Mindset
Fall prevention and safety measures (not only) for older adults
Falls among older adults are a frequent and often devastating issue. They frequently lead to serious injuries that result in long-term pain, loss of function, and a decline in your quality of life. But what are the risk factors? And can your risk of falling be influenced through fall prevention / fall prophylaxis and targeted training? Many authors and studies around the world focus on this widespread topic. In Germany, the Federal Fall Prevention Initiative (Bundesinitiative Sturzprävention, BIS)—a network of scientists and experts in the field of fall prevention—deals with this topic, develops recommendations, and recently published an updated recommendation paper [1]. In this blog post, we address and draw heavily upon this fascinating publication. We are very grateful for this work and for the permission to use it (license notice).
Falls and Their Consequences
Unintentional injuries are the fifth leading cause of death among older adults (following cardiovascular disease, cancer, stroke, and lung diseases), and falls account for two-thirds of these deaths. In the US, around three-quarters of fall-related deaths occur among the 13% of the population aged ≥65 years, highlighting a primarily geriatric issue. About 40% of this age group living at home fall at least once a year, and about one in 40 of them is admitted to the hospital. Of those admitted to the hospital after a fall, only about half are still alive one year later. Repeated falls due to instability and gait unsteadiness are very common triggers for admission to a nursing home [2]. In many cases, life after a fall is never the same as before [1]. In addition to the increased risk of injury and higher mortality rates, such falls also cause enormous economic costs [3].
Risks
Most falls are favored by risk factors such as weakness / loss of strength, decline in stamina and fitness, unsteady gait, orthostatic dizziness, confusion, and certain medications. In addition, as you get older, the mobility of your joints decreases (e.g., due to osteoarthritis, especially in the lower extremities, which strongly influences potential falls). This makes your gait stiffer, less controlled, and therefore more dangerous. Due to the slowing of nerve conduction velocity with age, postural reflexes and body control also decrease in older adults. Muscle strength is reduced and step height decreases. Spatial orientation also declines. Because of all these factors, you can no longer react as efficiently when you stumble or fall. Frequently, however, tripping hazards and environmental triggers such as exposed cables, frayed carpets, or unstable furniture also lead to falls. The problem with falls in the older population is clearly not just their high occurrence, as young children and athletes also experience high fall rates. Rather, it is the combination of high occurrence paired with a high susceptibility to injury resulting from a variety of 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 lead to severe injuries. Moreover, recovery from a fall-related injury is often delayed and diminished in older adults, which in turn increases the risk of further falls due to deconditioning. Another complication is post-fall syndrome, where you might reduce your activity out of an overly cautious fear of falling. This in turn contributes to further deconditioning, weakness, loss of strength, and an abnormal gait, significantly increasing your risk of falling even further in the long term [2].
Fall prevention
There is now ample evidence showing that the most effective (and cost-effective) fall reduction programs address multiple factors and should be tailored individually. First, obvious medical factors such as cardiovascular Conditions, anemia, or improper medication should, whenever possible, be resolved through medical evaluation. If you struggle with gait and balance disorders, assistive device adjustments (e.g., using walking sticks, walkers, and footwear modifications) can be helpful. Since environmental factors play a major role in falls as you age, hazards should be reduced through a home safety assessment. Risk factors and tripping hazards in your home—such as frayed rugs, loose cables, or unstable furniture—need to be identified and eliminated. Assistive devices like grab rails and non-slip mats in the bathroom or raised toilet seats are advisable to lower your fall risk [2]. Supportive manual therapy interventions aimed at restoring or improving mobility, performed by a physiotherapist or osteopathy practitioner, can be very beneficial. They can also help relieve and reduce any physical Conditions and restore your joy of movement. Crucially, however, you also need an independent, consistent home exercise routine to improve your physical abilities and ensure optimal fall prevention.
Optimal Training
For a prevention program to be as effective as possible, it should first include systematic tests to assess your fall risk, followed by targeted interventions with movement and exercise programs [1]. Guralnik et al. [4, 5] developed the Short Physical Performance Battery (SPPB), a clinical test battery that covers essential motor skills like strength, balance, and gait speed, and is widely used internationally [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 components. They should include and combine functional strength and balance exercises with coordination drills [1]. Recent meta-analyses and systematic reviews confirm this [1, 7, 8, 9, 10, 11]. Functional balance training should feature static exercises with a reduced base of support (e.g., [semi-]tandem stance and single-leg stance) as well as dynamic and reactive exercises where your body is intentionally thrown off balance (e.g., tandem walking and various types of body turns [= self-induced perturbations]) [1, 12]. Furthermore, you should aim for exercises that challenge the muscle groups involved in postural control, such as heel and toe stands, along with dual-task training [13] and sensory variations (e.g., training on uneven surfaces or with your eyes closed) [1, 14]. As always, the difficulty level of the training should be individually adapted to your abilities and progressively increased [1, 12, 15, 16]. Addressing psychosocial aspects—especially your fear of falling—is also essential; guiding you toward understanding the connection between well-being and physical activity, while considering your personal motivations, barriers, and cognitive factors, is key [1]. In addition to balance training, functional strength training helps you perform daily activities independently, like climbing stairs and doing household chores, for as long as possible. Here, exercises aimed at increasing the strength of your lower extremities should take center stage [1, 12, 17, 18]. After a build-up phase, you should target a moderate to high intensity (60–80% of your one-repetition maximum) [1]. This enables older adults to continue living independently in their own homes. Strength training is important, but on its own it does not appear sufficient to reduce fall risk [1]. You should also maintain and, whenever possible, train and improve your endurance and stamina. Ideally, older adults should complete the exercise program at least twice a week. In addition, if you are at risk of falling, you should commit to a lifelong training routine to continuously and sustainably counteract falls. Otherwise, once training stops, there is a risk that your gained functional capacity will decline again and your fall risk will rise [1].
Conclusion
First, your individual risk factors are identified so that a targeted therapy plan can be designed. Then, in Physiotherapy, customized gait training is conducted, specifically addressing your individual factors (such as weakness and strength, balance, joint restrictions, etc.). The latest studies demonstrate that early, preventive training leads to a significant reduction in fall risk. This program should combine functional balance exercises with strength and endurance training. Ultimately, it is the combination of many individual interventions that creates an effective fall prevention program. And you should continue these exercises for as long as possible—ideally for life—to protect yourself against falls 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 to this day [2].
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References
Update of the 2009 recommendation paper by the Federal Fall Prevention Initiative
Carl-Philipp Jansen, Michaela Gross, Franziska Kramer-Gmeiner, Ute Blessing, Clemens Becker, Michael Schwenk, corresponding, to the Federal Fall Prevention Initiative
Z Gerontol Geriatr. 2021; 54(3): 229–239.
Published online 2021 Apr 7. German. doi: 10.1007/s00391-021-01876-w; License 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.
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.
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.
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.
WHO (2020a) Accessed: May 19, 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 prophylaxis in old age – fundamentals and modules for course design. Neue Aktive Wege.
E. Freiberger, D.S. Schoene
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[16] Fall prophylaxis through physical activity.
P. Regelin
Mainz: Landeszentrale für Gesundheitsförderung in Rheinland-Pfalz e. V; 2017.
[17] Fall prophylaxis training
C. Becker, U. Lindemann, P. Regelin, J. Winkler, A. Hammes
Aachen: Meyer & Meyer; 2015.
N. Schott, B. Johnen, B. Holfelder
Exp Gerontol. 2019;122:15–24. doi: 10.1016/j.exger.2019.03.012.
WHO (2020b) Accessed: May 19, 2020
Cover Image Credit
DrTorstenHenning, D-W015 Warning of falling hazard ty,
designated as public domain, details on Wikimedia Commons
