Seniors and Safety - Falling Over The Answer

The direct and indirect costs of falls in the elderly exceeds $20 billion annually (1). Additionally, falls are the leading cause of injury-related death and hospitalization in patients more that 75 years-old (2).

Many medical studies have indicated that balance, vision and gait disturbance play an important role in the risk of falls in the 75+ age group. One such study indicated that gait disturbance and balance were the second most common cause of falls, just behind accidents, while vision-related problems were the eighth most common (3).

In many cases, the three are interrelated. For instance, accidents can happen as a result of vision impairment and gait disturbance caused by the vision impairment, thus throwing the patient off-balance.

Good vision is important for stabilizing balance. It provides the nervous system with updated information about position and movement of each body segment in relation to its environment. Two studies, one conducted in 1984 and another one in 1990, indicated that when people stand with their eyes closed, postural sway increases between 20 and 70 percent (4).

REDUCING RISK

So, what can health care professionals do to help reduce the risk of falls? First, the therapist or physician needs to assess functional balance and the patient's ability to ambulate safely. Postural control involves balance, the ability to ambulate, endurance, range of motion, sensation and strength.

Several simple tests assessing postural control can identify those who are risk of falling.

One-Leg Balance. The patient stands on one leg while flexing the other to clear the floor. The patient may choose which leg he will balance on. Clock the time he can stand with a stopwatch: It should be at least five seconds. This test predicts injurious falls.

Up and Go/Get Up and Go. In the "Up and Go" version of this test, the patient wears regular footwear and uses a customary walking aid, such as a cane. He gets up out of a normal chair and walks 10 feet. He then turns, walks back to the chair and sits down. The therapist/physician clocks the patient with a stopwatch. A time of 30 seconds or longer shows impaired mobility requiring assistance, and has been shown to be just as valid a test as sophisticated gait training.

The second "Get Up and Go" version of this test is untimed. The patient gets up from an armless chair facing a wall 10 feet away. He walks to the wall (with a customary walking device if applicable) and, without touching the wall, turns, walks back to the chair and sits down. The clinician watches and makes note of any balance or gait problems.

Physical Performance Test. The PPT tests a patient on seven usual daily activities: write a sentence, pick up a book, put on and take off a jacket, pick up a penny, turn 360 degrees, and walk 50 feet. If a problem is detected in any of the testing, the clinician should institute measures to prevent falls, i.e. reduce or ask the physician to reduce medications, do an environmental assessment, and/or establish exercises or interventions for improving balance or vision.

INTERVENTIONS

Here is a list of multifactorial interventions to prevent falls as included in the Guideline for the Prevention of Falls in Older Persons:

For community living environments:

� gait training by PTs and prescription and teaching the use of assistive devices by OTs
� exercise programs including balance training
� review and modification of medication, especially psychotropic and sympathomimetic varieties
� treatment of postural hypotension
� modification of environmental hazards
� treatment of cardiovascular disorders including arrhythmia.
For long term care and assistive living environments
� staff education programs to enhance sensitivity to identify risks for falls among all levels of caregivers
� gait training and advice on the appropriate use of assistive devices
� review and modification of medications, especially psychotropic medications.

To improve vision, some simple intervention strategies include: regular eyes exams, cataract surgery, eyeglasses as needed, the use of single lens instead of multifocal glasses, and the removal of tripping hazards.

Other potential interventions may include:

� bone-strengthening medication to prevent osteoporosis
� cardiovascular assessment and treatment
� footwear intervention, such as use of walking shoes for women and shoes with high mid-sole hardness and low mid-sole thickness for men
� elimination of restraints. Using restraints can cause lower extremity weakness and deconditioning, increasing the risk of falls.

Further research will surely identify additional appropriate interventions to reduce the risk of falls. Let's hope it is sooner than later, because a fall can be deadly.

References
1.Kochman A. Risk of falls in elderly patients reduced through improvement in sensation, balance and gait with monochromatic infrared photo energy and physical therapy. American Physical Therapy Association Combined Sections Meeting, Tampa, Fla., February 2003.
2.Lord S. Vision, balance and falls in the elderly. Geriatric Times 2003;November/December, Vol. IV, Issue 6, www.GeriatricTimes.com/ g031209.html.
3.Rubenstein LZ. Falls. Yoshikawa TT, Cobbs EL, Brummel-Smith, eds., Ambulatory Geriatric Care. St. Louis: Mosby, 1993. 296-304.
4.Lord S. Vision, balance and falls in the elderly. Geriatric Times 2003;November/December, Vol. IV, Issue 6, www.GeriatricTimes.com/ g031209.html.
5.The Guideline for the Prevention of Falls in Older Persons, www.AmericanGeriatrics.org.