Fighting Against Falls

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November 2001

By Maria H. Cole, OTR/L; Laura Ryan, OTR/L; Cheryl Adrean, PTA; and Julie Silver, MD

Fighting Against Falls

Proper assessment and ongoing education are important tools in the quest for fall prevention in the elderly.

Over the past year, two famous people experienced life-threatening falls. One resulted in a fractured hip, surgery, and recuperation at home. The other was more serious-a fatal head injury. Of course, we are speaking of Ronald Reagan and Katharine Graham, owner of the Washington Post. The fate of these celebrities highlights the risk of falls and their devastating effect.

Statistics Are Grim
The statistics are sobering. Approximately 35% of people over the age of 65 years experience one or more falls each year.¹ Nearly 70% of all emergency department visits by people over the age of 75 are related to falls.² Although the home is often considered the safest place, this is not true. More than 60% of falls occur in the home.³ As the population in the United States continues to age, preventing falls is paramount to keeping health costs down and preventing further disability of the elderly.

The causes of falls can involve both intrinsic and extrinsic factors. Intrinsic factors pertain to the individual's body, such as visual acuity, muscle strength, balance, and mental status. Medication changes, lack of sleep, or an acute illness can all affect mental status while cataracts or glaucoma can affect visual acuity. Extrinsic factors pertain to the individual's environment including stairs, clutter, and inclement weather.

At times, intrinsic and extrinsic factors may combine to contribute to a fall. For example, impaired mobility due to poor balance and decreased strength coupled with a set of stairs can cause a fall. Studies show that of falls that occur at home, 25% are caused by an extrinsic factor such as clutter or a slippery floor.⁴ Identifying both the intrinsic and extrinsic factors of a specific fall is important in eliminating the chances of a second incident. The following scenario illustrates how the above factors may coexist to contribute to a fall.

Doris is a 78-year-old widow living alone in a split-level ranch home where she has resided for more than 40 years. While she enjoys good general health, her vision is failing due to macular degeneration and she is stiffer due to osteoarthritis. She also has high blood pressure and suffers from chronic urinary tract infections (UTIs). She feels safe in her home, therefore she has made few modifications. She leaves the house daily and drives to the local market and to the mall.

Doris has experienced two falls in 2 years. One fall at home resulted in a fractured ankle. The other fall, in the local mall, resulted in torn cartilage in her knee, which required surgical repair. In Doris's case, her high blood pressure, chronic UTIs, decreased vision, and osteoarthritis are the intrinsic factors that contributed to her falls while the presence of stairs, scattered rugs, poor lighting, and community outings are extrinsic factors. Interestingly, fall prevention education or home modifications were never discussed during her rehabilitation programs at an outpatient facility.

Much has been studied about falls-why they occur and how to prevent them. Fear of falling is arguably one of the most important factors. It has been documented in 20%-50% of the general elderly population.⁵ Fear of falling can be just as debilitating as a history of actual falls. As people reduce the frequency or intensity of their activities due to a fear of falling, deconditioning, decreased social activity, and possible isolation result.

Falls Assessments
There are many scales and assessment tests designed to measure balance, vision, and strength and how those components relate to a fall. The Falls Efficacy Scale measures how confident the individual is when performing activities of daily living (ADLs).⁶ Other assessments include the Balance Self Perception Test, the Berg Balance Scale, and the Tinetti Mobility Assessment.⁶ They are reliable and can be administered easily by any clinician. While testing mobility and balance is important, assessing cognition and perception is essential in a falls prevention program. Studies have shown that altered mental status and impaired perception contribute to falls.⁷ The Mini Mental State Examination is one quick and effective tool for assessing cognition.

A comprehensive evaluation by both an occupational and a physical therapist should include a balance assessment, manual muscle test, and cognitive and perceptual/sensory assessment. Areas to focus on include the use of mobility aids, bracing, and home modifications. If a mobility aid is prescribed, does the individual know how to properly use it? If the individual wears a lower extremity brace, it should be inspected for wear and tear and the clinician should ensure that it is still appropriate. Education on the importance of daily inspection to ensure the brace's integrity should be provided. Recommendations on footwear including orthotics can be very helpful. Wearing well-fitted supportive footwear improves balance.

A comprehensive interview can yield a wealth of information. The interview should include questions such as "How many falls have you had in the last 6 months?" "Do you trip?" "When you do fall, do you fall backward or forward?" The clinician should ask about use of medications and inquire about dietary supplements. Consider using open-ended questions to determine the individual's comfort level with their abilities and whether fear has impacted their activities.

Determine whether there are any home modifications needed, particularly in the bathroom. A grab bar, raised toilet seat, and shower chair should be recommended. Many people, however, see bathroom equipment as giving into aging. Understanding this point of view is essential to gaining program compliance.

The next step is determining psychosocial status. Identifying the individual's values, interests, roles, responsibilities, and habits is important, as it will provide insight into how he or she will react to a proposal for change as well as foster a team-oriented feeling. Those who have specifically chosen to curtail an activity before an actual fall tend to have more satisfaction with their life's activities. This satisfaction leads to more confidence, which in turn, leads to less chance of falls. Questions regarding support systems and life roles are helpful in determining the individual's psychosocial status.
PREVENTION PROGRAMMING
The program to prevent falls is multifaceted with a focus on both improving clients' physical status as well as addressing their confidence level when performing ADLs. Ideally the program should include exercise and graded functional activities to foster confidence in their ability to ambulate safely. Exercises to improve balance flexibility and strength, as well as a walking program, will address the goal of improved physical fitness. Practical tasks simulating the chores done at home will allow them to realize their capabilities while offering the therapist an opportunity to give practical advice.

Educating the elderly on how a fall can drastically impair their ability to function is very important and should be ongoing. Consider providing a handout on home modifications including a checklist to evaluate how safe the home is. Whenever possible, schedule a home safety evaluation. Providing practical solutions and even completing simple modifications when possible are invaluable in facilitating the changes that will likely prevent a fall.

End Result
Unfortunately, Doris fell a third time, this time with more serious consequences. She suffered a closed head injury and required hospitalization. In the admitting interview at the rehabilitation hospital, Doris's family were distraught at the thought of possibly having to admit her to a nursing home. Doris was admitted for general rehabilitation with a fall prevention focus. She went for walks several times a day, at first on the floor where there were rails, and then outside around the grounds. She attended several groups: a balance group, an upper extremity exercise group, and a stabilization group that focused on strengthening her trunk and hip muscles.

She also attended homemaking and self-care treatments that were graded to build confidence and skills. It was determined that Doris would benefit from a cane. During her stay, she confided in the social worker and her therapists how her life had changed. Doris rarely saw her friends and was neglecting her volunteer position at the library because she was anxious she would fall. The week before her discharge home, Doris's team of therapists made a visit to her home to make recommendations. She was able to return there with much more confidence in herself and enjoy a safer environment due to the modifications made.

One of the integral components of a falls prevention program is empowerment. It is crucial that individuals be involved in all aspects of the program and be discharged feeling as though they can indeed make a difference in the safety of their lives. Using an open-ended question format, providing written information whenever possible, allowing time for the individual to problem-solve, providing a simple home exercise program, and engaging the patient in functional everyday tasks will allow the tools needed to take control. This approach will enable acceptance of change, boost confidence, and, in turn, likely decrease the likelihood of falls.

Although people grow older, they do not have to live with the limitations once thought to accompany aging. When implementing a falls prevention program that includes education, physical rehabilitation, home modification, and patient empowerment, the end result is many happy years of safe, productive, and fall-free living.

Maria H. Cole, OTR/L, is a senior staff occupational therapist; Laura Ryan, OTR/L, is an occupational therapist; Cheryl Adrean, PTA, is a physical therapy assistant; and Julie Silver, MD, is the medical director, all for the Spaulding-Framingham Outpatient Center in Framingham, Mass.

References
1. Cumming RG, Thomas M, Szonyi G, et al. Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. J Am Geriatr Soc. 1999;47:1397-1402.
2. Shumway-Cook A, Gruber W, Baldwin M, Liao O. The effect of multidimensional exercises on balance, mobility, and fall risk in community-dwelling older adults. Phys Ther. 1997;77:46-57.
3. Aiello D, Cole M, Ryan L, Silver JK. Safety in the home. Rehab Management. 2001;14(5):54-56.
4. Silver JK. Post-Polio Syndrome-A Guide for Polio Survivors and Their Families. New Haven, Conn: Yale University Press; 2001.
5. Peterson E, Howland J, Kielhofner G, et al. Falls self-efficacy and occupational adaptation among elders. Physical and Occupational Therapy in Geriatrics. 1999;16:1-17.
6. Tinetti M, Mendes de Leon C, Doucette J, Baker D. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49:140-149.
7. Benson C, Lusardi P. Neurologic antecedents to patient falls. J Neurosci Nurs. 1995;27:331-337.

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November 2001