Falls Are Not Accidents and They Are Preventable!!

Karim Khan, M.D., PhD
Associate Professor
Departments of Family Practice and Orthopaedics
Centre for Hip Health
University of BC
Vancouver, BC

Dr. Maureen Ashe, PT, PhD
Senior Research Fellow
School of Rehabilitation Sciences and GF Strong Rehabilitation Centre,
Vancouver, BC

Falls among seniors represent a major health care problem that is associated with direct costs that exceed one billion dollars annually in Canada. Over one third of those aged 65 year or more fall annually. Although a majority of these falls cause no injury, all falls among seniors warrant evaluation by a family physician or physiotherapist, so that future falls can be prevented. About one fifth of falls are associated with injury, such as a cut, bruise, or fracture; the most serious harmful effects of falls are head injuries and hip fractures. Unfortunately, these injuries are far too common in Canada there are over 20,000 hip fractures annually among seniors. In addition to the injuries described, both injurious and non-injurious falls can contribute to seniors being frightened to move about. Their mobility is thus restricted which, in turn, compromises health through inactivity and quality of life through social isolation.

Fall Risk Factors
Careful research into the events surrounding falls has shown that they are not random events certain personal (internal) and environmental (external) factors predict risk of falling. For example internal risk factors for falling include sex, age, muscle weakness, poor balance, visual impairments, and problems of the cardiovascular system that lead to sudden loss of blood pressure and collapse. External risk factors include use of prescription medications, that compromise stability, and hazards both inside and outside the home (e.g., slippery floors, uneven sidewalks, poor lighting).

The reader will note from the above list that some fall risk factors can be addressed rather easily; others are more difficult to alter. Fortunately, some programmes that aim to reduce falls have been successful among seniors who have normal mental function. Examples of three different successful interventions are: (i) balance and strength training among community-dwelling women and men aged over 80 years; (ii) geriatric specialist assessment with a programme of exercises, medication reduction, and home alterations as needed depending on the seniors risk factors, and (iii) pacemaker insertion for those whose falls are due to abnormal cardiac rhythms. Unfortunately, fall prevention remains a great challenge for the large number of seniors who have substantial loss of memory and mental function no research studies have yet reduced falls among this important group who have a high rate of falling, and fracturing.

Assessment of Those at Risk of Falls
Because falls can be due to many different factors, we recommend that a health professional evaluate an older person who has had a fall, particularly if the fall has been indoors. (Indoor falls appear to confer a greater risk for future falls than do outdoor falls.)

Health professional assessment will address the mechanism of the fall and seek to discover if there is an underlying medical cause. One new instrument that is helping physicians assess which body system may be the key contributor to falls is called the Physiological Profile Assessment (PPA) device. Invented by Australian falls researcher, Dr Stephen Lord, this 30-minute test measures the patients leg strength, proprioception (awareness of position in space), vision for edges (like steps, bumps in a sidewalk), reaction time and sway. From this assessment, the patient receives a single score, such as they do when having blood pressure measured. This score is easy to understand by both the patient and the treating doctor. This evidence-based, multifactorial assessment is not only useful for diagnostic purposes but it also allows targeted intervention. For example, if the leg strength test demonstrates relative weakness, a strength retraining programme may be effective. Further details are available on the web at http://www.powmri.edu.au/FBRG/.

Intervention Preventing the Next Fall
Fall prevention can be thought of as either primary prevention preventing falls among healthy seniors before they have their first fall, or secondary fall prevention which involves ensuring that, after a fall, the patient benefits from an intervention. In this section we discuss each of these in turn.

Primary prevention: As with primary prevention for overall health, childhood and adult behaviours play an important role in determining whether a healthy 80-year old has good pre-existing strength, balance, vision etc. However, as it is too late to turn back the clock , the good news is that there are many things an 80-year old, non-faller can do to prevent a first fall. The most important of these is strength and balance training. This type of training can be done at home, using a bench for support in the first instance. The person can use the activity of getting up from a chair as a leg strengthening mechanism. Leg weights are rather cheap and these enhance the progressive challenge that enables the person to become stronger. Details of the most-studied, effective strength and balance training programme for seniors aged 80 years can be found on the web at http://www.acc.co.nz/wcm001/idcplg?IdcService=SS_GET_PAGE&ssDocName=WCM002143&ssSourceNodeId=3996.

Another factor that is important in primary prevention is avoiding unnecessary medication. Multiple medications, particularly of those that affect blood pressure or brain function, greatly increase the risk of falling.

Secondary prevention: Once a senior has had a fall, it is important that this be acknowledged, and that the senior see a health professional such as the family physician, or physiotherapist; to have the cause of the fall assessed (as outlined above). Depending on the cause of the fall, treatments to prevent further falls may include: 1) adjustment of medication (usually reducing, as above); 2) investigation for cardiac causes of falls and, sometimes, insertion of a pacemaker to keep the heart rate steady and maintain blood pressure; 3) training to address muscle weakness and poor balance; 4) correction of visual impairment; 5) home assessment and improvement of stairs, lighting, and rails where appropriate. The most important thing is to acknowledge that falls are a preventable cause of injury and fracture, and not something to be ignored. There are many effective treatments now the challenge for health professionals and family members is to ensure that the treatments reach those older people who can benefit from them.

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