Fall prevention

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Fall prevention includes any action taken to help reduce the number of accidental falls suffered by susceptible individuals, such as the elderly (idiopathic) and people with neurological (Parkinson's, Multiple sclerosis, stroke survivors, Guillain-Barre, traumatic brain injury, incomplete spinal cord injury) or orthopedic (lower limb or spinal column fractures or arthritis, post-surgery, joint replacement, lower limb amputation, soft tissue injuries) indications.

Contents

Fall Death Rate in the US Fall Death Rate.png
Fall Death Rate in the US

Adults aged 65 years and older have a 30% chance of falling each year, making fall-related injuries the leading cause of accident-related death for this demographic. [1] Current approaches to fall prevention are problematic because even though awareness is high among professionals that work with seniors and fall prevention activities are pervasive among community living establishments, [2] fall death rates among older adults have more than doubled. [3] The challenges are believed to be three-fold. First, insufficient evidence exists that any fall risk screening instrument is adequate for predicting falls. [4] While the strongest predictors of fall risk tend to include a history of falls during the past year, gait, and balance abnormalities, [5] existing models show a strong bias and therefore mostly fail to differentiate between adults that are at low risk and high risk of falling. [6] [7]

Second, current fall prevention interventions in the United States are limited between short-term individualized therapy provided by a high-cost physical therapist or longer-term wellness activity provided in a low-cost group setting. Neither arrangement is optimum in preventing falls over a large population, [8] especially as these evidence-based physical exercise programs have limited effectiveness [9] (approximately 25%). Even multifactorial interventions, [10] which include extensive physical exercise, medication adjustment, and environmental modification only lower fall risk by 31% after 12 months, [11] and by 21% after 24 months. [1] Questions around effectiveness of current approaches (physical exercise and multifactorial interventions) have been found in multiple settings, including long-term care facilities and hospitals. [12]

The final challenge is adherence. Average adherence in group-based fall prevention exercise programs is around 66%, mostly due to the highly repetitive nature of the programs and the extremely long duration required for noticeable benefits accrue. [13] Adherence to physical therapy can be even lower. [14] When adherence is below 70%, effectiveness of fall prevention physical exercise programs can drop to less than 10%. [13]

Practitioners are aware that the most successful approach to fall prevention utilizes a multimodal, motor-cognitive training approach [15] that could be introduced to all adults over 65. The scientific basis of this approach is an understanding of how the dual-task paradigm induces neuroplasticity in the brain, especially in aging populations. [16] This is driving a growing body of research that specifically links the cognitive sub-domains of attention and executive function (EF) to gait alterations and fall risk. [17] [18] [19] [20] [21]

Cost of falls

Falls and fall-related injuries are among the most common but serious medical problems experienced by older adults. Nearly one-third of older people fall each year, half of which fall more than once per year. [22] Over 3 million Americans over the age of 65 visited hospital emergency departments in 2015 due to fall-related injuries, with over 1.6 million being admitted. [23] Because of decreased bone density due to osteoporosis, mobility, and reflexes, falls often result in hip fractures and other fractures, head injuries, and death in older adults. Accidental injuries are the fifth most common cause of death in older adults. [22] 75% of hip fracture patients do not recover completely and show signs of overall health deterioration. [22]

Strategies and interventions

Motor-cognitive training is increasingly viewed as the gold standard for healthy aging and fall prevention. [24] [25] One approach that has been researched is the introduction of semi-immersive virtual reality simulation during treadmill training. [26] Initially conceptualized by the Tel Aviv Sourasky Medical Center with funding from the Michael J Fox Foundation and the European Commission, V-TIME [27] projects a real-time image of participants' feet onto a large screen at eye-level while the participants are walking on a treadmill. The virtual environment introduces multiple physical and cognitive challenges while the participant is in dynamic motion. This one approach to motor-cognitive training was found to repeatedly reduce falls by 50% [28] after 5 weeks of 15 sessions across multiple clinical trials and multiple indications (idiopathic, [29] Parkinson's, [30] Multiple sclerosis [31] ). The biological manifestations of this improvement were identified through functional MRI, which showed changes in brain activity patterns for patients that were exposed to combined motor-cognitive training, as opposed to exclusively physical training. [32]

Other preventative measures with positive effects include strength and balance training, home risk assessment, [33] the withdrawal of psychotropic medication, cardiac pacing for those with carotid sinus hypersensitivity, and tai chi. Resistance exercise two or three times a week with ankle weights or elastic bands has been proven in tests to rebuild lost muscle mass and reduce falls in adults of all ages: it was first tested in New Zealand by the Otago Medical School in four controlled trials, in which about 1,000 older adults with an average age 84 participated. Falls among a test group that did the Otago routines three times a week for 12 months was 35% fewer than a control group that did not use the routines. [34] Two similar 12-month tests were conducted in the US using residents in assisted and skilled nursing facilities with one group showing a 54% reduction in falls. [35] After the age of 50, adults experience a decrease in muscle mass (sarcopenia) by approximately 2% every year. [36] A systematic review concluded that resistance training can slow down the rate of loss in muscle mass and strength. It has been recommended that older adults participate in resistance training two to three times a week to weaken the effects of sarcopenia. [36] Assistive technology can also be applied, although it is mostly reactive in case of a fall. [37] Exercise as a single intervention has been shown to prevent falls in community-dwelling older adults. A systematic review suggests that having an exercise regimen that includes challenging balance workouts for three or more hours per week results in a lesser chance of falling. [36] Resistance training has been shown to be beneficial beyond fall prevention, as it also helps improve functional mobility and activities of daily living such as walking endurance, gait speed, and stair climbing. [36] Research explains that this significant increase in performance can be accomplished after the age of 90. For older adults to gain confidence in resistance training, which may ultimately lead to falling prevention effects, they must obtain the recommended amount of daily activity. [36]

The aim of medical management is to identify factors that can contribute to falls and fracture risk such as osteoporosis, multiple medications, balance and gait problems, loss of vision and a history of falls. Beers Criteria is a list of medications that are potentially inappropriate for use in the elderly and some of them increase the risk of falls. [38]

Falls are well known amongst community-dwelling individuals ages 65 and older. [39] The risk of fall-related incidents nearly doubles when individuals are institutionalized. [40] The impact on different falls in certain situation of fall prevention programs on the rate differences of falls in elderly population has not been reported. As well as cognitive impairment, functional impairment, gait, and balance disorders, certain medications can increase fall risk factors for patients. At an advanced age, these risk factors are double and more likely to occur. It's important to identify the risk factors that increase the likelihood of injurious falls. State-level fall prevention strategies can also mitigate fall risk for community-dwelling older adults. [39]

Studies have shown that there is a high agreement on guidelines for fall prevention across clinical practices. These include (but are not limited to): the use of specific tests for gait and balance assessments, multifactorial interventions, medication review, physical exercises, vision and footwear intervention, physiotherapy referral, environment modification, risk stratification, management of osteoporosis and fracture risk, and cardiovascular interventions. [41]

Risk factors of falls

Older adults

Studies have shown that adults over the age of 65 are more prone to falls than younger, healthy adults. [42] [43] Most falls in older adults are due to: [44]

Stroke

Individuals who have had a stroke have higher fall rates. Approximately 30% fall at least once a year and 15% fall twice or more. [54] Risk factors for falls in stroke survivors are: [55]

Parkinson's disease

Most people with Parkinson's disease (PD) fall and many experience recurrent falls. [57] A study reported that over 50% of persons with PD fell recurrently. [58] Direct and indirect causes of falls in patients with PD: [59]

Multiple sclerosis

There is a high prevalence of falls among persons with multiple sclerosis (MS), with approximately 50% reporting a fall within the past six months. [60] About 30% of those individuals report falling multiple times.

Dementia

Studies suggest that men are twice as likely to fall as women. [65] Common causes of falls in dementia include:

Fear of falling (basophobia)

Basophobia is a term used in many circumstances to describe the fear of falling in either normal or special situations. It refers to uncomfortable sensations that may be experienced by older people. These sensations can include lower-body weakness or loss of balance, which can induce a frightening sensation of falling that can lead to serious and potentially fatal injuries. [67] [ self-published source? ]

Healthy young individuals

Accidents are the most common cause of falls involving healthy adults, which may be the result of tripping on stairs, improper footwear, dark surroundings, slippery surfaces, uneven ground, or lack of exercise. Studies suggest that women are more prone to falling than men in all age groups. [68] The most common injuries among younger patients occur in the hands, wrists, knees, and ankles. [68]

Environmental modification

Grab rails on a longer-distance commuter train catering for mainly seated passengers Passenger compartment Class 440.jpg
Grab rails on a longer-distance commuter train catering for mainly seated passengers
A staircase with metal handrails BMF Gelander.jpg
A staircase with metal handrails
Front-wheeled walker. Walker. frame.jpg
Front-wheeled walker.
Grab bar mounted in a bathroom Grab bar.jpg
Grab bar mounted in a bathroom
Forearm crutch/cane Strongarm cane design 4 lg.jpg
Forearm crutch/cane

The home environment can present many hazards. Common places for injurious falls include the bathtub and stairs. Changes to the home environment are aimed at reducing hazards and help support a person in daily activities; they include minimizing clutter, installing grab bars in the bathroom, and installing non-slip decals to slippery surfaces. [69] Stairs can be improved by installing handrails on both sides, improving lighting, and adding colour contrast between steps. Improvement in lighting and luminance levels can aid elderly people in assessing and negotiating hazards. Occupational therapists can help clients improve fall prevention behaviours. [70] In addition, they can instruct clients and their family members on factors that contribute to falls, and implement environmental modifications and strategies to decrease the risk of falls. [70] There is currently insufficient scientific evidence to ensure the effectiveness of modification of the home environment to reduce injuries. [71] Evidence suggests that pre-discharge home assessments are associated with a reduced risk of falling. [33]

Safety technology

Important improvements to prevent falls include handrails and grab bars, which should be easy to grip or grasp and should be near any stairs or change in floor level. Floors should always be flat and level, with no exposed corners or edges. Patterned floors can be dangerous if they create misleading or distorted images of the floor surface, and should be avoided. [72]

There are special handles and closed handgrips available in bathrooms and lavatories to help users bend down or over. For example, extra support for users when moving include walking sticks, crutches, and support frames, such as a walker. Flexible handles such as hanging straps can also be useful supports. [73]

Eyeglasses selection and usage

Bifocal spectacles and trifocal eyeglasses are used to provide refractory correction ideal for reading (12–24 inches (30–60 cm) when the wearer looks downward through them. Reading glasses are not ideal for safe walking, where correction for 4.5–5 feet (137–152 cm) would be more appropriate.

Occupational and physical therapy

Studies show that balance, flexibility, strength, and motor-cognitive training not only improve mobility but also reduce the risk of falling.[ citation needed ] This may be achieved through group and home-based exercise programs or engagement with physical therapy clinics with the appropriate equipment. The majority of older adults do not exercise regularly and 35% of people over the age of 65 do not participate in any leisurely physical activities.[ citation needed ]

Older adults

In older adults, physical training and perturbation therapy is directed to improving balance recovery responses and preventing falls. [74] Gait-related changes in the elderly provide a greater chance of stability during walking due to slower speed and greater base of support, but they also increase the chance of slipping or tripping and falling. [75] Appropriate joint moment generation is required to create sufficient push-off for balance recovery. Age-related changes in muscles, tendons, and neural structures may contribute to slower reactive responses. Interventions involving resistance training along with perturbation training may prove to be beneficial in improving muscle strength and balance recovery. [76]

Stroke recovery

Stroke exercises help patients regain mobility and strength in their bodies, and must be done regularly in order to regain muscle tone that helps prevent falls. [77]

Exercises for prevention

One of the most important things for fall prevention in elderly populations is to stay physically fit. Specialized facilities and programs like seniors' parks are a good place to keep the elderly in shape and increase their resistance to falling. These facilities contain specialized equipment and training stations where elderly people can exercise. The parks usually have an extended amount of space and different stages reserved for different body exercises. Research suggests that participation in such programs successfully mitigates fall risk in the majority of attendees. [78]

See also

Related Research Articles

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is a syndrome associated with many neurodegenerative diseases, which is characterized by a general decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control. Aside from memory impairment and a disruption in thought patterns, the most common symptoms include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, caregivers, and on social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than what is caused by normal aging.

<span class="mw-page-title-main">Exercise</span> Bodily activity intended to improve health

Exercise is intentional physical activity to enhance or maintain fitness and overall health.

<span class="mw-page-title-main">Geriatrics</span> Specialty that focuses on health care of elderly people

Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of the elderly. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient need and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently.

<span class="mw-page-title-main">Hip fracture</span> Broken bone in hip joint region

A hip fracture is a break that occurs in the upper part of the femur, at the femoral neck or (rarely) the femoral head. Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Usually the person cannot walk.

In the management of Parkinson's disease, due to the chronic nature of Parkinson's disease (PD), a broad-based program is needed that includes patient and family education, support-group services, general wellness maintenance, exercise, and nutrition. At present, no cure for the disease is known, but medications or surgery can provide relief from the symptoms.

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease that affects the central nervous system (CNS). Several therapies for it exist, although there is no known cure.

<span class="mw-page-title-main">Balance (ability)</span> Ability to maintain the line of gravity of a body

Balance in biomechanics, is an ability to maintain the line of gravity of a body within the base of support with minimal postural sway. Sway is the horizontal movement of the centre of gravity even when a person is standing still. A certain amount of sway is essential and inevitable due to small perturbations within the body or from external triggers. An increase in sway is not necessarily an indicator of dysfunctional balance so much as it is an indicator of decreased sensorimotor control.

Aquatic therapy refers to treatments and exercises performed in water for relaxation, fitness, physical rehabilitation, and other therapeutic benefit. Typically a qualified aquatic therapist gives constant attendance to a person receiving treatment in a heated therapy pool. Aquatic therapy techniques include Ai Chi, Aqua Running, Bad Ragaz Ring Method, Burdenko Method, Halliwick, Watsu, and other aquatic bodywork forms. Therapeutic applications include neurological disorders, spine pain, musculoskeletal pain, postoperative orthopedic rehabilitation, pediatric disabilities, pressure ulcers, and disease conditions, such as osteoporosis.

<span class="mw-page-title-main">Falls in older adults</span> Age-related health problem

Falls in older adults are a significant cause of morbidity and mortality and are a major class of preventable injuries. Falling is one of the most common accidents that cause a loss in the quality of life for older adults, and is usually precipitated by a loss of balance and weakness in the legs. The cause of falling in old age is often multifactorial and may require a multidisciplinary approach both to treat any injuries sustained and to prevent future falls. Falls include dropping from a standing position or from exposed positions such as those on ladders or stepladders. The severity of injury is generally related to the height of the fall. The state of the ground surface onto which the victim falls is also important, harder surfaces causing more severe injury. Falls can be prevented by ensuring that carpets are tacked down, that objects like electric cords are not in one's path, that hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated and that shoes have low heels or rubber soles.

<span class="mw-page-title-main">Falling (accident)</span> Cause of injury or death

Falling is the action of a person or animal losing stability and ending up in a lower position, often on the ground. It is the second-leading cause of accidental death worldwide and a major cause of personal injury, especially for the elderly. Falls in older adults are a major class of preventable injuries. Construction workers, electricians, miners, and painters are occupations with high rates of fall injuries.

<span class="mw-page-title-main">Parkinson's disease</span> Long-term degenerative neurological disorder

Parkinson's disease (PD), or simply Parkinson's, is a chronic degenerative disorder of the central nervous system that affects both the motor system and non-motor systems. The symptoms usually emerge slowly, and as the disease progresses, non-motor symptoms become more common. Early symptoms are tremor, rigidity, slowness of movement, and difficulty with walking. Problems may also arise with cognition, behaviour, sleep, and sensory systems. Parkinson's disease dementia is common in advanced stages.

<span class="mw-page-title-main">Parkinsonian gait</span> Type of gait due to Parkinsons disease

Parkinsonian gait is the type of gait exhibited by patients with Parkinson's disease (PD). It is often described by people with Parkinson's as feeling like being stuck in place, when initiating a step or turning, and can increase the risk of falling. This disorder is caused by a deficiency of dopamine in the basal ganglia circuit leading to motor deficits. Gait is one of the most affected motor characteristics of this disorder although symptoms of Parkinson's disease are varied.

<span class="mw-page-title-main">Geriatric trauma</span> Medical condition

Geriatric trauma refers to a traumatic injury that occurs to an elderly person. People around the world are living longer than ever. In developed and underdeveloped countries, the pace of population aging is increasing. By 2050, the world's population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. While this trend presents opportunities for productivity and additional experiences, it also comes with its own set of challenges for health systems. More so than ever, elderly populations are presenting to the Emergency Department following traumatic injury. In addition, given advances in the management of chronic illnesses, more elderly adults are living active lifestyles and are at risk of traumatic injury. In the United States, this population accounts for 14% of all traumatic injuries, of which a majority are just mainly from falls.

The Berg Balance Scale is a widely used clinical test of a person's static and dynamic balance abilities, named after Katherine Berg, one of the developers. For functional balance tests, the BBS is generally considered to be the gold standard.

<span class="mw-page-title-main">Neurobiological effects of physical exercise</span> Neural, cognitive, and behavioral effects of physical exercise

The neurobiological effects of physical exercise involve possible interrelated effects on brain structure, brain function, and cognition. Research in humans has demonstrated that consistent aerobic exercise may induce improvements in certain cognitive functions, neuroplasticity and behavioral plasticity; some of these long-term effects may include increased neuron growth, increased neurological activity, improved stress coping, enhanced cognitive control of behavior, improved declarative, spatial, and working memory, and structural and functional improvements in brain structures and pathways associated with cognitive control and memory. The effects of exercise on cognition may affect academic performance in children and college students, improve adult productivity, preserve cognitive function in old age, preventing or treating certain neurological disorders, and improving overall quality of life.

The Timed Up and Go test (TUG) is a simple test used to assess a person's mobility and requires both static and dynamic balance.

Video game rehabilitation is a process of using common video game consoles and methodology to target and improve physical and mental weaknesses through therapeutic processes. Video games are becoming an integral part of occupational therapy practice in acute, rehabilitation, and community settings. The design for video games in rehabilitation is focused on a number of fundamental principles, such as reward, goals, challenge, and meaningful play. 'Meaningful play' emerges from the relationship between player action and system outcome, apparent to the player through, visual, physical and aural feedback. Platforms that feature motion control, notably the Nintendo Wii, Microsoft's Xbox Kinect, Sony's Eye Toy, and virtual reality have all been effective in this field of research. Methodologies have been applied to all age groups, from toddlers to the elderly. It has been used in a variety of cases ranging from stroke rehabilitation, cerebral palsy and other neurological impairments, to tendinitis and multiple sclerosis. Researchers have promoted such technology based on the personalization of gaming systems to patients, allowing for further engagement and interaction. Additionally, gaming consoles have the ability to capture real-time data and provide instant feedback to the patients using the systems. Currently, several researchers have performed case studies to demonstrate the benefits of this technology. Repeat trials and experiments have shown that outcomes are easily replicated among various groups worldwide. Additionally, the outcomes have increased interest in the field, growing experiments beyond simple case studies to experiments with a larger participant base.

The neuroscience of aging is the study of the changes in the nervous system that occur with ageing. Aging is associated with many changes in the central nervous system, such as mild atrophy of the cortex that is considered non-pathological. Aging is also associated with many neurological and neurodegenerative disease such as amyotrophic lateral sclerosis, dementia, mild cognitive impairment, Parkinson's disease, and Creutzfeldt–Jakob disease.

<span class="mw-page-title-main">Thurmon E. Lockhart</span> American biomedical engineer

Thurmon E. Lockhart is an American biomedical engineer, researcher and educator. He is the Inaugural MORE Foundation Professor of Life in Motion at Arizona State University, a guest professor at Ghent University in Belgium and, serves as a research affiliate faculty at Mayo Clinic College of Medicine and Science. He is an associate editor of Annals of Biomedical Engineering and academic and guest editor of the Sensors journal He has worked significantly to bring research to practice with various businesses to reduce falls.

The benefits of physical activity range widely. Most types of physical activity improve health and well-being.

References

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