Falls
Definition
Falls are a common source of injury, particularly in the elderly population. They are more likely to occur if impairments in balance, strength, perception, joint range of motion, postural function or coordination are present. Serious injury from falls, such as fractures, occur commonly in people with osteoporosis, a common degenerative disease involving loss of bone mass. Hip fracture is one of the most serious potential consequences of a fall, with a mortality rate as high as 20%.
Description
Falling is a serious health problem in the United States, especially for the elderly. According to the National Center for Injury Prevention and Control, one in every three adults 65 years of age and older fall each year, with an increasing incidence as a person ages. Falls can result in serious injury, not only posing a burden on the individual who falls, but also on family members and the health care system.
Causes and symptoms
Falls can often be attributed to environmental hazards. Icy sidewalks and uneven terrain are common dangers. In the home, climbing on unstable step stools, sliding in wet showers, or slipping on throw rugs are frequent causes of falls.
Medical factors can also make falls more likely to occur. Orthostatic hypotension, sensory loss, stroke, dementia, medications, and neuromuscular disease increase the risk of falling. Deficits in strength, joint range of motion, coordination, sensory perception, and vision may further impair balance. Osteoporosis, common in the elderly population, makes a fall more likely to result in serious injury.
Diagnosis
Individuals who are at risk of falling because of a medical condition or medications need to be routinely tested for instability during functional activities. The following characteristics should also be assessed:
- balance
- strength
- sensation
- vision
- joint range of motion
- hearing
- postural awareness
- gait
Balance
Balance testing can be done in a rehabilitation facility to assess people's ability to transfer weight and control their center of gravity. Numerous tests such as the Berg balance assessment, functional reach test, get-up-and-go test, and Tinnetti tests are useful in a balance evaluation.
Strength
Strength testing should be done to identify weakness, strength asymmetry between sides, and muscle strength imbalance within the same limb.
Sensation
Sensation testing of the lower extremities assesses light touch, pressure, and limb awareness.
Vision
Vision should be assessed by a licensed professional. If corrective lenses are indicated, they should be used during further testing, such as balance and gait assessment.
Joint range of motion
Joint motion assessment evaluates the loss of range of motion and its relationship to impairments in transfers and gait.
Hearing
If hearing loss is suspected, it should be tested and corrected, if possible, before rehabilitation is addressed.
Postural awareness
In a rehabilitation center, individuals can be put through a battery of tests that assess perception of the center of gravity with relation to the environment. Specific tests include postural sway tests and perturbation tests.
Gait
Walking can be evaluated by direct observation to assess for gait abnormalities. If a severe gait disturbance is present, further gait analysis using motion analysis, force platforms, and electromyography should be done.
Falls among people 65 years of age and older
Falls are the leading cause of accidental deaths in persons over 65 years of age.
Falls are the seventh leading cause of death among people older than 65 years.
In the United States 75% of deaths from falls occur in the 12% of the population that is older than 65 years.
From 75 years of age the rate of death from falls rises for both genders and all racial groups.
Thirty-three percent of healthy community-dwelling elders (older than 65 years) fall annually.
Sixty-seven percent of nursing home residents fall annually.
Between 33% and 67% of older patients in hospital-like environments fall annually.
Complications from falls or prolonged floor contact after falls include fear of falling, dehydration, pressure sores, hypothermia, pneumonia, and rhabdomyolysis.
Whites who fall have twice the hip fracture rate as persons from other racial groups.
Five percent of falls among older people will result in fractures.
The most common fractures as a result of falls among the elderly are humeral, wrist, pelvis, and hip, with the presence of osteoporosis making fractures more likely.
Ten to twenty percent of falls among older people will result in soft-tissue injuries, with 50% of these requiring medical care.
Falls contribute to 40% of admissions to nursing homes.
Seventy percent of emergency room visits by people older than 75 years are due to falls.
SOURCE: National Center for Health Statistics, 1980, 1984.
Treatment
Individuals who have fallen may have injuries such as fractures, dislocations, bruising, cuts to the skin, and muscle tears that may require casting, surgery, or hospitalization, depending on the severity. Initiation of lifelong medications for osteoporosis to reduce the rate of further bone loss may be indicated. Most people, including the frailest elderly, can usually benefit from an exercise program that includes strengthening and balance components. Assistance in regaining confidence may also be needed.
Someone who has fallen, once medically stable, needs to be evaluated for:
- balance
- strength
- sensation
- vision
- joint range of motion
- hearing
- postural awareness
- gait
If deficits are noted and the reason for the fall is clear, a treatment plan can be developed that may include:
- balance training
- strength training
- aerobic exercise
- sensory integration
- correction of vision
- change in medication
- flexibility exercises
- hearing aids
- postural exercises
- patient education
- family and caregiver education
- analysis of environmental barriers
- gait retraining
Treatment may include the fabrication of an orthotic for lower limb dysfunction, prescription of an assistive device such as a cane or rolling walker, and education to the patient or caregiver regarding safety in the home.
Prognosis
How quickly and completely a patient recovers after a fall depends on the extent of the injury, the patient's medical condition prior to the fall, and the rehabilitation program. A positive attitude and adequate social support can be critical factors to a patient's recovery. Regaining mobility is critical, especially for the elderly patient who rapidly loses strength and function when immobile. A severe injury such as hip fracture has high morbidity and mortality, partially due to the long bed rest required after the injury.
Health care team roles
Nurses and other allied health professionals need to coordinate rehabilitation activities in an effort to integrate all facets of rehabilitation with functional activities. The rehabilitation team must take an active role in patient, caregiver, and family education, specifically related to restoring mobility and preventing falls in the home.
KEY TERMS
Coordination—The ability to do activities with precision and proficiency.
Electromyography—An evaluation tool that can detect electrical activity of muscles during an activity.
Force platform—A large plate, usually mounted in the floor, that records forces when an individual stands or walks on it.
Motion analysis—Use of an instrumented system to record whole-body and joint movement for later analysis.
Perturbation tests—Tests in which the patient stands on a platform, and a small, rapid movement of the platform is used to disturb balance. Forces and sway are recorded as the individual loses balance and then recovers.
Sensory perception—The ability to perceive touch, pressure, pain, and joint position in the limbs and trunk.
Transfers—The movement from one position to another, such as sit-to-stand, supine-to-sit, wheelchair-to-toilet, etc.
Prevention
Individuals, especially the elderly, should take the following steps to minimize their risk of falling:
- Take someone's arm when icy or slippery surfaces cannot be avoided.
- Remove loose rugs from floors.
- Use only steady stepstools with hand supports when additional height is needed.
- Install hand rails on stairs.
- Wear good walking shoes.
- Assess the home for small objects and cords that can be tripped on as well as unstable pieces of furniture.
- Install grab bars next to toilets and in showers.
- Evaluate home lighting. Use night lights in bathrooms and between the bedroom and bathroom.
- Have vision and hearing checked regularly.
- Report dizziness, fainting, unusual sensations, or sudden loss of function to a physician at once.
- Engage in daily exercise that incorporates aerobics, weight training, and balance and coordination exercises.
