Preventing Falls in the Senior Population: An ounce of Prevention . . .

By Joseph A. Benanti Jr., PT

It’s 7:45 AM at the Shady Grove Assisted Living Community, and like clockwork, Mrs. Smith steps out of her room with the assistance of her rolling walker, headed for the dining room.  It’s a walk that she has taken literally hundreds of times; why on this day does she fall halfway down the hallway?  What was the cause?  She never seemed to have any problem with balance or endurance.  She never complained about instability or pain.  There just seemed to be no way to have anticipated this fall from occurring; or was there?

In homes and extended care communities across the nation, there is a growing feeling of helplessness and hopelessness regarding falls in the senior population.  Here are some of the grim facts:

• Each year 35-40% of community-dwelling persons aged 65 or older suffer a fall.
• The incidence of falls rises with increasing age
• In long-term care, about 50% of residents fall annually
• Complications of falls are the leading cause of death from injury in persons age 65 and older
• Most falls by older adults result in some injury
• 10% to 15% of falls result in fracture or other serious injury
• The death rate attributable to falls increases with age. 75% of deaths due to falls occur in the 13% of the population over age 65
• In 1994, costs of fall-related injuries were estimated at $20 billion. By 2020, this is expected to increase to $32 billion

This problem will continue to grow as the 78 million baby boomers become seniors within the next decade, representing 20% of the population by 2020.

Why are falls so prevalent in the senior population?   Listen to what Debra J. Rose, Ph.D. & Leslie Allison, M.S., P.T., N.C.S state in their article,   “Identifying & Managing Elderly Fallers”

“Falls are prevalent, dangerous, and costly. Even falls that do not result in injury can have serious consequences. Psychological trauma and fear-of-falling produce a downward spiral of self-imposed activity reduction which leads to loss of strength, flexibility and mobility, thereby increasing the risk of future falls. However, falls are not a normal part of aging. Current research indicates that elderly fallers are different than their healthy, age-matched counterparts. Some have medical diagnoses such as diabetes or Parkinson\’s disease that contribute to falling, but many have no diagnoses at all that would explain their falls. This is because they do not have one large problem within a single system that would \”earn\” them a diagnosis. Instead, they often have many small problems across multiple systems, which interact to produce instability. Each of these impairments is a risk factor for falls. Individually, none of these factors would cause a fall, but in combination they can. The more risk factors a person has, the greater the likelihood that they will fall.”

There are a whole host of causes of falls that are categorized into two primary categories:  intrinsic and extrinsic.  Before we can understand how to prevent falls, we must first figure out what causes them by reviewing intrinsic and extrinsic causes:

• Intrinsic – Behavioral and physiological causes of falls
  • Vision Changes: As seniors age, there is decrease acuity of vision, and decreased adaptation to dark environments, therefore, increasing the risk of falls at night in darkened rooms or outdoors in poorly lit areas
  • Sensory Impairments: Circulatory problems can decrease the sensation on the soles of the feet, thereby, increasing the potential of stumbling especially on uneven terrain
  • Musculoskeletal System Changes: With inactivity, muscle strength and endurance will decrease, thereby decreasing stability in walking, especially with longer distances.  Increased incidence of osteoporosis in the senior population which is a weakening of the bone increases the chances of a fracture following a fall
  • Dizzyness: It’s been estimated that 65% of those over 60 years old experience dizziness or loss of balance, often on a daily basis.  This is due to problems with the vestibular system located in our inner ears.  Our vestibular system is what allows us to keep our balance, and disruptions in this system can cause dizziness similar to what is experienced after getting off an amusement park ride.
  • Acute and chronic disease conditions, confusion, incontinence, side effects of medication, and the fear of previous falls are other intrinsic factors that can increase the potentials of falls.

• Extrinsic – Environmental in nature; include household and community hazards
  • Low lighting especially at nighttime when a senior may have urgency to go to the bathroom and is an unlit or poorly lit area. Unfamiliar outdoor terrain is also hazardous since the walking surface is uneven
  • Obstacles such as throw rugs, pets, and other obstacles can make a living environment into a literal “mine field” for seniors trying to navigate
  • Spills or water on the floor, especially in the bathroom is very dangerous
  • Transitions from one room to another, especially where the surface changes from hard floors to carpeting is dangerous. This danger is increased if the senior is utilizing an assistive device such as a cane or rolling walker.
  • Poorly designed living spaces also increase the potential of falls such as locating dishes that are used frequently in an upper cabinet requiring reaching to take them out or put them back.

So now that we understand what causes falls, what can we do to prevent them

Dr. Judy Stevens, an epidemiologist at the CDC Injury Center states that:

“Falls usually involve many factors, so the most effective approach to preventing them is multifaceted. Especially important is educating long-term care staff about fall risk factors, monitoring medication use, and making environmental changes such as clearing pathways and lowering beds. Falls in the home can also be prevented, helping older adults to remain independent. Simple changes to an older adult’s home, such as removing throw rugs and adding grab bars to bathrooms, can quickly and easily reduce the risk of falling.”  

The best method of fall prevention is an adequate screening program.  In an extended care community or for a senior at home, this is accomplished via screening that is performed by the physician and physical therapist.  The physician will screen for the potential of falls by nature of a thorough history and physical.  A history of dizziness, or near fall incidents in addition to noted weakness of the lower extremities, loss of sensation in the feet, or visual problems can all be hallmarks of the increased potential for falls.  A close review of all medications is also necessary to ensure that a combination of medications won’t cause dizziness or grogginess.  A physical  therapist can perform a more thorough functional assessment and evaluate the person’s stability in transfers, walking, turning, and during activities of daily living such as dressing  If properly trained, they can also conduct an indepth evaluation of dizzyness, visual problems, and/or problems feeling the bottom of the foot on the ground.  In an extended care community, weekly resident review meetings with all relevant staff reviewing each resident will ensure that a regression in status will be quickly picked up and reported to the resident’s physician.

The other primary prevention of falls is regular exercise.  So often, people are looking for a cure in the form of a pill, however, there is no better prevention of falls than exercise, if properly prescribed.  Regular physical activity has a positive impact on every organ system of the body, and increases strength, endurance, and stability.  Exercise programs should always be under the guidelines of your physician, and developed in conjunction with your physical therapist, however, to be effective it must be done on a regular basis throughout your life.  Once stopped, all beneficial effects are quickly lost.

Finally, common sense is the best guide to preventing falls.  Be realistic about your functional endurance, and when you are tired, REST.  Many falls occur when a person is fatigued, and stability is decreased.  Also inspect your living area, and be aware of potential risks such as throw rugs, wet spots, transitions, excited pets, etc.  Always be most careful in dimly lit rooms, and improve lighting when able.

Floor mats are a significant cause of falls in the household, especially as edges become tattered or lip up. Removing them removes one of the leading causes of falls in the home.

Try to keep products that you use frequently near waist level to prevent losing your balance when reaching up or bending down. When you do need to get something at a high level or on the floor, a reaching device makes life easier and safer.

Bathrooms are especially hazardous since there may be moisture on the floor from the sink or shower. Make sure to keep the bathroom well lit, and keep your focus on the floor to avoid wet areas.

It is critical to keep all walking areas well lit since obstacles such as slippers, clothing, and pets can be obscured in poorly lit areas.