The Second Fifty Years Promoting Health and Preventing Disability (1992) / Chapter Skim
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Falls in Older Persons: Risk Factors and Prevention
Falls in Older Persons: Risk Factors and Prevention
Pages 263-290
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From page 263... ...
The first phase is an initiating event that displaces the body's center of mass beyond its base of support. Initiating events involve extrinsic factors such as environmental hazards; intrinsic factors such as unstable joints, muscle weakness, and unreliable postural reflexes; and physical activities in progress at 263
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From page 264... ...
This failure is generally clue to factors intrinsic to the individual, such as Toss of sensory function, impaired central processing, and muscle weakness. The third phase is an impact of the body on environmental surfaces, usually the floor or ground, which results in the transmission of forces to body tissue and organs.
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From page 265... ...
Source: National Center for Health Statistics annual mortality data tapes reporting external underlying cause of death. that falls in the frail elderly, especially falls with a "Ion" lie" ja long waiting time on the ground after a fall before help arrives!
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From page 266... ...
population. In a regional study in northeastern Ohio, the rate of emergency room treatment of fall-related injuries in persons aged 75 and older approached 80 per 1,000 per year in women and 60 per 1,000 per year in men.29 Another recent study in Dade County, Florida, found an exponential increase with age in the rate of fall injuries that received hospital and emergency room treatment among persons aged 65 and oilier.
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From page 267... ...
Most falls, however, do not cause sufficient injury to receive medical attention. Only 3 to 5 percent of falls in elderly persons who reside in the community and in nursing homes result in fractures, with fewer than 1 percent of falls causing hip fractures.36 7593 i03 Only about 5 to 10 percent of falls cause other serious injuries requiring medical care.36 ~02 Between 30 and 50 percent of falls result in a variety of minor soft tissue injuries that do not receive medical attention; the remainder cause no injury or only trivial damage.36~75~82 Trequency of Falls The few large community surveys of falls in this country and elsewhere have been retrospective, asking respondents about falls in the past year.
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From page 268... ...
Fall-related fractures, however, constitute the major portion of the costs of osteoporosis, which have recently been estimated at $7 to 10 billion annual. For example, about 90 percent of the estimated $5.2 billion in direct medical costs for osteoporosis in 1986 were attributable to hospital and nursing home care; 66 percent of hospitalizations and 82 percent of nursing home care admissions for osteoporosis involve fractures in which a fall is usually the source of trauma in an elderly person.83 Studies are needed of the costs of fall injuries other than fractures, of fall
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From page 269... ...
. Data from the National Health Interview Survey's 1984 Supplement on Aging indicate that persons aged 75 to 84 who require help with activities of daily living are 14 times more likely, and those with limitations in walking, transfer, and balance activities are 10 times more likely, to report having two or more falls in the previous 12 months compared with persons with no limitations.43 The association of falls with frailty and functional disabilities in the elderly is also evident in the high rates of falls reported in nursing homes.93 The design of effective preventive measures, however, requires knowledge of treatable impairments and conditions that contribute to functional disability, frailty, and falls in older populations.
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From page 270... ...
Weak Sensory Impaired visual acuity {11,15,17,75, Strong 82,90,103,1051 Reduced depth perception 1751 Weak Visual perceptual error (15,89,106 Weak Impaired lower extremity sensory Inconsistent function ( 1 1,1 4, 75,90,97,1 03,1 05 ) Other neurologic signs Frontal cortex/release 90,105)
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From page 271... ...
its base of support, and these sensory pathways may be compromised by age and disease.~4 In addition, age-related disturbances in the organization and central neurological integration of sensory and motor functions may impair the speed, effectiveness, ant! reliability of postural reflexes, leading to falIs.99 i i5 Age-related slowing of postural reflexes may increase the muscular force required for an effective response to postural disturbances,99 but the strength of skeletal muscles involved in postural control and walking declines with increasing age.~235 ii7 Weak muscles and unstable or painful joints may also initiate postural disturbances during voluntary movement.
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From page 272... ...
Whether the association of cognitive impairment ant] falls reflects neurological and psychomotor causes of falls, or behavioral factors related to mental and psychological states, is uncertain.70 It is suspected that psychotropic, diuretic, antihypertensive, and antiparkinsonian medications, especially when inappropriately dosed, may contribute to falls in the elderly by decreasing alertness, depressing psychomotor function, or causing fatigue, dizziness, and postural hypotension.60 Evidence is strongest for an association of falls with the use of hypnotic-anxiolytic drugs, particularly benzodiazepines85 fTable 15-1~.
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From page 273... ...
Compared with frail and impaired elderly persons, falls among the individuals in this group are thought more often to involve overt environmental hazards, risk-taking activities like climbing ladders, hurrying, or running; in addition, they are more often likely to occur away from home.56 Exposure to fall risks is spread over a wide range of physical environments and activities. In contrast, falls in health-impaired older persons are ~nougnt to occur during routine ambulation and transfer maneuvers, usually without an overt environmental hazard, and to occur at home.
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From page 274... ...
Other Outcomes of Falls For injuries resulting from mechanical energy, such as a fall, the severity of impact, the resistance of the body through inertial forces, the elastic capacity of tissue, and the viscous tolerance of the body organs play an important role in the risk of injury. Because of declines in the strength and resiliency of muscle, bone, and other tissues, older persons have an increased risk of injury compared with a younger person subjected to similar impact forces.94 For example, bone mineral density is highly correlated with bone strength; after age 50, bone density declines about 1 percent per year at key sites such as the proximal femur.65 The risk of fractures of the hip, forearm, and other sites increases with decreasing bone density independently of age.205l63 Other factors that contribute to the risk of fracture owing to a fall include the orientation of the fall, the speed and effectiveness of protective responses, the ability of skin, fat,
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From page 275... ...
Exercise might prevent falls and injury by strengthening muscles and increasing endurance; maintaining and improving posture, joint motion, and postural reflexes; stimulating cardiorespiratory function; ~ A growing body of evidence indicates tnat tne emery respond to exercise training and that this response Which may include increased muscle strength and mass and increased aerobic capacity24) continues at very old ages and extremes of frailty.3 25 Weight-bearing exercise may also help preserve bone mass, although this benefit is uncertain.438i Exercise and physical activity are positively associated with physical and mental function in crosssectional studies, but whether exercise training in the elderly can improve physical function, postural reflexes, mental function, or general health and well-being is uncertain.43 The type, level, intensity, and duration of exercise required to
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From page 276... ...
Nutritional causes of skeletal muscle weakness should also be considered as targets for intervention.93 There are no controlled studies specifically of exercise to prevent falls, though exercise has been included as a component of a few undifferentiated multiple risk factor interventions.50 78 Exercise, and strength training regimes in particular, will be a key feature of future trials of fall prevention. These studies must address important issues of content, cost, safety, acceptability, and compliance, particularly as these apply to a frail oilier population with multiple chronic conditions.
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From page 277... ...
Studies of the risk attributable to each of these home hazards, especially in relation to the person's time at risk and their functional disabilities, are critical to the design of prevention strategies. An approach that combines medical and physical therapy evaluation with a home environment assessment may be particularly effective owing to the fact that physical disabilities and environmental factors interact to cause many falls.93 t02 Education is an essential element of the prevention of falls
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From page 278... ...
Frameworks for Multiple Risk Factor Interventions Because of the multifactorial nature of falls and the wide range of factors involved, it is possible that the most effective clinic or community-based interventions will address several types of risk factors and involve diverse disciplines.56 93 i02 Intensive clinical evaluation of elderly individuals with instability problems often finds multiple conditions that could contribute to falLIs and that may be treatable.30 93 i02 To prevent falls, however, medical evaluation and treatment may need to target those impairments that are most likely to cause falls and include pharmacologic, rehabilitative, psychosocial, and environmental components in a treatment plan. Multidisciplinary geriatric assessment and treatment programs suggest one model for multiple risk factor interventions: "Comprehensive geriatric assessment generally includes evaluation of the patient in several domains.
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From page 279... ...
The success of preventive efforts may depend on the ability to target interventions toward those risk factors that are most important in subgroups of the population. Medical and rehabilitative approaches may be most beneficial in the very impaired elderly and those living in nursing homes, whereas environmental and behavioral interventions may have most value among healthy older persons [Living in the community.
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From page 280... ...
Agencies of the National Institutes of Health are currently sponsoring a program of such research, and consideration shouIc3 be given to increasing funding to support a greater number of trials. Interventions that should be given a high priority for randomized trials include the following: focused exercise and strength training regimes; physical therapy, rehabilitation, and training for specific balance and gait impairments; · comprehensive medical diagnosis and treatment focused on neuromuscular, muscuToskeletal, and sensory impairments thought to cause falls; .
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From page 281... ...
. ~ A ~ ~ ~ ^ ~ ~ ~ ~ ~— ~ ~ 4 ~ ~ 1 ~ ~ ~ r ~ ~ studies of the effect of psychosocial factors on adaptation and on the coping strategies of older persons adjusting to nhvsical impairments, postural instability, and falls; · greater understanding of the effects of injury on the psychological function and quality of life of older persons; · studies of where falls occur in the home and of the location and prevalence of various home hazards; · studies of the risk attributable to specific home hazards, espec~a'~y In relation to tne person s time at risk to these exposures and their functional disabilities; ~~= A i11~ 1 .
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From page 282... ...
~ ~ ~ ~ r . reliable methods of self-report ascertainment and description of falls in community-dwelling populations; · development of reliable falls surveillance mechanisms for institutionalized and cognitively impaired populations, including accelerometers and other technological approaches; · methods for quantifying exposure to fall risk, especially environmental and activity-related risk factors, which are important in assessing the efficacy of interventions that increase exposure by increasing physical activity and mobility; and · methods for describing and classifying the full range of fall injuries and other adverse sequelae, including fear of falling and activity limitations.
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From page 283... ...
Curriculum areas should include the significance of injury (and falls in particular) as a public health problem, risk factors for injury, and presumptive and demonstrated injury control strategies.
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From page 284... ...
. continued research on the full spectrum of physiological, functional, and psychosocial effects of exercise regimes and regular physical activity, including strength, endurance, bone mass, agility, coordination, flexibility, and well-being; and · research to determine the appropriate type, intensity, frequency, and duration of exercise necessary to achieve the potential benefits in health and functional capacity across a wide age span and range of health status and abilities.
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From page 285... ...
National Institutes of Health Consensus Development Conference statement: Geriatric assessment methods for clinical decision-making. Journal of the American Geriatrics Society 1988; 36:342347.
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From page 286... ...
Medications and diagnoses in relation to falls in a long-term care facility. Journal of the American Geriatrics Society 1987; 35:503-511.
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From page 287... ...
Journal of the American Geriatrics Society 1982; 30~3~:183-190.
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From page 288... ...
Current estimates from the National Health Interview Survey, United States, 1986. Vital and Health Statistics, Series 10, No.
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From page 289... ...
J Incidence of hip fractures, United States, 1970-83.
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From page 290... ...
F Risk factors for falls among elderly persons living in the community.
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