By Helen Rigney, Physiotherapist Healthcare Direct
So how do we classify a fall? WHO aptly described it as “an unexpected event in which the individual comes to rest on the ground, floor, or lower level”. Each year more than 1/3 of people over the age of 65 years sustain a fall, with 10% resulting in serious injury.1 These falls can result in distress, pain, injury, loss of confidence, loss of independence, poorer quality of life, high levels of anxiety or even mortality.2,3,1 Due to a previous fall or a fear of falling individuals may adapt a restrictive activity practice in order to reduce their perceived risk of a subsequent fall; leading to secondary deconditioning which will increase falls risk.4 As the old saying goes “use it or lose it”.
So, is a fall just a foregone conclusion once an individual reaches a certain age? Is there a way to identify an at-risk individual? Is there anything we can do to reduce falls in older adults? One way of identifying an at-risk individual is to adapt a screening process5 to try and reduce the number of falls and in doing so increase confidence and overall wellbeing in our older adults. Such a screening process should be carried out through an MDT approach/Multifactorial assessment2 encompassing the following:
- Falls history – including circumstances and causes of falls
- Evaluation of risk factors
- Gait, balance and mobility, muscle strength, joint range of movement
- Risk of osteoporosis
- Sensory Assessment – visual/auditory
- Cognitive impairment and neurological assessment
- Medication review, cardiovascular assessment
- Urinary incontinence
- Review of footwear
- Home hazard/Environmental assessment
- Individuals perceived functional ability and fear of falling
It has been stated that a history of falls is one of the greatest predictors of sustaining a subsequent fall.1 Some of the main health reasons that contribute to the risk of falls include loss of balance due to muscle weakness or disability, sudden episode of dizziness, drop attack, hypotension, visual impairment, incontinence, pain, frailty, infection/illness, polypharmacy, medications and dehydration. However other factors can also contribute to the risk of falling such as wet floors, poor lighting, rugs or carpets, clutter, overreaching for items, rushing, stairs, inappropriate or no footwear amongst others.6,5,2
One way we can reduce the risk of falls is providing appropriate mobility aids. The goals of assistive devices are to increase independent mobility, decrease disability, delay functional decline, decrease burden of care. Patients have reported increased confidence with their usage along with increased feelings of safety which in turn can contribute to increased activity levels and independence. Mobility aids should be selected dependant on the patient’s strength, balance, cognitive function and the surrounding environment. To ensure safe and appropriate use of mobility aids clinicians should undertake regular evaluation of the patients aid to ensure proper height and fit while also evaluating need for maintenance and education regarding proper use.7 NICE guidelines (2013) have stated that a successful multifactorial intervention programme should consist of the following measures:
- Strength and balance training 3,1
- Home hazard interventions
- Referral for visual impairments
- Review of medication and modification or withdrawal as needed
The guidelines2 also stated that the individual along with their carer should have the following information provided:
- Measures to prevent future falls
- How to remain engaged and compliant if referred for falls prevention strategies
- How to prevent/reduce the risk factors surrounding falls
- The physical and psychological benefits of modifying falls risk
- How and where to access further assistance and advice
- What to do if they sustain a fall
The following predictive tools have been reported as valid and reliable for identifying potential individuals at risk of falls – Reaction times, the Berg balance scale, activities-specific balance confidence scale, and postural sway along with the 6-minute walk test.1
The role of Occupational Therapists and Physiotherapists: As outline by the American Occupational Therapy Association (2017) the roles of the Occupational therapists are varied and can involve the following:
- Addressing of Intrinsic factors (lower limb weakness, impaired balance, cognitive impairment, urinary incontinence, sensory impairment, side effects of medications)
- Addressing Extrinsic factors (removal/securing of carpets and rugs, lighting, removal of clutter, uneven walking surfaces, provision of medical equipment and aids such as handrails, commodes, bath benches, raised toilet seats, grab bars)
- Addressing fear of falling and self-limiting behaviours
- Exercise treatment relating to functional activities of daily living
- Providing education of patients, family/carers, staff
- Breaking the cycle of inactivity and sedentary lifestyle
The role of Physiotherapists is also a varied one in falls prevention including the following:
- Providing group exercise or individual home exercise programmes 1,9
- Strengthening/resistance exercises, balance exercises or Tai Chi3,5,9
- Education on falls prevention,9 physical activity and healthy eating, appropriate footwear and use of mobility aids10
- Functional exercises, gait re-training1
- Addressing foot/shoe problems10
1. Hanley, A., Silke, C., Murphy, J. 2011. ‘Community- based health efforts for the prevention of falls in the elderly’. Clinical Interventions in Aging, 6, pp 19-25.
2. National Institute for Health and Care Excellence (2013) Falls in older people: assessing risk and prevention (NICE guideline 161). Available at: www.nice.org.uk/guidance/cg161
3. National Institute for Health and Care Excellence (2018) NICEimpact falls and frailty fractures. Available at: https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/measuring-uptake/NICE-Impact-falls-and-fragility-fractures.pdf
4. Lusardi, M.M., Fritz, S., Middleton, A., Allison, L., Wingood, M., Philips, E., Criss, M., Verma, S., Osbourne, J., Chui, K.K. 2017. ‘Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Posttest Probability’. Journal of Geriatric Physical Therapy. 40(1).
5. Al-Aama, T. 2011. ‘Falls in the elderly Spectrum and prevention’. Canadian Family Physician, 57(July), pp. 771-776.
6. Health Service Executive. (2020). Falls. Available at: https://www.hse.ie/eng/health/az/f/falls/ [Accessed 31 August 2020].
7. Bradley, S.M., Hernandez, C.R. 2011. ‘Geriatric Assistive Devices’. American Family Physician, 84(4), pp. 405-411.
8. American Occupational Therapy Association. 2017. Occupational Therapy and Prevention of Falls. Available at: https://www.aota.org/about-occupational-therapy/professionals/pa/facts/fall-prevention.aspx [Accessed 04 September 2020].
9. Sherrington, C., Tiedemann, A. (2015). ‘Physiotherapy in the prevention of falls in older people’. Journal of Physiotherapy 61: pp.54–60
10. World Health Organisation. 2007. Global Report on Falls Prevention in Older Age. Available at:https://www.who.int/ageing/publications/Falls_prevention7March.pdf [Accessed 04 September 2020]