Falls Elderly Population Running head: FALLS IN THE ELDERLY POPULATION

Literature review paper Falls in the Elderly Population

Falls in the Elderly Population

As America ages so do the number of elderly people in our population, and falls among our elderly are increasing at an alarming rate. The costs of falls are becoming a burden to society and to our elders. Sixty percent of fall-related deaths occur among persons 75 and older (Committee on Energy and Commerce, 2002, 1). A national approach to reduce elder falls, that focuses on the daily life of senior citizens is needed within our residential, institutional, and communities. The approach should include a wide range of organizations and individuals including family members, health care providers, social workers, architects, employers and others (Committee on Energy and Commerce, 2). The Federal government recognizes this as a community problem. Community health nurses need to implement educational programs that address falls and recruit community members to assist them. Risks for falls are separated into extrinsic factors involving the environment and intrinsic factors that are age and or psychosocial related. This literature review looked at the risk factors for falls, fall prevention programs, and adherence to different fall prevention programs. There are many factors that determine whether a fall prevention program will be successful in a community. They range from non-compliance due to the difficulties of scheduling the program to the communities convenience to not being flexible to any variances in their programs. Community health nursing needs to recognize the increase in falls in the elderly and to start prevention programs that the elders will adhere to. Community health nurses need to assess their population to assist in the development of a program that fits the community. Gardner, Robertson, mcGee &, Campbell site one of the reasons that people withdrew from a fall prevention program was ill health.

It has been projected that, by the year 2040, the number of Americans over the age of 85 years will reach 13 million, and those over 65 will number 66.6 million. The consequences of falls are social, physical, psychological, and economical, and sometimes- fatal (Brown-Commodore, 1995, 84). Falls can be defined as: a sudden unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force (Feder, Cryer, Donovan &, Carter, 2000, 1007). A major focus is on the risks of falls and methods to decrease them. Falls are the leading cause of death in people over the age of 65 (Committee on Energy and Commerce, 2002, 1). The complications and injuries from falls have detrimental consequences for elderly people. An elderly person experiencing one or more injurious falls is three times more likely to receive hospital care, four times more likely to visit the emergency room, seven times more likely to receive home health service, and sixteen times more likely to receive nursing home care than an elderly person who has not fallen (Lambert, Sterbenz, Womack, Zarrinkhameh &, Newton, 2001, 28). There are various reasons documented on why falls occur in the elderly. The risk of sustaining an injury from a fall depends on the individual patients susceptibility and environmental hazards. Studies show that certain factors place an older person at risk for fall (Mosley, Galindo-Ciocon, Peak &, West, 1998, 38). The risk factors responsible for a fall can be either intrinsic or extrinsic (Fuller, 2000, 2159). Intrinsic or host factors which are related to the health status of the elderly: non-bipedal fall risk factors, which are self-generated or due to failure of physical supports such as a cane, walker, or chair, for example (Brown-Commodore, 1995, 85); gait patterns in relationship to ground surfaces and shoes, drug regimen, nutritional status, and the psychosocial aspects of falls such as family support or lack of it, declining cognitive status, and

marital status (Mosley, Galindo-Ciocon, Peak &, West, 1998, 38). This would also include sensory deficits (hearing, vision, gait/balance impairment, orthostasis, chronic illness medication/polypharmacy, elimination problems, psychological issues (includes the fear of falling) and previous falls (Rawsky, 2000, 161). Fear of falling can result in self-imposed reductions in mobility and social interaction. Families of the elderly also become over protective and restrict the autonomy of the elderly person after a fall (Brown-Commodore, 85). Between 50% and 90% of elders who report a fall admit to restricting their activities for fear of another fall, this restriction, in turn, precipitates further functional decline, which contributes to an increased risk for falls (Rawsky, 1). Psychosocial factors can also increase the risk of falling. Depression and social isolation may result in unintentional-or possibly, intentional-falls as mechanisms to gain attention or end ones life (Rawsky, 162). As development of the number of chronic disease increases with age, so does the risk of polypharmacy to treat multiple ailments. Polypharmacy can greatly increase fall risk, particularly when drugs are combined with other drugs and/or alcohol, incorrect dosages are taken, or four or more drugs are used concurrently (Rawsky, 162). Withdrawing psychotropic drugs reduced the risk of falls by 66%, but there were difficulties in recruiting participants to the trial and a high dropout rate (Robertson, Devlin, Gardner &, Campbell, 2001, 5). Extrinsic factors (environmental) that were identified were slippery floors, and bathtubs, a lack of grab bars, low toilet seats, high beds, inadequate lighting, sliding carpets, nonlocking bed wheels, high steps, worn stair treads, inappropriate chair heights, lack of armrests, high cabinets, glare on floors, wheelchair transfers, ill-fitting walking aids or footwear, and objects on the floor (Brown-Commodore, 1995, 85). Outdoor hazards that have been reported include steps and sidewalks in poor repair (Rawsky, 2000, 162).

The risk of sustaining an injury from a fall depends on the individual patients susceptibility and environmental hazards. The frequency of falling is related to the accumulated effect of multiple disorders superimposed on age-related changes (Fuller, 2000, 2160). Postural control is a complex task that involves balance, ambulation capability, endurance, range of motion, sensation and strength (Fuller, 2160). There are different risk factor assessment tools available to measure the postural control of an individual. Using measurement tools was only seen by the author in physical therapy journal articles and rehabilitation nursing journals. In the articles that the author reviewed the most widely used intervention for fall prevention was exercise. A study reviewing eight trails of exercise interventions by Feder et al that used falls as an outcome measure showed the following information. Most exercise programs without other interventions do not reduce the incidence of falls in unselected older people living in the community. That individually tailored exercise programs (women over 80) administered by a qualified professional reduce the incidence of falls in a selected high-risk group living in the community. In a selected group (mild deficits in strength and balance) exercise programs reduce the risk of falls in a selected group of older people living in the community. For balance training Tai chi classes with individual tuition can reduce the number of falls in older people. Information on the effectiveness of exercise programs to reduce falls is conflicting. One study stated that the exercise programme made the major contribution, on the basis of this and the results of a tai chi trial, exercise programs with a balance improvement component could be considered for wider implementation among unselected older people living at home (Day et al., 2002, 6). Another states that the exercise group had the same number of moderate injuries but fewer serious injuries as a result of a fall than the control group (Robertson, Devlin, Gardner &, Campbell, 2001, 5).

In reading the literature there was a high rate of participants withdrawing from fall prevention programs. A study by Stevens et al stated that the main reasons that subjects left the study were that they moved, became ill, or died (Stevens, Holman, Bennett &, de Klerk, 2001, 1450). The most common reason given for stopping the exercise program or withdrawing from the trial was a health problem (48 of 98, 49%) (Gardner, Robertson, mcGee &, Campbell, 2002, 549). An important part of a fall prevention program is to determine the financial costs for the recommended change and the necessary support mechanisms to assist with the costs of the personal or home environment changes (Lambert et al., 2001, 39). Knowing participants stage of change can guide selection of more effective fall prevention programs (Lambert et al., 27). Home hazard management and vision screening and referral are not markedly effective in reducing falls when used alone but add value when combined with the exercise programme (Day et al., 2002, 6). Most people wanted to take part in the falls prevention program because they considered that exercise was beneficial or because they wished to improve walking, balance, or muscle strength (Gardner et al., 2002, 551). Custom-designed programs could enhance the success of the program whose ultimate goal is to reduce falls and increase safety awareness (Lambert et al., 39). The authors recommended (in one study) the following element for community-based fall prevention programs: six weeks in length, occurring on the same day of the week, compatible scheduling with the center's activities, and group discussions to facilitate adherence (Lambert et al., 41). Programs for older people should be able to be modified as health status changes (Gardner et al., 551). Fall prevention programs involving occupational therapy for training related to activities of daily living, conditioning, balance training, safety practices, assertiveness training, and use of resources must be implemented (Brown-Commodore, 1995, 88).

There is a need for further research noted in all of the studies. Several of the researchers have outlined future research targeting areas where more information is needed. Included are studies to identify the role of exercise and optimum levels of activity to reduce falls and enhance functional ability (Rawsky, 2000, 7). Assessment and monitoring tools related to risks for falls can be researched, and the one most appropriate for a specific patient population can be implemented (Brown-Commodore, 1995, 87). Cost effectiveness studies of exercise and other successful interventions would provide important information on which to base resource allocation for the prevention of falls among older people living at home (Day et al., 2002, 6). The knowledge base that underpins interventions for hazard reduction is limited. The association between home hazards and falls needs to be better understood, to elucidate the biomechanics of falls on hazards and the characteristics of hazards that cause falls (Stevens et al., 2001, 1454). The author personally sees a gap in any assessment tools that will pinpoint whether or not an elder is at high risk for falls. There are deficits that are noted with trying to use a universal assessment tool with the elderly. The author would like to see fall prevention programs that are tailored to a specific community. In community health nursing, the author has found, the community will have to be involved to help design a program that will work for them. The studies have shown that there has not been any input from the community in their studies. This is detrimental to adherence to a fall prevention program as the needs of the community are not being met. The author has noted that physical therapist studies have found assessment tools that could be utilized by the nursing discipline, but there is no research that attempted that approach with any effectiveness. In the author review of the studies, she has found that a multi-disciplinary approach to falls is needed. The healthcare system can be involved in reducing the problem of falls that occurring in

the United States. Fall prevention programs need to have three levels of health addressed primary, secondary and tertiary care, implemented to reduce falls. These programs would involve doctors, occupational therapist, physical therapist, community health nurse, public health nurses, social workers, employers, and the list could go on. All of the studies target the elder population but the author feels that education should occur at a younger age. People could design their home for a decrease in functional limitations when they get older; thereby making it a safer environment for their later years. We need to look at the fact that falls contribute to significant morbidity and mortality in the elderly. People who are responsible for formulating exercise programs for our elderly must be aware that individual needs differ. According to the Elder Fall Prevention Act of 2002 there is a need to develop effective public education strategies in a national initiative to reduce elder falls in order to educate the elders themselves, family members, employers, caregivers, and others who touch the lives of senior citizens.

References Brown-Commodore, D. (1995, March/April ). Falls in the elderly population: A look at incidence, risks, healthcare costs, and preventive strategies. Rehabilitation Nursing, 20(2), 84-88. Committee on Energy and Commerce (2002, February 7 ). Elder fall prevention act of 2002. Retrieved November 5, 2002, http://www.theorator.com/bills107/hr3695.html Day, L. Fildes, B. Gordon, I. Fitzharris, M. Flamer, H. & Lord, S. (2002, July 20). Randomised factorial trial of falls prevention among older people living in their own homes. British Medical Journal, 325, 1-6. Feder, G. Cryer, C. Donovan, S. & Carter, Y. (2000, October). Guidelines for the prevention of falls in people over 65. British Medical Journal, 321(21), 1007-1011. Fuller, G. F. (2000, April 1). Falls in the elderly. American Family Physician, 61(7), 2159 -2164. Gardner, M. M., Robertson, M. C., McGee, R. & Campbell, A. J. (2002). Application of a falls prevention program for older people to primary health care practice. Preventive Medicine, 34, 546-553. Lambert, C. Sterbenz, K. A., Womack, D. E., Zarrinkhameh, L. T., & Newton, R. A. (2001). Adherence to a fall prevention program among community dwelling older adults. Physical & Occupational Therapy in Geriatrics, 18(3), 27-43. Mosley, A. Galindo-Ciocon, D. Peak, N. & West, M. (1998, December). Initiation and evaluation of a research-based fall prevention program. Journal of Nursing Care Quality, 13(2), 3844. Rawsky, E. (2000, Fall). Fall risk in the elderly. Plastic Surgical Nursing, 20(3), 161-168.

Robertson, M. C., Devlin, N. Gardner, M. M., & Campbell, A. J. (2001, March 24). Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal, 322, 1-6. Stevens, M. Holman, C. D., Bennett, N. & De Klerk, N. (2001, November). Preventing falls in older people: outcome evaluation of a randomized controlled trial. Journal of the American Geriatrics Society, 49(11), 1448-1455.