Fall prevention and safety measures (not only) for older adults

Falls in older adults are a common and often devastating problem. They are frequently accompanied by serious injuries that lead to chronic pain, loss of function, and a decline in quality of life life. But what are the risk factors? And can the risk of falling be influenced by fall prevention / fall prophylaxis and targeted training? Many authors and studies worldwide address this widespread issue. In Germany, the Federal Initiative for Fall Prevention (Bundesinitiative Sturzprävention - BIS), an association of scientists and experts in the field of fall prevention, addresses this topic, develops recommendations, and recently published an updated recommendation paper [1]. In this blog, we process and refer in large part to this interesting publication. We are grateful for this work and the permission to use it (licensing notice).

Falls and Their Consequences

Unintentional injuries are the fifth leading cause of death in older adults (after cardiovascular disease, cancer, stroke, and pulmonary disease), and falls account for two-thirds of these deaths. In the US, about three-quarters of fall-related deaths occur in the 13% of the population aged ≥65 years, indicating a primarily geriatric problem. About 40% of this age group living at home fall at least once a year, and about one in 40 of them is hospitalized. Of those hospitalized after a fall, only about half are still alive one year later. Repeated falls due to instability and gait insecurity are very common triggers for nursing home admission [2]. In many cases, life after a fall is never the same [1]. In addition to the increased risk of injury and mortality rate, such falls also cause enormous economic costs [3].

Risks

Most falls are caused by risk factors such as weakness / loss of strength, decrease in endurance and stamina, an unsteady gait, orthostatic vertigo, confusion, and specific medications. In addition, as we age, the mobility of our joints decreases (e.g., due to osteoarthritis, especially in the lower extremities, which heavily impacts potential falls). This makes the gait stiffer, less controlled, and therefore more dangerous. Due to the slowing of nerve conduction velocity in older age, postural reflexes and thus body control in older people also decline. Muscle strength is reduced, and step height is decreased. Spatial orientation also declines. Because of all these influences, reacting efficiently to a trip or fall is no longer as easy. However, tripping hazards and environmental triggers such as exposed cables, frayed carpets, or unstable furniture also frequently lead to falls. The issue with falls in the older population is clearly not just the high occurrence, as young children and athletes also experience high fall frequencies. Rather, it is the combination of high occurrence coupled with a high susceptibility to injury due to various clinical conditions (e.g., osteoporosis) and age-related physiological changes (e.g., polymyelitis and slowed protective reflexes). These conditions make even a minor fall particularly dangerous and can result in serious injuries. Additionally, recovery from a fall injury is often delayed and limited in older people, which in turn increases the risk of further falls due to deconditioning. Another complication is post-fall syndrome, where an individual reduces their activity out of perhaps over-cautious fear of falling. This in turn contributes to further deconditioning, weakness, loss of strength, and abnormal gait, which can significantly increase the risk of falls in the long run [2].

Fall Prevention

By now, there is ample evidence that the most effective (and cost-efficient) programs to reduce falls involve multiple components and should be tailored individually. In advance, obvious medical factors such as cardiovascular issues, anemia, or incorrect medication should be addressed through medical evaluation whenever possible. For patients with gait and balance disorders, assistive device adjustments (e.g., walking canes, walkers, and footwear adjustments) can be incredibly helpful. Since external environmental influences play a major role in falls in older age, a home assessment should be conducted to reduce hazards. Household risk factors and tripping hazards, such as frayed carpets, exposed cables, or unstable furniture, should be identified and resolved. Assistive devices like grab bars and anti-slip mats in the bathroom or raised toilet seats are highly recommended to lower the risk of falling [2]. Supportive manual therapy interventions by physiotherapists or osteopaths to restore or improve mobility can also be highly beneficial. This can also address and reduce physical complaints, boosting the joy of movement. However, independent, long-term personal training to improve physical capabilities is also crucial for optimal fall prevention.

The Optimal Training

For a prevention program to be as effective as possible, it should first include systematic testing to assess the risk of falling, followed by targeted interventions with movement and training programs [1]. Guralnik et al [4, 5] developed the Short Physical Performance Battery (SPPB), a clinical test battery widely used internationally that covers essential motor skills such as strength, balance, and gait speed [1]. The Modified Timed Up-and-Go (TUG) [6] is also an excellent screening test for assessing functional mobility and fall risk [1].

Training Content and Recommendations

Effective training programs should consist of multiple elements. They should combine functional strength and balance exercises with coordination training [1], as shown by current meta-analyses and systematic reviews [1, 7, 8, 9, 10, 11]. Functional balance training should include both static exercises that reduce the base of support (e.g., [semi-]tandem stance and single-leg stance) as well as dynamic and reactive exercises where the body is deliberately thrown off balance (e.g., tandem walking and various types of body turns [= self-induced perturbations]) [1, 12]. Furthermore, exercises targeting muscle groups involved in postural control, such as heel and toe raises, dual-tasking exercises [13], and sensory variations (e.g., training on uneven surfaces or with closed eyes) should be incorporated [1, 14]. As always, the difficulty level of the training should be tailored individually to the patient's capabilities and progressed systematically [1, 12, 15, 16]. It is also highly beneficial to address psychosocial aspects, particularly the fear of falling, and to introduce the connection between well-being and physical activity, while considering individual motives, barriers, and cognitive factors [1]. In addition to balance training, functional strength training helps ensure that independent daily activities, such as climbing stairs and keeping up with housework, can be performed for as long as possible. The primary focus here should be on exercises to increase lower extremity strength [1, 12, 17, 18]. After an initial conditioning phase, a moderate to high intensity (60-80% of the maximum possible weight) should be targeted [1]. This enables older adults to lead independent lives in their own homes. Strength training is essential but does not seem sufficient on its own to reduce the risk of falling [1]. Endurance and condition should also be maintained, trained, and improved as much as possible. Ideally, older individuals should perform the exercise program at least twice a week. Furthermore, individuals at risk of falling should engage in a lifelong training program to continuously counteract falls in the long term. Otherwise, there is a risk that the improved functional capacity will diminish after training stops and the risk of falling will rise once again [1].

Conclusion

First, individual risk factors are identified so that a targeted therapy plan can be designed. Afterwards, customized walking training is conducted in physiotherapy, specifically addressing individual factors (such as weakness and strength, balance, articular limitations, etc.). The latest studies demonstrate that early, preventive training is highly effective at reducing the risk of falling. This should consist of functional balance and stability exercises, strength training, and cardiovascular conditioning. It is ultimatey the combination of many individual interventions that creates an effective fall prevention program. These exercises should be maintained for as long as possible—ideally, throughout life—to prevent falls sustainably and over the long term [1]. However, due to the complex nature of falls, the medical assessment of fall risks and the delivery of appropriate interventions remain a challenge today [2].

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References

[1] Recommendation Paper for Physical Group Training for Fall Prevention in Home-Dwelling Older Adults

Update of the 2009 Recommendation Paper of the Federal Initiative for Fall Prevention

Carl-Philipp Jansen, Michaela Gross, Franziska Kramer-Gmeiner, Ute Blessing, Clemens Becker, Michael Schwenk, corresponding,  on behalf of the Federal Initiative for Fall Prevention

Z Gerontol Geriatr. 2021; 54(3): 229–239.

Published online 2021 Apr 7. German. doi: 10.1007/s00391-021-01876-w; Licensing notice

[2] Falls in older people: Epidemiology, risk factors and strategies for prevention

L. Z. Rubenstein

Age Ageing, vol. 35, no. SUPPL.2, pp. 37–41, 2006.

[3] The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: Systematic review and meta-analysis of randomised controlled trials

F. El-Khoury, B. Cassou, M. A. Charles, and P. Dargent-Molina

BMJ, vol. 347, no. October, pp. 1–13, 2013.

[4] Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability

J.M. Guralnik, L. Ferrucci, E.M Simonsick, M.E.  Salive, R.B. Wallace

N Engl J Med. 1995;332(9):556–562. doi: 10.1056/NEJM199503023320902.

[5] A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission

J.M. Guralnik, E.M. Simonsick, L.  Ferrucci, R.J. Glynn, L.F. Berkman, D.G. Blazer, P.A. Scherr, R.B. Wallace

J Gerontol. 1994;49(2):M85–M94. doi: 10.1093/geronj/49.2.M85.

[6] The timed “Up & Go”: a test of basic functional mobility for frail elderly persons

D. Podsiadlo, S. Richardson

J Am Geriatr Soc. 1991;39(2):142–148. doi: 10.1111/j.1532-5415.1991.tb01616.x.

[7] Interventions for preventing falls in older people living in the community

L.D. Gillespie, M.C. Robertson, W.J. Gillespie, C. Sherrington, S. Gates, L.M. Clemson, S.E. Lamb

Cochrane Database Syst Rev. 2012 doi: 10.1002/14651858.CD007146.pub3.

[8] Interventions to prevent falls in community-dwelling older adults: US preventive services task force recommendation statement

Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Krist AH, Kubik M, Landefeld S, Mangione CM, Pignone M, Silverstein M, Simon MA, Tseng C-W.

JAMA. 2018;319(16):1696–1704. doi: 10.1001/jama.2018.3097.

[9] Exercise to prevent falls in older adults: an updated systematic review and meta-analysis

Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Cumming RG, Herbert RD, Close JC, Lord SR.

Br J Sports Med. 2017;51(24):1750–1758. doi: 10.1136/bjsports-2016-096547.

[10] Exercise for preventing falls in older people living in the community

Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE.

Cochrane Database Syst Rev. 2019 doi: 10.1002/14651858.CD012424.pub2.

[11]  WHO Draft for Consultation: Exercise for preventing falls in older people living in the community: update of Cochrane Systematic Review

WHO (2020a) Accessed: 19 May 2020

[12] Exercise for preventing falls in older people living in the community

C. Sherrington, N.J. Fairhall, G.K. Wallbank, A. Tiedemann, Z.A. Michaleff, K. Howard, L. Clemson, S. Hopewell, S.E. Lamb

Cochrane Database Syst Rev. 2019 doi: 10.1002/14651858.CD012424.pub2.

[13] Dual-task performances can be improved in patients with dementia: a randomized controlled trial

M. Schwenk, T. Zieschang, P. Oster, K. Hauer

Neurology. 2010;74(24):1961–1968. doi: 10.1212/WNL.0b013e3181e39696.

[14] An exercise sequence for progression in balance training

T. Muehlbauer, R. Roth, M. Bopp, U. Granacher

J Strength Cond Res. 2012;26(2):568–574. doi: 10.1519/JSC.0b013e318225f3c4.

[15] Fall Prevention in Older Age – Principles and Modules for Planning Courses. New Active Paths. (Sturzprophylaxe im Alter – Grundlagen und Module zur Planung von Kursen. Neue Aktive Wege.)

E. Freiberger, D.S. Schoene

Cologne: Deutscher Ärzte Verlag; 2010.

[16] Fall Prevention Through Movement (Sturzprophylaxe durch Bewegung).

P. Regelin

Mainz: Landeszentrale für Gesundheitsförderung in Rheinland-Pfalz e. V; 2017.

[17] Fall Prevention Training (Sturzprophylaxe-Training)

C. Becker, U. Lindemann, P. Regelin, J. Winkler, A. Hammes

Aachen: Meyer & Meyer; 2015.

[18] Is strength training with free weights superior to machines for increasing strength in high functioning older adults?

N. Schott, B. Johnen, B. Holfelder

Exp Gerontol. 2019;122:15–24. doi: 10.1016/j.exger.2019.03.012.

[19] Draft for consultation: guidelines on physical activity and sedentary behaviour for children and adolescents, adults and older adults

WHO (2020b) Accessed: 19 May 2020

Cover Image Credits

DrTorstenHenning, D-W015 Warning of danger of falling ty (D-W015 Warnung vor Absturzgefahr ty),
marked as public domain, details on Wikimedia Commons