Foals Lecture Notes

Epidemiology of Falls

• Definition: An unexpected event resulting in a person resting on the ground, floor, or lower level.
  • Includes falls due to loss of consciousness or overwhelming hazards (e.g., seizures, strokes).
  • Patients may not recognize trips as falls.
  • Falls are not a normal part of aging but are pathological.
• Incidence in the Older Population:
  • Community-dwelling individuals over 65: 1 in 3 fall annually.
  • Long-term care facilities: 1 in 2 fall annually.
  • More frequent in women than men.
  • Leading cause of injury-related death in older adults.
• Common Locations for Falls:
  • Outside the home (most frequent).
  • Level surfaces, showers/baths, stairs, getting out of bed, using chairs or ladders.

Mechanism of Falls

• Important to determine the mechanism:
  • Trips.
  • Loss of balance.
  • Legs giving way.
  • Dizziness.
  • Loss of consciousness or blackout.
• Most Common Mechanisms:
  • Trips (majority).
  • Slips.
  • Loss of balance.
  • Legs giving way.
  • Dizziness.
  • Fainting.
  • Unsure.
• Example: Elderly man tripping over a dog due to altered center of mass over base of support.

Outcomes of Falls

• Injuries: Up to 60% of falls lead to injury.
• Fractures: Up to 6% of falls result in a fracture.
• Hip Fractures: Up to 2% of falls lead to hip fractures.
  • Major predictor of nursing home placement.
• Post Fall Syndrome:
  • Reduction in activity and independence.
  • Increased fear of falling.
• Hospital Admissions:
  • Increase with age; more so in women than men.
  • Projected to increase with an aging population.
• Costs:
  • Each fall costs at least 1,600.
  • ED admission: Approximately 6,756.
  • Annual acute care costs: 648,000,000 (data from some time ago, likely increased).

Risk Factors for Falls

• Intrinsic Factors:
  • Medical conditions: Stroke, Parkinson's disease.
  • Vision effects: Cataracts.
  • Psychoactive medications.
  • Physiological factors: Poor vision, muscle weakness, decreased sensation, slow reaction time, impaired balance.
• Extrinsic Factors:
  • Footwear.
  • Household hazards: Cluttered home, mats.
  • Bifocal glasses.
  • Slippery surfaces.
  • Stairs.
  • Poor footpaths.
  • Poor lighting.

Evidence-Based Risk Factors

• Demographic/Lifestyle:
  • Strong evidence: Age, history of falls, activities of daily living.
  • Moderate evidence: Female gender, inactivity, living alone.
  • Weak/no evidence: Alcohol consumption (though it can contribute in specific cases).
• Balance and Mobility:
  • Strong evidence: Reduced gait velocity, cadence, step length, impaired sit-to-stand.
  • Moderate evidence: Increased postural sway, impaired stability when reaching.
  • Weak/no evidence: Inadequate responses to perturbations.
• Physiological Factors:
  • Strong evidence: Poor visual contrast sensitivity, muscle weakness, slow reaction time, reduced peripheral sensation.
  • Moderate evidence: Low visual acuity.
  • Weak/no evidence: Reduced vestibular function.
• Psychological Factors:
  • Strong evidence: Increased fear of falling.
  • Some evidence: Impaired dual tasking.
  • Less evidence: Risk-taking behavior.
• Medical Components:
  • Evidence: Cognitive impairment, stroke, Parkinson's disease, foot problems.
  • Moderate evidence: Incontinence, osteoarthritis, depression.
  • Less/no evidence: Dizziness, vestibular disorders.
• Medications:
  • Strong evidence: Use of more than four medications, antidepressants, antipsychotics.
  • Less evidence: Antihypertensives.
  • No evidence: Non-steroidal anti-inflammatories.
• Extrinsic Factors:
  • Some evidence: Inappropriate footwear, inappropriate glasses.
  • Home/Environmental Hazards: Flagged as potential risks but evidence level not specified.

Screening for Falls

• Considerations: Accuracy, feasibility, reliability, equipment needs, timeliness.
• Falls Screen (Neura):
  • Short version: Contrast sensitivity, proprioception, quadriceps strength, reaction time, postural sway.
    • Takes 15-20 minutes.
    • 75% accuracy in predicting falls.
  • Long version: 15 components (visual, peripheral sensation, lower limb muscle groups, reaction times, body sway).
• Quick Screen (Neura):
  • Visual acuity, tactile sensitivity, tandem standing, alternative step test, sit-to-stand.
  • Takes 5-10 minutes.
  • 72% accuracy.
  • Simple tick box form, limited equipment.

Screening Tools for Nursing Home Residents

• Objective: Develop screening tools for predicting falls in nursing home residents who can and cannot stand unaided.
• Standing Unaided:
  • Significant event modifier for falls.
  • People who could stand unaided: Poor balance or two or three other risk factors (residents or urinary incontinence) increase fall risk (73% sensitivity, 55% specificity).
  • People who could not stand unaided: One of three risk factors (previous falls, hostile residents, using nine or more medications) increases fall risk two-fold (87% sensitivity, 29% specificity).

Falls Prevention

• Multifactorial: Exercise, environmental modification, medication modification, visual interventions, assistive devices.

Components of Falls Prevention

• Exercise:
  • Cochrane review: 108 RCTs, 23% average reduction in falls.
  • Effective Features: Weight-bearing, balance and functional exercises, at least two hours per week, progressive challenge.
  • Walking/dancing programs may not be sufficient.
• Environmental Modification:
  • Home hazard assessments and interventions.
  • Six RCTs, 19% reduction in falls.
  • OT implementation more effective.
  • More effective among higher-risk older people and those with visual impairments.
  • Adherence issues: Patients not wanting to change their home or remove mats.
• Medication Withdrawal:
  • Three RCTs: Not effective.
  • Another study: 65% reduction in falls, but limited participation and adherence.
• Visual Interventions:
  • Howard et al.: Expedited cataract surgery reduced falls by 34% in women aged 70+.
  • Harron et al.: Single lens glasses reduced outdoor falls by 40% in bifocal wearers regularly participating in outdoor activity.
• Assistive Devices:
  • No evidence of effectiveness in isolation.
  • May increase fall risk in some cases due to deconditioning or increased attentional demand.

Multifactorial Interventions

• Individual assessment and targeted interventions:
  • Combination of exercise, vision, medications, environmental factors.
• 62 RCTs: Average falls reduction of around 23%.
• Adherence issues with increasing complexity.
• Cost effectiveness yet to be determined.

Falls in Hospital

• 95 RCTs looking at falls prevention in hospitals and care facilities: Uncertain effectiveness.
• Vitamin D: Effective in long-term care facilities, reducing falls by 28%.
• Multifactorial interventions: May be effective in the subacute setting (33% reduction).
• Hip Protectors:
  • 19 trials, 11,808 participants: 18% reduction in neck of femur fractures.
  • Slight increase in pelvic fractures.
  • Poor acceptance and adherence, loss of independence with toileting.

Future Directions

• Immediate Fall Detection Devices:
  • Accuracy: 90-100% in systematic reviews.
  • Sensitivity: 70-100%.
  • Specificity: 77-100%.
  • Issues: Lack real-world validation, trunk sensors may be more accurate, battery life, adherence (nighttime use).
• Accelerometer Gait Aids:
  • Help with dorsiflexion in real-time gait (e.g., WalkAide).
  • Minimize trip hazards.
• Hip Hope:
  • Potential, but issues include wearability and risk of increasing injury at other regions.

Summary

• Falls are common, disabling, and costly.
• Multifaceted with many interacting risk factors.
• Many falls can be prevented.
• Appropriately prescribed exercise is essential, and physiotherapy plays a significant role.