Falls

There is substantial evidence and research that demonstrates falls and falls-related fractures are significant among older people living in residential aged care.  Falls can be prevented. However, up to 50% of older people living in residential aged care services fall every year, with 40% experiencing recurrent falls.

Approximately 20–32 per cent of older people who fall will experience a fall-related fracture. Adverse clinical events that can occur as a result of falls include:

• death
• fracture
• decreased independence
• increased functional decline
• anxiety and fear of falling.

Key facts

People aged 80 years or more are at the highest risk of falls and fractures. This age group represents the highest proportion of residents in aged care.

Aged care residents are up to five times more likely to fall than those who live in the community. The proportion of residents with a diagnosis of dementia who fall has been reported as even higher.

Dementia, stroke, diabetes and Parkinson’s disease are common conditions associated with high risk of falls. Nearly 85% of fall-related deaths occur in people who are aged 70 years and over.

The hip is the most comon site of fall-related fracture.

Fall related injuries - a major health threat

Fall-related injuries are a major health threat for nursing home residents. When older people fall, they can experience decreased physical functioning, a reduction in the quality of life, decreased confidence, and an increased fear of falling, which can lead to further functional decline, depression, social isolation, and feelings of helplessness.

When a resident enters a nursing home, a plan of care must be developed. Within this plan of care, the resident’s risk of falling must be assessed to determine what assistance the person may need to get around.

There are a variety of reasons why the elderly might experience a fall, including weakness and gait problems associated with old age, in some cases due to negligence. Examples include falls caused by:

• Wet floors; Poor lighting; Clutter
• Medications, especially psychoactive (antipsychotic medication, drugs)
• Difficulty in moving patients, or assisting them to the restroom, due to understaffing
• Failure to have sufficient staff to answer call buttons
• Failure to have call buttons that are in proper working condition
• Failure to properly train staff in lifting and handling techniques
• Failure of the staff to adequately supervise residents
• Poor foot care
• Restraints
• Weakness and gait problems associated with malnutrition and/or dehydration
• Lack of necessary bedrails and improper bed height
• Improperly maintained or fitted wheelchairs

Falling, prevention and tips

"The amount of human suffering associated with falling accidents is staggering," says Dr. Thurman Lockhart, an assistant professor of industrial systems engineering at Virginia Polytech Institute and State University. "And by 2020, medical costs from hip fractures alone—resulting from falling accidents—are expected to cost the healthcare system between 20 and 50 billion dollars."

In a study sponsored by the Centers for Disease Control and the National Institutes of Health, Dr. Lockhart is researching the mechanics of falling in order to develop intervention strategies. Below, he talks about the mechanics of falling, and offers some practical prevention advice.

Why do people fall more as they age?

There are intrinsic changes associated with the ageing process. The changes that increase the risk of falling are a degrading musculoskeletal system, sensory function, and gait changes associated with ageing.

How do changes in sensory function affect balance?

The maintenance of balance is organised, or controlled by three senses: sight, inner-ear function, and sense of touch, or tactile sensation. We maintain balance with these senses.

So these three factors contribute to falling as we age?

Yes. For example, you can divide slip-and-fall accidents into three different stages: Initiation, or the beginning of a slip, detection, or when we realise we're slipping, and recovery. So imagine when you are slipping and falling. There is the initiation process, where you slip a little bit, and in order to make a recovery, you have to detect that you're falling, which is assessed by your vision, inner-ear, and sense of touch. After that detection period, you have to make some recovery.

So the initiation, detection and recovery phases are all altered for the older individuals, because we have a gait change and the sensory change, as well as musculoskeletal degradation.

Are there other reasons why the elderly are at risk?

There are actually many factors that contribute to slip-and-fall accidents in the elderly. Medication side-effects can cause balance problems or dizziness, which can lead to falling. Elderly people have more chronic illnesses. Arthritis, for instance, is one of the major factors in falling. Pain associated with joints can cause falling. Fatigue, osteoporosis, dementia, and all sorts of things that more commonly strike the elderly, can lead to falls.

At what age does falling become a real risk?

Well, it's different for everybody. But after about fifty-five, our muscle mass begins to decrease and all of the factors associated with musculoskeletal degradation begin to develop. Including bone loss.

Also around age fifty-five, there is a drastic decrease in strength of the lower extremities. And this reduction in strength affects our gait style, or the way we walk. This change is one of the factors associated with how we recover from slip-and-fall accidents.

But it all depends upon a person's lifestyle. We have tested some eighty-five year old individuals who are very, very healthy and active. Their strength is maintained, and they didn't slip and fall in our tests. So age in years is not as important as actual physiological age.

Are the rates of falls different among women and men?

Elderly men fall more often than elderly women, but elderly women are more at risk of hip fractures.

We know that bones are affected by falling. Hip fractures are associated closely with the osteoporosis, or a fragility of bones and their liability to fracture. And osteoporosis is much more common in women than men. But the risk of hip fracture is also related to muscle mass. You have very thin muscle lining around your hips, and as it gets thinner, it becomes very bony. When you hit that area, the fracture rate increases as well.

Any advice to prevent falls?

One important piece of advice is: stay healthy. Walk around and keep the lower parts of your body strong. An active lifestyle is very important. And be aware of your surroundings. That's tougher for older individuals, because their senses and awareness of their surroundings is not as keen as younger individuals.

But it's also very important that people not be overly afraid of falling. Fear should not prevent you from going outside and exercising and doing your activities. Just take some considerations of your surroundings and eliminate all of the hazards associated with fall accidents.

Below is a list of tips from Dr. Lockhart for preventing falls around the house:

General areas

• Minimise changes in walking surfaces, and use slip-resistant coverings such as rough tile and carpet with short, dense pile
• Use lighter-coloured floor surfaces to create colour contrasts between walls and floors
• Increase lighting and reduce the contrasts in lighted areas
• Install wall-mounted light fixtures, accessible while standing on the floor
• Install more outlets to minimise the use of extension cords
• Relocate switches so that the homeowner doesn't have to walk through darkened areas

Kitchen and bathroom

• Securely install two grab-bars positioned for support when entering and exiting in tub/shower and near toilet at height and angle best suited for homeowner's needs
• Install slip-resistant tile/matt
• Increase door width to 30 inches for homeowners with wheelchairs or walkers
• Clean up grease, water and other liquids immediately
• Don't wax floors
• Avoid climbing and reaching to high cabinets or shelves and use a sturdy step stool with handrails if necessary
• Always keep a night-light on in your bathroom
• Use bathroom rugs with nonskid backing
• Add bright decals or red tape to provide contrast between the white tub, white toilet and white walls
• Be sure shower stalls have code standard shatterproof glass

Stairways

• Install handrails on both sides of the stairs and extend them one foot beyond the last step at both top and bottom
• Position top of the railing at elbow height of the homeowner
• Use handrails that allow the homeowner encircle their thumb and fingers around it
• Use a different color contrast to mark the first and last step
• Limit stair rise to seven inches
• Make tread at least 11 inches deep
• Use incline risers with 15-degree angles
• Remove carpets 3/8 inch or thicker and underpads on treads
• Make sure stair height and tread widths are adequate, and each step is identical in size
• Install light switches at the top and bottom of stairs
• Be sure carpeting is tightly woven and installed so it doesn't move or slide

Source: This article was inspired by an excellent piece on falls published in the Denver Post on 15 Jan 2003 which is no longer available, but has been modified for an Australian audience.