Falls prevention in the elderly

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1 Falls prevention in the elderly Ilse Truter, DCom, BPharm, MSc, PhD Drug Utilisation Research Unit (DURU), Nelson Mandela Metropolitan University Correspondence to: Prof Ilse Truter, Keywords: falls, elderly, polypharmacy, risk factors, psychotropic medication Abstract Falls in the elderly are common and often the first sign of frailty and other medical conditions. Fall-induced injuries are said to be the fifth leading cause of death in elderly people, and one of the most common causes of long-standing pain and disability in this population. Potential causes of falls are varied and include a history of previous falls, the use of psychoactive medicine, cognitive or functional impairment, environmental hazards, balance and gait problems, loss of muscle strength, and impaired vision. The success of interventions is optimised by early identification of those at risk, before a serious fall occurs. Treatment is directed at the underlying cause of the fall. The role of the pharmacist in fall prevention is health education, to identify those patients at risk of falling and to assist them to minimise their risk and to develop a fall care plan. Medpharm S Afr Pharm J 2011;78(9):12 17 Introduction Falls in the elderly are common and often the first sign of frailty and other medical conditions. 1,2 They may have serious consequences, result in an increased rate of institutionalisation and represent an enormous cost to the community. 1,2 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 a stroke or an epileptic seizure. 2 Another definition states that a fall is an event reported either by the faller or a witness, resulting in a person inadvertently coming to rest on the ground or another lower level, with or without loss of consciousness or injury. 3 This article deals with falls in the elderly, focusing on its epidemiology, the risk factors for falls, fall prevention measures, the different screening tests and assessments that may be performed and interventions on how to reduce the risk of falls, and concludes with a falls care plan. Epidemiology An estimated 30% of people aged 65 years or older living in the community in their own homes. More than 50% of those living in residential care facilities or nursing homes fall every year and about 50% of these fall repeatedly. 1,4 The actual incidence is likely to be even higher, since many falls are not reported. Falls often lead to reduced functioning, which increases morbidity and mortality. Around 20% of falls need medical attention, 5 10% result in fractures (with one in five of these being a hip fracture), severe head injuries and joint distortions, and 5 10% in soft-tissue contusions and lacerations. 1,4 Fall-induced injuries are the fifth leading cause of death in elderly adults and are one of the most common causes of long-standing pain and disability in this population. 4 Falls account for over 80% of injury-related admissions to hospital of people older than 65 years. 4 Between 10% and 25% of nursing home falls result in fractures or hospital admissions. 4 There are also the more subtle consequences of a fall, including fear of falling, anxiety, depression and loss of confidence, all of which lead to greater disability. A single fall is not always a sign of a major problem and an increased risk for subsequent falls. The fall may simply be an isolated event. However, recurrent falls, defined as more than two falls in a six-month period, should be evaluated for treatable causes. 5 In addition, falls that produce injuries, or are associated with a new acute illness, loss of consciousness, fever or abnormal blood pressure, require immediate evaluation. Risk factors for falls The risk of sustaining an injury from a fall depends on the individual s susceptibility and medication, underlying medical conditions and environmental hazards. The likelihood of falling increases with the number of risk factors. Factors that contribute to the risk of falling are wide and varied, and include the following: 2,5 Medical conditions Neurological conditions, such as deep white matter ischaemic disease (leading to mild cognitive dysfunction, gait dyspraxia and balance impairment) and Parkinsonism. Cardiovascular conditions, such as hypotension, syncope and strokes. S Afr Pharm J 12

2 Visual conditions, such as cataracts, macular degeneration and glaucoma. Lower extremity problems, such as osteoarthritis, peripheral vascular disease and ulcers. Psychological conditions, such as depression, fear of falling and social isolation. Cognitive conditions, such as dementia, cognitive impairment and delirium. Pain Pain acts as a distractor for people who need to be cautious regarding their balance and gait impairment. Vitamin D deficiency Insufficient vitamin D (osteomalacia or bone softening) may lead to bone and muscle weakness, causing fractures and pain. The symptoms of vitamin D deficiency are widespread pain and weakness, both of which may easily be dismissed as being a consequence of getting old or arthritis. Vitamin D and calcium supplementation is therefore suggested for all individuals affected by recurrent falling and impaired balance, and those who are likely to get reduced sun exposure. Environmental hazards Hazards in the home include, for example, loose rugs or carpets, power cords on the floor, unstable furniture, obstacles in traffic ways, poor illumination, footwear, stairs, lack of steps or stair railing, pets and slippery floors. Outside hazards include sloping, slippery, obstructed or uneven pathways, crowds, lack of resting places, brief-cycle traffic lights, and certain weather conditions (such as snow or rain). Incontinence Falls related to incontinence are generally thought to result from loss of balance when rushing to the toilet or an increased likelihood of slipping on urine. Incontinence may not be a primary cause but simply a marker of generalised physical frailty. Other There are also more specific common age-related disorders which increase the risk of falling, such as sensory dysfunction (vision and/or hearing impairment), neurological and musculoskeletal disorders (as mentioned before), painful foot conditions (such as bunions or corns) and lifestyle factors (such as a poor social network, underweight or malnutrition, leaving residence only once per week or less, and requiring help with one or more activities of daily living). Multiple medicine use or polypharmacy (usually four or more medicines) also increases the risk for falls. Furthermore, medicines which depress central nervous system function are associated with falls in epidemiological studies, since a clear or Table I: that may impair mobility or increase fall tendency 2,5 Medicine class Central nervous system depressants with side-effects of Parkinsonism causing postural hypotension causing cerebellar ataxia which may produce neuropathy or muscle weakness Examples Major and minor tranquillisers, especially long-acting benzodiazepines (nitrazepam, flunitrazepam, diazepam) Anti-epileptic drugs (phenytoin, carbamazepine) Narcotic analgesics Some vestibular sedatives (especially prochlorperazine) Prochlorperazine Metoclopramide Major tranquillisers (variable including risperidone) Lithium Antihypertensives Diuretics Antiparkinsonian medicines Major tranquillisers (especially chlorpromazine) Benzodiazepines (truncal ataxia) Corticosteroids Nitrofurantoin unmedicated brain compensates for physical disability much more readily. 2 Some medicines that may impair mobility or increase fall tendency are listed in Table I. Frontal gait dyspraxia is a condition that presents with short, shuffling steps on a wide base with good arm swing. 2 There is usually no evidence of Parkinsonian symptoms. However, there is an associated postural instability, similar to Parkinsonian postural deficits. Patients have difficulty in maintaining an upright posture and have no reflexes to protect themselves from falls if they are suddenly pushed off-balance. Maintenance of postural stability involves sensory (affector) systems (visual, proprioceptive and vestibular), motor (effector) systems (muscles, joints and feet) and integrating processes in the nervous and locomotor systems. These components are overlapping and compensatory, and a fall may not occur until several parts of the system are dysfunctional. Maintenance of adequate blood pressure is also necessary to avoid falls. Poor vision reduces postural stability and significantly increases the risk of falls and fractures in older people. 6 Most studies have found that poor visual acuity increases the risk of falls. 6 Table II lists the effects on vision of correctable visual impairment, and interventions to correct or limit these effects. S Afr Pharm J 13

3 Visual conditions, such as cataracts, macular degeneration and glaucoma. Lower extremity problems, such as osteoarthritis, peripheral vascular disease and ulcers. Psychological conditions, such as depression, fear of falling and social isolation. Cognitive conditions, such as dementia, cognitive impairment and delirium. Pain Pain acts as a distractor for people who need to be cautious regarding their balance and gait impairment. Vitamin D deficiency Insufficient vitamin D (osteomalacia or bone softening) may lead to bone and muscle weakness, causing fractures and pain. The symptoms of vitamin D deficiency are widespread pain and weakness, both of which may easily be dismissed as being a consequence of getting old or arthritis. Vitamin D and calcium supplementation is therefore suggested for all individuals affected by recurrent falling and impaired balance, and those who are likely to get reduced sun exposure. Environmental hazards Hazards in the home include, for example, loose rugs or carpets, power cords on the floor, unstable furniture, obstacles in traffic ways, poor illumination, footwear, stairs, lack of steps or stair railing, pets and slippery floors. Outside hazards include sloping, slippery, obstructed or uneven pathways, crowds, lack of resting places, brief-cycle traffic lights, and certain weather conditions (such as snow or rain). Incontinence Falls related to incontinence are generally thought to result from loss of balance when rushing to the toilet or an increased likelihood of slipping on urine. Incontinence may not be a primary cause but simply a marker of generalised physical frailty. Other There are also more specific common age-related disorders which increase the risk of falling, such as sensory dysfunction (vision and/or hearing impairment), neurological and musculoskeletal disorders (as mentioned before), painful foot conditions (such as bunions or corns) and lifestyle factors (such as a poor social network, underweight or malnutrition, leaving residence only once per week or less, and requiring help with one or more activities of daily living). Multiple medicine use or polypharmacy (usually four or more medicines) also increases the risk for falls. Furthermore, medicines which depress central nervous system function are associated with falls in epidemiological studies, since a clear or Table I: that may impair mobility or increase fall tendency 2,5 Medicine class Central nervous system depressants with side-effects of Parkinsonism causing postural hypotension causing cerebellar ataxia which may produce neuropathy or muscle weakness Examples Major and minor tranquillisers, especially long-acting benzodiazepines (nitrazepam, flunitrazepam, diazepam) Anti-epileptic drugs (phenytoin, carbamazepine) Narcotic analgesics Some vestibular sedatives (especially prochlorperazine) Prochlorperazine Metoclopramide Major tranquillisers (variable including risperidone) Lithium Antihypertensives Diuretics Antiparkinsonian medicines Major tranquillisers (especially chlorpromazine) Benzodiazepines (truncal ataxia) Corticosteroids Nitrofurantoin unmedicated brain compensates for physical disability much more readily. 2 Some medicines that may impair mobility or increase fall tendency are listed in Table I. Frontal gait dyspraxia is a condition that presents with short, shuffling steps on a wide base with good arm swing. 2 There is usually no evidence of Parkinsonian symptoms. However, there is an associated postural instability, similar to Parkinsonian postural deficits. Patients have difficulty in maintaining an upright posture and have no reflexes to protect themselves from falls if they are suddenly pushed off-balance. Maintenance of postural stability involves sensory (affector) systems (visual, proprioceptive and vestibular), motor (effector) systems (muscles, joints and feet) and integrating processes in the nervous and locomotor systems. These components are overlapping and compensatory, and a fall may not occur until several parts of the system are dysfunctional. Maintenance of adequate blood pressure is also necessary to avoid falls. Poor vision reduces postural stability and significantly increases the risk of falls and fractures in older people. 6 Most studies have found that poor visual acuity increases the risk of falls. 6 Table II lists the effects on vision of correctable visual impairment, and interventions to correct or limit these effects. S Afr Pharm J 13

4 Table II: Effects on vision of correctable visual impairment, and interventions to correct or limit these effects 7 Impairment Cause Effect on vision Intervention Refractive errors (myopia and hypermetropia) Outdated spectacles Spectacles not worn Wearing multifocal lenses Reduced acuity and contrast sensitivity Update spectacles Wear distance-vision spectacles when walking Wear single-vision distance spectacles, particularly when walking Refractive error (astigmatism) Recent change in astigmatism in spectacles Visual distortion, e.g. floors/doors appear sloping (large changes in astigmatism are difficult to adapt to) Update spectacles but keep correction of astigmatism to a minimum Diffuse blur (cloudy vision) Cataracts Dirty/scratched spectacles Reduced contrast sensitivity Increased glare problems Remove cataract surgically Clean or update spectacles Poor or no depth perception Visual function of one eye is worse than the other Depth is determined by monocular cues only Update spectacles Remove cataract from second eye Reduced illumination Poor lighting; this is a particular problem on stairs and/or night routes to bathrooms Vision is poorer in lower light levels ( rod or mesopic vision lacks detail) Improve lighting levels but ensure there is no glare present Falls prevention measures The risk factors for falls allow identification of those older people who are likely to fall, and can provide a basis for preventive measures to be taken. The flowchart in Figure 1 may be useful in guiding the pharmacist to identify and evaluate patients at risk of falling. Apart from minimising the risk factors for falls, falls prevention measures should also be discussed with the patient. It is often useful to ask patients if they had a fall in the last 12 months, if they are frightened of having a fall, and if they want or can do anything to prevent falling. Table III shows an example of a falls evaluation checklist. Screening and function assessments A thorough history should be taken with emphasis on medications and risk factors for falls, followed by a directed physical examination, and tests of postural control and overall physical function. There are various assessments that may be performed to determine postural control and the risk of a person falling. The following tests are some examples. 3 Get-up-and-go test (timed or unstructured) This is a useful screening test for any patient with a history of falls, unsteadiness or abnormality of balance or gait. It is testing normal postural changes using a variety of muscle groups and muscle mechanisms. The patient is required to get up from a firm chair with arms (the patient may use his or her own arms for assistance as necessary), walk three metres at normal pace (with his or her walking aid if normally used), turn on the spot and return to sit in the chair. Timing this test provides some measurable objectivity. Under normal circumstances this should be completed in 10 seconds. The unstructured test provides the opportunity to note functional difficulties with transferring and gait. It may reveal arthritic disease of the hip, knee and ankle, weakness of lower limbs or back, in-coordination such as cerebellar ataxia or apraxia, Parkinsonism, bradykinesia or dyskinesia, cerebrovascular disease with hemiparesis and associated spasticity, and gait features including quality of arm swing, step height, length and cadence, base of support and gait speed. Romberg s test With advanced age, individuals commonly have some impairment of proprioception (the sense of how a person s own limbs are oriented in space), as well as impaired visual and vestibular function, and all sensory input is important in maintaining balance without there necessarily being visual, neuropathic or related pathology. Romberg s test assesses the capacity to withstand balance challenges with reduced visual input. The patient is required to stand with his or her feet as close together as is comfortably possible with the eyes initially open and is then instructed, with standby supervision and reassurance, to close the eyes. Impaired proprioception will cause loss of balance. Cerebellar dysfunction causes ataxia with feet together, even with eyes open. Further discriminating assessment of proprioception is then necessary. Sternal push test and Pastor s test (shoulder tug test) The sternal push test evaluates the patient s ability to withstand an external disturbance of motion or equilibrium (perturbation). The patient stands with his or her feet comfortably close together, with the practitioner close to the patient. It is often prudent to have a chair a half-step behind the patient. After a warning, the patient is pushed firmly on the sternum and observation is made of the patient s functional falls prevention ability. A normal patient can resist the sternal push without stepping, and utilises hip, trunk and upper limb strategies to assist in maintaining balance. An impaired patient may take one or two protective steps, but does save him- or herself from falling with normal balance reactions. The test is definitely abnormal if the patient tends to fall backwards without taking any protective step or remedy. This test is observational and gives information on how each individual patient copes with external stresses. S Afr Pharm J 14

5 Pastor s test (or the shoulder tug test) is a useful alternative to the sternal push test. The practitioner stands behind the patient, provides a warning description, and delivers a brief tug backwards on both shoulders. The patient is standing with feet comfortably close together and eyes open and is warned prior to the perturbation being applied. Some practitioners prefer this test because of improved patient safety, since a falling patient will simply prop on the examiner behind them. Tandem gait or heel toe walking The patient walks forward placing the heel in front of the toes, thereby walking with a narrow base of support. Cerebellar disorders and disorders of the brain stem lead to difficulty performing this task. This test may unmask fairly subtle unilateral cerebellar pathology, as well as midline cerebellar abnormalities that may not be revealed by routine finger-nose or heel-shin-type cerebellar assessment. Functional reaching and bending The ability of the patient to reach any direction outside his or her base of support is essential for independent domestic functioning. A standardised functional reach test has been developed. The patient stands with an arm extended at a set point next to a wall with a tape measure stuck or drawn on, and leans forward with his or her arm reaching as far forward along the tape as possible. The distance between steady standing and maximal reach is recorded. There is some age-related variability (in general, normal subjects can reach over 30 cm). Less objective but more observational, assessment may be made without formal measurement. Standing on heels and toes Standing on the heels and toes provides rapid assessment of power in dorsiflexion and plantar flexion of the ankles respectively. An L4/5 lesion makes walking on one s heels impossible, and the patient would ordinarily have a notable foot drop. An S1 lesion makes it impossible to walk on the toes. Ankle strength, ankle joint quality and ankle balance strategies are all important for balance. Vestibular stepping test This is a useful screening test to assess if a vestibular lesion is peripheral or central. The patient marches on the spot for 50 steps with eyes closed. A positive test secondary to a unilateral peripheral vestibular lesion causes a patient inadvertently to turn more than 45 degrees towards the affected side. Hallpike manoeuvre This test is used to diagnose benign paroxysmal positional vertigo. The patient is required to sit on a firm flat examination couch with legs extended along the couch, and is warned his or her balance system will be challenged by this test. The patient is required to lie down supine, with the head rotated to either left or right with eyes open. No pillows are used. Older patients rarely tolerate their head dropping below the horizontal position. The test is positive if the patient complains Table III: Falls evaluation checklist 3 Assessment Intervention History Number of falls Circumstances of falls Suspected environmental hazards Refer to occupational therapist Related symptoms Altered consciousness Disequilibrium Medications Four or more in total Psychotropic medication Acute medical problems Chronic medical problems Mobility level Reliable use of gait aid Cognitive assessment Impaired cognition Depression Vision Corrected acuity < 12/20 Bifocal use General condition Nutritional status, skin care Physical endurance Muscle bulk Neurological assessment Muscle strength, tone and reflexes Proprioception Cerebellar function Extrapyramidal function Cardiovascular Heart rate, rhythm, postural pulse and blood pressure Heart sounds Feet and footwear Disturbed foot anatomy Get-up-and-go test Single leg stance Sternal push test Vestibular assessment if indicated by symptoms Vestibular stepping test Hallpike test Examination Altered consciousness Consider cardiology Consider neurology Critical review of medication requirements Liaise with physician or psychiatrist as required Treat all acute medical problems Manage all chronic geriatric medical problems in view of optimising function Refer to physiotherapist for education if in doubt about technique Investigate for cause, consider specific dementia treatment, manage depression to improve activity levels Optometry/ophthalmologically review Be wary of bifocal use when ambulating Dietetic advice Physical exercise/training Neurological diagnostic assessment Allied health management of identified disability Manage orthostatic hypertension (symptomatic or > 20 mmhg) Assessment of valvular lesions, ventricular function and rhythm Podiatry/orthotic advice Office-based function assessments Poor functional performance Refer to physiotherapy One-on-one/group physiotherapy/home-based exercise programme Vestibular dysfunction Ear, nose and throat specialist Falls and mobility clinic Specialist physiotherapy S Afr Pharm J 15

6 Periodic case finding in primary care Ask all patients about falls in the past year Observe patients getting in and out of chair and walking No falls No medical intervention Recommend participating in exercise programmes that includes strength and balance training Recurrent falls Single fall No obvious problem Check for balance and gait problems Patient presents to a medical facility after a fall Falls Evaluation Gait/balance problems Assessment History Medications Vision Gait and balance Lower limb joints Neurological Cardiovascular Multifactorial interventions (as appropriate) Gait, balance and exercise programmes Medication modification Postural hypotension treatment Environmental hazard modification Cardiovascular disorder treatment Vestibular rehabilitation programme Figure 1: Falls risk identification and evaluation 3 of true vertigo of delayed onset subsiding within 60 seconds and accompanied by rotatory nystagmus. There is a two to 10-second latency before the onset of dizziness. The vertigo fatigues with repetition of the provoking manoeuvre. If positive, the test may induce vomiting. Resumption of sitting posture may precipitate similar symptoms. If the patient complains of vertigo without the latent period, with no fatiguability or with variable nystagmus, then another underlying cause is presumed. Interventions to reduce the risk of falls in the elderly There is evidence that a range of interventions may effectively reduce the rate of falls among older people (Table IV). The interventions best supported by evidence include: 3 Professionally prescribed muscle strength and balance retraining. Professionally prescribed home hazard assessment and modification. Multidisciplinary health and environmental risk screening, and intervention programmes. T ai chi exercises. Withdrawal of psychotropic medication where possible. Table V summarises a falls care plan that may be used to assist in health promotion in a pharmacy. Conclusion Fall-related injuries in the elderly lead to functional decline and loss of independence. Fall injuries are said to cost more than injuries from any other source, and that the cost of fallsrelated morbidity is expected to double by There are various interventions that can reduce the incidence of falls in the elderly. A comprehensive multifaceted strategy should be followed that involves early prevention, early identification of risk factors and a comprehensive falls care plan according to each patient s individual needs. All healthcare professionals, as well as caregivers, should be involved in this process. A starting point in a pharmacy is to identify and target patients risk factors to assist and educate them to reduce their incidence or their risk of falling. References available on request S Afr Pharm J 16

7 Table IV: Interventions to reduce the risk of falls in the elderly 3 Risk factors Postural hypotension: a drop in systolic blood pressure of 20 mmhg or to <90 mmhg on standing Use of a benzodiazepine or other sedativehypnotic drug Use of four or more prescription medications (polypharmacy) Environmental hazards for falling or tripping Impairment in gait Impairment in balance or transfer skills Impairment in leg or arm muscle strength or range of motion (hip, ankle, knee, shoulder, hand or elbow) Interventions Behavioural recommendations, such as ankle pumps or hand clenching and elevation of the head of the bed Decrease in the dosage of medicine that may contribute to hypotension; if necessary discontinuation of the medicine or substitution of another medicine Pressure stockings If indicated a medication to increase blood pressure Education about appropriate use of sedative-hypnotic drugs Nonpharmacological treatment of sleep problems, such as sleep restriction Tapering and discontinuation of medications Review of medications Home safety assessment with appropriate changes, such as removal of hazards, selection of safer furniture (correct height, more stability) and installation of structures such as grab bars in bathrooms or handrails on stairs Gait training Use of an appropriate assistive device Balance or strengthening exercises if indicated Balance exercises and training in transfer skills if indicated Environmental alterations, e.g. installation of grab bars or raised toilet seats Exercises with resistive bands and resistance training two or three times a week, with resistance increased when the patient is able to complete 10 repetitions through the full range of motion Table V: Falls care plan 1 Current health needs Goal Planned actions/tasks Recent falls Unstable gait Mobility aid Recent falls Poor balance or strength Medication risk for falls Chronic condition affecting balance and mobility Sensory deficit: Visual impairment Hearing impairment Somatosensory impairment Foot problems Problems with footwear Poor nutrition Low body mass index Cognitive deficit Inactivity Fracture or history of fracture Osteoporosis Prevent falls and fractures Safe mobility Prevent falls and fractures Improve balance and strength Prevent falls and fractures Correct use of medication with minimal side-effects Optimal management to reduce falls and fractures Improve and/or maintain: Vision Hearing Sensation Minimise effect on balance and mobility Improve nutrition Maintain a healthy weight and healthy diet Maintain in own home Ensure safety Recommend exercise for at least 30 minutes, most days of the week Prevent further fractures Maintain and improve bone density Assess gait, balance and need for mobility aid Assess home Assess balance and mobility Strength and balance exercises Review medication: Compliance Adverse reactions Over-the-counter medicine Effects on gait and balance Regular review Review every six months Annual assessment and review Six monthly assessment and review Increase understanding of healthy eating Review diet/nutrition six monthly Assess and review Assistance in the home Establish a regular exercise routine Reinforce activity Assess bone density S Afr Pharm J 17