Mindset
Fall prevention and safety measures (not only) for older adults
Falls among older people are a common and often devastating problem. Frequently, they are accompanied by serious injuries that lead to long-term pain, functional limitations, and a decrease in quality of life. But what are the risk factors? And can the risk of falling be influenced by fall prevention and targeted training? Many authors and studies worldwide address this widespread topic. In Germany, the Federal Initiative for Fall Prevention (BIS)—a group of scientists and experts in the field of fall prevention—addresses this issue, develops recommendations, and has recently published an updated recommendation paper [1]. In this blog, we process and refer to a large extent to this interesting publication. We are grateful for this work and the permission to use it (license notice).
Falls and Their Consequences
Unintentional injuries are the fifth leading cause of death in older adults (after cardiovascular disease, cancer, stroke, and lung disease), and falls account for two-thirds of these deaths. In the US, approximately 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 admitted to hospital 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 admission to a nursing home [2]. In many cases, life after a fall is never the same again [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 driven by risk factors such as weakness / loss of strength, decline in endurance and conditioning, an unsteady gait, orthostatic dizziness, confusion, and certain medications. In addition, joint mobility decreases with age (e.g., due to arthrosis, especially of the lower extremities, which has a major impact on potential falls). This makes the gait stiffer, less controlled, and therefore more dangerous. Due to the slowing of nerve conduction velocity in old age, postural reflexes and thus body control also decrease in older people. Muscle strength is reduced and step height is diminished. Spatial orientation also declines. Due to all these influences, it is no longer possible to react as efficiently in the event of a stumble or fall. 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 have a high frequency of falls. Rather, it is a combination of high occurrence combined with high susceptibility to injury due to a mix of 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 lead to serious injuries. In addition, recovery from a fall injury is often delayed and reduced in older people, which in turn increases the risk of further falls due to deconditioning. Another complication is the fear-of-falling syndrome, in which an individual reduces their activity due to an perhaps overcautious fear of falling. This in turn contributes to further deconditioning, weakness, loss of strength, and abnormal gait, and can significantly increase the risk of falling even further in the long term [2].
Fall Prevention
There is now abundant evidence that the most effective (and cost-effective) fall reduction programs incorporate multiple factors and should be tailored to the individual. In advance, obvious medical factors such as cardiovascular complaints, anemia, or incorrect medication should be resolved through medical evaluation if possible. For patients with gait and balance disorders, assistive device adjustments (e.g., using walking sticks, rollators, and footwear adjustments) can be helpful. Since external environmental influences play a major role in falls in old age, hazards should be reduced through an environmental inspection. Risk factors and tripping hazards in the household, such as frayed carpets, exposed cables, or unstable furniture, should be identified and eliminated. Assistive devices such as grab bars and non-slip mats in the bathroom or any toilet seat elevators are advisable to reduce the risk of falling [2]. Supportive manual therapy interventions to restore or improve mobility by physical therapists or osteopaths can be useful. These can also influence and reduce physical complaints and increase the joy of movement. However, independent, long-lasting personal training is also key to improving physical abilities and thus to optimal fall prevention.
The Optimal Training
To ensure a prevention program is as effective as possible, it should first include systematic tests to assess the risk of falling, followed by targeted interventions with exercise and training programs [1]. Guralnik et al. [4, 5] developed the Short Physical Performance Battery (SPPB), a clinical test battery that covers the most important motor skills such as strength, balance, and gait speed, and is widely used internationally [1]. But 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 several components. It should include and combine functional strength and balance exercises as well as coordination exercises [1]. This is demonstrated by current meta-analyses and systematic reviews [1, 7, 8, 9, 10, 11]. Functional balance training should include both static exercises with a reduction of the support surface (e.g., (semi-)tandem stance and single-leg stance) as well as dynamic and reactive exercises in which the body is deliberately unbalanced (e.g., tandem walking and various types of body rotations (=self-induced perturbations) [1, 12]. Furthermore, exercises that challenge the muscle groups of the body involved in postural control, such as heel and toe stands, as well as multi-tasking [13] and variations in sensory input (e.g., training on uneven surfaces or with eyes closed) should be pursued [1, 14]. As always, the difficulty level of the training should be individually adapted to the patient's ability and progressively increased [1, 12, 15, 16]. Addressing psychosocial aspects, particularly the fear of falling, should also be worked through; introducing the connection between well-being and physical activity, as well as considering individual motives, barriers, and cognitive aspects, is highly beneficial [1]. In addition to balance training, functional strength training helps ensure that independent daily activities such as climbing stairs and doing household chores can be performed for as long as possible. Here, exercises to increase the strength of the lower extremity should be the main focus [1, 12, 17, 18]. After a build-up phase, a moderate to high intensity (60-80% of the maximum possible weight) should be targeted [1]. This enables older people to live an independent life in their own four walls. Strength training is important, but alone it does not seem to be enough to decrease the risk of falling [1]. Endurance performance and conditioning should also be maintained and, as far as possible, trained and improved. Ideally, older people should perform the exercise program at least twice a week. People at risk of falling should also follow a lifelong training program to counteract falls permanently and in the long term. Otherwise, there is a risk that after completion of the training, the increased functional capacity will decline again and the risk of falling will rise once more. [1]
Conclusion
First, individual risk factors are identified so that a targeted therapy can then be designed. Afterwards, individual gait training is performed in physiotherapy, specifically addressing the respective factors (such as weakness and strength, balance, articular limitations, etc.). The latest studies show that, above all, early, preventive training leads to a reduction in the risk of falling. This should consist of functional balance and equilibrium exercises, strength, and endurance training. It is therefore the combination of many individual interventions that makes an effective fall prevention program. And the exercises should be carried out for as long as possible—even throughout life—to counteract falls over the long term and permanently [1]. However, due to the complex nature of falls, the medical assessment of fall risks and the provision of appropriate interventions remain a challenge to this day [2].
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References
[1] Recommendation paper for physical group training for fall prevention in older people living at home
Update of the recommendation paper of the Federal Initiative for Fall Prevention from 2009
Carl-Philipp Jansen, Michaela Gross, Franziska Kramer-Gmeiner, Ute Blessing, Clemens Becker, Michael Schwenk, corresponding, to 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; 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
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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
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WHO (2020a) Accessed: May 19, 2020
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[13] Dual-task performances can be improved in patients with dementia: a randomized controlled trial
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Cover Image Credits
DrTorstenHenning, D-W015 Warnung vor Absturzgefahr ty,
marked as public domain, details on Wikimedia Commons
