strategies should be introduced and again stressed during treatment activities.

One important issue to address is fear of falling. This fear has been reported by individuals who have fallen and those who have not. This serious condition can lead to an elder restricting their activities and limiting social interaction.3 This cycle of inactivity leads to weakness and immobility, which further enhances fall risk. The CDC has identified lower-extremity weakness and gait disturbances as two major modifiable risk factors associated with falls.1 As fear of falling might be a consideration, PTs must chose their words carefully—in an attempt to educate, they must use care not to further promote this fear, but rather empower the patient with information. Our patients should be encouraged to develop confidence in newly learned mobility skills.

Therapeutic exercise programs should address areas of deficit indicated during the examination and evaluation process. Home exercise programs should be created with adherence issues in mind. The program should be meaningful to the patient to promote successful completion. Therapeutic activities can challenge balance systems. Training in activities of daily living (ADLs) can promote balance improvements along with postural recovery. Gait training on various surfaces can promote safe ambulation and increase confidence. Use of an assistive device may be indicated. The patient must be made aware of the proper fit, use, and maintenance of the chosen assistive device.

Although fall prevention remains an important issue throughout all treatment procedures, another fall may occur. Therefore, fall recovery must also be incorporated into the plan of care. Floor-transfer training should be included in transfer training whenever it can be safely performed. In the event that floor-transfer training is not appropriate, alternate procedures must be considered. Patients who live alone would benefit greatly from having some type of emergency alert system in place. In the event of a fall, help could be summoned.

As therapists, we have all treated patients who fell and were on the floor for extended periods of time before being discovered. This delay in medical care can encourage additional complications related to the fall. The associated cost of an emergency alert system would be well worth the improved safety and peace of mind. If the patient’s income prohibits the purchase of a commercial emergency alert system, then use of portable phones and/or “check-in” visits or calls from friends and family might be suitable alternatives for frail elders who live alone. In my experience, I have encountered different community agencies that provide daily calls to vulnerable residents.

Home modification is another important component to the overall treatment plan. Removing environmental hazards can greatly improve safety within the home setting. Safety checklists can be extremely helpful during a home visit so that all areas are assessed. Adaptive equipment such as shower seats and elevated toilet seats can help the patient complete ADLs. Installing grab bars and railings can promote safer transfers and ambulation. All adaptive equipment must be appropriately fit to the patient, and the patient must be instructed on its proper use. As technology changes, it is helpful to review equipment catalogs and visit medical supply stores for updated products. Local vendors are a great resource for reimbursement information. Providing appropriate lighting, as well as properly fitting clothing and appropriate footwear can also reduce trip hazards.

Compliance issues need to be sensitively addressed, as some older adults do not have the financial or physical resources necessary to implement these environmental changes. For example, an individual who rents a home may not be able to make any permanent home modifications. In addition, some older adults may not even perceive the hazards.2 This situation presents challenges for the PT. Education and creativity become key elements in promoting safety for patients at risk for falls.

Research indicates that fall-prevention activities do have a positive impact. A study by Campbell et al with women aged 80 and older indicated that an exercise program that included strength, balance, and walking activities produced a decreased fall rate over a 2-year period. Each participant in the group was given an individualized program designed by a PT.4 Another study by Means et al indicated that a 6-week exercise-intervention program also reduced the incidence of falls and associated injuries. This study provided the intervention group with a progressive program of stretching, strengthening, postural control, walking, and coordination activities geared toward the elderly participants. All exercise sessions were supervised by a PT.5 Other research that studied the use of tai chi by community-dwelling older adults demonstrated positive findings. Individuals in the tai chi group had a reduced fall risk, compared to the control group.2 Community group activities also provide social interaction and support.

RESOURCES

The Internet has made information retrieval much easier for both patients and PTs. Multiple peer-reviewed journal articles are available. The CDC has developed “A Tool Kit to Prevent Senior Falls,” which includes information about fall research findings.6 The National Safety Council has various articles and resources concerning fall prevention on its Web site.7 The American Physical Therapy Association publishes several consumer-education brochures and other public relations items.8 These items may be purchased and used for educational opportunities such as community health fairs, in addition to direct patient-care activities.

This brief discussion of physical therapy intervention following a fall outlines many issues the patient and PT must address. One future goal for PTs should include community education surrounding fall-prevention principles. Physicians and other health care providers should be encouraged to screen older adults to assess their fall risk. An article by Shobha Rao, MD, looks at falls from the physician perspective. This article summarizes fall-prevention activities, including the identification of risk factors, medical and pharmacologic management, exercise, home assessment, use of hip protectors to reduce the fall impact, and rehabilitation.9 This article supports a team approach to fall prevention and post-fall treatment. I am hopeful that one day our third-party payors will discover the value of early physical therapy intervention and stress fall-prevention activities.

Lisa Roberts, PT, MS, GCS, is a geriatric clinical specialist and a clinical assistant professor at Florida International University, Miami.

REFERENCES

  1. Centers for Disease Control and Prevention. Falls and hip fractures among older adults. Available at: www.cdc.gov/ncipc/factsheets/falls.htm. Accessed August 29, 2005.
  2. Tideiksaar R. Falls. In: Bonder BR, Wagner MB, eds. Functional Performance in Older Adults. 2nd ed. Philadelphia: FA Davis Co; 2001:267–286.
  3. Legters K. Fear of falling. Phys Ther. 2002;82:264–272.
  4. Campbell AJ, Robertson MC, Gardner MM, et al. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age and Ageing. 1999;28:513–518.
  5. Means KM, Rodell DE, O’Sullivan PS. Balance, mobility, and falls among community-dwelling elderly persons: effects of a rehabilitation exercise program. Am J Phys Med Rehabil. 2005;84:238–250.
  6. Centers for Disease Control and Prevention. A tool kit to prevent senior falls. Available at: www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm. Accessed August 23, 2005.
  7. National Safety Council. Falls in the home. Available at: Link no longer available. Accessed August 23, 2005.
  8. American Physical Therapy Association. Consumer awareness. Available at: www.apta.org/AM/Template.cfm?Section=Consumer_Awareness. Accessed August 30, 2005.
  9. Rao SS. Prevention of falls in older patients. Am Fam Physician. 2005;72:81–88.