Falls in the Elderly

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Falls in the Elderly

• Miryoung Lee, MPH
• Dept. of Epidemiology
• University of Pittsburgh

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Learning Objectives

• Identify the scope of the problem e.g. impact of
  falls in the elderly
• Describe the contributing factors for falls
• Address fall prevention, and intervention
  programs

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Performance Objectives

• Understand the seriousness of problems and
  contributing factors of falls, and fractures
• Develop effective strategies to prevent falls

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Falls
Introduction

• Unintentional injuries
• External causes of the injury
• Multifactorial causes
• e.g. falls due to intrinsic factors vs.
  extrinsic factors

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How serious is the problem of falls?
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Incidence rates of Falls in U.S.

• Per person annually
• Community 0.2 - 0.8
• Hospital 0.6 - 2.9
• Long term- 0.2 - 3.6
• Care (per bed)

One of every three adults over 65 years fall in
every year
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Where are people likely to fall?

• For people 65 years old or older..

Nursing Home 10
Home 60
Public Places 30
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Consequences of Falls

• Mortality
• Morbidity
• Fractures
• Soft tissue injuries
• Head trauma
• Joint distortions and dislocations
• Loss of confidence - fear of falling
• Restricted activity
• In 1994, estimated fall-related injury cost was
  20.2 billion.

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Unintentional Fall Death Rates by Gender, Age 65
, U.S. 1996
Source National Center for Health Statistics,
Vital Statistics
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Unintentional Fall Age-Adjusted Death Rates, Age
65 , gender and race U.S.
White, Men
Black, Men
White, Women
Black, Women
Source National Center for Health Statistics,
Vital Statistics
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Fractures

• 3 of all falls cause fractures.
• Approx. 95 of hip fractures in older people aged
  over 65 years are the result of a fall
• People who have a hip facture are 5 20 more
  likely to die in the first year following the
  injury than any other reason in the same age
  groups

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Common Types of Fractures

• Forearm (Wrist) Fracture
• Spine Fracture
• Hip Fracture (pelvis, hip, femur)
• Ankle Fracture
• Upper arm, forearms, hand

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Rate of hospitalization for hip fractures, aged ?
65 years, 1996
Per 100,000 population Source National Center
for Health Statistics, CDC
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Fear of Falling

• Loss of self confidence
• Decrease of physical activity level and quality
  of life
• Fear of not being able to get up after a fall

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Intrinsic (Personal) factors for Falls
Risk Factors

• Aged (over 65 years)
• Female
• Low mobility or fragility lower extremity
  weakness, and poor grip strength
• Functional impairments - limited Activities of
  Daily living (ADL)
• Poor gait and balance
• Low body weight

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• Cognitive impairment or dementia
• Chronic illness
• - Parkinson disease, visual difficulties, stroke,
  hypertension, or urinary incontinence
• Psychoactive medication
• - tranquilizers or antidepressants
• Previous falls
• Heavy drinking

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Relative risk ratio (RR) or Odd Ratio (OR) of Fall
J Am Geriatr Soc. 2001
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Extrinsic or Environmental Factors

• Polypharmacy four or more prescription
  medications combination
• Home hazards
• Clutter, or loose rugs
• Poor lighting on stairs and hallways
• Lack of bathroom safety, e.g. grab bars in
  bathtub
• Footwear
• Busy street or elevated walkways

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Mechanisms of Fall
Contributing factors
Intrinsic Aging, poor balance

Extrinsic Home hazards
Occurrence of falls
No injuries
Fall Outcomes
Soft tissues injures, trauma
Disability, reduced quality of life
Loss of Confidence
Fractures
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Dimension of Fractures
Force
Bone Fragility
Fall itself
Source National Osteoporosis Foundation
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Fall itself

• Loss of footing or loss of traction
• Changes of reflex with age
• Changes of muscle mass and body fat
• Loss of muscle strength
• Changes in vision and hearing
• Chronic conditions with medications

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Force and Direction of a Fall

• Fall ? 400 500J of potential energy
• Being tall is related to increased risk of hip
  fractures
• How you land and on what surface increases risk
  of fracture

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Fall directions and Hip Fracture
Age adjusted OR Schwartz et al. 1998
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Fragile Bone

• Osteoporosis, or brittle bones
• Fall induced fractures

Normal Bone
Osteoporotic Bone
Dempster et al., JBMR 1986
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Assessment of Risk
Prevention/Intervention

• Get-up and Go Test (Mathias et al., 1986)
• Check for balance, gait, and mobility
• Review
• Chronic medical conditions
• Medications
• Visions and hearing ability
• Foot disabilities
• Evaluate environmental hazards
• Home hazards

J Am Geriatr Soc. 2001
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Personal Prevention

• Home Safety Reducing hazards
• Check for Safety List (CDC)
• Balance Exercise Lessen Fall impact hip
  protectors
• Healthy Life Style

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Assistant Devices

• Hip pads
• Mobility aids
• Cane
• Walkers
• Wheelchairs
• Bathroom aids
• Raised toilet seats
• Grab bars

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Intervention Programs

• Exercise or physical therapy to increase/gain
  muscle strength, balance, and gait
• Assessment of home fall hazards
• Evaluation of medical condition, medications, and
  nutrition
• Support groups

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Community Intervention

• Example
• The Frailty and InjuriesCooperative Studies of
  Intervention Techniques (FICSIT) meta-analysis
• Incorporated exercises study seven studies
• Intensive strength, endurance training, or
  balance training
• Overall significant reduction of fall
• e.g. Tai Chi Cuan reduced the rate of falls
  during the 4 months follow up in women at
  moderate risk of falls.

Province et al., 1995 JAMA
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Nursing Home Intervention

• Physical rehabilitation program
• Staff education
• Environmental assessments and modification
• Reduce medications, or physical restraints

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Conclusions

• Falls, and related injuries, e.g. fractures are
  significant health hazards to the aging society.
• Identifying fall risk factors help to evaluate
  the problems, and to plan personal, and community
  intervention strategy.
• Intervention studies has mostly focused on white
  men and women, and on hip fractures outcomes.

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Resources

• CDCs National Center for Injury Prevention and
  Control
• National Resource Center on Aging and Injury
• WHO Ageing and Life Course
• National Fire Protection Association
• National Womens Health Information Center
• Elder Web
• Additional Reading List