June/July 2000

Reducing the Risk of Falls in the Elderly

By Linda B. Horn, PT, NCS

As the number of people 65 years and older increases, so does the number of people who fall. Approximately 30% of all community-dwelling elderly and 50% of nursing home residents aged 65 years and older fall each year.^1,2 The Centers for Disease Control and Prevention (CDC) reported unintentional injuries as the seventh leading cause of death in the United States in the 65 and over age group in 1997.³ Falls were listed as the primary cause of death in this category, which represented 9,023 fatalities (28.7% of the total number of deaths).⁴

There are both significant financial and personal costs after an individual falls and requires medical attention. Three percent of those 65 years and older who fall will sustain a fracture.⁵ Fall-related injuries in the elderly cost $20.2 billion in 1994 with the average cost at $1,400 per person.⁶

There was an increasing number of hospitalizations related to hip fractures in 1988-1996.6 A prospective study of community-dwelling elderly in Baltimore reported that the cost of a hip fracture was $37,250 (calculated in 1993 dollars) for the year following the fracture.⁷ When the expected medical costs, based on the subject’s use of health care services in the previous year, were subtracted from the total, the additional costs that were attributed to the hip fracture were approximately $16,300 to $18,700.

Risk Factors For Falls

Risk factors for falls are well identified in the literature (see Table 1, page 96). Studies done on risk factors for falls include both community-dwelling and institutionalized elderly individuals. Several studies found that a history of recent falls is a risk factor for subsequent falls.^8-10 Three or more falls are associated with an increased risk of an individual having multiple falls.⁹ More falls may also increase the risk for sustaining a hip fracture.¹⁰ An increased number of falls was noted in individuals who had recently been hospitalized.

Medications can increase the risk of falls in all elderly regardless of their living situation. Studies have shown that sedative use increases fall risk in both community-dwelling and institutionalized elderly.^8,12 Using four or more medications may also increase a person’s risk for falls.^8,13

A history of chronic lung disease, arthritis, Parkinson’s disease, and stroke has been shown to increase fall risk.^9,10 Incontinence and orthostatic hypotension have also been identified as increasing fall risk.^9,13 The presence of the palmomental reflex is identified as a risk factor since it may represent involvement of the central nervous system.¹² Race can also be a factor. Nevitt et al report that being caucasian was an independent predictor of more than two falls.⁹

Impairments that increase fall risk include decreased lower extremity strength, decreased range of motion, cognitive impairment, sensory impairments, visual deficits, and decreased reaction time.^8,12,13,14 Strength deficits in the hip, knee, and ankle increase fall risk.^8,13,15 Robbins et al reported that fallers, both community-dwelling and institutionalized, have more hip weakness, poor balance, and use more prescription drugs than nonfallers.¹³

In an institutionalized elderly population, Tinetti et al found that decreased spinal extension and decreased neck range of motion both increase the risk of falls in the elderly.⁸ Sensory impairments that may contribute to an increased risk of falling include decreased vibratory sense and proprioception.¹⁴ A number of visual deficits are risk factors including low contrast visual acuity and contrast sensitivity.¹⁴ Decreased visual fields and the presence of cataracts have also been associated with falling in the elderly.¹⁶

Functional limitations such as inability to perform activities of daily living (ADLs) and problems with mobility may indicate an increased fall risk.^8,9 Individuals who use assistive devices are at an increased risk of falling.^8,11 Tinetti et al identify several balance and gait characteristics associated with an increased risk of falling.¹² Balance impairments include unsteadiness during stand to sit, turning, and after a sternal nudge. An inability to do single limb support is also more prevalent in fallers.

Gait impairments that identify fallers include increased trunk sway, inability to increase speed of walking, and more path deviations. Lord et al were able to discriminate fallers with more than one fall by the amount of postural sway present when the subject was standing on foam with eyes open.¹⁴

Since no one study has looked at all of the identified risk factors, these factors can not be ranked by importance. It may not be possible to screen individuals on all of the possible risk factors in the clinical setting due to time constraints.

Identifying Those At Risk

Identifying elderly individuals who are at risk for falling can be partially accomplished through screenings. Ideally, a screening should be quick to perform, inexpensive, transportable, and reliable. Commonly used tests for screening elderly individuals include Single Limb Support, Functional Reach, and the Timed Up & Go.^17-20 These tests are easy to perform in any setting and require little or no equipment. However, these tests may miss individuals with higher level deficits who still may be at significant risk for falls.

If available, force platforms can objectively identify balance deficits. These systems are generally expensive and require the individual to travel to where the equipment is located; however, force platforms may identify deficits not identified by other tools. In general, it is important to consider the population being screened, where the screening will take place, and time constraints. At present, there is no single screening tool or set of tools that has been established as the gold standard.

Another way to identify and examine this population is by establishing a balance clinic or center, where multidisciplinary examinations are performed and the team can consult each other to determine an appropriate intervention. Team member disciplines that may be included as part of the clinic or as referrals by the clinic include a neurologist, physiatrist, gerontologist, physical therapist, occupational therapist, audiologist, social worker, pharmacist, psychiatrist or psychologist, podiatrist, dietician, and nurses.

Selecting the Most Effective Intervention

Identifying risk factors is only part of a risk reduction plan. The next task is to identify which interventions will be effective in reducing risk based on the presence of specific risk factors. In 1994, Tinetti et al reported a significant decrease in the risk of falling when an intervention program focusing on specific risk factors was completed.¹ The study identified community-dwelling elderly persons who had at least one of the following risk factors: postural hypotension, use of sedatives, use of four or more prescription medications, inability to transfer, impairment of balance or gait, and impairment of upper or lower extremity strength or range of motion.

Each program was individualized to meet the needs of the subject. The interventions included education, adjustment of medications, and/or exercise programs specific to the impairment(s) that were present. During the follow-up period, the group who received intervention had less falls and less risk factors present.

Another important study is the trials that comprise The Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT). The FICSIT trials provide important information on the effectiveness of various interventions. Different types of exercise programs were studied at various sites throughout the United States along with other interventions such as nutrition and the use of hip pads. The conclusion from the meta-analysis of the results of all of the studies was that the number of falls decreased when balance training was part of the treatment protocol.²⁷ The types of balance training included balance exercises, tai chi, and the use of force platforms. Fall risk was significantly decreased in the group of subjects that performed tai chi.²⁸

Therapists may believe that it is unrealistic to use the strategies developed in the research protocols in the clinic. For example, in the study of community-dwelling elderly by Tinetti et al, physical therapy was conducted in the subject’s home. This may not be feasible if the subject is not homebound by Medicare regulations. Some of the exercise programs in the FICSIT studies are done for 10-36 weeks, which is longer than skilled care can usually be justified. While therapists may not be able to incorporate all aspects of the research into their practices, it may help guide therapists in choosing the most effective examination and intervention techniques.

Linda B. Horn, PT, NCS, is the inpatient physical therapy coordinator for St Agnes Healthcare, Baltimore.

References

1. 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.
2. Falls in Nursing Homes (Factsheet). Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 1999. US Department of Health and Human Services.
3. 10 Leading Causes of Death, United States, 1997, All Races, Both Sexes. Atlanta: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 1999. US Department of Health and Human Services.
4. 1997 United States Unintentional Injuries and Adverse Effects. Atlanta: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 1999. US Department of Health and Human Services.
5. Falls and Hip Fractures Among Older Adults (Factsheet). Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 1999. US Department of Health and Human Services.
6. The Costs of Fall Injuries Among Older Adults (Factsheet). Atlanta; National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 1999. US Department of Health and Human Services.
7. Brainsky A, Glick H, Lydick E, et al. The economic cost of hip fractures in community-dwelling older adults: a prospective study. J Am Geriatr Soc. 1997;45:281-287.
8. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986;80:429-434.
9. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls. JAMA. 1989;261:2663-2668.
10. Cumming RG, Klineberg RJ. Fall frequency and characteristics and the risk of hip fractures. J Am Geriatr Soc. 1994;42:774-778.
11. Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J Am Geriatr Soc. 1994;42:269-274.
12. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701-1707.
13. Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D, Fine G. Predictors of falls among elderly people: results of two population-based studies. Arch Intern Med. 1989;149:1628-1633.
14. Lord SR, Ward JA, Williams P, Anstey K. Physiological factors associated with falls in older community-dwelling women. J Am Geriatr Soc. 1994;42:1110-1117.
15. Gehlson GM, Whaley MH. Falls in the elderly: part II, balance, strength, and flexibility. Arch Phys Med Rehabil. 1990;71:739-741.
16. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains eye study. J Am Geriatr Soc. 1998;46:58-64.
17. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45:735-738.
18. Bohannon RW, Larkin PA, Cook AC, Gear J, Singer J. Decrease in timed balance test scores with aging. Phys Ther. 1984;64:1067-1070.
19. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a clinical measure of balance. J Gerontol Med Sci.1990;45:M192-197.
20. Podsiadlo D, Richardson S. The timed Up & Go@: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-148.
21. Berg KO, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physio Can. 1992;41:304-311.
22. Tinetti ME. Performance-oriented assessment of mobility problems in elderly persons. J Am Geriatr Soc. 1986;34:119-126.
23. Shumway-Cook A, Woollacott M. Motor Control: Theory and Practical Applications.

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