What Falls are to Geriatrics

Dr. Barry Goldlist,
Editor in Chief,
Geriatrics & Aging

After many years of practice in geriatric medicine, I am almost convinced that if any doctor truly grasps all of the issues related to falls and the elderly, she understands everything about geriatrics. This may be an exaggeration--but not as much as one may be inclined to think. The reason for this is twofold: First, many of the geriatric syndromes--confusion, immobility, falls, incontinence, dizziness etc.--share the same risk factors and predisposing factors. Secondly, to understand falls in the elderly, the physician has to understand the factors that make the elderly susceptible to falls. These include changing physiology, environmental and social circumstances, and age-related diseases.

Falls are an important cause of morbidity and mortality in the elderly. Over 50% of all trauma admissions in Ontario are caused by falls (in comparison, motor vehicle accidents account for only 13%). About 40% of trauma admissions (Ontario figures) are comprised of patients over 65, and in this group over 80% of trauma admissions are caused by falls. In my hometown of Toronto, in an average year there will be over 15,000 visits to the emergency department by people who have suffered a fall and who are over the age of 75. Yet despite this, emergency physicians seem to have difficulty with this common cause of injury. The reason is simple: The emergency department is not an ideal place to tease apart the multiple contributing factors that might have resulted in the fall. Emergency physicians are more interested in the acute life-threatening causes or con-sequences of falls. Similarly, for those of us who do consultations on orthopedic wards, there is often little description of the fall that resulted in a fractured hip, let alone a careful delineation of the factors that caused the fall. Although I would agree that this is not really for the orthopedic surgeon to work up, often nobody takes responsibility. Perhaps that is why we see so many patients presenting with a second fractured hip!

What is the solution to this problem? I do not think that we will ever develop the necessary assessment skills, within the emergency department, to satisfactorily handle this type of problem. The process is too time consuming and perhaps contradictory to the way emergency departments have to operate. The obvious solution is to establish accessible clinics in the community. The services offered within such clinics would, by necessity, have to be multidisciplinary, with particularly strong contributions from doctors and physiotherapists. When one considers the cost of a single fractured hip (both in dollars and lost quality of life), it is not hard see that the cost-effectiveness of such assessments would be similar to that of other geriatric interventions.

Of course it would be preferable to prevent such falls in the first place, but is that possible? The first inkling that falls prevention was indeed possible came from Mary Tinetti at Yale University in her article published in the New England Journal of Medicine in 1994. In the past year, there has been further evidence of the positive outcomes of falls prevention measures. Dr. Chris Brymer from the University of Western Ontario summarizes this evidence in his article "From Research to Practice: Three Falls Prevention Trials". Dr. Brymer is quite persuasive, and I think it should now be standard medical practice for primary care physicians to identify elderly patients at risk for falls, and to actively strive to prevent them. There are also related articles on the approach to diagnosis and the management of elderly patients who fall.

Preventive strategies focus on individual patients, and at times can be 'labour intensive' for the practicing physician. It is therefore necessary to determine whether there are any broad-based public health approaches to falls prevention. These types of questions are not always easily answered by randomized clinical trials (not that any randomized trials are easy). However, I think there is very persuasive evidence from epidemiological studies and small interventional studies (Fiatarone's trials measuring the benefits of weight training in the elderly), and the FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) Trials to suggest that increasing the fitness of the elderly through exercise will be beneficial. Improving a patient's fitness is, of course, beyond the ability of a single physician, although please note that this edition does have an article on prescribing exercise for seniors that will at least help us with our individual patients.

We have several other articles of interest in this edition, that cover a broad range of important issues: geographic differences in restraint use, the limitations of provincial health insurance and related risks for those travelling abroad (save this for your next vacation!), innovative programs, and Dr. Matear's column on oral health, among others.

I would also like to take this opportunity to thank our former Associate Editor Dr. Margaret Grant, who is taking up a new position as consultant in geriatric medicine at Credit Valley Hospital in Mississauga, Ontario. Our new Associate Editor is Madhuri Reddy. Madhuri is a specialist in internal medicine who is taking advanced training in geriatric medicine while doing research for her master's degree! I am pleased that she is, nonetheless, available to help us with Geriatrics & Aging.

Enjoy this edition.

Use it or Lose it! Is Weakening Musculature a Result of Aging or Muscle Disuse?

Nadège Chéry, PhD

If physical appearance owes its beauty to strong, shapely muscles, it is a rather short-lived feature of human charm, as nice biceps, sculpted thighs and other graceful or bulging aspects of our musculature eventually wither as we age. Far more than our attractive physique is altered, unfortunately, since with advancing age the loss of muscle strength and mass also greatly contributes to frailty (resulting in falls and fractures).¹ Nevertheless, this undeniable consequence of the aging process is not entirely unavoidable. Indeed, simple, effective strategies that can significantly slow (or perhaps reverse) the age-related decline in muscular performance exist, yet they are often overlooked (or even feared) by the elderly.

In an individual between 30 and 80 years of age, muscle, the largest tissue of the human body,1 undergoes important decreases (up to 40%) in both strength and mass.¹⁰ This age-related loss of muscle strength and mass is typically referred to as "sarcopenia".^3,9,10 The expression "muscle wasting" is also used in geriatric medicine in reference to unintentional loss of weight, when fat mass and fat-free mass decrease, as occurs following starvation (at any age) or in geriatric failure to thrive.^7,8

The extent of the loss of strength is not the same across different types of muscles, and also varies greatly among individuals.

How We Move and Why We Fall

Fall Avoidance Dependent on Exquisitely Sophisticated Neural Control System

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 known that aging brings an elevated risk of falls and serious injuries, as well as other adverse medical and psychosocial outcomes. In recent years, exercise has been widely promoted as a potential means of reducing the risk of falling in older adults. There is no doubt that exercise and physical fitness is associated with a myriad of health benefits, and that older adults are able to improve strength, flexibility, aerobic capacity and other fitness measures as a result of exercise programs.^1-4 Even the very frail and very old have shown that they can improve their functional fitness through exercise.⁵ But what is the evidence to support the view that exercise and fitness could actually help to prevent falls and their consequences?

Certainly, there is evidence supporting an association between strength and falling risk. Severe compromise in the strength of the ankle dorsiflexors has been documented in nursing home residents with a history of falling.⁶ Other studies of less impaired individuals have also found evidence of associations between leg muscle weakness and an increase in the risk of falling.

Falls are Leading Cause of Injury Admissions to Ontario Hospitals

Falls are the leading cause of injury admissions to Ontario acute care hospitals, especially for people over 65, according to figures released by the Canadian Institute for Health Information (CIHI).

Of the 68,222 injury admissions to Ontario's acute care hospitals in 1996/97, 58% were caused by falls, followed by motor vehicle collisions (14%) and intentional injuries (6%).

In 1996/97, Ontario residents spent 628,211 days in acute care hospitals due to injuries. Of these patient days, 72% were due to falls. The average length of stay in hospital was 11 days for falls compared to 9 days for all injury hospital admissions.

"Falls account for 86% of hospital admissions for people 65 years of age and older [with an injury] and the statistics are quite striking for older women. In fact, twice as many older women are admitted to hospital because of falls than men of the same age," explains CIHI spokesperson Daria Parsons.

Slipping, tripping, stumbling and falling from one level to another are the most common causes of injury admissions due to falls, in all ages and particularly for people aged 65 and older. The majority of falls occur in January, February and March. The most frequent type of injury is orthopaedic, largely bone fractures and dislocations, which are seen more often in the elderly.

CIHI's analysis shows that from 1992/93 to 1996/97, the number of injury admissions due to falls has remained relatively stable, with women representing more than half of the hospital admissions.

Information from the OTR is used by researchers and injury prevention specialists to develop and monitor injury prevention programs. The Ontario Ministry of Health has identified falls in the older population as a priority theme for injury prevention.

The Canadian Institute for Health Information

Created in 1994, CIHI is a national, not-for-profit organization with a mandate to develop and maintain Canada's integrated health information system. To this end, CIHI is responsible for providing accurate and timely information that is needed to establish sound health policies, manage the Canadian health system effectively and create public awareness of factors affecting good health.

The CIHI can be found on the world wide web at www.cihi.ca.

Fall Prevention Clinics Minimize Risk, Maximize Independence

Sandra MacMillan, RN, BScN,
Irene Swinson, RN, BScN,
Angela Pisan, RN, BScN,
Jennifer Fuller, RN, BScN, MEd
The North York Public Health Department

Introduction

Falls are a leading cause of morbidity and mortality in seniors. In Ontario, falls cause 600 deaths annually for those over the age of 65.¹ In North York, falls are the second leading cause of hospitalization in females over the age of 65, and the fifth leading cause for males of the same age.² Hill et al. reported that one third of seniors experience one or more falls each year.³ The City of North York Public Health Department has developed and implemented a Falls Prevention Program in conjunction with community partners, designed to reduce the incidence of falls in seniors. The newest component of this program is the Fall Prevention Clinics which have been modelled after the Fall Prevention Project conducted at the Ottawa-Carleton Health Department and the Community Health Research Unit, University of Ottawa. Preliminary results from the Ottawa study suggest that it was successful in reducing the number of falls, however, a final report is pending. North York Public Health Nurses have worked closely with The Bernard Betel Centre for Creative Living, North York Seniors Centre and Taylor Place.