prevention of falls in the elderly - university of pittsburghsuper7/3011-4001/3571.ppt · ppt...
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Falls in the Elderly
Miryoung Lee, MPH Dept. of EpidemiologyUniversity of Pittsburgh
Learning Objectives
Identify the scope of the problem e.g. impact of falls in the elderly
Describe the contributing factors for falls Address fall prevention, and intervention
programs
Performance Objectives
Understand the seriousness of problems and contributing factors of falls, and fractures
Develop effective strategies to prevent falls
Falls
• Unintentional injuries • External causes of the injury • Multifactorial causes
e.g. falls due to intrinsic factors vs. extrinsic factors
Introduction
How serious is the problem of falls?
Incidence rates of Falls in U.S.
Per person annually
Community 0.2 - 0.8Hospital 0.6 - 2.9Long term- 0.2 - 3.6Care (per bed)
One of every three adults over 65 years fall in every year
Where are people likely to fall?
For people 65 years old or older…..
Home 60% Public Places 30%
Nursing Home 10%
Consequences of Falls Mortality Morbidity
Fractures Soft tissue injuries Head trauma Joint distortions and dislocations Loss of confidence - fear of falling Restricted activity
In 1994, estimated fall-related injury cost was $20.2 billion.
Unintentional Fall Death Rates by Gender, Age 65 +, U.S. 1996
Source: National Center for Health Statistics, Vital Statistics
0
20
40
60
80
100
120
140
Per
100
,000
65-74 75-84 85+
MenWomen
Unintentional Fall Age-Adjusted Death Rates, Age 65 +, gender and race U.S.
0
5
10
15
20
25
30
35
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
White, Men
Black, Men
White, Women
Black, Women
Source: National Center for Health Statistics, Vital Statistics
Fractures • 3% of all falls cause fractures. • Approx. 95% of hip fractures in older
people aged over 65 years are the result of a fall
• People who have a hip facture are 5 ~20% more likely to die in the first year following the injury than any other reason in the same age groups
Common Types of Fractures
Forearm (Wrist) Fracture Spine Fracture Hip Fracture (pelvis, hip, femur) Ankle Fracture Upper arm, forearms, hand
Rate of hospitalization for hip fractures, aged 65 years, 1996
Men ( n=68,783)Rates
Women(n=270,909)Rates
Age (years)65-7475-84 85
168.0 682.1
2,256.2
501.11,620.33,958.3
Per 100,000 populationSource: National Center for Health Statistics, CDC
Fear of Falling
• Loss of self confidence • Decrease of physical activity level and
quality of life • Fear of not being able to get up after a fall
Intrinsic (Personal) factors for Falls • Aged (over 65 years)• Female• Low mobility or fragility – lower extremity
weakness, and poor grip strength • Functional impairments - limited Activities of
Daily living (ADL)• Poor gait and balance • Low body weight
Risk Factors
• Cognitive impairment or dementia • Chronic illness
- Parkinson disease, visual difficulties, stroke, hypertension, or urinary incontinence
• Psychoactive medication - tranquilizers or antidepressants
• Previous falls • Heavy drinking
4,4
2,9 2,92,3
1,82,2 2,4 2,5
3,02,6
1,7
0,00,51,01,52,02,53,03,54,04,55,0
Mea
n R
R o
r OR
Relative risk ratio (RR) or Odd Ratio (OR) of Fall
J Am Geriatr Soc. 2001
Extrinsic or Environmental Factors
• Polypharmacy – four or more prescription medications combination
• Home hazards – Clutter, or loose rugs – Poor lighting on stairs and hallways– Lack of bathroom safety, e.g. grab bars in bathtub
• Footwear • Busy street or elevated walkways
Intrinsic :Aging, poor balance
Occurrence of falls
Fall OutcomesNo injuries
Contributing factors Extrinsic :
Home hazards
Loss of ConfidenceFractures Soft tissues
injures, trauma
Disability, reduced
quality of life
Mechanisms of Fall
Dimension of Fractures
Fall itself Bone Fragility
Force
Source: National Osteoporosis Foundation
Fall itself Loss of footing or loss of traction Changes of reflex with age Changes of muscle mass and body fat Loss of muscle strength Changes in vision and hearing Chronic conditions with medications
Force and Direction of a Fall
Fall 400~ 500J of potential energy Being tall is related to increased risk of
hip fractures How you land and on what surface
increases risk of fracture
Fall directions and Hip Fracture
Circumstances Odds Ratio 95% CI
Hit hip/thigh when fallHit hand when fallHit knee when fallFell sideways vs other directions Fell forward vs other directions Fell backward vs other directions
48.60.420.263.17
0.22
1.03
22.5-1050.23-0.760.14-0.491.78-5.66
0.12-0.38
0.53-1.99
Age adjusted OR; Schwartz et al. 1998
Fragile Bone Osteoporosis, or brittle bones Fall induced fractures
Normal Bone Osteoporotic Bone
Dempster et al., JBMR 1986
Assessment of Risk
• “Get-up and Go” Test (Mathias et al., 1986) Check for balance, gait, and mobility
• Review Chronic medical conditionsMedications Visions and hearing ability Foot disabilities
• Evaluate environmental hazardsHome hazards
Prevention/Intervention
J Am Geriatr Soc. 2001
Personal Prevention Home Safety – Reducing hazards
Check for Safety List (CDC) Balance Exercise Lessen Fall impact – hip
protectors Healthy Life Style
Assistant Devices • Hip pads • Mobility aids
– Cane – Walkers – Wheelchairs
• Bathroom aids - Raised toilet seats- Grab bars
Intervention Programs
• Exercise or physical therapy to increase/gain muscle strength, balance, and gait
• Assessment of home fall hazards• Evaluation of medical condition,
medications, and nutrition• Support groups
Community InterventionExample • The Frailty and Injuries:Cooperative Studies of
Intervention Techniques (FICSIT) meta-analysis Incorporated exercises study – seven studiesIntensive strength, endurance training, or balance
trainingOverall significant reduction of fall e.g. “Tai Chi C’uan” reduced the rate of falls during the 4
months follow up in women at moderate risk of falls.
Province et al., 1995 JAMA
Nursing Home Intervention
• Physical rehabilitation program • Staff education • Environmental assessments and
modification • Reduce medications, or physical restraints
Conclusions• Falls, and related injuries, e.g. fractures are
significant health hazards to the aging society.
• Identifying fall risk factors help to evaluate the problems, and to plan personal, and community intervention strategy.
• Intervention studies has mostly focused on white men and women, and on hip fractures outcomes.
Resources • CDC’s National Center for Injury Prevention
and Control • National Resource Center on Aging and Injury • WHO –Ageing and Life Course • National Fire Protection Association • National Women’s Health Information Center • Elder Web • Additional Reading List