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Keys to aging well

Falls and Fall Prevention:
A Clinical Perspective
Elizabeth A. Phelan, MD, MS
Associate Professor
Medicine / Gerontology and Geriatric Medicine
July 10, 2009
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Definition: coming to rest inadvertently
on the ground or lower level
• Excludes falls due to an acute event
(seizure, stroke, syncope, overdose)
• One of most common “geriatric syndromes”
• NOT a normal part of aging!
Epidemiology of Falls
Community
Each year ~1/3 of community-dwelling persons
aged ≥65, and 1/2 of residents of long-term-
care facilities, experience falls
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Fall-Related Mortality
• Leading cause of injury deaths
among elders (~15,000 nationwide in
2004)
• Number of fatal falls doubled from
1993-2003
• Death rates rise with increasing age
– greatest increase after age 79
• Men more likely to die from a fall;
reasons unclear
Fall-Related Morbidity
• Most falls result in some injury
• 10% of falls result in serious injury
– Head injury
– Fractures
• Most serious and disabling fracture: hip
– 20% die within a year after hip fracture
– 25% in nursing home at one year
Fall-Related Cost of Care
• Total direct costs of fall-related injury care in
2000: $19 billion
• National annual cost of fall-related injuries:
By 2020: $43.8 billion
By 2040: $240 billion
Adverse Sequelae of Falls
• Loss of independence
• Diminished quality of life
• Fear of falling
• Activity restriction
• Functional decline
• Permanent nursing home residence
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Falls Occur Due to a
Combination of Reasons
Intrinsic Factors
Extrinsic Factors
Age related
Medications
Footwear
conditions
Environmental
LE weakness
Balance problems
Assistive device
Intrinsic Factors:
Age Related Changes
in Gait and Balance
• Increased postural sway
• Decreased step height
• Decreased proprioception
• Slowed righting reflexes
Intrinsic Factors:
Age Related Changes in Vision
• Pupil decreases in diameter and becomes less
responsive to variations in light
– Harder to see in dim light
– Longer time to adapt to changes in illumination (e.g.,
dark to light)
• Lens of the eye loses elasticity and becomes thicker
– Harder to see up close
– Harder to see contrast and sharpness of objects
• Lens of the eye yellows
– Reduces contrast between colors
Extrinsic Factors: Medications
• Psychoactive medications
– Benzodiazepines
– Antidepressants
– Antipsychotics
– Anti-epileptics
– Anticholinergic side effects (benadryl, atarax)
• Blood pressure lowering agents
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Clinical Approach to Fall Prevention
Ask all older persons about falls
& gait / balance problems
annually. Observe gait.
two or more falls
gait or balance problem
no gait or balance problem
medical attention due to a fall
Recommend exercise
program with strength and
balance component
Multifactorial fall risk
assessment and management
AGS/BGS/AAOS Panel. J Am Geriatr Soc 2001:49;664.
Tinetti ME. New Engl J Med 2003;348:1.
Multifactorial Fall Risk Assessment
and Management
• Multifactorial risk assessment with
longitudinal follow-up is most effective
approach (reduces falls by 30-40%, NNT=20)
– Educate about fall prevention
– Encourage exercise (gait retraining, muscle
strengthening, balance exercises)
– Update vision exam
– Stop medications that increase fall risk
– Identify and treat postural hypotension
– Modify environment, footwear, assistive device
Chang JT et al. BMJ 2004;328:680-87.
Multifactorial Fall Risk Assessment
and Management
• Management goals:
Reduce chances of falling
Prevent injuries if and when a fall occurs
Environmental modifications
Personal alert systems
Bone strengthening interventions
Self-efficacy enhancing interventions
Other Outcomes of Multifactorial
Approach to Fall Prevention
• Reduce fear of falling
• Improve physical functioning
• Enhance falls self-efficacy
• No effect on mortality
• No effect on nursing home placement
• No published data on HRQOL or
physical activity
Zijlstra GAR et al. J Am Geriatr Soc 2007;55:603-15.
Hill KD et al. J Am Geriatr Soc 2008;56:600-8.
Gates S et al. BMJ 2008;336:130-3.
Cost of Multifactorial Approach to
Fall Prevention
• Multifactorial targeted fall prevention
programs are cost-effective
– Mean intervention cost/person: $905
– Mean total healthcare costs $2,000 lower than
usual care (primarily via reduced hospitalization
costs)
– Fewer overall falls and falls requiring medical
attention, especially among those with four or
more fall risk factors
– Intervention cost per medical fall prevented:
$7,727-$11,834
Rizzo JA et al. Med Care 1996;34:954-69.
Single Interventions to Prevent Falls
• Regular physical activity is most
effective single intervention (reduces
falls by 20%; NNT=16)
– May be done in a group or individually
– Must include strength, gait, and balance
– Should include periodic review and
progression of challenge level as
appropriate
Chang JT et al. BMJ 2004;328:680-87.
Summary and Conclusions
• Falls are common, usually multifactorial in
etiology, and associated with multiple adverse
sequelae
• Falls are often preventable
• Multifactorial targeted fall prevention programs
are cost-effective and improve quality of life of
older persons
• Healthy older persons should do strength and
balance exercises routinely for primary prevention
of falls
Thank you for your attention!

Source: http://www.agingkingcounty.org/advisory-council/docs/Presentation_FallPrevention_July2009.pdf