Fall Prevention and Safety Measures (Not Just) for Older Adults
March 19, 2022
Falls in older individuals are a common and often devastating issue. They are frequently accompanied by serious injuries, leading to long-term pain, functional losses, and a decrease in quality of life. But what are the risk factors? And can fall risk be influenced by fall prevention and targeted training? Many authors and studies globally engage with this widespread topic. In Germany, there is the National Initiative for Fall Prevention (BIS), a coalition of scientists and experts in the field of fall prevention, who deal with this topic and have developed recommendations, recently publishing an updated position paper [1]. In this blog, we largely rely on and reference this compelling 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 among older adults (after cardiovascular diseases, cancer, stroke, and lung diseases), with falls accounting for two-thirds of these fatalities. In the USA, about three-quarters of fall-related deaths occur in the 13% of the population aged ≥65 years, indicating primarily a geriatric problem. About 40% of this age group living at home fall at least once per year, and about one in 40 of them is hospitalized. Only about half of those hospitalized for a fall are still alive a 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 not the same as before [1]. In addition to the increased injury risk and elevated mortality rate, such falls also cause enormous economic costs [3].
Risks
Most falls are facilitated by risk factors such as weakness/loss of strength, decreased endurance and fitness, unsteady gait, orthostatic dizziness, confusion, and certain medications. Additionally, with advancing age, the mobility of joints decreases (e.g., due to osteoarthritis), especially in the lower extremities, which significantly influence potential falls. Consequently, gait becomes stiffer, less controlled, and therefore more dangerous. The slowing of nerve conduction velocity with age also reduces postural reflexes and thus body control in older individuals. Muscle strength is reduced, and step height is decreased. Spatial orientation also declines. Due to these influences, a stumble and fall cannot be reacted to as efficiently. However, tripping hazards and environmental triggers, such as exposed cables, frayed carpets, or unstable furniture, often lead to falls. The problem with falls in the older population is clearly not just the high frequency, as young children and athletes also have a high incidence of falls. Rather, it is a combination of the high occurrence along with a high susceptibility to injury due to a combination of various clinical conditions (e.g., osteoporosis) and age-related physiological changes (e.g., slower protective reflexes). These conditions make even a minor fall particularly dangerous, leading to serious injuries. Additionally, the recovery from a fall injury in older individuals is often delayed and diminished, further increasing the risk of additional falls due to deconditioning. Another complication is the fear syndrome following a fall, where an individual, from perhaps an overcautious fear of falling, reduces their activity. This then contributes to further deconditioning, weakness, and decreased strength and abnormal gait, and can, in the long term, significantly increase the risk of falls again [2].
Fall Prevention
There is now ample evidence that the most effective (and cost-effective) programs for reducing falls encompass multiple factors and should be individually tailored. Initially, obvious medical factors such as cardiovascular conditions, anemia, or incorrect medication should be addressed through medical evaluation. For patients with gait and balance disorders, the adjustment of aids (e.g., with walking sticks, walkers, and shoe modifications) can be helpful. As external environmental factors play a significant role in falls in the elderly, an environmental inspection should be conducted for hazard reduction. Risk factors and tripping hazards in the home, such as frayed carpets, exposed cables, or unstable furniture, should be identified and addressed. Aids like grab bars and anti-slip mats in the bathroom or potential raised toilet seats are advisable to reduce fall risk [2]. Supportive manual therapeutic interventions to restore or improve mobility by physiotherapists or osteopaths can be beneficial. These can also influence and reduce any physical complaints and increase enjoyment in movement. However, it is also important to have independent, long-lasting self-training to improve physical abilities and achieve optimal fall prevention.
The Optimal Training
For a prevention program to be as effective as possible, it should first include systematic tests to assess fall risk, 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 covering the main motor skills like strength, balance, and walking speed, and is widely used internationally [1]. However, the Modified Timed Up-and-Go (TUG) [6] is also a very good screening test for assessing functional mobility and fall risk [1].
Training Contents and Recommendations
Effective training programs should consist of multiple components. They should include functional strength and balance exercises, as well as coordination exercises, and combine these [1]. Current meta-analyses and systematic reviews demonstrate this [1, 7, 8, 9, 10,11]. A functional balance training program should include both static exercises with a reduction in the base of support (e.g., (semi)-tandem stand and single-leg stand) and dynamic and reactive exercises where the body is intentionally destabilized (e.g., tandem walking and various types of body turns (self-induced perturbations) [1, 12]. Additionally, exercises that engage muscle groups involved in postural control, such as heel and toe stands, along with dual tasks [13] and sensory variations (e.g., training on uneven surfaces or with eyes closed) should be pursued [1,14]. The difficulty level of the training should always be adapted to the individual's ability and progressively increased [1, 12, 15, 16]. Addressing psychosocial aspects, particularly fear of falling, should be addressed, with a focus on the connection between well-being and physical activity, considering individual motives and barriers, and cognitive aspects being beneficial [1]. In addition to balance training, functional strength training helps ensure that independent daily activities like climbing stairs and household chores can be performed for as long as possible. Exercises aiming to increase the strength of the lower extremities should be prioritized [1, 12, 17, 18]. After an initial phase, a moderate to high intensity (60-80% of the maximum possible weight) should be targeted [1]. This enables older individuals to lead an independent life in their own homes. Strength training is important, but it alone does not seem sufficient to reduce fall risk [1]. Endurance capabilities and fitness should also be preserved and, as much as possible, trained and improved. Ideally, older individuals should perform the exercise program at least twice a week. Fall-prone persons should also follow a lifelong training program to counteract falls persistently and long-term. Otherwise, there is a risk that the increased functionality gained from training will decline again, and the fall risk will rise once more after the training ends [1]
Conclusion
First, the individual risk factors are determined to subsequently create a targeted therapy. This is followed by an individual gait training in physiotherapy, focusing specifically on the respective factors (like weakness and strength, balance, articular restrictions, etc.). Recent studies show that especially early preventive training leads to a reduction in fall risk. This should consist of functional balance and equilibrium exercises, strength, and endurance training. It’s 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 for a lifetime, to permanently and consistently counteract falls [1]. However, the medical assessment of fall risks and the provision of appropriate interventions remain a challenge due to the complex nature of falls to this day [2].
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References
[1] Recommendation Paper for Physical Group Training for Fall Prevention in Older, Home-Living People
Update of the recommendation paper by the National Initiative for Fall Prevention from 2009
Carl-Philipp Jansen, Michaela Gross, Franziska Kramer-Gmeiner, Ute Blessing, Clemens Becker, Michael Schwenk, corresponding, to the National 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
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Image Credit
DrTorstenHenning, D-W015 Warning of Fall Hazard ty,
marked as public domain, details on Wikimedia Commons
