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Preventing Falls Among Seniors

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I Introduction

Falls among seniors is one of the most critical injury problems in Ontario and is poised to become an even more central health issue as our population continues to age. While falls are a common source of injury among all age groups, they vary in the severity of their results. For seniors, a fall can spell the end to a life of independence. For some, it is the beginning of a decline that is never reversed and may lead to a permanent loss of independent living or even death. In fact, 90% of hip fractures are due to a fall and 20% of those aged 65 and older die within a year of a hip fracture. (1)

In addition to the personal costs of pain, suffering and loss of independence, falls among seniors are a heavy burden on the health care system. In many cases, seniors cannot be discharged back home after a fall and may wait in hospital for a chronic care bed to become available. In fact, 40% of nursing home admissions are the result of falls. (2)

This article will outline ways seniors and professionals can work to lower the risk of falls. Statistics on falls will be highlighted, followed by fall risk factors and interventions to prevent falls.

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II Facts on Falls

Here are some more facts on falls among seniors:

  • Seniors 65 and older are nine times more likely to suffer fall injuries as those of younger ages. Half of falls among seniors result in a minor injury and 5-25% lead to serious injury. (3)
  • Seniors represented about 13% (1.6 million) of Ontario's population in 2007 and this proportion is expected to nearly double to almost 25% (3.5 million) by 2031. (4)
  • Falls among Ontarians aged 55 and over accounted for $962 million in direct and indirect costs in 1999. (5)
  • In 2005-2006, seniors 65+ made 150,470 visits to Ontario emergency departments and 30,478 were hospitalized. Unintentional falls accounted for 59% of all emergency visits and 79% of hospitalizations due to injury. The hospitalized cases accounted for more than 300,000 days in acute care hospitals with an average length of stay of 9.9 days. For hospitalized seniors, about 42% were discharged home (some with support services), 27% were transferred to a long-term care facility and 22% were transferred to another facility that provides inpatient hospital care. (6)
  • Women are at higher risk for fall-related injuries than men, partly due to their higher rates of osteoporosis. (7)
  • Fall-related injuries among those 65+ in residential care are far more frequent than among those living in the community. Seniors in care account for 7% of the population but 15% of fall-related hospitalizations for that age group. About half of all long-term care residents fall each year and of those, 40% fall twice or more each year. (8)
  • Between 1997 and 2002, over 7,000 Canadians 65+ died as a direct result of a fall, the majority of which occurred at home. (9)

Yet, the good news is that falls among seniors are not inevitable; just like most injuries, they are largely predictable and preventable. A growing body of research is pointing to effective preventive measures that can keep the elderly healthy and active and less prone to falls. This coincides nicely with Ontario's Aging at Home Strategy, which is designed to assist people interested in remaining in their homes by providing home care, assistive devices, assisted living services and the like. These items also help prevent falls among older adults.  

Effective fall prevention strategies address multiple factors and involve multiple different disciplines. Pharmacists, physiotherapists, physicians, home care workers, public health practitioners, city planners, family members, all have a role to play in keeping seniors from falling.  

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III Risk Factors for Falling

  • Falls occur due to a loss of balance or an inability to recover balance. A range of risk factors influence whether people are likely to have falls, including biological, behavioural, social, economic and environmental factors. (10) Typically, the more risk factors a person has, the greater the risk of falling.
  • Biological and medical risk factors include muscle weakness and reduced physical fitness, impaired balance and gait, vision impairment, chronic illness including arthritis and osteoporosis, physical disabilities and acute illnesses, dementia and depression.
  • Behavioural risk factors include a history of previous falls, which is one of the best predictors of a future fall, taking certain medications and multiple prescriptions, drinking excessive amounts of alcohol, wearing incorrect footwear, inactivity and a poor diet or hydration.
  • Environmental factors can include hazards in the home, community or institution, including poorly lit, narrow or high stairs and hazards such as loose rugs or cracked garden walks.
  • Social and economic factors may include a lack of ability to pay for home modifications or assistive devices, poor family support, language barriers, etc.

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IV Tools for Assessing the Risk

Recognizing the importance of falls among seniors, an increasing number of interventions have been developed and used to prevent falls, whether among seniors in the community or institutions. Selecting which one to use in a given situation involves combining the research evidence for a practice with practical experience and clinical judgment. (11)

A risk assessment is typically the first step in determining who would benefit from a particular intervention. It may begin with a brief risk assessment to identify those who should be referred for a comprehensive fall risk evaluation. Seniors who have had one or more falls, those with unsteady gait or balance or lower limb weakness and those taking multiple medications are among groups identified in brief assessments who would likely be sent for a more thorough assessment.

Risk assessment tools help tailor interventions to individual risk profiles and help to maximize resources by targeting interventions to those at greatest risk.  Because falls result from a variety of causes, no one tool is going to identify everyone at risk. But assessment tools can separate people into different risk levels.

A number of different tools are available, which can be used in the community (e.g., the Five-minute Walk, the Five-step Test, the Functional Reach, the Clinical Test Sensory Interaction for Balance); in supportive housing (e.g., BERG Balance, Physiological and Clinical Predictors); in the residential care setting (e.g., Mobility Fall Chart, Area Ellipse of Postural Sway), and in an acute care setting (e.g., Schmid Fall Risk Assessment, Morse Fall Scale.)

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V A Comprehensive Falls Prevention Intervention: BEEEACH

The Canadian Falls Prevention Curriculum notes that the most effective falls prevention interventions use a multifactorial approach targeting selected individuals or groups of older persons based on their risk profiles. Taking into account the best evidence and research, the Curriculum presents a comprehensive falls prevention model, BEEEACH, incorporating the following categories:

  • Behaviour change--a common goal of all strategies
  • Education--of program participants
  • Equipment--appropriate use of mobility aids and assistive devices
  • Environment--in the home and public places
  • Activity--physical and social
  • Clothing and footwear--appropriate for risk reduction
  • Health management--including medication reviews, vision tests, bone health, healthy nutrition and hydration and chronic disease management.

Behaviour change

Program participants must be actively involved in the behaviour change process. Rather than lecture to the participants, it is important to use a collaborative approach to understand the person's view and experience and to creatively explore possibilities for change.

Education

Education can increase awareness about the issue and understanding that prevention is possible, as well as promote learning about effective strategies.  It is not enough to produce a brochure informing people about the risks and strategies to reduce the risks. Such tools should be followed up with face-to-face sessions where you can understand persons' perceptions of risk and explore prevention strategies that will work for them.

Education is necessary for seniors at risk of falling, as well as for staff working with seniors. Community education is also important, making it clear that everyone has a role in falls prevention.

Equipment

Older persons may choose to not use equipment that could reduce their risk of falls and injuries or they may use equipment inappropriately. Equipment that can be useful in preventing or addressing falls includes: personal electronic alarms; mobility aides, such as canes, walkers, wheelchairs and scooters; bathroom aids, grab bars and hip protectors.

Environment

Good evidence suggests that assessing and modifying environmental hazards can reduce fall risk, especially when applied to those known to be at risk for falling. Areas to consider are:

  • Indoors - doors should have minimal resistance, stable furniture at appropriate height, walkways free of clutter and slip/trip hazards.
  • Outdoors - cleared walkways, sanded or salted in winter.
  • Public spaces - uneven sidewalk surfaces are a hazard as are short crossing times at crosswalks.
  • Lighting - higher wattage, no-glare bulbs are useful.
  • Flooring - uneven surfaces should be modified, scatter rugs removed.
  • Stairs - uniformity is important with a maximum stair height of 17.5 cm and a maximum depth of 27.5 cm, with good contrasting visibility and handrails.

Activity

Strong evidence exists for the benefits of physical activity in reducing the risk of falls. Exercise should be tailored to the individual's capacity and focus on training for balance, gait, muscle strength and coordination.

Clothing and footwear

Clothes should be easy to put on and take off and not restrict movement. Good walking shoes are recommended.

Health management

While medical conditions can increase the risk of falls, these can be reduced or eliminated when properly assessed and treated. Health professionals and community leaders can promote effective health management, including annual medical assessments, referrals to specialists when necessary, annual medication reviews and modification, good sleep habits, annual vision tests, bone health and fracture risk reduction, healthy nutrition and hydration and chronic disease self-management.

Residential and acute care settings

In these settings, there are opportunities for both facility-wide interventions and the individual approaches discussed above. Facility-wide interventions include staff education, restraint reduction, continence management, gait training and use of assistive devices, reduction of benzodiazepine use, sleep habits, vitamin D and calcium supplements, hip protectors and energy-absorbing flooring.

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VII Smart Moves: An Ontario-developed Resource

The Smart Moves toolkit was developed by SMARTRISK to be a comprehensive and easy to understand package of information for older adults to take action to reduce falls and injuries in four critical areas: bone health, exercise, medication management and home modifications. The toolkit is a large-type coil-bound booklet containing information and suggestions for older adults to prevent falls. A removable exercise poster illustrating 15 simple exercises to increase strength, balance and flexibility, is also included.

The toolkit was created in consultation with focus groups of seniors, health care providers and caregivers of older adults, and pilot tested and evaluated in 2004 with the assistance of two Ontario public health units and six community health centres. About 400 male and female seniors, mostly between 65 and 75 years old, took part in the pilot test in nine Ontario communities over about six weeks using a pre and post-test survey with intervention and comparison groups.

The evaluation found that more than 90% of participants rated the toolkit as useful and easy to read and 77% put into practice some of the information provided. In addition, fewer toolkit participants fell during the post-test period (15%) than the pre-test period (38%.) The toolkit was further updated in 2005, based on evaluation results and suggestions from seniors and professionals.

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VIII Conclusion

This article has outlined the issues around seniors' fall prevention, including the extent of the problem, evaluating the risks of falling and highlighting multifactorial interventions. Issues in program implementation and evaluation were not covered, due to lack of space.

It is encouraging that the topic of falls among seniors is achieving greater recognition, in keeping with its importance as a health issue. For professionals interested in learning more about this area, many resources are available, including the two-day Canadian Falls Prevention Curriculum, from which some of this material was drawn. The curriculum is suitable for health care professionals, community support providers and policy and program personnel.

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VII References

1. Public Health Agency of Canada. (2005). Report on Seniors' falls in Canada. Ottawa, ON: Public Health Agency of Canada, Division of Aging and Seniors. http://www.phac-aspc.gc.ca/seniors-aines/pubs/seniors_falls/index.htm
2. Ibid.
3. Ibid.
4. Statistics Canada. Population Projections for Canada, Provinces and Territories 2005-2031. Ottawa: Statistics Canada. Cat. No.: 91-520-XIE.
5. SMARTRISK. (2006). The Economic Burden of Injury in Ontario. Toronto: SMARTRISK, 2006.
6. Ontario Injury Prevention Resource Centre. (2007). Injuries among Seniors in Ontario: A Descriptive Analysis of Emergency Department and Hospitalization Data. Toronto: Ontario Injury Prevention Resource Centre, 2007.
7. PHAC (2005).
8. Ibid.
9. Ibid.
10. Ibid.
11. Canadian Falls Prevention Curriculum. (2007).