Falls: A Perfect Paradigm for Multifaceted Management

When medical residents rotate through our geriatric service at the University Health Network, we provide a group of seminars on the "Geriatric Giants": confusion, instability and falls, incontinence, geriatric pharmacology and failure to thrive. I have to admit that my personal favourite among the geriatric giants is the topic of falls. I find it to be a perfect paradigm for the clinical practice of geriatric medicine, and thus an excellent tool for teaching the general principles of geriatric care.

What are those principles? I think the first is that any number of problems can result in falls, and that the overwhelming majority of falls in the elderly are not caused by a single factor but by the combination of a multitude of problems. This allows me to demonstrate to the students the various factors that can predispose to falls. These can be intrinsic to the patient (age-related changes or diseases), or external to the patient (environmental factors). The key for the doctor is to determine what factors are operant in a particular patient, and of these, which are modifiable. The next step is to determine which factors can be improved rapidly (e.g., stopping certain medications) and which require long-term strategies (e.g., proximal muscle strengthening). I also emphasize to the residents that there is no such thing as a trivial fall, although some falls only result in trivial injuries. That person's next fall might result in a devastating injury.

The nature of the scientific study of falls in the elderly took an exciting and dramatic turn in the early 1990s, with the article by Mary Tinetti in the New England Journal of Medicine.¹ Her study demonstrated that proper attention to falls risk factors in a primary care setting could actually reduce the number of falls these people would have (absolute risk reduction of 12%, number needed to treat to prevent one fall is 8). This demonstrated clearly that with a comprehensive interdisciplinary approach, complex functional issues in the elderly could be systematically approached and improved.

The new issue in falls prevention is how to reach all those at potential risk. With our rapidly aging population, the individual doctor-patient interaction, while very important, is not enough. The next step in falls prevention is the implementation of community-based programs (e.g., exercise programs) that can have a broader impact. These programs have shown clear efficacy in high quality clinical trials, and we now need to determine if they will be effective when introduced into the community at large.

This issue of Geriatrics & Aging has been designed to provide the tools for primary care physicians to assess the risk factors for falls in their elderly patients, and to allow them to prevent some of these devastating occurrences. Gabriele Meyer, Andrea Warnke and Ingrid Mühlhauser tackle the general topic of fall and fracture prevention in the elderly, and Dr. Fiona E. Shaw addresses the thorny problem of falls in those with dementia. Drs. Nadine Gagnon and Alastair Flint review one of the crippling consequences of falls, namely fear of falling, which dramatically reduces function and quality of life. Dr. Boyd Swinburn and Richard Sager give some practical advice in their article on the promotion of exercise prescriptions for elderly populations. Dr. Margaret Grant provides treatment strategies for one of the most potent risk factors for falls, orthostatic hypotension, while Dr. Karim Khan, et al. present strategies for the optimal delivery of falls prevention programs to the elderly in the community.

Enjoy this issue.

Reference

1. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7.

Falls Prevention Strategies for Elderly People

M. Clare Robertson, PhD
Research fellow,
Department of Medical and Surgical Sciences,
University of Otago Medical School,
Dunedin, NZ.

A. John Campbell, MD, FRACP
Professor of Geriatric Medicine,
Department of Medical and Surgical Sciences,
Dean, Faculty of Medicine,
Dunedin, NZ.

Introduction
Falls are a common problem in older people and substantial healthcare resources are required for the treatment of injuries, for rehabilitation and for long-term care after a fall. For the older person and their family or caregivers, a fall can have serious consequences: trauma, pain, impaired function, loss of confidence in carrying out daily activities, loss of independence and autonomy, or even death.

Falls prevention strategies have been based on the multiple risk factors for falls and these are well defined in the literature.¹ There is now good evidence from randomized controlled trials that carefully designed, single or multiple interventions can reduce falls in older people living in the community.² There are fewer reports on the cost effectiveness of these strategies--useful information for making informed decisions on the allocation of scarce healthcare resources.

Figure 1 gives a list of the falls prevention strategies for community living older people that have been tested in randomized, controlled trials.

Physical Consequences of Falls Part II

An Aging Population will Lead to Mounting Fall-Related Health-Care Costs

Brian E. Maki, PhD, PEng
Professor, Department of Surgery and Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

It is well established that falling is a common occurrence in persons aged 65 and older. Among those living independently, 30-60% will fall one or more times each year,^1-3 and the falling rate is even higher among those living in long-term or acute-care institutions.^4,5 Although the degree to which the falling rate among older adults differs from that among younger adults has not been well established, it is clear that falls in older persons are much more likely to result in serious physical and psychosocial consequences. The first part of this two-part article dealt with the fear of falling and other psychosocial correlates of falls, which has tended to be an under appreciated aspect of the problem. The now forthcoming second part, will focus on what has, historically, received the most attention-the physical consequences of falls.

Although the majority of falls do not result in serious physical injury, the societal costs associated with fall-related injuries are immense. Falls are, in fact, the leading cause of fatal injuries among seniors, accounting for twice as many deaths in this population as motor vehicle accidents.

Tai Chi: Mind Over Body to Prevent Falls

Brian E. Maki, PhD, PEng

Tai Chi has been shown to increase balance confidence and reduce risk of falling in elderly patients.1 Although direct effects on balance control have yet to be demonstrated, it seems likely that Tai Chi may improve the ability to control balance by training the mind and body to integrate balance-related sensory information and by helping an individual to develop a greater "awareness" of both body position and limits to stability. By requiring a series of movements that involve lateral weight transfer and narrowing of the base of support, Tai Chi may bring about specific benefits with respect to control of lateral stability and the consequent capacity to avoid lateral falls, which are the ones that are most likely to result in debilitating (and life-threatening) hip-fracture injuries. Tai Chi has a number of other positive features that may facilitate adherence to a program: it requires no special equipment, it is enjoyable to most participants, it can be performed either in social settings or at home, and it can be safely tailored to match the physical abilities of the individual.

Notwithstanding the above, it is likely that there is nothing "magical" about Tai Chi per se. It would seem that the key factor is developing an exercise program that trains balance, as opposed to strength, flexibility or endurance alone, and incorporating into the balance training a wide range of movements that allow the limits of anteroposterior and lateral stability to be challenged in a safe, enjoyable and convenient manner.

To be linked to a community program that may include Tai Chi please contact the Falls Prevention Program at Sunnybrook Hospital.

References

1. Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of tai chi quan and computerized balance training on postural stability in older subjects. Phys Ther 1997; 77:371-381.

Typically, the practice of Tai Chi requires the performance of a series of movements (comprising one 'form') which involve the shifting of weight from one leg to another in bent knee positions, accompanied by coordinated arm movements, and which must culminate in a final, well-balanced stance maintained for a brief period of several seconds.
In 1980, a book illustrating the 88 'forms' of Taijiquan (Tai Chi) reported the findings of an investigation carried out by the Beijing Sports Medical Research Centre on 88 elderly individuals ranging from 50 to 89 years of age. Group A, comprised of 32 regular practitioners of Taichi, had scores dramatically superior to Group B, the control group, in tests designed to asses cardiovascular function, including blood pressure and rate of arteriosclerosis (cardiographs confirmed the tests), spinal deformity, osteomalacia, and flexibility and range of movement. In Tai Chi, the waist is kept relaxed, the spine erect, and the body is held straight. Consequently, regular practice strengthens the spinal column, reinforcing postural balance and preserving strength and flexibility at the waist.

Source: Taijiquan in 88 Forms (5th ed.), Hai Feng Publishing Company, Hong Kong, 1988.

Too Many Pills Can Cause Life-threatening Spills

Psychotropic Drugs and Polypharmacy are Proven Risk Factors for Falls

Tawfic Nessim Abu-Zahra, MSc

Many risk factors have been shown to contribute to falls suffered by the elderly, including the use of sedatives¹ and the concurrent use of several medications.^2-4 Evidence-based conclusions concerning the relationship between drugs and falls provide limited confirmation due to the studies results' variability, inconsistencies in classification schemes of drugs, and because of the small number of subjects participating in most studies.³ Thus, singling out specific agents and recommending guidelines for prescribing to the elderly is difficult. However, some studies have implicated psychotropic or CNS-active drugs, including sedatives, antidepressants and neuroleptics, as being especially high-risk in terms of leading to falls. Hence, special caution should be taken in prescribing these for the elderly.

Leipzig and colleagues reviewed^3,4 all existing literature dealing with the association between drugs and falling in the elderly. Pooled odds ratios that measure the likelihood that a person taking a drug will also experience a fall were calculated for different classes of drugs.

Start Exercising Already!

Start Exercising Already!
A Physician's Step-by-step Guide to Prescribing Exercise for Elderly Patients

Dr. A. S. Abdulla, BSC, MD, LMCC, CCFP, DipSportMed

Introduction
I have spent many years counselling patients on the merits of dietary modifications in diabetes, hypercholesterolemia, and obesity. I have advocated the avoidance of salt and caffeine for hypertensives, adequate calcium and vitamin D intake for the prevention of osteoporosis, cessation of smoking for the improvement of cardiac and pulmonary risk factors, and cognitive therapy for depression and anxiety disorders. However, I have never found anything to have a more profound impact on all of the above medical conditions, as well as on a patient's general well-being, than a properly prescribed and facilitated exercise regimen. This article will briefly review the epidemiology of sedentarianism and the general benefits and risks of exercise, and will include a short primer on types of exercises along with a step-by-step approach to exercise prescription. The aim of this article is to help you increase the level of activity among your geriatric patients safely and to work through the basics of exercise prescription. The medical approach to dealing with more advanced levels of physical activity is beyond the scope of this article.

Going from Research to Practice: Three Falls Prevention Trials

Chris Brymer, MSc, MD, FRCPC
University of Western Ontario,
London, Ontario

Falls are the leading cause of injury admissions to acute care hospitals in Ontario, and are a common cause of admission to an inpatient geriatric assessment unit. Although falls prevention has been an active, ongoing area of geriatric research for many years, the publication of the results of 4 randomized controlled trials in 1999, addressing falls prevention in the outpatient setting, suggests we may be 'turning the corner', going from research to actual practice.

Close et al's January 1999 study published in Lancet, randomized 397 patients, 65 years of age and older, who had presented to an emergency department with a fall and who were provided with either usual care (n=213), or a detailed falls assessment (n=184).¹ Intervention patients underwent a detailed assessment of their visual acuity, balance, cognition, affect, and medication use by a physician in a day hospital setting, and had their functional status and home environment assessed by an occupational therapist. Although the intervention was essentially a 'one-time' assessment, follow-up care was recommended in 84% of cases. During a one-year follow-up period, self-reported falls, recurrent falls, and hospital admission were 61%, 67%, and 39% lower, respectively, in the intervention group by comparison with the usual-care group. Follow-up data was available after one year for approximately 77% of the patients in each group.

Death, Disability, Institutionalization--All Preventable Consequences of Falls

Mobility Devices and Good Caregivers Facilitate Recovery and Deter More Falls

Nariman Malik, BSc

Falls in the elderly are a common problem, and often can have serious sequelae. The physical injuries that may be sustained after a fall can lead to hospitalization or even institutionalization. Falls are often considered to be an inevitable consequence of aging; however, they may in fact signal the onset of an illness or an underlying cause of frailty.¹

Falls are a significant cause of disability and death in older persons.² Fractures are a result in 3-5% of cases.³ The most serious fracture in the elderly is the hip fracture, which often requires surgical repair, a procedure which itself is plagued by a high incidence of morbidity and mortality.³ A fall may also lead to immobility which can lead to dehydration, rhabdomyolysis and pressure ulceration. Falls can also often lead to a fear of falling, which may result in withdrawal from usual activities and even social isolation and/or depression which ultimately results in both decreased mobility and a loss of independence.^2,4 Primary care physicians managing elderly patients should be prepared to assess appropriately patients who have fallen, and strive to develop a management plan tailored to meet patients' needs.

An Organized Approach to Post-Fall Assessment

Identifying Modifiable Risk Factors in Order to Prevent Future Falls

D'Arcy Little, MD, CCFP
Director of Medical Education and Research
York Community Services, Toronto, ON

Introduction and Epidemiology
Falls are a major health problem for the elderly and have been referred to as one of the "Geriatric Giants."¹ The annual incidence of falls among the community-dwelling elderly is estimated to be 30% among those between 65 and 80 years of age, and 50% among those over 80 years of age.² The annual incidence of falls among elderly nursing home residents is estimated to be 50%, with 40% of residents suffering multiple falls each year.²

Falls are a cause of significant morbidity and mortality in the elderly. Accidents are the 6th leading cause of death in persons over 65, and falls are estimated to be responsible for two-thirds of these deaths.² As a result, falls directly or indirectly cause 12% of deaths within the geriatric population.³ In addition, up to 50% of falls in the elderly give rise to soft-tissue injury, with 5% of these being classified as serious. One percent of falls results in hip fractures, and two-thirds of these patients are unable to return to their pre-fracture functional level. Up to 5% of falls give rise to other varieties of fractures.