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Fall Prevention & Assessment Strategies

Falls are the leading cause of injury and death among those 65 or older. According to the CDC (U.S. Centers for Disease Control and Prevention):
  • More than 20,000 elders die from fall injuries every year (every 28 minutes, an elder dies from a fall!).
  • More than 2 million elders are treated in emergency rooms for nonfatal falls (every 15 seconds an elder is treated in the emergency department for a fall related injury!).
  • More than 600,000 elders are hospitalized because of falling.
In response, much of the recommendations on ‘the best way to prevent falling’ (from Google searches and health professionals) is to start an exercise program and/or to make one’s home safer. There’s little doubt that both hold promise against falling. But is this the best advice for elders to follow?

I have many older patients (and their family caregivers) who have spent  a lot of time, effort  and money on exercising and/or clearing the home of safety hazards, with little to show for their efforts in reducing fall risk. The problem is that exercise and home safety may be needed, but may not be sufficient enough in reducing risk; especially when other preventive lines of attack may be more suited. For instance, exercising or home safety may have little effect on elders who are taking medications (with side effects that cause them to lose their balance), poor vision that may interfere with their ability to see things as well as they once did (leading to trips and falls) and/or other health conditions affecting balance. In many ways, this is like putting the cart before the horse. Many falls experienced by elders are a symptom of an underlying health condition, which requires medical investigation and treatment.

To be effective, any plan to avoid falling (and especially before any intervention is put into place), needs to be based on identifying health conditions that place the elder at risk. Doctors and other healthcare professionals are the best persons to conduct fall risk assessments. Towards this goal, Medicare provides coverage for a number of fall related services, including:
  • A falls risk assessment that is included in the initial ‘Welcome to Medicare’ physical examination.
  • An ‘Annual Wellness Visit’ that reviews the elder’s functional level and safety (falls).
  • The ‘Physician Quality Reporting Initiative’ that incentivizes health providers to assess fall risk and to create fall prevention plan if a risk is identified. Under the program providers (including physicians, nurse practitioners, physician assistants, occupational and physical therapists) receive incentivize payments if they succeed in providing fall prevention services.
Despite Medicare’s initiatives, the identification and management of elders at high risk for falls remains largely neglected in clinical practice. Only 37% of elders in primary care are even asked about falls. Moreover, doctors may not always know how to conduct fall risk assessments or don’t know what to look for. As a result, families play a crucial role in identifying health conditions placing their loved ones at risk.

Assessing Fall Risk

Does the elder have:
  • Any recent falls in the past 3 months (including slips and trips)?
  • Any observed changes in walking and balance?
  • Any observed changes in mobility (the ability to get up and down safely from chairs, toilets, bed, etc.)?
  • Any worries (or fears) about falling? Another way to assess risk is through a balance self-test:
  • Stand with feet together and eyes closed. How long before you begin to lose your balance? Can you do it at all?
  • Or stand on one leg without holding on to anything. If you cannot remain stable for 30 seconds, you need help with balance. Now try it with your eyes closed. A normal younger person can do it for about 30 seconds, while a 65-year-old may last only 5 seconds.
An elder who scores a ‘yes’ to any of the above key questions and/or fails the balance test is considered at increased risk of falling, and further assessment by a doctor is recommended.

Next steps

Visit the Doctor

It’s important that elders with one on more falls and/or difficulties with balance schedule a doctor’s visit. The doctor will evaluate the root cause (s) of the elder’s problems and recommend a plan of action to avoid future falls.

Caregivers can be helpful in this effort by:
Documenting the circumstances of the elder’s fall (s).

For each fall, include:
  • Symptoms at the time (such as dizziness, confusion, tripping, etc.).
  • Activity engaged in at the time (going to the bathroom at night, climbing stairs, getting into the shower/tub, etc.).   Reporting of other health problems that may add to the severity of fall risk:
  • Taking any drugs for anxiety, depression, high blood pressure, Parkinson’s, or sleep?
  • Any anxiety, depression, poor judgment, disorientation, memory problems?
  • Any difficulty seeing objects /finding way around?
Any plan to reduce falls will include:

Exercises that include some balance and strength training for elders can be very effective in reducing falls. Leading a sedentary and inactive lifestyle weakens the body and makes falling more likely. When people stop exercising as they get older it leads to poor muscle strength, loss of bone strength, and loss of balance/flexibility. Working to build muscle, stamina and balance can go a long way to keep elders on their feet and off their butt.
Home Safety
Up to half of all falls occur in the home. Important areas to support and elder’s balance include: Bathrooms
Add shower/bathtub grab bars, nonslip flooring (both inside and outside the bathtub/shower), and grab bars by the toilet.
Install handrails on both sides of the stairs (fix loose handrails).
Keep stairs clear of any objects.
Repair broken treads, loose or torn carpet and other coverings.  
Install good lighting in the bathroom (and along the pathway from the bed to the toilet), and on stairs/steps (especially at the top/bottom steps).

So ‘What’s the best way to prevent falls? First, by assessing a person’s risk of falling and identifying any health problems responsible. Second, by recommending preventive strategies based on risk factors discovered. And finally, an awareness that fall risk is libel to change with a person’s health status. Therefore, monitoring of fall risk needs to be an ongoing process.

Guest post by Dr. Rein, this post originally appeared in E-CareDiary.com

Rein Tideiksaar Ph.D., PA-C is the president of FallPrevent, LLC, Blackwood, NJ, a consulting company that provides educational, legal and marketing services related to fall prevention in the elderly. Dr Tideiksaar is a gerontologist (health care professional who specializes in working with elderly patients) and a geriatric physician's assistant. He has been active in the area of fall prevention for over 30 years, and has directed numerous research projects on falls and has developed fall prevention programs in the community, assisted living, home care, acute care hospital, and nursing facility setting.

Dr. Rein has written several online continuing education course on falls: 

Caring for People With Fall Risks
Facts About Falls
Managing Falls In the Nursing Home: Who, Why and What Next?
Managing Falls IN the Nursing Home for Administrators
Preventing Falls
The Fall Prevention Care Process

Dr. Lisa Goins has written a fall prevention course:

Vitamin D Prevent Falls in Older Adults 

Posted: 5/20/2015 1:07:54 PM
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