Falls occur more frequently as individuals age due to variables such as decreases in strength, loss of flexibility, and changes in vision.

Falls occur more frequently as individuals age due to variables such as decreases in strength, loss of flexibility, and changes in vision.


by Donna Bainbridge, PT, EdD, AT-Ret, CIFT

“It happened so fast that I do not know how I fell.” This is a frequent refrain spoken by those who fall, as falls do often occur without expectation. A fall is an unexpected event resulting in a person finding themselves on a lower supporting surface, either a chair or the floor.

Epidemiology of Falls

The number of falls in persons aged 65 years and older, especially injurious or fatal ones, have risen sharply in recent years. One in four Americans aged 65 years and older falls each year1; if someone has fallen, their chance of falling again is doubled.2 One of five falls causes serious injury, so more than 3 million older people are treated in emergency departments for fall injuries each year.3

Hospitalizations of more than 800,000 patients were related to a fall-related injury4,5 with 300,000 related to hip fracture.6 One of every 200 falls results in hip fracture in the 65- to 69-year-old group with this rate increasing to 1 in 10 for those who are 85 years+.

Deaths among older adults caused by falls increased 30% from 2007 to 2016, so that the anticipated mortality rate will be seven fall deaths per hour by 2030. When assessing the very old (75+ years), analysis of US vital statistics demonstrated an increase in fatal falls from 8,600 in 2000 to 26,440 in 2017.

Falls among people with disability at younger and older ages are also a significant issue. Researchers noted that fall risk increases with the number of chronic conditions or co-morbidities including arthritis, cancer, pulmonary disease, diabetes, depression, heart disease, hypertension, or stroke.7 Also, chronic diseases increase fall risk secondary to polypharmacy, limited activity and changes in sensation and strength.

Adults aging with intellectual disability have falls rates three times higher than other elders.8 Their lower bone mineral density puts them at greater risk for fracture.9 Likewise, people with dementias and Alzheimer’s disease are twice as likely to fall,10 secondary to gait deficits and decline in postural control.11,12,13

People with multiple sclerosis demonstrated falls rates of >50%,14,15 as do people diagnosed with Parkinson’s disease.16 People who have sustained a stroke also have a greater fall risk,17 most frequently when walking.18,19

While many falls do not result in injury, 47% of fallers cannot get up without assistance and spend some time immobile on the floor.

Cost of Falling

The cost of falls is enormous. Total medical costs totaled more than $50 billion in 2015 with Medicare and Medicaid funding 75% of these costs20; $12.5 billion were out-of-pocket expenses. Costs are expected to increase to $67.7 billion by 2020. Medical expenditures for women were 2-3 times higher than men.21 The personal cost of falls is also high, resulting in fear of falling with reduction in activity and loss of independence.

Why People Fall More Frequently As They Age

Decreases in strength, particularly lower extremity and core muscles, contribute. Loss of flexibility and endurance, as well as changes in vision, also impact fall risk. Less balance secondary to age-related changes as well as medications and vision can further increase fall risk. Foot pain or poor footwear can contribute to poor balance. Deficiency in Vitamin D is also a factor.

Where Falls Most Frequently Occur

Data from the 1997-1998 National Health Interview Survey show that 55% of fall injuries among older persons occur inside the house; 23% occurred outside the house, and 22% happened away from home.22 In residences with no stairs, falls most frequently occurred in living rooms (31%), bedrooms (30%), kitchens (19%), bathrooms (13%), and hallways (10%).

How to Lower Risk or Prevent Falls

Falls are not an unavoidable consequence of aging. Risk assessment, lifestyle adjustments, and fall prevention programs and strategies can substantially decrease the risk of falling among both elders and persons with disability.

Fall Risk Assessment

Screening tools that can either be self-administered or provided by minimally trained medical staff can be utilized to assess fall risk. These tools, validated in broad populations, can identify low, moderate or high fall risk. This risk assessment assists with definition of next steps, either simple home strategies, a fall prevention program, or further evaluation by primary practitioner or physical therapist. The most widely disseminated tool, developed by the Centers for Disease Control and Prevention (CDC), is “Stopping Elderly Accidents, Deaths and Injuries” (STEADI). This tool has been validated for community-dwelling elders who are ambulatory and able to respond to questions. Current research is now validating this tool with other populations of older persons.

Elders who are independent can simply utilize the Stay Independent brochure developed by the CDC to self-assess their personal fall risks. This simple assessment will define not only risks but potential areas that need addressing, such as strength, balance, medication review, incontinence, or depression.

Home Assessment

Simple home assessments can be self-administered, or provided by a friend, family member, or caregiver. Both tools below are available online at no cost and can guide a home assessment so that it is an orderly learning process.

The most available assessment is AARP Home Fit Guide. This free assessment evaluates both home livability and safety, provides ideas for change and resources to accomplish these changes.

The other home assessment is Home Safety Self-Assessment Tool (HSSAT), developed by the University of Buffalo. This tool provides a room-by-room assessment with a tally of hazards, how-to instructions for improvement, and tips for fall prevention.

Fall-Prevention Strategies

The CDC has created two brochures—“Check for Safety” and “What You Can Do”—that provide simple remedies and suggestions for increased safety.

Standard and Simple

Many simple and inexpensive home modifications can be made by the individual or family. Among the guides to home modifications are two made available by the CDC: “Check for Safety: A Home Fall Prevention Checklist for Older Adults,” and “What You Can Do to Prevent Falls.” Both documents can be accessed online and are available for download as PDFs.

General modifications to increase safety would include:

1) Lighting
• Install lights on stairways both inside and out. Motion-sensitive lights will come on when someone is on the stairs, saving on electricity. If switch operated, glow-in-the-dark switches should be installed on the top and bottom of the steps.
• Make home lighting brighter with bulbs that do not add glare.
• Place LED night-lights in hallways, bedrooms, and bathrooms.
• Position a lamp within arm’s reach of the bed for use at night.
• Store flashlights in defined places in case of power outages. Purchase several battery back-up lights in critical places like the bedroom and bath.
2) Stairs
• Install at least one railing on each stairway.
• If stairs are not carpeted, add nonslip treads to wooden stairs.
3) Bathroom
• Install grab bars strategically by the toilet and inside and outside the shower or tub.
• Place non-slip mats or strips on the floor of the shower or tub.
• Position rugs with non-slip backs outside the tub to keep the floor dry.
• Consider using a tub chair with a back if balance, strength, or dizziness are issues.
4) Floors
• Remove all throw rugs from the floors.
• Use two-sided carpet tape, non-slip backing, or tacks on any remaining rugs.
• Repair any loose carpeting or floorboards.
• Consider painting door sills a different, brighter color to avoid tripping.
• Immediately clean any spilled liquids or food.
5) Clutter
• Remove obstacles both inside and outside of the house that might cause tripping.
• De-clutter main living areas so that they are easy to navigate.
• Tie up or stash cords to lights or computers so they cannot be tripped on.
• Keep pet toys off to the side, not in the main walking areas.
6) Clothing
• Wear sensible, sturdy shoes that fit properly and cover the heel.
• Assure that all shoes have non-skid soles.
• Wear clothing that is not overly blousy or easy to entangle.
7) Room Arrangement
• Reassess the location of dishes, food, and cooking items in the kitchen, and store them within easy reach.
• Reassess the location of clothing in drawers and closets so they are easily reachable.
• Place shoes on an elevated shoe rack to eliminate bending.
• Position chairs for sitting to dress, if needed.
• Position a chair by the washer/dryer to sit in while doing laundry.
8) Safety Devices
• Use an assistive device, if needed and recommended by a healthcare practitioner. This might be a cane or walker, as indicated.
• Consider the use of a Personal Emergency Response System (PERS) to alert others if a fall occurs or assistance is needed.
9) General Medical
• Have vision checked regularly every year.
• Keep glasses handy on a neck chain.
• Attempt to do some regular exercise, either at home or in a class (tai chi or yoga).
• Ask the doctor to review medications regularly for side effects and interactions.
• Note new symptoms when walking or moving, such as dizziness, numbness, or shortness of breath. Communicate these to the healthcare practitioner so they can be evaluated.

Targeted

Targeted modifications are changes more specific to the individual situation that may have additional cost. For example, if a person uses a walker or wheelchair, doorways may be too narrow. Thus, key doorways must be widened or a special narrow device should be ordered. If an individual resides in a location that has snow and ice in winter, they need to consider the use of a device like YakTraks to walk safely outside. Likewise, electric heated mats for steps and entrances melt the ice and snow.

Costly and Complex

Occasionally, the reduction of fall risk necessitates more costly and complex modifications. The cost is worth the risk reduction and can often be partially covered by insurance.

The first example of a more expensive and complicated modification might be a ramp. Sometimes, stairs are just too dangerous or not navigable, so consideration of a ramp is a safer alternative. Ramps can be portable (such as aluminum ramps) and purchased or built to be more permanent. The angle of the ramp is important, so specifications for ramps can be found online. Manufacturers offer several configurations of aluminum ramps that are foldable and portable for residential and commercial spaces.

Another example might be a lift. If an individual has significant difficulty getting into and out of bed, chairs and shower, a lift can offer safety for both person and caregiver. Several types of home portable lifts are available. Several lifts permit the patient to bear weight on the foot with knees supported as they stand and transfer. Other lifts have an overhead bar that allows the patient to be lifted entirely in a sling for transfer. Finally, ceiling lifts can be installed over beds or tubs for lifting from chair to surface.

A stair lift may be another consideration for individuals who live in homes with stairs in which they wish to remain. However, their disability or age make these areas of the home either unsafe to access or inaccessible. The development of installable seated chair lifts for straight and curved stairways has provided a safe solution. Stair climbers also exist for moving a wheelchair up and down stairs both inside and out.

Finally, transportation solutions have also assisted elders and persons with disability to travel. Lifts for cars and trucks permit transportation of wheelchairs and scooters. Rotating swivel seat platforms make entrance and exit from a car seat easier, as do car transfer aids and bars. Turning automotive seats are the next level of easier and safer ingress and egress from vehicles and perhaps into a wheelchair. RM

Donna Bainbridge, PT, EdD, AT-Ret, CIFT, is Special Olympics Global Advisor for FUNfitness, Chair, WCPT Network on Intellectual and Developmental Disabilities, Adjunct Clinical Professor, University of Montana College of Health Professions and Biomedical Sciences, Consultant, University of Montana Rural Institute on Inclusive. For more information, contact RehabEditor@medqor.com.

References

1. Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged > 65 years – United States, 2014. Morb Mortal Wkly Rep. 2016; 65:993-998. DOI: http://dx.doi.org/10.15585/mmwr.mm6537a2.

2. O’Loughlin J, Robitaille Y, Boivin J_F, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137:342-354.

3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed August 5, 2016.

4. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall–related injuries in older adults. Am J Pub Health. 1992;82(7):1020–1023.

5. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma–Injury, Infection and Critical Care. 2001; 50(1):116–119.

6. Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov External. Accessed August 5, 2016.

7. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14(22).

8. Wilson B, Jones KB, Weedon D, Bilder D. Care of adults with intellectual and developmental disabilities: Down Syndrome. FP Essent. 2015;439:20-25.

9. Glick NR, Fischer MH, Heisey DM, Leverson GE, Mann DC. Epidemiology of fractures in people with severe and profound developmental disabilities. Osteoporosis Int. 2005;16(4):389-96.

10. Allan LM, Ballard CG, Rowan EN, Kenny RA. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS One. 2009;4(5):e5521.

11. Cedervall Y, Halvorsen K, Aberg AC. A longitudinal study of gait function and characteristics of gait disturbance in individuals with Alzheimer’s disease. Gait Posture. 2014;39(4):1022-1027.

12. Taylor ME, Delbaere K, Lord SR, Mikolaizak AS, Close JCT. Physical impairments in cognitively impaired older people: implications for risk of falls. Int Psychogeriatr. 2013;25(1):148-156.

13. Taylor ME, Lord SR, Delbaere K, Mikolaizak AS, Close JCT. Physiological fall risk factors in cognitively impaired older people: a one-year prospective study. Dement Geriatr Cogn Disord. 2012;34(3–4):181–189.

14. Gunn HJ, Newell P, Haa B, Marsden JF, Freeman JA. Identification of risk factors for falls in multiple sclerosis: a systematic review and meta-analysis. Phys Ther. 2013;93(4):504-513.

15. Matsuda PN, Shumway-Cook A, Bamer AM, Johnson SL, Amtmann D, Kraft GH. Falls in multiple sclerosis. Phys Med Rehab. 2011;3(7):624-632.

16. Allen NE, Schwarzel AK, Canning CG. Recurrent falls in Parkinson’s disease: a systematic review. J Parkinsons Dis. 2013;906274. Epub 2013 Mar 5.

17. Jorgensen L, Engstad T, Jacobsen BK. Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke. Stroke. 2002;33(2):542–547.

18. Dean, JC, Kautz SA. Foot placement control and gait instability among people with stroke. J Rehabil Res Dev. 2015;52(5): 577-90.

19. Mansfield A, Wong JS, McIlroy WE, et al. Do measures of reactive balance control predict falls in people with stroke returning to the community? Physiotherapy. 2015;101(4):373-380.

20. Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C. Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc. 2018 March. DOI: http://www.doi.org/10.1111/jgs.15304

21. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls amount older adults. Inj Prev. 2006;12(5):290-295.

22. Kochera A. In Brief: Falls among Older Persons and the Role of the Home: An Analysis of Cost, Incidence, and Potential Savings from Home Modification. AARP Public Policy Institute, 2002. Assessed online at https://www.aarp.org/home-garden/home-improvement/info-2002/aresearch-import-797-INB49.html.