Introduction to Fall Risk in Elderly Individuals

BACKGROUND INFORMATION:

Falls among elderly individuals are a significant public health concern worldwide. As the aging population
continues to grow, the incidence and impact of falls are expected to increase, placing a considerable burden
on healthcare systems and individuals. Falls can lead to severe injuries, reduced mobility, loss of
independence, and even mortality in older adults. Understanding the factors contributing to fall risk is
crucial for developing effective prevention strategies and optimizing the care provided by physiotherapists.

Numerous intrinsic and extrinsic factors contribute to fall risk in elderly individuals. Intrinsic factors include
age-related physiological changes, such as reduced muscle strength, impaired balance and gait, visual and
sensory impairments, cognitive decline, and the presence of chronic health conditions. Extrinsic factors
encompass environmental hazards, such as uneven surfaces, poor lighting, inadequate footwear, and
obstacles within the living environment.

ROLE OF PHYSIOTHERAPIST:

Physiotherapists play a pivotal role in fall prevention and management. They possess the knowledge and
skills to assess an individual's fall risk, identify underlying impairments, and design tailored interventions to
address specific deficits. Physiotherapy interventions commonly include exercise programs to improve
strength, balance, and coordination, as well as education on home safety and environmental modifications.

While considerable research has been conducted on fall risk in elderly individuals, there are still gaps in our
understanding. Further investigation is warranted to explore novel risk factors, refine assessment tools, and
enhance the effectiveness of interventions. Additionally, the integration of emerging technologies, such as
wearable sensors and virtual reality, holds promise for advancing fall risk assessment and intervention
strategies.

RATIONALE OF STUDY:

The aim of this research proposal is to address some of these gaps by investigating specific aspects related
to fall risk in elderly individuals. By identifying modifiable risk factors and evaluating the effectiveness of
physiotherapy interventions, we can enhance the quality of care provided to older adults, reduce the
incidence of falls, and ultimately improve their overall well-being and quality of life.

Objectives:
 Identify the etiology of falls in the elderly.
 Describe the patient history associated with falls in the elderly.
 Summarize the management considerations for patients presenting with falls.
  Review the importance of collaboration and communication among the interprofessional
team to improve outcomes for patients affected by falls.

LITERATURE REVIEW:

Etiology

Normal gait results from effective coordination of the following neural components: basal ganglia brainstem
system, regulated muscle tone, and functional processing of sensory information such as vision, hearing, and
proprioception. The risk of falling is increased in the elderly because (1) these functions decline with age (2)
the probability of accumulating medical issues increases with age, and (3) associated medications are often
increased as well. With aging usually comes a wide-based gait, along with a decrease in gait velocity, step
length, and lower limb strength. A fall most often results from interactions between these long-term
predisposing factors and short-term predisposing environmental factors such as an adverse drug reaction,
acute illness, or a trip on an irregular surface.

Risk factors for falls in order of evidence strength include a history of falls, impairment in balance, reduced
muscle strength, visual problems, polypharmacy (defined as taking over four medications) or psychoactive
drugs, gait difficulty, depression, orthostasis or dizziness, functional limits, age over 80 years, female sex,
incontinence, cognitive difficulties, arthritis, diabetes, and pain.

Fall risk escalates as the number of risk factors increases. The 1-year risk of falling doubles for every added
risk factor. It starts at 8% with no risk factors and increases by up to 78% with four risk factors. Medications
related to falls include antihypertensives, neuroleptics and antipsychotics, sedatives and hypnotics,
antidepressants, nonsteroidal anti-inflammatory drugs, and benzodiazepines.

Epidemiology

Over 30% of individuals who are over the age of 65 fall every year. In approximately half of the cases, the
falls are recurrent. This percentage increases to around 40% in individuals aged 85 years and above.
[3] Approximately 10% of falls result in serious injuries, including fracture of the hip, other fractures,
traumatic brain injury, or subdural hematoma.[4][5] Falls are the most common type of accidents in people
65 years of age and older, and are the major cause of hospitalization related to injury in this age group.
Injuries that are caused by falls are associated with increased mortality. Associated use of ambulance
services, social care, and hospital care results in substantial financial costs.[6]

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Pathophysiology

An important cause of falls in the elderly population is the presence of sarcopenia. Sarcopenia can be
related to a food decline, a long hospital stay, and/or a long illness. Generally, the elderly have a decrease in
mass volume and coordination, with phenotypic changes, such as selective loss of white fibers.

Another cause of falls is the presence of cognitive impairment that is often found in the elderly, especially in
those with a long illness, pain, or mood changes.

Postprandial hypotension is a non-physiological reason that causes falls in elderly subjects, probably due to
an autonomic system dysfunction or the declining function of the cardiovascular system.
Obesity in the elderly is another cause linked to the increase in falls, probably due to a further decline in
muscle mass and neuromuscular function.

Osteoporosis can cause rupture of the femoral neck in elderly subjects, and this event can often confuse the
providers, particularly when the patient is uncooperative.

Another cause that leads to motor instability and an increase in the percentage of falls is the decline in the
strength of the diaphragm muscle. A decrease in strength and function of the diaphragm causes instability in
the back area and leads to falls.

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Histopathology

Basically, the phenomenon of sarcopenia begins from the 4th decade, to arrive at a 50% muscular loss
(inactive elderly) in the elderly with 80 years of age. The causes are different: decrease in anaerobic or white
fibers; decline in protein synthesis (maintenance or hypertrophy), increase in connective tissue and fat
within muscle fibers, mitochondrial alteration and increase in free radicals (ROS), increase in an inflamed cell
environment, neurological, central and peripheral remodeling.

History and Physical

When the history of the present illness is taken, it is important to understand the intrinsic and extrinsic
causes of falls. Tailoring questions to the following causes can help provide an accurate assessment of a
patient's fall risk.

Intrinsic Causes

 History of falls: Predisposes one to an increased risk of recurrent falls

 Age: Increased age is associated with decreased reaction time, particularly in step initiation and
execution timing.

 Gender: In most elderly individuals, women fall more often than men

 Race: Studies show that Whites fall more often than Africans, Caribbeans, Hispanics, and South
Asians.

 Drugs: If more than four medications are taken, the risk of falls is raised significantly. The use of
benzodiazepines in the elderly increases the risk of night falls and hip fractures by 44%. Drugs such
as antiarrhythmics, digoxin, diuretics, sedatives, and psychotropics also increase the risk of falling
substantially.

 Solitary lifestyle: Living alone appears to be a risk factor in falls. Injuries and consequences can be
increased if the fallen individual cannot get up from the floor.

 Medical conditions associated with an increased risk in falls include vascular diseases, arthritis,
thyroid dysfunction, diabetes, depression, and chronic obstructive pulmonary disease. Vertigo and
incontinence are common in populations with falls.

 Impairment in gait and mobility: After the age of 30, strength and endurance decrease by 10% per
decade. When strength, power, and endurance are decreased, a slip or trip can turn into a fall. Any
 lower limb disability can increase the risk of falling, and difficulty rising from a seated position in a
chair is associated with an increased risk as well.

 Immobility/Deconditioning: Sedentary individuals fall more than those who are relatively active.

 Fear of falling: Among individuals with a recent fall, up to 70% report fears of falling. Of these
individuals, 50% may limit or exclude physical or social activity because of this fear, thereby
increasing their fall risk.

 Poor nutrition: Deficiencies in nutrients can result in low body mass index, which is associated with
an increased risk of falls. Vitamin D deficiency can result in muscle weakness, osteoporosis, and
impaired gait patterns.

 Cognitive disorders: Dementia, poor memory, and a score of under 26 on the Mini-Mental State
Exam are all related to an increased risk of falls.

 Impaired vision: Glaucoma, cataracts, visual acuity, the field of vision, and contrast sensitivity lead to
an increased risk of falls.

 Foot issues: General pain when walking, calluses, long toe deformities, ulcers, and nail deformities
increase balance difficulty and risk of falling.

Extrinsic Causes

Environmental factors correlated with falls in the elderly population include poor lighting, uneven surfaces,
and floors that are slippery. Studies show that these factors account for 30%-50% of falls in this population.
Missed steps, slips, and trips occur with more frequency in elderly populations.

Physical Exam

The physical examination should correlate to the above-mentioned causes of falls and is tailored to the
patient's history of present illness. Blood pressure and postural changes can rule out orthostatic
hypotension. Examination of the feet can point to any foot deformities. A targeted neurological exam may
reveal visual acuity deficits or eighth cranial nerve deficits that can point to possible vestibular issues.
Manual muscle motor testing can point to generalized or lower extremity weakness.[1]

Screening Tools

To date, none of the screening tools is able to accurately assess the fall risk among elderly individuals. There
are many tools available. Some of which are: The Tinetti Gait and Balance Assessment Tool and The one-
legged and tandem stance assessments. Neither of these tests accurately identifies fall risks and are poor
predictors.[7][8][9]

Activities of Daily Living

Because patients with difficulties with basic or instrumental activities of daily living (ADLs) are at increased
risk of falling, assessment of the patient's functional status should be completed in detail. Assessment of
basic ADLs should include bathing, toileting, dressing, feeding, grooming, and ambulation. Assessment of
instrumental ADLs should include shopping, cooking, managing their own finances, telephone use, laundry,
housekeeping, and transportation. Asking patients about any difficulties completing these activities can
provide valuable information.
Clinical Practice Guideline

A 2012 Cochrane Systematic Review reported that clinical assessment by a

health care provider combined with individualized treatment of identified
risk factors, referral if needed, and follow-up reduced the rate of falls by
24%.14 Similarly, the US Preventive Services Task Force found that
multifactorial clinical assessment and management, combined with follow-
up, was effective in reducing falls.15

The American Geriatrics Society and British Geriatrics Society (AGS/BGS)

have published a clinical practice guideline on fall risk screening,
assessment, and management. 13 The AGS/BGS guideline13 recommends
screening all adults aged 65 years and older for fall risk annually. This
screening consists of asking patients whether they have fallen 2 or more
times in the past year or sought medical attention for a fall, or, if they have
not fallen, whether they feel unsteady when walking. Patients who answer
positively to any of these questions are at increased risk for falls and should
receive further assessment. People who have fallen once without injury
should have their balance and gait evaluated; those with gait or balance
abnormalities should receive additional assessment. A history of 1 fall
without injury and without gait or balance problems does not warrant
further assessment beyond continued annual fall risk screening.13
A fall risk assessment is required as part of the Welcome to Medicare
examination. PCPs can receive reimbursement for fall risk assessment
through the Medicare Annual Wellness visit and incentive payments for
assessing and managing fall risk through voluntary participation in the
Physician Quality Reporting System.

MANAGEMENT OF FALL RISK

Management Goals for Older Adults at Risk of Falls

Goals for fall risk management include (1) reduce the chances of falling, (2)
reduce the risk of injury, (3) maintain the highest possible level of mobility,
and (4) ensure ongoing follow-up.

Clinical Approach to Managing Fall Risk

Collaborate with patients and their caregivers to address fall risk factors 

Providers should explore older adults’ perceptions of the causes of their

falls and willingness to make changes to reduce their risk of falling again.
Approaches that facilitate behavior change include presenting the
information that falls can be prevented, providing choices, personalizing
options, and focusing strategies on enhancing quality of life (eg, maintaining
independence).8 The STEADI tool kit16 includes guidance on talking about
fall prevention with patients. There are examples of patients in various
stages of readiness to make changes to reduce their fall risk, with possible
provider responses for each stage.
Discuss the importance of strength and balance exercise 

Exercise interventions that focus on improving strength and balance are the
most effective single intervention for reducing falls and fall-related
injuries.14 Most older adults do not routinely practice these types of
exercises.31 Other forms of exercise (eg, stretching, walking) have not been
shown to reduce falls.32
To be effective, exercise must (1) focus on improving balance, (2) be of
moderate to high challenge and progress in difficulty, and (3) be practiced a
minimum of 50 hours, which equates to 2 hours weekly for 25
weeks.32 PCPs can educate patients about exercise that prevents falls and
refer to appropriate resources (eg, physical therapists [PTs], community fall
prevention programs) to initiate it. It is important to emphasize that the
effects of exercise will not be apparent for several months, and that practice
must be ongoing in order to maintain the benefits.

Evidence-based exercise programs may be either home based (eg, Otago

Exercise Program33) or group classes offered in community settings (eg, tai
chi34).
Prioritize interventions for modifiable risk factors 

Because the risk of falling increases with the number of risk factors, risk can
be reduced by modifying even a few contributing factors. Three key risk
factors (balance, medications, and home safety) should be addressed in
everyone at high risk.35 In addition, if the PCP suspects that a cataract is
affecting vision, it is beneficial to refer the patient for cataract extraction,
assuming that the patient is a surgical candidate, because first eye cataract
surgery decreases falls.13,14

In our experience, most high-risk patients are amenable to decreasing

medication dosages and appreciate having their physician reduce the
number of prescription medications. Most older adults are willing to
consider balance training, especially if the instructions are not complicated
and the exercises can be done at home.36 A referral from a health care
provider, particularly a physician, encourages follow-through with
environmental assessment and modifications.8
Address fall injury risk 

To reduce the chances of a fall injury, optimize bone health by

recommending calcium and vitamin D supplementation and evaluating and
treating osteoporosis.15 Strengthening lower extremity muscles and
teaching older adults how to get up from the ground after a fall may prevent
a so-called long lie (remaining on the ground involuntarily because of
inability to get up without help) with its associated medical
complications. 37 High-risk patients should carry a cellular phone or wear a
personal medical alert device to reduce the risk of a long lie in the event of a
fall.

In the subsequent sections, we will outline the objectives, methodology, expected outcomes, and potential
implications of the proposed research study.