Falls

Introduction

A fall is defined as an incident in which a person comes to rest accidentally on the ground or floor or another low floor. Fall injuries can be fatal but most are non-fatal. While all people who fall are at risk of injury the age and health of the person can affect type and severity of injury.

• Falls are the second leading cause of unintentional death worldwide. Every year worldwide: an estimated 684 000 people die as a result of falls; 37.3 million falls are severe enough to require hospitalization.
• Adults over the age of 60 have the highest incidence of fatal falls.[1]

Causes of Falls

Falling down stairs

All people who fall are at risk of injury but the age and health of the person can affect the nature and severity of the injury.

1. Age is a major risk factor for falls. Older people are at greatest risk for death or serious injury from falls and the risk increases with age. These risk levels are partly due to physiological and cognitive changes associated with aging[2] and environments that are not adapted for the elderly people. See Exercise in Growth and Decline
2. Shape. All genders are at risk of falling. Older women and young children are more likely to be seriously injured as a result of falls. Globally men maintain consistently high mortality rates and lost DALYs possibly due to men with higher risk exposure and hazards in occupations.

Other risk factors include:

• Work at heights or other hazardous working conditions.
• Alcohol or substance use.
• Socioeconomic factors, eg. Poverty overcrowded housing single parent young maternity age.
• Examples of underlying medical conditions include nervous system (such as falls and traumatic brain injury falls and dementia orthostatic hypotension Parkinson’s disease and freezing of gait) cardiovascular disease (such as heart rhythm problems weakness on one side in people recovering from a stroke) [3] or other disabling conditions (eg, amputee falls). [4]
• Medication Side Effects (see Medications and Falls)
• Sendentary lifestyle.
• Mobile cognition and poor vision, especially in aged care facilities.
• Unsafe environments, especially for those with poor balance and limited vision (see Aging Vision and Special Senses in Older Adults). [1]

Intrinsic and Extrinsic Risk Factors

phone isn’t for some people

Fall risk factors can be divided into intrinsic and extrinsic factors.

1. Intrinsic risk factors are individual characteristics that increase the risk of falls [5]; these are more important in the oldest age groups and may be associated with neurosensory impairment with certain medications or with conditions associated with an increased risk of falls (eg, Parkinson’s disease )related stroke osteoarthritis or diabetes [4]). The risk of falling or recurrent falls increases with the number of associated intrinsic risk factors.
2. Extrinsic causes are social and physical factors related to the external environment not related to the disease or drug use; eg, slipping on ice. Falls in people younger than 75 were more likely to be due to external factors than in people 75 and older. If both intrinsic and extrinsic factors Current falls are classified as combined [6] [7].

Health literacy was positively associated with gait speed. According to the study, older people in communities with higher health literacy have faster gait speed. [8]

Management of Falls

The management of falls can be complex. For example, a combination of interventions—medication reviews, exercise programs, vitamin D supplements, and home assessments—is recommended. Because the causes of falls are often multiple, treatment should be tailored to each patient Medical history and physical examination. [9]

Clinical practice guidelines (CPGs) clearly state that all older adults should be screened for falls risk at least once a year. Screening for balance impairment and gait and mobility limitations are components of falls risk screening. Fall risk screening may prompt multifactorial risk assessment Some of these are administered by physical therapists in consultation with other healthcare providers. [10]

It is increasingly recognized that preventing falls requires behavioral changes and should be approached from a psychological rather than just physical perspective. This is becoming the focus of health promotion [11], and it is this multidisciplinary intervention that has Proven to be most effective for people with falls. [12][13].

It is the physiotherapist’s role to work with an interdisciplinary team (whether physical or virtual) to investigate possible causes of falls and address the problem holistically [14]. Management is multifactorial and aims to prevent and minimize the risk of future falls.

Physiotherapy Assessment

NICE guidance addresses fall risk assessment and prevention for all:

1. People 65 and older during hospitalization.
2. Individuals aged 50-64, judged by clinicians to be at higher risk of falls due to underlying medical conditions. [15]

A complete falls assessment will be part of a larger interdisciplinary multifactorial assessment that includes liaison with physicians, nurses, OT, and other healthcare professionals. Key components of a multifactorial assessment include:

1. Detailed falls history medication review risk factor assessment including osteoporosis and bone health urinary incontinence and cardiovascular disease.
2. Physical examination including gait and balance, neurological and cognitive function, lower body strength, vision, feet and footwear
3. Functional assessments such as perceived functional capacity for activities of daily living and fear of falling [16].

History

Physiotherapists should be clear about why they are asking specific questions and what physical assessments they need to guide their management options. A good history allows the clinician to build a picture around the fall and identify any pattern risk factors or possible causes interpretation or clinical diagnosis. A physiotherapist is well placed to lead a falls assessment, as other professionals (whether qualified or not from a health or social care background) may have only completed a falls ‘screen’ rather than a full multifactorial falls risk assessment Evaluate.

A thorough physical therapy evaluation may identify other previously unknown causes of falls, which may be addressed. To include falls and near misses (also indicators of fall risk), it is recommended to ask the question using the following wording: “During the past month, have you A fall including a slip or trip that caused you to lose your balance and fall to the floor or ground or lower? “[17]

Physical Examination

The physical examination should include assessment of gait balance, range of motion, and muscle strength. It is recommended to use a validated assessment tool. Available on Physiopedia or via Timed Up and Go Test or Berg Balance Scale Evidence-Based Health Database.

Falls or potential falls should be assessed with multifactorial tools such as the Physiological Profile Assessment (PPA). This screening program assesses the likelihood of falls in older adults [6]. It involves a comprehensive series of simple tests of the visual peripheral senses Muscle strength reaction time and postural sway that can be managed quickly with a portable device. The results can distinguish people at risk of falling (“fallers”) from those at less risk (“non-fallers”) because the test identifies a specific contribution of vision Vestibular proprioception and the musculoskeletal system to create a “balance profile”. Research has shown a difference between the instability produced by decreased sensitivity in the legs (such as diabetes), vision problems (such as glaucoma), and strength failure from other problems.

Functional Ability

Functional ability can be examined by subjectively asking how a person manages personal and household activities of daily living; or by observing how the person performs everyday tasks, such as getting up from a chair, or multitasking, such as walking and carrying objects. Poor response The dual task setting is a possible prognostic value for multiple falls [18].

In addition to the reduction in financial costs to the health system, there will be a major impact on the lifestyle of individuals and their families [6]. The psychological and physical consequences of a fall include loss of confidence in activities limiting social interaction and increased concern for Caregivers who may cause family or caregiver stress [6][19][20]. Scales such as the Falls Efficacy Scale International (FES-I) developed by ProFaNE (see Further Reading section below) can be used to determine a patient’s confidence in performing activities. it can highlight fear Falls can interfere with mobility and therefore need to be addressed.

Physiotherapy

Exercise, including structured physical therapy, is an effective part of a falls prevention program, and physical therapists can also provide direct access to home hazards and footwear modifications and education about fall risks.

When treating older adults with falls, four main goals of physical therapy have been identified [21].

1. Prevention of further falls by improving mobility balance and strength (most effective intervention)
2. Train clients to deal with further falls and minimize the consequences of chronic lying. Also teach clients how to get off the floor or call for help while keeping warm.
3. Make sure their living environment is as safe as possible.
4. Restore confidence and self-esteem to improve their quality of life.

Physiotherapy Interventions

Exercise (strength and balance) has been shown to have the most effective results in reducing the rate of falls [22]. Since most people on a balance program repeat the same mistakes after six months, physiotherapists should try to reinforce and encourage them to stay at home exercise program.

For examples of physical therapy interventions, see:

• Preventing Falls: A Balanced Intervention Strategy
• Reactive Balance Training
• Otago Exercise Programme
• Backward-chaining
• Tai Chi and the Older Person

The study by Sherrington et al. [22] demonstrates these factors:

1. Balance training needs to be highly challenging and should be individualized and progressive
2. Exercises should be done at least twice a week and for at least 6 months.
3. Only walking should be prescribed in conjunction with higher intensity / volume programs
4. People in low-risk inpatient care can benefit from multiple interventions – especially those at high risk for falls if the fall involves an unstable posture. The person had to be able to participate in 45 minutes of group exercise at least 3 x week for length of stay.

Prevention

The extent to which prevention can be achieved can be appreciated by considering some of the common conditions and risk factors for falls in the elderly. From this we can appreciate the many preventive and therapeutic possibilities. Falls should be viewed as a symptom rather than an if diagnosis so that if a patient is usually elderly with a history of falls, attempts should be made to determine the cause or etiology[23].

Fall prevention techniques[24]:

1. Exercise regularly. Importantly, the exercises focus on increasing leg strength and improving balance, and they can become more challenging over time. The Tai Chi program is particularly good. In addition, according to systematic reviews, unimodal exercise programs focused on prevention include Strength-only training approaches appear to be as effective as alternative single-modal (tai chi stretching) or multimodal exercise programs (balance + tone training or balance + strength training) in addressing fall risk in older adults. Thus, the findings suggest that the implementation of supervisory intensity Training may be a time-saving exercise strategy that may prevent falls in older adults. [25]
2. Ask their doctor or pharmacist to review their medicines — both prescription and over-the-counter — for ones that may cause side effects or interactions, such as dizziness or drowsiness. Vitamin D supplementation and psychotropic drug withdrawal are also effective [16]. recent Implementing a falls treatment program that includes a multidisciplinary team of family medicine (FM) physicians, internal medicine (IM) physicians, physical therapists, and home health (HH) nurses can provide more consistent care for older patients with falls, research suggests .However Protocols need to be reviewed and updated based on the results, and follow-up studies are needed to improve patient care [26].
3. Have your eyes checked by an ophthalmologist at least once a year, and have your glasses updated to maximize vision. Consider a pair of single vision distance lenses for certain activities, such as walking outside.
4. Make their home safer by reducing trip hazards Add rails in and around the bathtub or shower and next to the toilet Add railings on the sides of stairs and improve lighting in your home.

Further Reading

• Lord S Sherrington C Menz H Close J. Falls in Older People: risk factors and prevention strategies. second edition. New York: Cambridge University Press 2007.
• NICE (2013) Falls in older adults: assessment of risk and prevention.
• UK Ministry of Health. Prevention kit for the elderly.
• The ProFaNE network (made up of 25 partners) is focused on preventing falls and improving postural stability in older people in Europe.
• The Falls and Balance Research Group, based in New South Wales, Australia, is leading the field of applied research looking at the different factors that contribute to falls in older adults and conducting experimental interventions to reduce the impact of any single factor.
• Postural Stability Coach Course for Later Life Training: http://www.laterlifetraining.co.uk/page5.html

Falls factors

There are many causes and effects as shown below.

Falls Factors (from the UK Department for Work and Pensions) .