Falls are unintentional events that are of major public health concern in the elderly due to the morbidity and mortality associated with them – they are the leading cause of accidental death in older persons and often indicate an underlying health problem. A fall is defined as “unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure” . To maintain a stable posture (and avoid falls) is dependant on the interaction of a number of complex tasks (biomechanical, neurological, physiological, cognitive) that all are impaired with ageing unable to as easy to respond to postural perturbations as younger person increased risk for falls.
Females > males. 1 in 3 older people over 65 will have one fall a year. The rate is higher in those in hospital or long term care facilities. 20% to 50% of falls result in injury – up to 6% being fractures (1.5% hip fractures) . Almost all hip fractures are caused by falls. 20% of hip fractures fatal. Falls account for 4% of hospital admissions over age of 65 years . After the age of 40 years the admission rate increases by 4.5% for males and 7.9% for females .
Causes of falls (wide variation between studies):
~50% - base of support falls (trip, slipping etc)
~30% - centre of mass fails (push, turning, collision, etc)
~20% - no obvious reason
Most occur indoors when usually doing normal activities – usually in the bathroom, bedroom or kitchen. 10% occur on stairs. Falls outdoors normally occur at steps or curbs.
Over 100 risk factors have been identified – many are correlated with each other or interact in a complex manner. Most important risk factor is a previous fall. Falls are not necessarily accidents, but can be explained by risk factors intrinsic to the individual and extrinsic factors in the environment.
Intrinsic risk factors (most are due to age-related declines or diseases):
decline in sensory processing functions, cognitive impairment, dementia, delirium
decreased ability to detect changes in the environment and body posture and react to them
reduced peripheral sensation (vibration perception declines with age; higher risk in those with diabetes mellitus or cervical degeneration)
visual impairment (eg death perception, poor vision, cataracts, increased sensitivity to glare)
slower reaction time
vestibular dysfunction or vestibular pathology (eg previous ear infection, furosemide)
gait changes (eg lower foot height during swing)
foot pathology (foot pain impairs balance – Menz & Lord (2001); hyperkeratotic lesions and the presence of HAV has been linked to falls – Dolinis et al (1997).
medication (eg antiarrhythmics, sedatives, alcohol, antihypertensives, MAO inhibitors, diuretics) – especially if taking >4 drugs
disease (eg Parkinson’s; CVA; depression; epilepsy; hypotension; peripheral neuropathy; arthritic conditions)
nocturia (due to urgency/speed in movement)
Extrinsic/environmental risk factors:
• poor lighting
• slippery surfaces
• damaged/rough/irregular surfaces
• lack of hand rails, unsafe stairwells
• colder weather
• electrical cords, furniture
• uneven footpaths
Falls can be considered as consisting of 3 stages – initiation, descent and impact. Different risk factors will act or affect what happens at each stage. For example, the risk of tissue damage at impact will be related to environmental factors (eg hard surface) or intrinsic factors (eg osteoporosis). Other factors may affect the seriousness of the consequences. For example, Kennedy (1987), found that 50% of those who could not get up from a fall for more than one hour, died within 6 months. The risk of sustaining a major injury is increased in the presence of cognitive impairment or neuromuscular disease .
Footwear and falls:
Considered that high heels, narrow heels, heel slippage and slippers are inappropriate if other risk factors are present. Poor fitting footwear or badly worn footwear may also play a role. Slip resistance of outer sole of shoe could be important in preventing falls as many falls are due to slipping use shoes with textured, slip resistant soles. Heel geometry has also been shown to influence slip resistance – an Oxford shoe with a bevelled heel was shown to have the better slip resistance, but all shoes generally performed badly during the testing.
Footwear with ankle support may give more support and increase proprioceptive input and help reduce the risk of falls . There is no consensus if footwear should be hard or soft soled. Soft sole may be needed for shock absorption, but at the same time may reduce plantar sensory input – compromise may have to be reached if shock absorption is desirable.
Post-fall syndrome/subsequent consequences:
Increased risk for subsequent falls; restricted mobility and its related consequences (deconditioning increased risk for cardiovascular disease); quality of life is affected; fear associated with subsequent falls (maybe a phobic response)
Falls prevention (most falls are preventable):
falls prevention programs are essential in settings/facilities in which services are provided to older persons
exercises to improve balance (eg Tai Chi – Wolf et al , 1997), strength and endurance. But the optimum type of program/prescription has not yet been established.
vision (eg glasses)
modification of medication (eg psychoactive drugs affect balance)
withdrawal of unnecessary medication – in one study this resulted in a 66% decrease in risk
safer shoes (lower heel, ‘harder’ soles, textured sole, higher heel collar)
foot orthoses (unclear if reduce risk as evidence is lacking)
walking aids (sticks, frames)
protection (eg hip padding to dissipate force if fall occurs; reduce force transmitted to femur, but need to be worn a all times)
environmental changes (eg lighting, surfaces, obstructions/obstacles)
making home safe (eg grab bars in bathroom, remove electrical cords from walkways, non-skid wax on floors, not climbing on stools or stepladders, remove throw rugs, tack down carpet edges, etc)
specialised fall prevention clinics/services may be available
frequency of contact/social support or use of remote alarm system for access to help if fall occurs and are unable to get up
Role of Podiatry:
treatment of predisposing foot problems and pain
footwear screening and advice
foot orthoses (theoretically may make foot a more stable base to prevent falls, but evidence is lacking) (find Armstrong’s paper on orths in DM and postural stability).
involvement in multidisciplinary falls prevention clinics/programs