FALLS IN THE ELDERLY by Sandeep Kumar Rajavelu Balachander, RPT
A Fall is defined as any event that leads to an unplanned, unexpected contact with a supporting surface, such as the floor or a piece of furniture, that is not the result of a push or shove or the result of a medical event, such as a heart attack or fainting. A Near-Fall is a stumble or loss of balance that would result in a fall if you were unable to catch yourself. Falls and fall related injuries are among the most serious and common medical problems experienced by older adults. About one in three seniors above age 65, and nearly one in two seniors over age 80, will fall at least once this year, many times with disastrous consequences. Falls may often be falsely perceived as a ‘‘normal’’ part of aging by patients and physicians, minimizing the seriousness of falls and their consequences. There are many potentially deleterious consequences of falls and fall-related injuries, such as fractures in patientswithosteoporosis, thatareagrowingproblem among older adults, often causing longstanding pain, functional impairments, reduced quality of life and excess health-care costs and mortality. Falls could also cause serious and life-threatening injuries to the brain. Falls can be reflective of underlying pathology and should not be viewed as an independent disease entity. 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. Because of underlying osteoporosis and decreased mobility and reflexes, falls often result in hip fractures and other fractures, head injuries, and even death in older adults. Accidental injuries are the fifth most common cause of death in older adults. In around 75% of hip fracture patients, recovery is incomplete and overall health deteriorates. Specific subgroups of patients often require special attention because they frequently have numerous risks for falls. Patients with chronic and disabling medical conditions such as osteoporosis, spinal cord injury, stroke, traumatic brain injury, and amputation are some of the special subpopulations of patients who may be at increased risk for falls. • Individuals afflicted with Stroke have been reported to have high fall rates; approximately 30% fall at least once a year and 15% fall twice or more. • Most people with Parkinson’s disease (PD) fall and many experience recurrent falls; A study reported that over 50% of persons with PD fell recurrently. • Studies suggest that with Dementia, men are twice at the risk of falling than women. The risk factors for falling are many and include intrinsic and extrinsic factors: Intrinsic Issues include history of a fall during the past year, muscle weakness, gait and balance dysfunction, visual impairment, cognitive impairment, depression, functional decline, decreased activities of daily living, use of an assistive walking device, medications (especially psychotropic drugs) and alcohol consumption - taking medications for a long time can make one feel dizzy, confused, and slow.
Alcohol Consumption causes a delay in reflexes and hampers balance, syncope, postural hypo-tension, acute and chronic infections, and dehydration. Gait Deviations are the main changes that occur in the gait patterns of older adults, which may contribute to the incidence of falls. There may be a 10-20% reduction in gait velocity and reduction in stride length; an increase in stance width and double support phase; and bent posture. Studies show that a wider stride does not necessarily increase stability but instead seems to predict an increased likelihood of experiencing falls. Extrinsic Factors consist poor lighting, clutter, accidents/environmental factors – a fall may be from stable or unstable surfaces, slipping or tripping on wet surfaces or ice, from stairs or rugs, and/or due to improper footwear. Treatment of falls can be challenging because falls are often multi-factorial in nature and because optimal treatment plans incorporate a multi-modal approach that addresses all contributing factors. How a Physiotherapist Can Help: Physiotherapist can help prevent falls with evaluation and development of individualized treatment plans including exercises to improve strength, mobility, and balance. If necessary, the physiotherapist will refer you to other medical professionals, such as an ophthalmologist or neurologist. A physiotherapist can conduct a brief check (“screening”) of your fall risk. If the screening shows that you are at risk, the therapist will perform a thorough evaluation, including: Review of your medical history, review of your medications, simple vision test, home safety assessment, simple test of your thinking abilities, check of your heart rate and blood pressure measurements at rest and while you change positions (from sitting/lying to standing), foot and footwear assessment, balance, strength, and walking ability assessment. Basedon theevaluation results,yourphysiotherapist will design a plan that is tailored to your needs. Your treatment plan may include: Balance Training: Balance Training has been shown to be an important and effective part of falls prevention. Your physiotherapist will design exercises that challenge your ability to keep your balance as well as recover from a loss of balance, including exercises such as single-leg standing, or holding your balance while performing an action like reciting the alphabet. Walking and Moving: A prescribed exercise program should include a walking program. However, starting a walking program with poor balance can actually increase your risk for falling. While working with a physiotherapist, you may be asked to perform activities, such as: Dance steps, walking in circles, “Figure 8” exercises to strengthen the core abdominal muscles that help stabilize your body, working through an obstacle course Doing More Than One Thing at the Same Time—
Safely: Older adults who have difficulty walking and talking at the same time are at a higher risk of falling. To help increase your safety during daily activities, your physiotherapist can design a “dual-task” training program. This kind of training will challenge you to maintain walking speed, while you perform another task, such as counting backward, engaging in a conversation, or carrying a bag of groceries. Strength Training: Strengthening is a key element of fall prevention and is very effective in preventing falls, especially when combined with balance exercises. Your physiotherapist will design an individualized strengthening program that focuses on specific muscle groups to help improve your standing balance, your balance while walking, and your ability to recover from a loss of balance. Endurance Training: Aerobic exercise is physical exercise of relatively low intensity and long duration; it can help improve almost every aspect of your health, especially your endurance. Your physiotherapist can work with you to plan a safe aerobic program, such as a walking or an aquatic program, to address your specific needs. The program may start with as little as 10-minute sessions and progress to 30-minute sessions, as your endurance improves. Pain Management: Pain management plays a crucial role in older adults’ risk for falling and quality of life. Certain exercises, such as strengthening and aerobic exercises, are appropriate interventions to relieve pain in addition to decreasing fall risk. Treatments need to be modified appropriately, depending on each individual’s source of pain. Physiotherapy has been shown to help individuals reduce or eliminate their need for pain medication, including opioids. Education: Your physiotherapist will take the time to explain how you can best manage your own risks for falling. Your therapist also may talk to you about the best activities to help maintain your quality of life, and offer educational resources, such as: • National Council on Aging • Falls prevention • Centers for Disease Control and Prevention Fear Management: It is important for you to talk with your physiotherapist about the fear you have of falling. The therapist will work with you to build your confidence and help you get back to the activities that you may be avoiding because you are afraid of falling. Your individual assessment can also identify the activities that you should avoid in order to remain safe. Reduce their fear of falling, set goals for increasing their physical activity, make their homes safer, and exercise more to increase their strength and balance. Increase the safety of your home environment by making changes, such as removing throw rugs or clutter, adjust how you complete your daily tasks to reduce your fall risk, choose appropriate footwear, learn about proper nutrition, improving your sleep schedule, and other general information that can help reduce your fall risk. • STEADI – older adult fall prevention • Fall Prevention Center of Excellence
Works Cited: • American PhysicalTherapy Association, 2010. • Laurence Z. Rubenstein: Falls in Older People: epidemiology, risk factors, and strategies for prevention. Age and Ageing: 2006 • Normative Values for the Unipedal Stance Test with Eyes Open and Closed. Journal of Geriatric Physical Therapy: 2007; CPT Holly Roberts, MPT, GCS; MAJ Norman W. Gill, PT, DSc, OCS, FAAOMPT. • Physical therapy approaches to reduce fall and fracture risk among older adults, Karinkanta S, Piirtola M, Sievänen H, Uusi-Rasi K, Kannus P, Nat Rev Endocrinol. 2010 Jul;6(7):396-407 Review.
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