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Keys to aging well

Falls and Fall Prevention:
A Clinical Perspective
Elizabeth A. Phelan, MD, MS
Associate Professor
Medicine / Gerontology and Geriatric Medicine
July 10, 2009
Objectives
Know and understand:
How often falls occur
Consequences of falls
Why falls occur
How falls may be prevented
Definition: coming to rest inadvertently
on the ground or lower level
Excludes falls due to an acute event
(seizure, stroke, syncope, overdose)
One of most common “geriatric syndromes”
NOT a normal part of aging!
Epidemiology of Falls
Community
Each year ~1/3 of community-dwelling persons
aged ≥65, and 1/2 of residents of long-term-
care facilities, experience falls
Objectives
Know and understand:
How often falls occur
Consequences of falls
Why falls occur
How falls may be prevented
Fall-Related Mortality
Leading cause of injury deaths
among elders (~15,000 nationwide in
2004)

Number of fatal falls doubled from
1993-2003
Death rates rise with increasing age
– greatest increase after age 79
Men more likely to die from a fall;
reasons unclear
Fall-Related Morbidity
Most falls result in some injury
10% of falls result in serious injury
Head injury
Fractures
Most serious and disabling fracture: hip
20% die within a year after hip fracture
25% in nursing home at one year
Fall-Related Cost of Care
Total direct costs of fall-related injury care in
2000: $19 billion
National annual cost of fall-related injuries:
By 2020: $43.8 billion
By 2040: $240 billion
Adverse Sequelae of Falls
Loss of independence
Diminished quality of life
Fear of falling
Activity restriction
Functional decline
Permanent nursing home residence
Objectives
Know and understand:
How often falls occur
Consequences of falls
Why falls occur
How falls may be prevented
Falls Occur Due to a
Combination of Reasons
Intrinsic Factors
Extrinsic Factors
Age related
Medications
Footwear
conditions
Environmental
LE weakness
Balance problems
Assistive device
Intrinsic Factors:
Age Related Changes
in Gait and Balance
Increased postural sway
Decreased step height
Decreased proprioception
Slowed righting reflexes
Intrinsic Factors:
Age Related Changes in Vision
Pupil decreases in diameter and becomes less
responsive to variations in light
Harder to see in dim light
Longer time to adapt to changes in illumination (e.g.,
dark to light)
Lens of the eye loses elasticity and becomes thicker
Harder to see up close
Harder to see contrast and sharpness of objects
Lens of the eye yellows
Reduces contrast between colors
Extrinsic Factors: Medications
Psychoactive medications
Benzodiazepines
Antidepressants
Antipsychotics
Anti-epileptics
Anticholinergic side effects (benadryl, atarax)
Blood pressure lowering agents
Objectives
Know and understand:
How often falls occur
Consequences of falls
Why falls occur
How falls may be prevented
Clinical Approach to Fall Prevention
Ask all older persons about falls
& gait / balance problems
annually. Observe gait.
two or more falls
gait or balance problem
no gait or balance problem
medical attention due to a fall
Recommend exercise
program with strength and
balance component
Multifactorial fall risk
assessment and management
AGS/BGS/AAOS Panel. J Am Geriatr Soc 2001:49;664.
Tinetti ME. New Engl J Med 2003;348:1.
Multifactorial Fall Risk Assessment
and Management
Multifactorial risk assessment with
longitudinal follow-up is most effective
approach (reduces falls by 30-40%, NNT=20
)
Educate about fall prevention
Encourage exercise (gait retraining, muscle
strengthening, balance exercises)
Update vision exam
Stop medications that increase fall risk
Identify and treat postural hypotension
Modify environment, footwear, assistive device
Chang JT et al. BMJ 2004;328:680-87.
Multifactorial Fall Risk Assessment
and Management
Management goals:
Reduce chances of falling
Prevent injuries if and when a fall occurs
Environmental modifications
Personal alert systems
Bone strengthening interventions
Self-efficacy enhancing interventions
Other Outcomes of Multifactorial
Approach to Fall Prevention
Reduce fear of falling
Improve physical functioning
Enhance falls self-efficacy
No effect on mortality
No effect on nursing home placement
No published data on HRQOL or
physical activity
Zijlstra GAR et al. J Am Geriatr Soc 2007;55:603-15.
Hill KD et al. J Am Geriatr Soc
2008;56:600-8.
Gates S et al. BMJ
2008;336:130-3.
Cost of Multifactorial Approach to
Fall Prevention
Multifactorial targeted fall prevention
programs are cost-effective
Mean intervention cost/person: $905
Mean total healthcare costs $2,000 lower than
usual care (primarily via reduced hospitalization
costs)

Fewer overall falls and falls requiring medical
attention, especially among those with four or
more fall risk factors

Intervention cost per medical fall prevented:
$7,727-$11,834
Rizzo JA et al. Med Care 1996;34:954-69.
Single Interventions to Prevent Falls
Regular physical activity is most
effective single intervention (reduces
falls by 20%; NNT=16
)
May be done in a group or individually
Must include strength, gait, and balance
Should include periodic review and
progression of challenge level as
appropriate

Chang JT et al. BMJ 2004;328:680-87.
Summary and Conclusions
Falls are common, usually multifactorial in
etiology, and associated with multiple adverse
sequelae

Falls are often preventable
Multifactorial targeted fall prevention programs
are cost-effective and improve quality of life of
older persons

Healthy older persons should do strength and
balance exercises routinely for primary prevention
of falls

Thank you for your attention!

Source: http://www.agingkingcounty.org/advisory-council/docs/Presentation_FallPrevention_July2009.pdf

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