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GLOBAL STRATEGIES FOR FALL PREVENTION IN ELDERLY POPULATION Sushmitha P.B, Aaveril Rinita Rebello, Ghulain Jeelani Qaidri
Author affiliations: Sushmitha P B , Post G raduate; Averil Rinita R ebello, Lecturer; Ghulam Jeelani Q aidri, P rofessor: Department o f Hospital Administration, Yenepoya Medical College, Deralakatte, Mangalore 575018, Karnataka
Abstract: Background: India is in a phase o f demographic transition. It is projected that by the year 2021, the elderly in India will number 143 million. The major area o f concern is the health o f the elderly. It is seen that falls are one o f the major causes o f injuries and non-communicable diseases associated with old age. Studies on falls in elderly population were reviewed to determine the prevalence, consequences, risk factors, and interventional strategies to prevent falls. Purpose: To study the strategies regarding prevention o f falls in elderly population. Methods: Literature research o f relevant articles, studies, reports in Internet databases o f MEDLINE, PubMed, Google, PMC, Science direct. Studies and articles related to falls in elderly population published after 2012, were found using the key words: falls, quality o f life, prevalence, consequence, injuries, risk factors, health, strategies to reduce falls and fall management. Approximately 2 1 number o f Journals and 10 articles regarding the topic were studied and analyzed. Results: The magnitude o f the problem and strategies, particularly preventive strategies was identified.It is seen that in India, prevalence o f falls among the geriatrics ranges from 14% to 53%, in Japan it was 13.7% and in China it was 26.4%. In the US, 29 million falls were reported in the year 2014, causing 7 million injuries.
Keywords: Geriatric, fall prevention, fall risk assessment, risk factors
Correspondence: JK-Practitioner 2017; 22(1-21: 10-19 Dr. Ghulam Jeelani Qaidri Professor . Dept, o f Hospital Administration ,Yenepoya Medical College , Deralakatte, Mangalore 575018. Karnataka
Indexed: Scopus .IndMED, EBSCO, Google Scholar among others
Cite: This article as: Sushmitha PB, Rebello AR , Qaidri GJ:Global Strategies For Fall Prevention In Elderly Population. JK-Practitioner2017;23( 1-2): 10-19
Introduction The major emerging demographic issue of the 21stcentury is the aging of population. In almost every country, the proportion of people aged above 60 years is growing faster than any other age group as a result of longer life expectancy.2 The WHO proposes “active aging” which aims to extend healthy life expectancy and quality of life for all people as they age, including those who are frail, disabled and in need of care.'
A ‘senior citizen’ or ‘ older adult ‘is defined as a person aged 60 yrs and older.' In india, the proportion of the population aged 60 yrs and above was 7% in 2009 and is projected to increase to 20% by the year 2050.1 By 2021 It is estimated to rise to about 143 Million.4 The major area of concern is the health of elderly. The elderly are faced with multiple medical and psychological problems. Among them, ‘falls’ are one of the major problem5. Falls are defined as “an untoward
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event which result in the patient coming to rest unintentionally on the ground or the lower surface”/' Falls are considered as a non-communicable chronic disease.'They are coded ,as W00-W19 in International classification o f disease-10. Falls are considered as one of the “Geriatric Gaint”. Recurrent falls, are important cause of morbidity and mortality in the elderly and a marker of poor quality of life.'
Statistics of Geriatric F alls Accidental fall is a major complex health issue, threatening the independence and quality of life and overall-well being of the elderly/ Fall, is the second highest cause o f accidental death for people aged 65 and above, following traffic accidents. Death rate from fall increases with age for both men and women. In the age group 65-74 men have higher death rate than women, but after the age of 75 women are more likely than men to die as a result o f a fall/ The most prevalent fall-related injuries among older adults are fracture of the hip, spine, forearm, bones of the pelvis, hand and ankle. Of these, the most serious injury is hip fracture,a leading cause of morbidity and excess mortality among older adults.1(1 Falls that do not result in serious injury may still have serious consequences for an older person, who may fear falling again, which can lead to reduced mobility and increased dependence through loss of confidence." In the United states about 30%of individuals aged 65yrs and older fall at least once a year
and about three-fourth death due to falls occur in 13% of the population aged 65 and above, indicative of primary a geriatric syndrome.10 Every 11 seconds ,an older adult is treated in the emergency room for a fall, every 19 minutes ,an older adult dies from fall." In Japan, the prevalence o f falls is approximately 13.7% 'and in China, it is approxim ately 26.4%. In India the prevalence of falls among older adults above 60 year and older is about 14% to 53%/ The rate of hospital admission due to falls for people at the age of 60 and older in Australia, Canada and the United Kingdom of Great Britain and Northern Ireland (UK) range from approx. 1.6 to 3.0 per 10,000
population. According to EUNESE(European Network For Safety among Elderly) 1 out of 10 elderly is treated at the emergency department due to accidental fall / Fall in hospital leads to injury in about 30% o f cases with(l-5%)leading to serious injury. As they occur predominantly in older people with frailty or multiple health problems, even minor injuries leads to impaired rehabilitation ,loss of confidence, fear of falling and a longer stay.10 Accidental falls in patients account for 30-40% o f reported safety incidents (N a tio n a l P a tie n t S a fe ty A gency, 2007).They occur at a frequency of 4-14 falls per 1,000 bed-days, which equates to about 10 falls per month on a 28-bed ward.I_ About 40% of the elderly population , living at home, will fall at least once each year,and about 1 in 40 of them will be hospitalized. O f those admitted to hospital after a fall, only about half will be alive a year later.Repeated falls and instability are very common precipitators of nursing home admission.1' Risk F actors ForFallln Older People Falls occur more often among older adults because fall risk factors increase with age. A fall risk factor is something that increases a person’s chances of falling." Falls may occur as a result of a complex interaction of various risk factors. The risk factors for older adults can be categorized into: 1) Biological 2) Behavioural 3) Environmental 4) Socio - Economic 5) Others Biological risk factors B i o l o g i c a l r i s k f a c t o r s e m b r a c e characteristics o f individual that are pertaining to the human body * Age Age is a non -modifiable risk factor, which is associated with the changes in the p hys i c a l , c o g n i t i v e , and af f e c t e d capabilities of an healthy individual. The older a person gets, he/she is more vulnerable to falls. " • Gender Health seeking behaviour differs according to gender. Male have higher fatality rate, may be due in part to the tendency of men not seeking medical care, until a condition
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become severe, resulting in substantial delay to the access to prevention and management o f d isease.' Women’s muscle mass decline faster than that o f men, especially in the immediate few years after menopause. Hence, women are more likely to fall, resulting in twice more hospitalization and emergency department visit than men • M u s c le w e a k n e s s or b a la n c e problems Among old people aged 50 and above, the prevalence o f muscle weakness or balance problem is more due to the vitamin D deficiency,’ leading to low bone mineral density. The prevalence o f vitamin D d e f ic ie n c y in o ld e r p o p u la tio n is approximately 91.2%, that o f osteoporosis is approxim ately 31.2% and that o f osteopenia is about 50.2% .’ • M edication sid e effe c ts and/or interactions Falls in older adults are often iatrogenic. Over prescription o f medications causes side effects and interaction among drugs. Older people tend to take more drugs than young people. Also, as people age, they develop altered mechanisms for absorption and metabolizing drugs. Inadequate dosage and lack o f warning to make older people aware about their effects may results in elderly fall. ' • Health conditions Older adults commonly have more than one health related condition ,and their risk of falling increases with the number o f chronic condition such as , depression, dem entia, u rin ary in co n tin en ce, and c h ro n ic d is e a s e su c h as d ia b e te s , hypertension, etc.' It is hypothesised that the symptom of weakness, fatigue, syncope .p o stu ra l h y p o ten sio n c o n trib u te to decrease activity level and subsequent physical deterioration that increases risk for fall.7 • Visual Problems The vision problems contributing to falls includes, poor depth perception, Cataract, and Glucoma. Impaired vision can also result in fall. One reason is that, it may take a w'hile for older people to adjust to see clearly when they moved between darkness and light.1" '’ • Loss of sensation in feet Sensory problems can cause fall too. If the senses
doesn’t work well, for instance having numbness in the feet may mean that they don’t sense where they are stepping and moving ahead may lead to fa ll." 1 Behavioral risk factors • Sedentary behaviour Sedentary lifestyle with no or irregular physical activity is commonly found in both the developed and developing world," 15 the se d e n ta ry a c tiv ity in c lu d e s s ittin g , watching television, and computer uses for much of the day with little or no vigorous exercise, can have a negative health consequence, such as falls.1'’ • Risk taking behaviour Men are more likely to be engaged in intense and dangerous physical activity, and risky behaviour, such as, climbing high ladder, standing on unsteady chair, rushing with little attention to the environm ent. Not using mobility devices prescribed to them such as cane or w'alker, wearing poor fitting shoes, walking in socks without shoes or in slippers without a sole increases the risk of fall.7" • Alcohol use Use o f excessive alcohol has been shown to be a risk factor o f fall, consumption o f 14 or more drink per week is associated with an increased risk offall in older adults. ’1 Environmental risk factors Factors related to environment are the most common cause o f falls in older people A high particular risk to tails are found in hom es, irreg u lar side w alks to the residence, loose carpets on the kitchen and bathroom floors, loose electrical wires and inconvenient doorsteps.' • Flaws in facility design Uneven or excessively high or narrow steps, slip p e ry su rfa c e s, u nm arked edges, discontinued or poorly fitted handrails, loose electrical wires, and inconvenient d o o rste p s, in ad e q u a te or e x c essiv e lightning , are factors that leads to elderly fall.," • Poorly designed public spaces Poor surroundings around home such as garden paths and walks that are cracked or irregular side walks, slippery from rain, snow, or moss and poor night lightings are dangerous.’ Socio-economic risk factors Socio-economic status is a key factor in determining the quality o f life.
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Socio-economic status is often measured as a combination of education, income and occupation. It is commonly conceptualized as the social standing or class o f an individual or group. • Low income and education level There is a relationship between socio economic status and fall.1 Lower income is associated wit increase risk of falling, older people especially, who live alone or in rural with unreliable and insufficient income face an increase risk of fall.3 The negative cycle of poverty and falls in older age is particularly evident in rural areas and in developing countries. • Inadequate housing The poor housing design and maintenance o f house is one o f the risk factors of fall in elderly. As high proportion of accident occur inside the home. Falls on the level I (tripping) accounts approximately 11% of non fatal accidents and 2% of death in home
18,19
• Lack of social interaction In some culture, social participation in older adults is not seen as a virtue. The perception is that old people are meant, “to rest”. In practice, this result in some older people adopting sedentary life often in isolation due to the resignation from social, economic and cultural participation, with a resulting increase in the risk of falling. Isolation and loneliness are commonly experienced by older people particularly among those who lose their spouse or live alone, they are much more likely than other group to experience disability and the physical,cognitive,sensory limitation that increases the risk o f fall. 11 • Limited access to health and social services One third of older adults age 60 yrs and older live below poverty line, upto 65% of older adults are economically dependent, especially widowed women;' Lack o f access or limited to health greatly impacts on older health status. In India only 25% o f people have health insurance coverage and medical expenses are predominantly borne out of pocket ’,when individual do not have insurance they are less likely to participate in preventive care and are most likely to delay medical treatment.
• Lack of community resources Many older adults as well as their family members and caregivers are unaware of factors or behaviour that put them at a risk of falling. They are also unaware of action they can be taken to reduce risk for fall. Fall in older age has been a neglected public health problem in many societies, particularly developing world." The elderly lack sufficient knowledge, regarding the public health policies.7 Other risk factors Fear of falling has been identified relatively recently as a risk factor in the fall prevention literature. Fear o f falling is widespread and has been reported as the most common fear of older adults. It is an important aspect to consider, particularly for those who develop fear after having fallen . Fear o f falling is reported by a significant number o f older persons . Specific fears vary but often include fear o f falling again, being hurt or hospitalized, not being able to get up after a fall, social em barrassm ent, loss o f independence, and having to move from home. 1 Risk For Fall In Hospitalized Patient Being hospitalized increases a person risk for falls.' This is because hospitalized persons are often weak from their illness. They may also be dizzy, light-headed or unsteady from their illness, medications or other treatment. Getting out of bed in the hospital without asking for help is a very common reason for falls. Walking to the bathroom without help also puts patients at risk for falls. 711 Fall Prevention Strategies Fall prevention programme can be effective in reducing the rate of falls, thereby improving quality of life in elderly.21 If preventive measures are not taken in immediate future, the number of injuries caused by falls is projected to be 100% higher by the year 2030 . Studies have shown that, certain fall prevention strategies can be effectively used to reduce the rate o f falls. The strategies are be broadly classified as follows. 1) Systemic fall risk assessment 2) Integrated care management system 3) Exercise programme 4) Environmental -inspection & hazard
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reduction programme Systemic fall Risk assessment Tools Risk assessment are the cornerstone o f any falls preventing program because they allow for a more efficient use o f resources as well as focusing the attention of an individual’s care team when they are at a high risk o f falling.12 Some of the risk assessment tools are • Long term care fall risk assessment
form • Berg balance scale • Dynamic gait index • Mini mental status examination Long term care fall assessment form l3'2” '’ There are eight subtests in the long tenn care fall risk assessment form 1. Level o f c o n s c io u s n e s s /m e n ta l
status 2. History of fall in the past 3 month 3. Ambulation/elimination status 4. Vision status 5. Gait/balance 6. Systolic blood pressure 7. Medication 8. Predisposing disease If the persons score is <10 he/she will be classified into the low risk group and into the high risk group if the score is> 10 Berg balance scale The berg balance scale contains 14 task, to be performed that are graded from 0 unable,to 4 independent with a maximum of score 56 .The higher score indicates better performance Berg suggested that score <45 indicates that a person is impaired with an increase risk of falls.2’"4 Dynamic gait index The dynamic gait index consists of eight subtest each tasks are scored on a 4 point scale.O (poor) & 3 (excellent) the maximum score is 24, scores <=19 are related to increased incidence o f falls in elderly people.1’"’ Mini mental status examination Mini mental status examination is an question measures that tests five areas of c o g n i t i v e f u n c t i o n s , o r i e n t a t i o n , registration, attention, and calculation, recall and language. The maximum scores is 30.A score of<=23 is an indicative of cognitive imapirement.” The Falls Risk Assessment Tool (FRAT)
The Fall Risk Assessment Tool, was
developed by the Peninsula Health Falls Prevention Service. It is a reliable and validate tool, consists o f three section.2' Part 1 - falls risk status; Which evaluates the risk factors o f recent fall, medication, psychological condition and cognitive status. Part 2 -ris k factor checklist; The risk factor checklist, assess the vision, Mobility behaviour, Activities of Daily living, O rientation to environm ent, N utritional status and level of continence. Part 3 -action plan. Based on the risk factor identified. Theaction plan is made and interventional strategies are developed to reduce the risk o f falls.25 The Morse Fall Scale. This scale is shown to be effective in gauging the risk of falls in variety of different settings. Briefly, this scale evaluates a patient’s previous history of falls, number of additional diagnosis a patient has, which reflects the severity of the current condition. It also evaluates if patient can currently move without aid or requires IVs or other therapies involving physical impediments and his or her current gait status and mental state."1’ ( S T R A T I F Y ) St . T h o m a s Ri s k Assessment Tool In Falling. St.Thom as risk o f assessm ent tool developed in the year 1997, and is used to identify clinical risk factors in the elderly and to predict fall chance. A risk assessment score range from(0-5) is designed by rating 1 for presence and 0 for absence, o f 5 fall risk factor"” 1' This scale has been considerably used in risk prediction, and are termed as ‘high’ ‘medium’ or ‘low’ risk of falling or ‘at risk o f falling.12 Integrated Care Management System In Health Care Setting Integrated care management is a process whereby an individual needs are assessed and evaluated, eligibility for services is determined, care plan are implemented services are provided and need are monitored and re assessed. ’1 The WHO European office for integrated health care service defines integrated care as ” A concept bringing together inputs, delivery management and organisation of
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services related to diagnosis, treatment, c a r e , r e h a b i l i t a t i o n , an d h e a lth promotion”. " The goal of integrated care management is to improve accessibility, quality of care and financial sustainability.3132 The delivery o f the integrated services provided to those with chronic condition requires a paradigm shift from episodic short term intervention, which characterize care for acute condition, to long -term com prehensive care for those with continuing care needs.12 The WHO Falls Prevention Model is an example o f such a systematic, coordinated, and comprehensive strategy designed to reduce the burden of one of the most significant causes of age-related injuries and n o n -co m m u n ica b le c o n d itio n s associated with old age. The WHO Falls Prevention Model provides a comprehensive multisectoral framework for reducing falls and fall-related injuries among older persons.7'21 The WHO fall prevention model consists of three pillars. Pillar one -Building awareness of the importance of fall prevention and treatment among older people. Pillar two-improving the identification and assessment of risk factors and determinants of falls P i l l a r t h r e e - i d e n t i f y i n g a n d implementing realistic and effective intervention. In relation to the building awareness of fall prevention, The Center for Disease Control and P rev en tio n 's Stopping E lderly Accidents, Deaths, & Injuries (STEADI) tools and educational materials can assist health care providers in reducing their patients’ risk of falling.0 In relation to the implementing and p r o v id i n g e f f e c t iv e in t e r v e n ti o n strategies.The National Institute on Aging (NLA) and the Patient-Centered Outcomes Research Institute (PCORI) are testing evidence-based interventions that deploy nurses or nurse practitioners as “falls care managers.’4 Exercise Programme Physical activity can help prevent disease and injury. However less than 60% of older adults engage in physical activity and
strength training. FallScape Programme has been developed and tested with support for national institute on aging started in 2004.35 FallScape is a customized program for anyone who has experienced a fall or regular loss o f balance; regardless of w alking ability, m edical condition, mobility, cognitive or fitness level. FallScape consists of one or two training sessions with a set o f brief (less than 1 min.) Multimedia vignettes that are selected specifically to help an individual prevent falls in their own unique situation. FallScape is offered in-home or community space. Research shows that Participants achieve maximum benefit with the addition o f this multimedia training.35'36 The Otago Exercise Program Developed by the New Zealand fall prevention research group in the late 1990’s35'39 The Otago Exercise Program is a series of 17 strength and balance exercises delivered by a Physical Therapist at home, that reduces falls between 35% and 40% for frail older adults. ” This evidence-based program calls for Physical Therapists to assess, coach and progress patients over the course of six months to one year.’6'38 Stay Active and Independent for Life (SAIL) Stay Active and Independent for Life (SAIL) is a strength, balance and fitness program for adults 65 and older. Implemented in the year 2006,32 the program focuses on most important activities, that adults can do to stay active and reduce their chance o f falling like, performing exercises that improve strength, balance and fitness. SAIL exercises can be done standing or sitting. The primary target audiences are older adults (65+) and people with a history of falls. The SAIL program is able to accommodate people with a mild level of mobility difficulty (e.g. people who are occasional cane users)35’36 Stepping On Stepping on is a group program that helps older people reduce their risk of falling, there by improving their quality of life36. Developed by Dr. lindy Clemson in Australia, It was brought U.S and adopted
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for U.S audience by Dr.Jane .E.Machoney o f University o f Wisconsin.1 About 30% of older people who fall lose their self-confidence and start to go out less often. Inactivity leads to social isolation and loss o f muscle strength and balance, increasing the risk o f falling. Stepping On aims to break that cycle, engaging people in a range o f relevant falls prevention
, • 35,40strategies. Tai Chi for Arthritis In 1997, Dr. Paul Lam Led a team o f Tai Chai and medical specialist to create this programme." Many studies have shown Tai Chi to be one o f the m ost effective exercises for preventing falls. Tai Chi for Arthritis helps people with arthritis to im prove all m uscular strength, flexibility, balance, stamina, and more. Environmental Inspection And Hazard Prevention Programme Precautionary measures to be followed in the hospital settings includes " <u' 1. The Patient and caretaker o f the elderly
need to talk to the h ealth care professionals, about the medication, side effects o f the medication which could make elderly dizzy, unsteady on their feet.
2. Advice the elderly to seek help to get out o f the bed and whenever they are moving, especially if they are not feel ing well, advice them to use their call buttons in the hospital.
3. Noticing whether they’re holding onto walls, furniture or someone else while walking or if they appear to have difficulty walking or arising from a chair
4. Advice the elderly to use cane, walker or other device to make walker safer.
5. Advice them to wear comfortable rubber- soled, low -heeled slippers or shoes that fit properly.
6. Advice the elderly to check for a clear and safe pathway before they walk ,ask them to avoid walking on wet or cluttered floors.
Measures To Be Followed By The Caretaker To Avoid Fall In Elderly After Discharge Or Follow Up Care At Home Setting There are many simple and inexpensive ways to make a home safer. If you’re
providing care or planning on providing care to someone in the home, it’s important to make modification o f home. Special attention to the bedroom, bathroom, and equiments should me more emphasised." " Safety in the Bedroom Install night lights, Avoid raised rugs or unsecured rugs that could cause slipping, Get bed rails if the patient is at risk to fall out o f bed, Place a bell or other summoning device in the bedroom that the patient can use to call for assistance. 20,43 Safety in the Bathroom Install grab bars in the tub/shower and near the toilet, place non-skid mats in the shower and on bedroom floors, installraised toilet seat for easy on and off the toilet, hang up night lights., Safety Elsewhere in the Home: Put handrails in the hallways, entryways,
and stairs. Clear paths around furniture and in hallways. Install a ramp on entryways and stairs, A medical alert system if the patient will need to activate help quickly, A medical alert system if the patient will need to activate help quickly. Put a fully charged cordless phone w ithin reach o f the
, 7.20.42patient. Equipment Safety If your loved one uses a walker or cane, make sure there is room in the hallways and room to allow its use, 1 f your loved one uses a wheelchair and he is at risk o f falling out due to weakness, use a lap tray. Any medical equipment supplier can provide you with one o f these, I f your loved one xteeds a hospital bed, decide whether you will need
Source : ‘WHO Global Report On Falls Prevention In Older Age"
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bed rails to prevent falls out o f bed. If your loved one uses an oxygen concentrator, make sure it is plugged into it’s own power outlet. D on’t allow anyone to smoke around
7,2 03 5 ,4 2oxygen. Falls can't always be prevented but ensuring that the home is a safe place will make your job o f caring for your loved one much easier and provide you with added piece o f mind. ° Fall Prevention Awareness Week In 2008 ,The National Council On Aging (NCOA) has sponsored a Fall Prevention A w areness Day on Septem ber, with participation o f the event from 11 states to 48 states and the District o f Columbia.35.The 9th annual FPAD was observed on Sept. 22, 2016. The theme o f the event was Ready, Steady, Balance: Prevent Falls in 2016.35 Fall Related Financial Burden On Older Adult And Their Families Falls create a large cost burden for both the public and private purse,’ regardless o f how health and social care is funded. There are not only direct costs o f treatment and care, but also indirect costs o f lost productivity from carers o f those who fell, and opportunity costs associated with use o f resources, which could otherwise have been effectively used in another way.’1 Direct costs o f falls include health care costs, and indirect costs include societal productivity o f individuals or caregivers (such as income loss)’. The total economic burden o f falls may be significantly higher if direct nonm edical, intangible, and indirect costs o f falls are also included. The costs related to medical management, hospital stay, and rehabilitation o f fall- related injuries are considerable. The consequent morbidity and dependency for daily activities may require assistance of family members (informal caregivers) or nursing aides (formal caregivers). Both types o f assistance are associated with considerable direct and indirect costs.1'4'1 Conclusion Falls are an emerging public health problem and a barrier to active ageing. Falls are easily preventable. They represent an attractive target to increase the quality o f life. Thus, by eliminating or reducing injuries from accidental falls amongst elderly people, can improve their quality o f
1 ife and social well-being. 44
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