Falls in the Elderly

Learning Objectives Identify the scope of the problem Describe the contributing factors for falls Address fall prevention Discuss intervention programs

Falls “Unintentional” injuries Cause can be multifactorial Fall related injuries can be debilitating or deadly A fall is not a disease, rather regarded as a cause leading to serious outcomes. The term ‘Fall-related injuries’ is widely used to describe the outcomes (e.g. brain trauma, or hip fracture) of fall events. There are several factors that are related to a fall. For instance, a fall can occur the result of loss of footing, or stroke.

How serious is this problem?

Incidence of Falls in U.S. One out of three adults over 65 years fall every year Among adults aged over 65 years, unintentional injuries are the seventh leading cause of death in the United States. Of these fatalities, deaths from fall-related injuries are the greatest number. In the United State, one of every three older persons (aged over 65 years) living in community fall every year. This trend increases to 50% by the age of 80 years (Blake et al., 1988; O’Loughlin et al., 1993).

Less than half tell their doctor Millions of people fall every year Less than half tell their doctor Each fall doubles your risk of falling again

Where are people likely to fall? For people 65 years old or older….. Nursing Home 10% For adults 65 years old or older, 60% of fatal falls happen at home, 30% occur in public places, and 10% occur in health care institutions. However, injury rates are more higher with 10 ~ 25% of nursing home, or long-term care facilities resulting in fracture, or severe tissue injuries (Rubenstein, 1999) Falling will tend to occur within the first few days or first weeks upon entering a nursing home or transferring to a nursing home, It may be due to unfamiliar environment. Also, person who admitting in has more chronic illness, medications, and immobility due to long time sitting or in bed (Sorock 1988; Sattin 1992). Home 60% Public Places 30%

Consequences of Falls Mortality Morbidity Fractures Soft tissue or head trauma Joint dislocations Loss of confidence - fear of falling Restricted activity estimated fall-related injury cost is $34 billion. (CDC) Falls is a major cause of severe nonfatal injuries and common cause of hospital admissions (40%) for traumatic injuries among the elderly. (Evans, 1996) Falls are also the second leading cause of spinal cord and brain injury among older adults . Approximately 30 ~ 50 % of falls result in minor soft tissue injuries (Nevitt et al., 1989). Overall, 20~30% of those who fall suffer from moderate to severe injuries that limit mobility and independence, even the risk of death (Alexander et al., 1992). The total direct cost of all fall injuries for people age 65 and older in 1994 was 20.2 billion, and it is projected to increase to 32.4 billion by 2020.

Unintentional Fall Death Rates Source: National Center for Health Statistics, Vital Statistics

More and more elders are dying due to unintentional falls

Fractures Most falls do not cause fractures Falls are the cause of 80-90% of all fractures (for those >65 years old) ~95% of hip fractures in those >65 are caused by falls People who have a hip fracture are 5 ~20% more likely to die in the first year following the injury Falls account for 87% of all fractures for people 65 years and older. An estimated 1 ~ 2 % of of falls cause hip fractures which account for the majority of fall-related morbidity and mortality; 3~ 5 % of falls result in other type of fractures, e.g. hand, and ankle fractures (Sattin 1992). The most common sites of fractures include hip, spine, hand, forearm, leg and ankle. Nine out of ten hip fracture in older people result from a fall. People who have a hip fracture are 5 ~20% more likely to DIE in the first year following that injury than any other reason. (Kiel et al., 1991).

Common Types of Fractures Forearm (Wrist) Fracture Spine Fracture Hip Fracture (pelvis, hip, femur) Ankle Fracture Upper arm, forearms, hand Because the U.S. population is aging, the problem of hip fractures will increase substantially over the next four decades. By the year 2040, the number of hip fractures is expected to exceed 500,000 per year (Tinetti, 1989)

Fear of Falling Loss of self confidence Decrease in physical activity level and quality of life Fear of not being able to get up after a fall As a psychological result of a fall, Fear of falling(Loss of confidence) may also limit the daily living activities. It is estimated that 20% of older persons who fear falling limit their activity. Limiting activity also may lead to increase frailty more, and result in recurrent fall occurrence.

Low mobility or fragility – Risk Factors Aged (over 65 years) Female Low mobility or fragility – lower extremity weakness, and poor grip strength Functional impairments Poor gait and balance Low body weight

Cognitive impairment or dementia Chronic illness - Parkinsons, visual difficulties, stroke, hypertension, or urinary incontinence Psychoactive meds Previous falls Heavy drinking

Relative Risk Factors From selected 16 studies, the most common risk factors for falls were listed. ‘American Geriatrics Society (AGS) Panel on Falls in Older Persons’ Guidelines for the Prevention falls in older persons. (JAGS, 2001;49:664-672)

Environmental Factors Polypharmacy – ≥4 meds Home hazards Clutter or loose furniture Poor lighting Lack of “grab bars” Footwear Busy street or elevated walkways The most commonly cited environmental causes of falls at home are loose rugs, slippery or uneven floor. Poor lighting on stairs and hallways interfere with visual changes with aging. The combination of lack of instruments (e.g. hand rails), poor vision, and weaker balance may cause a fall in older persons.

Contributing factors Intrinsic : Aging, poor balance Extrinsic : Home hazards Occurrence of falls No injuries Fall Outcomes A fall is not usually caused by a single factor. Most falls by older persons result from the numerous, or complex interaction of intrinsic ( personal or host) factors, and extrinsic (environmental) factors. Soft tissues injures, trauma Disability, reduced quality of life Fractures Loss of Confidence

Dimension of Fractures Force Bone Fragility 3 contributing factors to fractures Fall itself Source: National Osteoporosis Foundation

Cause of the Fall itself Loss of footing changes in reflexes with age Changes in muscle mass and body fat Loss of muscle strength Changes in vision and hearing Chronic conditions with medications

Force and Direction of a Fall Being tall  increased risk of hip fractures How you land what surface you fall on

Fall directions and Hip Fracture Circumstances Odds Ratio Hit hip/thigh when fall Hit hand when fall Hit knee when fall Fell sideways Fell forward Fell backward 48.6 0.42 0.26 3.17 0.22 1.03 Schwartz et al. (1998) demonstrated that hitting the hip or thigh in a fall resulted in significant risk of hip fracture (OR 48.6; 95% 22.5-105) in 214 hip fracture cases and 86 controls who had fallen, aged over 45 years.

Fragile Bone Normal Bone Osteoporotic Bone There is an important link between falls, broken bones, and osteoporosis. Osteoporosis is defined as low bone mass and worsening of bone tissue leading to bone fragility and increased risk of fractures. In other word, a gradual deterioration of bone tissue or bone density, or bone resistance to mechanical energy makes bone so fragile that they can break with even slightest strain. Falls impact on osteoporotic bones and increase the chance of fractures. This slide shows an individual with normal bone compared to someone with osteoporotic bone. The interior of normal bone has a spongy, rigid, honey-comb like structure. However, in people with osteoporosis, the holes of the honeycomb are greatly enlarged leaving an architecturally weakened structure with significantly reduced bone mass.

Prevention/Intervention Assessment of Risk “Get-up and Go” Test Check for balance, gait, and mobility Review Chronic medical conditions Medications Visions and hearing ability Foot disabilities Evaluate environmental hazards Home hazards

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

Intervention Exercise to improve muscle strength, balance, and gait Assessment of home fall hazards Evaluation of medical condition, medications, and nutrition Support groups

Community Intervention Example strength, training, or balance training Overall significant reduction of fall e.g. “Tai Chi” reduced the rate of falls during the 4 months follow up in women at moderate risk of falls.

Conclusions Falls, and related injuries are significant health hazards to the elderly Identify fall risk factors to evaluate problems, and plan interventions.