Fall prevention

Fall prevention is a system of strategies (and the study thereof) for preventing accidental falls by older people. Falls are not only more common in older adults than the general population, they have more serious medical implications due to the higher incidence of osteoporosis, decreased mobility, and joint weakness among the elderly. Furthermore, beyond a certain age, any injury must be considered more serious than it would have been in middle age because healing takes longer, the immune system is weaker, and surgery and anesthesia are more likely to involve complications. Falls are the leading cause of injury among older adults, and accidental injuries are one of the leading causes of death in older adults. Nonfatal injuries can have long-lasting consequences and seriously diminish a person’s mobility and quality of life. In older patients, for instance, the majority of hip fractures do not heal completely, which impairs mobility and reflexes, making further falls even more likely and contributing to a decline in independence and overall well-being.

Background

The leading indicators of fall risk are gait abnormalities, balance problems, and a previous history of a fall. Impaired vision and cognition are also associated with heightened risk. The side effects and interactions of certain medications that older people are more likely to be prescribed can increase fall risk as well. While many people assume that postural hypotension or a "head rush"—the phenomenon of blood pressure dropping when an individual stands up suddenly from a seated or supine position—is implicated in falling because older people are more likely to suffer from low blood pressure and are therefore more prone to the phenomenon, the linkage is actually unclear in medical literature. While it is true that older people are more susceptible to postural hypotension, it is not clear that a statistically significant number of falls among older people actually occur following postural hypotension or that a significant percentage of postural hypotension incidents are followed by falls. Nevertheless, the American Geriatrics Society (AGS) has recommended the assessment and treatment of postural hypotension in fall prevention efforts because at least some evidence has supported the conclusion that such interventions improve health outcomes and the benefit of such treatments outweighs the harm.

One of the leading complications in falls among the elderly is osteoporosis, a condition that weakens the bones. Osteoporosis leads to decreased mobility (and in some cases chronic pain), increases the chances of a fall, and increases the severity of the fall itself by increasing the risk of bone fractures. Hip, wrist, forearm, and ankles are among the most likely bones to break or fracture. Many of the factors that contribute to osteoporosis are prevalent among the elderly—menopause and hysterectomy are both risk factors for osteoporosis, for instance, due to the lowered levels of estrogen, as is the reduction in testosterone levels that men experience as they age. Decreased activity also makes osteoporosis more likely, as do several medications, especially when used over a long period of time. Certain medical conditions more likely to affect the elderly contribute to the likelihood of osteoporosis, including Parkinson’s disease, rheumatoid arthritis, and renal insufficiency.

Other major risk factors for a fall include muscle weakness, particularly in the lower body; vitamin D deficiency; poor vision; and joint pain. Other dangers include poor footwear, lack of handrails along stairs or in bathrooms, and trip hazards such as throw rugs and electrical cords.

Overview

There are several strategies for preventing falls. Where possible they include identifying and treating conditions that make falls more likely and taking into consideration a patient’s medications and their side effects and possible interactions. Safety technology also plays a role in fall prevention. Handrails and grab bars can be installed in bathrooms and anywhere there is a change in floor level, such as near stairs. Patterned floors should be avoided because they can distort the patient’s impression of the floor’s surface, and high-friction floors are ideal for preventing slips. Nonslip mats can be added to bathtubs and showers. Good lighting can help patients with degrading vision to distinguish obstacles, changes in floor level, and other fall hazards. Patients can also be provided with walkers and walking sticks and with footwear that has serrated, high-friction rubber soles to resist slipping. High heels, flip-flops, and loose slippers should be avoided as they can increase the risk of falling. Homes and waiting areas can be "slip-and-trip-proofed" by removing loose rugs and clutter and by clamping power cords that could be tripped over. These improvements can be made in the home as well as in waiting areas of doctor’s offices and other places that serve the elderly population.

Furthermore, the damage from falls can be mitigated. Carpeted floors can be given a foam underlay to cushion falls, and tiled floors can use rubber tiles to the same effect. Exposed objects can be surveyed to avoid sharp edges and corners, primarily with head injuries in mind.

Older adults should make a list of the prescription and over-the-counter medications they take and then review the list with their doctor. The AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, or the Beers List, is a list of guidelines for health-care professionals that recommends avoiding certain medications for older patients unless they are absolutely necessary and no alternative treatment is available. The guidelines were first created by geriatrician Mark Beers in 1991 with a panel of experts and were later updated by the AGS. While a variety of criteria inform the list, fall prevention is one of the major considerations.

Many older adults have low levels of physical activity, and many who have already experienced a fall—even if it did not result in injury—avoid physical activity out of fear of falling again. This decreased mobility is one of the contributing factors to muscle weakness and fall frequency, and so one fall prevention strategy is to encourage activity and exercise. Balance, flexibility, and strength training, such as may be incorporated into exercise classes at senior centers or in home exercise programs, is a promising fall prevention strategy, especially for older patients who are otherwise healthy apart from their low levels of activity. Low-impact exercises such as walking, water workouts, or tai chi are excellent exercise options for older adults with limited mobility.

One of the hardest risk factors to manage is cognitive impairment, such as that resulting from dementia or Alzheimer’s disease. Fall prevention preparations such as walkers, guide rails, and improved lighting cannot help when a patient wakes up in the middle of the night and is too confused to turn on the light or forgets to use their walker. Such confusion can also contribute to mobility problems even in physically healthy patients as they hesitate or stutter-step in their movements. And more simply, falls can occur simply because a confused patient wanders from the "safe" area to somewhere more hazardous or less familiar. Maintaining physical activity and decluttering high-traffic areas remain the best fall-prevention strategies for individuals who are suffering from dementia.

Morse Fall Scale

In many acute care settings, nurses and other caregivers rely upon the Morse Fall Scale to quickly and accurately assess and determine a patient's fall risk. The scale is typically used upon a patient's admission to a care facility, after a patient's status has changed, and at the time of prospective discharge. Ideally, the proper administration of the scale allows a caregiver to also figure out which risk factors may be the most important contributors to a patient's probability of falling. The assessment consisted of six risk factors that are each scored according to a certain number of points: history of falling, secondary diagnosis, ambulatory aid, IV, gait, and mental status. Once the total score is calculated, the caregiver can decide whether any interventions are necessary based upon the patient's risk level (no risk, low risk, or high risk).

Bibliography

Abele, Jon R., et al. Slips, Trips, Missteps, and Their Consequences. Lawyers and Judges, 2012.

"About Older Adult Fall Prevention." Centers for Disease Control and Prevention, 16 May 2024, www.cdc.gov/falls/about/index.html. Accessed 5 Sept. 2024.

Di Pilla, Steven. Slip, Trip, and Fall Prevention: A Practical Handbook. 2nd ed., CRC, 2009.

Eldridge, Carole. Evidence-Based Falls Prevention. HCPro, 2007.

Ham, Richard J., et al. Primary Care Geriatrics. Saunders, 2014.

"Important Facts about Falls." Centers for Disease Control and Prevention, 20 Jan. 2016, www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed 24 Aug. 2016.

"Morse Fall Scale." Network of Care, www.networkofcare.org/library/Morse%20Fall%20Scale.pdf. Accessed 14 Aug. 2017.

National Center for Injury Prevention and Control. Preventing Falls: How to Develop Community-Based Fall Prevention Programs for Older Adults. National Center for Injury Prevention and Control, 2014.

National Falls Prevention Resource Center. Falls Free: 2015 National Falls Prevention Action Plan. National Council on Aging, 2015, www.ncoa.org/wp-content/uploads/FallsActionPlan‗2015-FINAL.pdf. Accessed 14 Aug. 2017.

Smith, William. Exercises for Better Balance: The Stand Strong Workout for Fall Prevention and Longevity. Hatherleigh, 2015.

Staples, William H. Geriatric Physical Therapy. McGraw-Hill, 2016.