In today’s healthcare system, literature about seniors falling and its impact on patient lives and system costs is ever increasing. This month’s spotlight is devoted to defining clinically what a fall is, and methods for patients to decrease their risks for such events.
Let’s begin with some figures to demonstrate the impact of falls, and why concern over this subject is growing:
About one in four people 65 years and older fall each year. Falls have become the leading cause of injury and death for this age group. Healthcare costs associated with falls amount to billions of dollars each year in both U.S. and Canadian communities. The information below will provide guidelines how to assess fall risk, and strategies to help prevent falls.
What is a “fall”?
What actually is a “fall?” The World Health Organization defines a fall as “a sudden, unintended change in position, resulting in the person landing on a lower level.”
What factors increase fall risk?
Patient factors commonly associated with increased fall risk include:
- Previous falls
- Gait and balance impairment
- Use of psychoactive medications
Other contributing factors include visual problems, polypharmacy, depression, dizziness, orthostasis, functional limitations, age >80 years, female sex, low body mass index (BMI), urinary incontinence, cognitive impairment, arthritis, diabetes, and under treated pain. The greater number of risk factors present, the higher the risk of falling.
Environmental factors that increase fall risk include lack of stair handrails, dim lighting, and tripping hazards (e.g., throw rugs).
How can fall risk be assessed?
Individuals 65 and older should be assessed yearly for fall risk. About 50% of patients who fall don’t discuss it with a provider, for fear of losing independence.
In the U.S., CMS has incentives for providers to conduct fall prevention activities through “Welcome to Medicare Visit” and “Medicare Annual Wellness Visits.”
Individuals with history of at least one fall, or difficulty with gait and balance, should be assessed for this using the “Timed Up and Go” test.This simple test is as follows: the patient begins by sitting in a chair with armrests. They are timed as he or she rises from the chair, walks three meters (10 feet), turns around, returns to the chair, and sits back down. The patient may use their usual walking aid if needed. A time of 12 seconds or more denotes a high risk of falling; this cut-off point may vary according to different protocols.
Patients who have difficulty with gait and balance should undergo a multifactorial fall risk assessment. Factors includes a focused history including medication use, physical exam, functional assessment, and environmental assessment. This assessment needs to be performed by a trained person. Results can be used to provide tailored interventions to reduce fall risk. Some examples are included at the end of this document.
The CDC also provides fall risk assessment tools through the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) Initiative, which can be accessed at https:// www.cdc.gov/steadi/index.html. The Timed Up & Go test is included, as well as additional optional assessments such as 30 Second Chair Stand and 4 Stage Balance Test.
In Fresno, where I am located, there is a SAFE (Senior Awareness & Fall Prevention) program sponsored by the Central Valley Coalition and coordinated through Fresno State. Information can be obtained by calling 559-278-7539 or visiting the website www.safecvd.org.
Which medications are associated with an increased fall risk?
Psychoactive meds pose the greatest risk of increasing fall risk. These include:
• Sedatives (non-benzodiazepine sedatives, etc)
Whenever possible, any medications that increase fall risk should be tapered when needed and discontinued, switched to a less risky med, or have the dose adjusted to the lowest effective dose.
Other meds associated with increased fall risk include:
• Muscle relaxants
Another method for decreasing fall risk is lowering the total number of meds a patient takes. Individuals who take four or more meds may be at an increased risk of falling.
What are safer alternatives to meds commonly associated with an increased fall risk?
Some examples of switching to a less risky med to help prevent falls include the following:
• Avoid first-generation antihistamines for allergies(Benadryl); use second-generation antihistamines(Loratadine) or nasal steroids(Flonase).
• Employing sleep hygiene methods or possibly melatonin for insomnia instead of a benzodiazepine(Valium, Ativan).
Which medications can help prevent falls?
Vitamin D, at least 800 units/day, may help prevent falls by improving bone, joint, and nerve health.
It is recommended in guidelines for older patients with known or suspected vitamin D deficiency, or who have an increased fall risk.
Currently, the American Geriatrics Society suggests at least 1,000 units/day of vitamin D plus calcium in the range of1,000 to 1,200 mg/day for adults 65 and older to reduce the risk of fractures and falls.
Treatment of orthostatic hypotension where patients change position too quickly, blood pools in the lower extremities, patients get dizzy and falls occur, is also recommended to reduce fall risk. This may involve stopping/adjusting doses of meds that can cause orthostatic hypotension, using non-drug strategies, or starting drug treatment such as fludrocortisone or midodrine that can help prevent postural hypotension.
What non-drug strategies can be recommended to help prevent falls?
Patients are encouraged to do the following to help prevent falls:
• Rise slowly to standing.
• Exercise regularly with activities that includes balance, gait, and strength training. (walking, water workouts, Tai Chi, etc)
• Wear sturdy shoes that fit properly, with non-skid soles. Avoid styles such as high heels or floppy slippers.
• Use anti-slip shoe devices for walking on snow and ice.
• Avoid wearing multifocal lenses while walking, especially on stairs.
In addition, refer patients to physical therapy for evaluation and recommendations for ambulatory aids/assistive devices (e.g., cane, walker). Home safety measures that can be recommended to help prevent falls include the following:
• Install grab bars in the bathroom, and make sure stairways have hand rails on both sides.
• Provide adequate lighting; night lights in bedrooms and bathrooms, and a lamp within reach of the bed.
• Remove throw rugs, repair loose carpet or floorboards, and equip wood stairs with nonslip treads.
• Clear clutter from walkways.
• Arrange furniture to lessen obstacles in high-traffic areas, and keep walking paths clear of electrical cords.
• Keep necessities of daily living stored within reach. Avoid storage on high shelves.
• Have an alert device or cell phone to contact help in case of a fall.
• Keep pets from getting underfoot. Use a collar with a bell to indicate if the pet is nearby.
• Use a strategy to keep patients from getting tripped up by oxygen tubing. This may mean placing brightly colored tape on the tubing to improve its visibility to patients as they’re moving about.
Additional information for patients about fall prevention is available at https:// www.cdc.gov/steadi/patient.html and https://nihseniorhealth.gov/falls/aboutfalls/01.html.
The author freely admits to recently crossing the line into senior territory where fall prevention has become a concern. If you have relatives or friends in similar situations, this information will provide simple tools and resources to protect the safety of your loved ones.