Health care providers play important role in fall prevention

Falls are the leading cause of injury-related deaths and 95% of hip fractures in the elderly.

Douglas W. Jackson, MD
Chief Medical Editor:

I am pleased to share with you the thoughts and expertise that Dr. Kathleen Buckwalter brings to the area of falls in the elderly. As we treat our patients and care for our elderly parents, this information will help us formulate a better understanding of the risk factors and how to minimize the consequences from falling. As the crest of the baby boomers enters retirement, we will see more individuals sustaining falls requiring medical care.

Douglas W. Jackson, MD: What are some of the current data that highlight the significant challenges that falls in the elderly represents to health care providers and society?

Kathleen Buckwalter, PhD, RN: Falls represent a complex and increasing public health problem. They are the leading cause of injury-related deaths among people older than 65 years, and 30% of people older than 65 fall each year. Data from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (2002) revealed that death rates from unintentional falls continue to increase and that fall-related deaths were higher among whites than people of color. Thus, there is a clear-cut pattern of growth in the number of falls in later life, with increased rates for women.

About 60% of all falls occur in the home (usually related to everyday activities), 30% in the community and 10% in institutional settings. Every year about 1800 nursing home residents die as a result of a fall. Further, around 95% of hip fractures are due to falls, and the number of hospital admissions for hip fractures among the elderly — 332,000 — is steadily rising.

Falls are common among the elderly and can lead to increased morbidity, social isolation, diminished quality of life and placement in an institutional setting. Health care providers can play an important role in fall assessment and risk modification, and by anticipating issues related to mobility, and providers can help elders lead more independent and satisfying lives. They can also help educate older adults, their family members and caregivers about strategies to decrease fall risk.

Jackson: What are some of the more common factors that predispose a patient to falling in this population?

Buckwalter: The epidemiological factors associated with falls include a history of falls, being female, functional dependence/impaired mobility, fear of falling, advanced age, recent use of medications and impaired musculoskeletal function. Other factors are incontinence, sensory loss, impaired mental status/faulty judgement, syncope/dizziness or feelings of faintness, acute illness/infection, delirium and poly-pharmacy.

The ergonomic factors associated with falls in the home and institutional setting are as follows:

• Increased distance between bed and bathroom
• Transferring to and from wheelchairs
• Reduced grip strength in dominant hand
• Visability of lower extremities, including reduced strength, sensation or balance
• Gait and balance impairment
• Increased postural sway
• Muscle weakness
• Use of ambulatory assistive devices
• Ill-fitting shoes and those with slippery soles

Environmental factors associated with falls in the home (H) and institutional setting (I):

• Use of physical restraints (I)
• Facilities and furniture with inappropriate height for transfers (eg, toilets, tubs) (I/H)
• Slippery and glaring floor surfaces (I/H)
• Height and location of handrails or unavailability of handrails (I/H)
• Loose throw rugs, frayed carpets, cords and wires (H)
• Cracked, elevated and uneven sidewalks/floor surfaces (H)
• Inadequate lighting (H)
• Use of bedrails (I)

Jackson: What are some of the basic measures that should be avoided in the living quarters for the at risk population?

Buckwalter: Health care providers can remind their older patients that since most falls occur at home and most fractures result from a fall at home, simple modifications to the interior of their houses or apartments can cut risk of falling by one-half. Where necessary, they should encourage their at-risk patients to install safety devices, and to:

• Eliminate tripping hazards in your home
• Install handrails, grab bars, especially in bathrooms along the bathtub/shower and toilet, and on both sides of the stairway, and be sure to use them
• Make changes in furniture arrangement to allow easy navigation, avoiding clutter
• Assure proper lighting for rooms, hallways and stairs
• Make sure that carpets/floorings are tight, including stairs and steps
• Install light switches at both the top and bottom of the stairs
• Keep flashlights nearby in case of power outages
• Do not leave objects on the stairs
• Put non-slip treads on each bare-wood step
• Do not place loose area (throw) rugs at the bottom or top of stairs
• Place a slip-resistant rug adjacent to the bathtub for safe exit and entry
• Mount a liquid soap dispenser on the bathtub/shower wall
• Place nonskid adhesive textured strips on the bathtub/shower floor
• Use a sturdy, plastic seat in the bathtub if you are unsteady or if you cannot lower yourself to the floor of the tub
• Stabilize yourself on the toilet by using either a raised seat or a special toilet seat with armrests
• Install nightlights along the route between the bedroom and the bathroom
• Enhance lighting throughout the house
• Sleep on a bed that is easy to get into and out of and keep a telephone near your bed
• Install easy-access light switches at entrances to rooms so you won’t have to walk into a darkened room in order to turn on the lights
• Keep electric, appliance and telephone cords out of your pathways, but don’t put cords under a rug. Use cordless telephones.
• Eliminate wobbly chairs, ladders and tables
• Do not sit in a chair or on a sofa that is so low it is difficult to stand up
• Place secure carpeting over concrete, ceramic and marble floors to lessen the severity of any injury
• Immediately clean up any liquid, grease or food spilled on the floor
• Store food, dishes and cooking equipment at easy-to-reach waist-high level
• Don’t stand on chairs or boxes for out of reach objects. Use only a step stool with an attached handrail so you are supported

Jackson: What methods have been documented to prevent and/or reduce falls in elders?

Buckwalter: Health care providers should remind their older patients that since a fall can be a major life-changing event, decreasing their mobility and independence can lead to a hospitalization, and that staying fit is important. Specific advice they can provide includes:

• Engage in regular, moderate physical activity to maintain your strength, coordination, agility and balance. Yoga and Tai Chi are valuable.
• Get an eye examination and physical each year.
• Check with your doctor/pharmacist about side effects and drug-to-drug interactions of all your prescription and over-the-counter medications.
• Take only those medications and herbal remedies that your physician thinks are essential.
• Wear properly fitting shoes with nonskid soles.
• Obtain adequate intake of calcium and vitamin D.
• Avoid excessive alcohol intake.
• Stop smoking and avoid second hand smoke.
• When you first wake up, sit on the edge of the bed and make sure you are not dizzy.
• Eat breakfast every morning; skipping a meal could make you dizzy.
• Wear glasses if you need them, but remove reading glasses before you walk.
• Wear clothes that fit you properly since you can trip on a coat, pair of pants or bathrobe that is too long.
• Avoid icy outdoor pavements.
• Use a recommended and well-fitted cane or walker if you are unsteady, promptly replace worn rubber tips of these devices.
• Make sure you have access to a telephone that you can reach to call for help if you fall. Consider carrying a portable phone, or getting a personal emergency response system (PERS), especially for older women who live alone. A PERS can prevent lengthy “lie-time” in the event of a fall and may increase feelings of security and confidence.
• If you do experience a fall, do not ignore it. Discuss it with your physician and request an examination to evaluate for a new health condition or the progression of a chronic illness that may signal a need for diagnosis, treatment or modification of activities of daily living.

For more information:

• Stephens, JA, Dellinger AM (2002). Motor vehicle and fall related deaths among older Americans 1990-98: Sex, race, and ethnic disparities. Inj Prev. 8(4), 272-275.
• Baker SP, Harvey AH. Falls injuries in the elderly. Clin Geriatr Med. 1985; 1:501-527.
• Malmivaara A, Heliovarra M, Knekt P, Reunanen A, Aromaa A. Risk factors for injurious falls leading to hospitalization or death in a cohort of 19,500 adults. Am J Epidemiol. 1993;138:384-394.
• Messinger-Rapport BJ, Thacker HL. Prevention for the older woman. Mobility: A practical guide to managing osteoarthritis and falls. Part 6. Geriatrics. 2003;58: 22-29.
• Buckwalter KC, Cutillo-Schmitter TA. Fall prevention for older women. Women Health Primary Care. 2004;7:363-369.