1. Falls in the Elderly Miryoung Lee, MPH Dept. of Epidemiology University of Pittsburgh

2. 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

3. Performance Objectives  Understand the seriousness of problems and contributing factors of falls, and fractures  Develop effective strategies to prevent falls

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

5. How serious is the problem of falls?

6. 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

7. Where are people likely to fall? For people 65 years old or older….. Home 60% Public Places 30% Nursing Home 10%

8. 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.

9. Unintentional Fall Death Rates by Gender, Age 65 +, U.S. 1996 Source: National Center for Health Statistics, Vital Statistics National Center for Health Statistics, Vital Statistics

10. 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 StatisticsNational Center for Health Statistics, Vital Statistics

11. 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

12. Common Types of Fractures Forearm (Wrist) Fracture Spine Fracture Hip Fracture (pelvis, hip, femur) Ankle Fracture Upper arm, forearms, hand

13. Rate of hospitalization for hip fractures, aged  65 years, 1996 Men ( n=68,783) Rates Women(n=270,909) Rates Age (years) 65-74 75-84  85 168.0 682.1 2,256.2 501.1 1,620.3 3,958.3 Per 100,000 population Source: National Center for Health Statistics, CDC

14. 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

15. Intrinsic (Personal) factors for Falls 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 Risk Factors

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

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

18. 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

19. Intrinsic : Aging, poor balance Occurrence of falls Fall Outcomes No injuries Contributing factors Extrinsic : Home hazards Loss of Confidence Fractures Soft tissues injures, trauma Disability, reduced quality of life Mechanisms of Fall

20. Dimension of Fractures Fall itself Bone Fragility Force Source: National Osteoporosis FoundationNational Osteoporosis Foundation

21. 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

22. 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

23. Fall directions and Hip Fracture CircumstancesOdds Ratio95% CI Hit hip/thigh when fall Hit hand when fall Hit knee when fall Fell sideways vs other directions Fell forward vs other directions Fell backward vs other directions 48.6 0.42 0.26 3.17 0.22 1.03 22.5-105 0.23-0.76 0.14-0.49 1.78-5.66 0.12-0.38 0.53-1.99 Age adjusted OR; Schwartz et al. 1998

24. Fragile Bone  Osteoporosis, or brittle bones  Fall induced fractures Normal Bone Osteoporotic Bone Dempster et al., JBMR 1986

25. Assessment of Risk “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 Prevention/Intervention J Am Geriatr Soc. 2001

26. Personal Prevention Home Safety – Reducing hazards Check for Safety List (CDC) Check for Safety List Balance Exercise Lessen Fall impact – hip protectors Healthy Life Style

27. Assistant Devices Hip pads Mobility aids –Cane –Walkers –Wheelchairs Bathroom aids -Raised toilet seats -Grab bars

28. 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

29. Community Intervention Example The Frailty and Injuries:Cooperative 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 C’uan” reduced the rate of falls during the 4 months follow up in women at moderate risk of falls. Province et al., 1995 JAMA

30. Nursing Home Intervention Physical rehabilitation program Staff education Environmental assessments and modification Reduce medications, or physical restraints

31. 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.

32. Resources CDC’s National Center for Injury Prevention and ControlCDC’s National Center for Injury Prevention and Control National Resource Center on Aging and InjuryNational Resource Center on Aging and Injury WHO –Ageing and Life CourseWHO National Fire Protection Association National Women’s Health Information CenterNational Women’s Health Information Center Elder Web Additional Reading List