Falls prevention among elderly populations and behavior modification strategies

Incidence of Falls

Accidental or unintentional injury deaths are attributable to falls as the second leading cause worldwide (WHO Media Center 2010). The first leading cause is road traffic injuries. Global statistics say that approximately 424,000 persons die from falls, more than 80% of whom live in low-and-middle-income countries. Of this number, the majority are adults older than 65. A fall is an event wherein the person accidentally drops to lower ground. It may be fatal or non-fatal and most are non-fatal. Even among non-fatal cases, 37.3 million occur every year and are serious enough to require medical attention. The incidence is highest in the Western Pacific and South East Asia at 2/3 (WHO Media Center).

While everyone is at risk for falls at all ages, type and severity are affected by age, gender and health status (WHO Media Center 2010). The risk of death increases with age or serious injury. In the U.S.A., 20-30% of the older population is prone to bruises, hip fractures or head traumas. In most cases, these are due to age-related physical, sensory and cognitive changes and an environment un-adapted to ageing persons. Children are also at risk because of their developmental stage and natural curiosity. Other risk factors include elevated heights, alcohol or substance use, socio-economic conditions, medical conditions, side effects of medications and unsafe environments. Average health care expense for people aged 65 or older in Australia is approximately U.S.$1,049 (WHO Media Center).

Multifaceted and comprehensive prevention strategies are thus needed. They should focus on education, training, safer environments, fall-related research and effective risk-reducing policies (WHO 2010). Healthcare practitioners should be trained on evidence-based prevention strategies and community education to raise awareness (WHO Media Center).

Impact on the Australian Community

The Australian Institute of Health and Welfare reports that accidental falls in the country in the last two decades account for more than 1,000 deaths among those 65 years old and older (Cripps 2001). Deaths from falls occur 40 times more in the 85-year-olds and older than in the younger age groups. AIHW also says that more than 45,000 hospitalizations were the result of fall-related injuries in 1998 alone. These injuries among older persons represented 54% of injury-related hospitalizations. Their number increased by at least 17% in the last two decades studied. This trend indicates that the highest risk of injury and deaths from falls is in this age group (Cripps).

The report likewise says that older women are hospitalized due to accidental falls thrice as much as men in the older age groups (Cripps 2001). Older men, however, had a higher death rate among these groups at 48% when hospitalized for falls, which occur at home. In response to these trends, the AIHW's National Injury Surveillance Unit concluded that falls prevention among older persons is a serious public health issue that must be adequately addressed (Cripps).

Traumatic Brain Injury or TBI

One in every 3 injury transmissions in Australia in 2003-2004 was due to a fall (Rushworth 2009, Watson et al. 2010). That is equivalent to almost 126,800 cases. Consequently, 42% of those hospitalized for falls in Australia develop TBI in 2004-2005. TBI is also the most fatal of all causes, resulting in deaths in 63% of the cases in 2004-2005. Those who develop TBI and eventually die in 2004-2005 comprise 62% of all cases. This means 1 out of 6 fall cases ends in death. The recorded 70,000 Australians aged 65 and over in 2005-2006 for falls meant a 10% increase over the 2003-2004 records. Hip and thigh injuries have decreased in this age group while head injury rates have increased at an equivalent of 1 out of 5 admissions (Rushworth, Watson et al.).

The 26,000 TBI inpatient cases in 2004 and 2005 incurred almost 206,000 hospital bed days and $184 million, per AIHW estimates (Rushworth 2009, Watson et al. 2010). Of this total, 34% were all fall-related TBIs costing $62.7 million. It is second only to transport-related TBI, which was $85.7 million. TBIs and injuries of the lower extremities represented 78% of deaths as well as 79% of falls-related hospital costs. These figures are higher than those reported in 1995-2001 studies, reflecting an increase. In addition, 2003 statistics show that the cost for treating TBI patients of older age groups went beyond $2.2 billion. With the projected increase in the older adult population, the monetary and human costs the increase will entail in their care will be nightmarish. Brain Injury Australia organization recommends a similar public awareness campaign to that of the U.S. On helping seniors live longer. The organization supports the government's proposed national disability insurance for TBI sufferers. The projected costs of falls-related TBI in older persons justify their inclusion in this insurance. It has, however, remained unclear if the ones who need the support most, namely older adults, are included in the prevention policy (Rushworth, Watson et al.)).

Obesity

A study found that older adults who are heavier are more prone to falls than thin or frail older adults (Reuters 2011). Researcher Christine Himes of Syracuse University in New York, who conducted the study, said that heavier older adults may have a harder time with balance than thinner counterparts. It is assumed often that thinner and more frail older persons are at a great risk with a fall and fracture because of their weaker bone density. Himes and a colleague, Sandra Reynolds, investigated 10,755 people aged 65 and over. They found that obese older adults are 12-50% likelier to suffer from falls than those of normal weight. The risk increases as the obese condition gets worse. The highest risk is among those with a body mass index of 40 and more. This translates into about 100 lbs overweight for a man or 80 lbs overweight for a woman (Reuters).

The respondents were surveyed every two years from 1998 to 2006 (Reuters 2011). The study recorded a total 9,621 falls, incurring more than 3,100, which required serious medical attention. Of those who suffered falls, 23% were obese as against less than 20% of those who did not suffer falls. Data showed that health conditions were linked to obesity and the risk for falls. These included arthritis, pain in the legs, diabetes and stroke. Obesity alone, however, posed a higher risk for falls. Those moderately obese older adults tended to report longer-term disabilities they suffer after falls than those with normal weight. Himes figured that the most obese derive some protection from their fatty padding and denser bones than thinner ones. But they are less likely to recover when they get injured. Himes concluded that the trend is likely to get worse, as those in these age groups are likely to suffer from falls each year. Obesity is thus an important public health issue, she said (Reuters).

Strokes among Older Community Residents

Stroke victims are also at a high risk for injurious falls among older adults (Wagner et al. 2009). A study examined the incidence of falls among this group, using the responses of a mixed group of 231 patients. Some were first-time fallers and a few were repeat fallers. Repeat fallers were more inclined to report their fall experiences but these fallers were fewer than first-time fallers. One-third of them said they experienced a loss of balance each month. Few factors differentiated fallers from non-fallers (Wagner et al.).

Reports of falls were made in the first month after discharge at 14% at most (Wagner et al. 2009). After 5 months, less than 10% reported; then 10.4% and 13.2%. The investigation revealed that the number of reports increased after month 9 on single falls with a fall history at twice as high, compared with those without a prior fall. The differences were negligible. The study concluded that falls are likelier to occur during first-time strokes in the first 6 months from discharge. Falls among stroke survivors who dwell in communities often occur after patient rehabilitation. These data will be helpful in designing effective interventions for the prevention of falls among stroke survivors, especially older ones (Wagner et al.).

Financial, Social and Emotional Costs

Falls among older people in NSW alone were estimated at $560 million by the 2006-2007 (CFA 2011). This was according to the NSW report on Incidence and Cost of Falls Injury among Older People in NSW. The incidence of falling among their age group has been targeted by support organizations. Falls often occur in the older community when older persons rush to the toilet or slip in their urine (CFA).

Moreover, falls, which result in injuries, negatively affect the older person's sense of well-being and dignity (CFA 2011). If they are hospitalized, their living arrangements and relationships are disturbed. They can develop dementia and incontinence. Mobility also becomes a problem when they have to be placed in residential aged care. With restricted movements, they lose independence. They develop the fear, often groundless, of deteriorating health, especially when it does not improve with time or treatment. The other problem is that falls are often unreported when there are no serious injuries. Incontinence is another condition not frequently intimated to their doctor. Less than a third of them actually report falls despite the availability of initiatives and measures, which can address falls. These include home-based exercises, home environment assessment, cataract surgery, medication review and Vitamin D and calcium supplements (CFA).

Falls Prevention Intervention

Studies reveal the importance of physical activity in preventing or reducing the risk of falls among older persons in the community and at home (Rose 2007). There is, however, limited evidence at present that physical activity benefits very weak ones in care facilities. Physical activity promises benefit to healthy older adults against the risk of falls. Those at moderate risk, on the other hand, will gain more from structured exercise programs aimed at risk factors, which can be manipulated or changed. They can be adjusted to progress according to the individual's capabilities and earlier physical activity experience. And those at high risk will profit from individually-tailored exercise program drawn from a larger, multifactor intervention approach. It is more resource-intensive. It determines key risk factors, which can be adjusted. These include the type and number of medications, cardiovascular abnormalities, environmental medication, depression, and risk-taking behavior (Rose).

Physical activity programs should be designed to appeal to older adults from various cultural and socio-economic classes or groups (Rose 2007). These programs have a built-in behavioral aspect, which helps older adults in self-regulation and self-monitoring of their own progress skills. These skills are needed to incorporate physical activity into their daily routine (Rose).

An illustrative example is a home program conducted by an occupational therapist at the homes of the participants (Steven and Sogolow 2008). The participants were aged 65 years and older, residing in Sydney. The occupational therapist identified relevant hazards at the participants' homes and their unsafe behaviors, using the Westmead Home Safety Assessment. The hazards identified were slippery floors, poor lightning and rugs and curled edges. The unsafe behaviors were wearing loose shoes, leaving clutter in high-traffic areas, and using furniture to get or reach out for objects in high places. The occupational therapist then recommended changes in their home setup and behaviors, using occupational therapy principles. The home visits took an average of 2 hours each (Steven and Sogolow).

Telephone follow-ups made two weeks later revealed a decrease in fall rates to a third among those who followed the recommended changes but only among those who had one or more previous falls during the year of the study. (Steven and Sogolow 2008). The level of experience of the occupational therapist was critical in the success of the program. Researchers emphasized that this should not be used by those without the appropriate skills in conducting untargeted home modification programs for older persons (Stevens and Sogolow).

A Matter of Balance/Volunteer Lay Leader Model

This is a statewide evidence-based fall prevention program for older adults to prevent falls and promote active aging among them (Ory et al. 2009). Its goal is to reduce the fear of falling among community-dwelling older adults and to increase physical activity among them, at the same time. Researchers analyzed two secondary databases. One was a centralized administrative data set to document implementation processes and structures for conducting the program. The other was a common set of outcome measures for assessing the effect of the program on older adults in a particular area. Multivariate analyses were used to investigate changes on key outcome variables (Ory et al.).