Fall Prevention: Positively Impacting the Health and Quality of Life of Older Adult Patients

According to the Centers for Disease Control and Prevention (CDC), at least one in three adults age 65 and older falls each year, and three quarters of them will fall again within six months. Based on recent census estimates, this means that nearly 122,000 older San Diegans will fall this year. Not only will 91,000 of these older adults fall again, but between 24,000 and 35,000 will suffer injuries that will make it difficult to get around or to live alone. Without preventive interventions, these figures are expected to double by 2030 as the population increases and ages in the county. It should come as no surprise that falls are already the leading injury-related cause of 911 calls, emergency department visits, hospitalizations, and deaths among older adults in San Diego. The latest available data show that falls in older San Diegans resulted in 5,606 prehospital calls in 2009, 12,535 emergency department discharges in 2008, 6,056 hospitalizations in 2006, and 186 deaths in 2008.

Falls and fall rates are higher in women than in men, and the fall rate rises with age, especially after age 85. Most older San Diegans fall at home, usually by tripping or slipping at the same level. Falls are a greater per-capita burden in the eastern and north coastal regions of the county, the areas where many older adults live. The social, emotional, and economic costs associated with fall-related injuries are significant, and the overall well-being of older adults is strongly undermined by falling and the fear of falling. The acute hospitalization costs after falls for older patients were reported at $207 million in the county in 2004. Nearly half (48 percent) of older patients admitted with a fall are discharged to a long-term care setting, so the actual economic and social costs are much higher.

Although falls in older adults are a serious concern, the most recent California Health Interview Survey revealed that only 45 percent of local patients 65 years and older who fell within the previous year received professional advice about how to avoid falls, and only 28 percent indicated that a healthcare professional reviewed their medications after a fall. Few older San Diegans started physical activity, were referred to therapy, made changes to their home, or changed their routine as a result of a fall in the past year. This reflects a significant opportunity for primary care, acute care, and emergency physicians to identify individuals at high risk for falls, to fully evaluate older patients who fall, and to reduce risk through appropriate fall-preventive measures.

The American Geriatrics Society recommends that older persons be asked about falls at least once a year, and that those who report a single fall be observed in a brief screen such as the “Get Up and Go Test.” Those who demonstrate difficulty or unsteadiness on the screen, who report more than one fall, or present for medical attention because of a fall should have a detailed fall-risk assessment. A history of fall circumstances, medication review, and examinations of vision, gait, and balance, lower limb joints, and basic neurologic and cardiovascular functions are key assessment components.

Modifiable medical fall-risk factors such as medication side-effects, vision problems, or muscle weakness may be found in up to one-third of patients. Evidence-based interventions that have been shown to reduce fall risk include the gradual withdrawal of psychotropic medications, first eye cataract surgery, vitamin D supplementation in those with demonstrated deficiency, and pacemakers in those with carotid hypersensitivity. Patients on anticoagulants deserve directed attention for fall prevention. Physical therapists experienced in vestibular rehabilitation are a valuable referral resource for patients with dizziness, vertigo, or disequilibrium.

A major strategy to prevent falls involves exercise programs. A 2009 Cochrane Review noted that programs for older adults that contain two or more of the following components are effective in reducing fall rates and the number of people falling: strength, balance, flexibility, and endurance. Exercising in supervised groups, participating in tai chi, and carrying out individually prescribed exercise programs at home have all been shown to be effective in reducing falls. A wide variety of exercise programs tailored for older adults is available in the county, including the free-of-charge “Feeling Fit” clubs and a new, free tai chi program through a CDC fall-prevention grant.

Interventions to improve home safety may be effective in reducing falls, particularly in high-risk patients such as those with visual impairments, and when included in a multifaceted approach to risk reduction. A typical multifaceted approach might combine a thorough medical assessment with specific interventions such as a home modification evaluation, an exercise program, and/or a specialty referral.

Along with several recently published reviews of prevention programs by the CDC and others, an excellent local resource for providers and patients is the San Diego Fall Prevention Task Force, originated in 2004 by the County of San Diego’s Aging and Independence Services (AIS). Staffed by AIS, chaired by a community agency representative, and consisting of more than 160 volunteer members from health organizations across the county, the Task Force has produced and made accessible existing best-practice information and other local resources, some of which are listed in Table 1. Physicians can positively impact the health and quality of life of their older adult patients by utilizing these resources to reduce both the risk and fear of falling.

Table 1. Available Resources

• Toolkit for Providers: An information resource for providers including details on the “Get Up and Go Test,” patient handouts for older adults, and an exercise guide.
• “Don’t Fall for It” Video: English and Spanish versions of videos suitable for waiting room use detailing the fall problem and simple steps to reduce fall risk.
• “Preventing Fall-related Injuries in High-risk Patients” Webinar: A continuing-education series for providers.
• Fall Prevention Resource Guide: An annually updated listing of community resources that provide fall-prevention services, such as exercise programs, home safety modification, home health services, and more.

These materials and much more are available online or call (858) 495-5061 to arrange a presentation or to obtain paper copies and DVDs. For more information about Task Force products or to join, contact Kristen Smith at kristen.smith@sdcounty.ca.gov.

Chart 1. Mechanisms of Injury, Emergency Department Discharges for Adults Over 64 After a Fall, San Diego County, 2008 (N=12,535)

43.1%: Same Level: Slipping or Tripping
29.0%: Other/Unspecified Fall
9.4%: Against Object
6.1%: Stairs or Steps
5.1%: From Other Furniture
4.5%: From Bed
1.8%: Other One Level to Another
1.0%: From Ladder/Scaffolding

Source: Hospital Association of San Diego and Imperial Counties, Community Health Improvement Partners, County of San Diego Health and Human Services Agency, Public Health Services, Emergency Medical Services, Emergency Department Discharge Database, 2008.

Chart 2. Nature of Injury, Emergency Department Discharges After a Fall in Adults Over 64, San Diego County, 2008 (N=12,535)

27.7%: Superficial/Contusion
23.5%: Fracture
21.7%: Open Wounds
12.0%: Other/Unspecified
6.2%: Sprains and Strains
5.6%: Non-injury
1.9%: Internal Organ
1.5%: Dislocation

Source: Hospital Association of San Diego and Imperial Counties, Community Health Improvement Partners, County of San Diego Health and Human Services Agency, Public Health Services, Emergency Medical Services, Emergency Department Discharge Database, 2008.

Acknowledgement: The authors would like to acknowledge Holly Shipp, Epidemiologist, County of San Diego Health and Human Services Agency (HHSA), Public Health Services (PHS), Division of Emergency Medical Services (EMS). Data sources include the San Diego Association of Governments (SANDAG) current population estimates, UCLA California Health Interview Survey, Emergency Department Discharge Surveillance database (Hospital Association of San Diego and Imperial Counties, Community Health Improvement Partners; HHSA, PHS, EMS), Prehospital database (HHSA, PHS, EMS), Hospital Discharge database (CA OSHPD; HHSA, PHS, Community Epidemiology), and the Medical Examiner database (HHSA, PHS, EMS).

References:

• American Geriatric Society Panel of the Prevention of Falls in Older Persons (AGS). (2001) Guideline for the Prevention of Falls in Older Persons. JAGS, 49(5):664-672. Available here.
• Gillespie, LD, et al. (2009) Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2009(2):CD007146. Available here.
• Stevens, JA, & ED Sogolow. (2008) Preventing Falls: What Works, A CDC Compendium of Effective Community Based Interventions Around the World. National Center for Injury Prevention and Control, Atlanta, GA. Available here.