Falls in the Elderly

Miryoung Lee, MPH Dept. of EpidemiologyUniversity of Pittsburgh

Learning Objectives

Identify the scope of the problem e.g. impact of falls in the elderly

Describe the contributing factors for falls Address fall prevention, and intervention

programs

Performance Objectives

Understand the seriousness of problems and contributing factors of falls, and fractures

Develop effective strategies to prevent falls

Falls

• Unintentional injuries • External causes of the injury • Multifactorial causes

e.g. falls due to intrinsic factors vs. extrinsic factors

Introduction

How serious is the problem of falls?

Incidence rates of Falls in U.S.

Per person annually

Community 0.2 - 0.8Hospital 0.6 - 2.9Long term- 0.2 - 3.6Care (per bed)

One of every three adults over 65 years fall in every year

Where are people likely to fall?

For people 65 years old or older…..

Home 60% Public Places 30%

Nursing Home 10%

Consequences of Falls Mortality Morbidity

Fractures Soft tissue injuries Head trauma Joint distortions and dislocations Loss of confidence - fear of falling Restricted activity

In 1994, estimated fall-related injury cost was $20.2 billion.

Unintentional Fall Death Rates by Gender, Age 65 +, U.S. 1996

Source: National Center for Health Statistics, Vital Statistics

0

20

40

60

80

100

120

140

Per

100

,000

65-74 75-84 85+

MenWomen

Unintentional Fall Age-Adjusted Death Rates, Age 65 +, gender and race U.S.

0

5

10

15

20

25

30

35

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

White, Men

Black, Men

White, Women

Black, Women

Source: National Center for Health Statistics, Vital Statistics

Fractures • 3% of all falls cause fractures. • Approx. 95% of hip fractures in older

people aged over 65 years are the result of a fall

• People who have a hip facture are 5 ~20% more likely to die in the first year following the injury than any other reason in the same age groups

Common Types of Fractures

Forearm (Wrist) Fracture Spine Fracture Hip Fracture (pelvis, hip, femur) Ankle Fracture Upper arm, forearms, hand

Rate of hospitalization for hip fractures, aged 65 years, 1996

Men ( n=68,783)Rates

Women(n=270,909)Rates

Age (years)65-7475-84 85

168.0 682.1

2,256.2

501.11,620.33,958.3

Per 100,000 populationSource: National Center for Health Statistics, CDC

Fear of Falling

• Loss of self confidence • Decrease of physical activity level and

quality of life • Fear of not being able to get up after a fall

Intrinsic (Personal) factors for Falls • Aged (over 65 years)• Female• Low mobility or fragility – lower extremity

weakness, and poor grip strength • Functional impairments - limited Activities of

Daily living (ADL)• Poor gait and balance • Low body weight

Risk Factors

• Cognitive impairment or dementia • Chronic illness

- Parkinson disease, visual difficulties, stroke, hypertension, or urinary incontinence

• Psychoactive medication - tranquilizers or antidepressants

• Previous falls • Heavy drinking

4,4

2,9 2,92,3

1,82,2 2,4 2,5

3,02,6

1,7

0,00,51,01,52,02,53,03,54,04,55,0

Mea

n R

R o

r OR

Relative risk ratio (RR) or Odd Ratio (OR) of Fall

J Am Geriatr Soc. 2001

Extrinsic or Environmental Factors

• Polypharmacy – four or more prescription medications combination

• Home hazards – Clutter, or loose rugs – Poor lighting on stairs and hallways– Lack of bathroom safety, e.g. grab bars in bathtub

• Footwear • Busy street or elevated walkways

Intrinsic :Aging, poor balance

Occurrence of falls

Fall OutcomesNo injuries

Contributing factors Extrinsic :

Home hazards

Loss of ConfidenceFractures Soft tissues

injures, trauma

Disability, reduced

quality of life

Mechanisms of Fall

Dimension of Fractures

Fall itself Bone Fragility

Force

Source: National Osteoporosis Foundation

Fall itself Loss of footing or loss of traction Changes of reflex with age Changes of muscle mass and body fat Loss of muscle strength Changes in vision and hearing Chronic conditions with medications

Force and Direction of a Fall

Fall 400~ 500J of potential energy Being tall is related to increased risk of

hip fractures How you land and on what surface

increases risk of fracture

Fall directions and Hip Fracture

Circumstances Odds Ratio 95% CI

Hit hip/thigh when fallHit hand when fallHit knee when fallFell sideways vs other directions Fell forward vs other directions Fell backward vs other directions

48.60.420.263.17

0.22

1.03

22.5-1050.23-0.760.14-0.491.78-5.66

0.12-0.38

0.53-1.99

Age adjusted OR; Schwartz et al. 1998

Fragile Bone Osteoporosis, or brittle bones Fall induced fractures

Normal Bone Osteoporotic Bone

Dempster et al., JBMR 1986

Assessment of Risk

• “Get-up and Go” Test (Mathias et al., 1986) Check for balance, gait, and mobility

• Review Chronic medical conditionsMedications Visions and hearing ability Foot disabilities

• Evaluate environmental hazardsHome hazards

Prevention/Intervention

J Am Geriatr Soc. 2001

Personal Prevention Home Safety – Reducing hazards

Check for Safety List (CDC) Balance Exercise Lessen Fall impact – hip

protectors Healthy Life Style

Assistant Devices • Hip pads • Mobility aids

– Cane – Walkers – Wheelchairs

• Bathroom aids - Raised toilet seats- Grab bars

Intervention Programs

• Exercise or physical therapy to increase/gain muscle strength, balance, and gait

• Assessment of home fall hazards• Evaluation of medical condition,

medications, and nutrition• Support groups

Community InterventionExample • The Frailty and Injuries:Cooperative Studies of

Intervention Techniques (FICSIT) meta-analysis Incorporated exercises study – seven studiesIntensive strength, endurance training, or balance

trainingOverall significant reduction of fall e.g. “Tai Chi C’uan” reduced the rate of falls during the 4

months follow up in women at moderate risk of falls.

Province et al., 1995 JAMA

Nursing Home Intervention

• Physical rehabilitation program • Staff education • Environmental assessments and

modification • Reduce medications, or physical restraints

Conclusions• Falls, and related injuries, e.g. fractures are

significant health hazards to the aging society.

• Identifying fall risk factors help to evaluate the problems, and to plan personal, and community intervention strategy.

• Intervention studies has mostly focused on white men and women, and on hip fractures outcomes.

Resources • CDC’s National Center for Injury Prevention

and Control • National Resource Center on Aging and Injury • WHO –Ageing and Life Course • National Fire Protection Association • National Women’s Health Information Center • Elder Web • Additional Reading List