By Daisy G. Ciocon, PhD, and Jerry O. Ciocon, MD
The Fall Factor Understanding the causes of falls and a well-developed gait and balance program may prevent falls in older adults but more research needs to be done. Falling among older people is a challenging problem with potentially serious consequences and morbidity.1 Fall-related events are among the leading causes of death among the elderly.2 An older person who falls is also at significant risk for disability and injury and, consequently, institutionalization.3 Functional disability4 and gait patterns in relationship to ground surfaces and shoes5 have been documented as key intrinsic factors that place an elderly person at risk for falling.6 Because recurrent fallers are most likely to experience injury from repeated episodes, they constitute an important target group for diagnostic and preventative efforts. Practical and Clinical Tools to Determine Risk of Falling The gait and balance activities performed when doing a mobility assessment using the Tinetti scale7 include direct observation of sitting balance; the ability to rise from sitting to standing position; immediate stance on standing; balance with eyes closed; movements of the lower extremities, arms, and trunk while walking; and ability to sit down without support. Sitting and standing balance provide objective information about tendency to fall and prognosis with gait training during physical therapy. For example, an older person who had a stroke with complete hemiplegia and poor sitting balance will most likely require total assistance in activities of daily living and predictably become wheelchair-bound. Similarly, an older person with difficulty getting out of a chair and with an inability to stand steadily is considered to have poor balance and will most likely fall or have fallen in the past. Observing for foot drop can also determine the cause of falling. Certain abnormal reflexes including the palmomental reflex, snout reflex, and glabellar signs are objective abnormalities due to cerebral (frontal lobe) dysfunction and predispose one to falling. Contusion, hematoma, and bone deformities are other subtle signs of previous injuries due to falls and elder abuse. Certain biomechanical equipment can actually measure specific body, leg, and foot movements that may explain difficulties with gait and balance. They can provide measurements of range of motion and muscle strength, and define certain weaknesses that will predispose to falling. Determining Risk Factors External factors that indicate fall risk include poor or excessive lighting, loose carpets, and cords; fragile support structures, eg, antique furniture that older persons hang on to; use of standard low toilet seats; and slippery floor surfaces. Intrinsic factors are the inherent body weaknesses that predispose an older person to falling, which include poor eyesight, prolonged time to adapt to dark environment, hearing difficulties, leg weakness, joint pains, leg swelling, foot drop, and distal neuropathy. A combination of these abnormalities are common in older persons and, when combined with external factors, lead to the event of falling. Recognition of these risk factors may help minimize falling and prevent serious injuries. Home visits by occupational therapists and specific physical therapy to strengthen balance and improve gait have been shown to minimize further falls but more controlled and long-term studies are needed. Remedies to Improve Gait and Balance Proper walking technique with the guidance of physical and occupational therapy including specific muscle strengthening exercises has been shown to improve mobility and minimize falling.8 Use of walking aids such as canes, hemiwalkers, and rolling walkers, with proper instruction, theoretically should improve mobility and prevent further falls. However, patient compliance due to the inconvenience of using these devices, and the labeling of frailty that goes along with it, may lead to further falls. An ankle foot orthotic (AFO) device will prevent excessive plantar flexion in those with foot drop and will help prevent falls. Specific physical therapy programs usually include: 15 minutes of flexibility exercises; 30 minutes of mattress exercises; 15 minutes of parallel bar exercises; pelvic tilt, hip extensors, quads sets, and ankle exercise; heel strike, foot stride; falling exercises, ie, proper falling recovery; and home exercise program instructions. This specific physical therapy program is usually augmented with muscle strengthening exercises particularly for the big muscle groups in the lower extremities and the main muscle groups that control movements of the ankle and feet. Proper falling techniques and an efficient way of getting up from the ground are also important parts of the physical therapy program. An older person has less injury if the fall is forward instead of backward. Forward fall is usually associated with upper extremity injuries while backward falls lead to serious head injuries and pelvic and/or hip fractures. Recognizing external factors and detailed improvement of the environment may further prevent falls. A thorough home inspection provided by an occupational therapist (a Medicare-covered service) will help define and correct environmental hazards for falls. A home physical therapy program will augment the safety hazard corrections performed by the occupational therapist. Installation of a raised toilet seat, appropriate grab bars in the bathroom and hallways, and improving lighting fixtures are a few specific examples of improvements to the environment. The emphasis on abnormal internal factors, eg, poor visual acuity, arthritic conditions, leg edema, muscle weakness, and sensory deficits, will make an older person aware of these dysfunctions that may predispose them to falling. Symptomatic improvement of these disorders may also help with the improvement of balance and prevent falls but there is no data yet to support this. Both the internal and external factors play a role in the causation of falls in older persons. Although fear of falling may persist after a serious fall, the compliance of older persons with the use of walking devices (walkers, canes) is low. Furthermore, a planned intensive physical therapy home program may not always be performed as outlined by the therapist for whatever reason. These factors may explain why the outcomes of physical therapy to prevent further falls are not always positive. Further studies looking into long-term effect of gait training during physical therapy and occurrence of falls in older persons need to be done. References 1. Brown A. Reducing falls in elderly people: a review of exercise interventions. Physiotherapy Theory Practical. 1999;15:59-68. 2. US Bureau of the Census. A Current Population Report, Special Studies: Total Nursing Home Residents, 1990: 65 Plus in America. Washington, DC: US Bureau of the Census; 1992. P23-P178. 3. Bezon J, Eschevarria K, Smith G. Nursing home indicator, preventing falls for elderly people. Outcomes Management Nursing Practice. 1999;3:112-116. 4. Stewart RB, Moore MT, May FE, Marks RG, Halle WE. Nocturia: a risk factor for falls in the elderly. J Am Geriatr Soc. 1992:40:1217-1220. 5. Dunne RG, Bergman AB, Rogers LW, Inglin B, Rivara FP. Elderly person’s attitudes toward footwear—a factor in preventing falls. Public Health Report 108. 1993;2:245-248. 6. Whedon MB, Shedd P. Prediction and prevention of patient falls. Image: Journal of Nursing Scholarship. 1989;21(2):108-114. 7. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-827. 8. Galindo-Ciocon D, Ciocon JO, Galindo DJ. Gait and balance training and falls in the elderly. J Gerontol Nurs. 1995;21:10-17. Daisy G. Ciocon, PhD, is a nurse researcher at Veterans Affairs Medical Center, Miami, and associate professor, Florida International University. Jerry O. Ciocon, MD, is chief of staff, Department of Geriatric Medicine and associate chief of staff, Department of Internal Medicine, Cleveland Clinic Florida, Weston, Fla.
