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Reducing Falls

Contact Hours: 3

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Contact Hours: 3

This online independent study activity is credited for 3 contact hours.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of the causes of falls, steps to assess risks for falls, and the mechanics of ambulation.

Overview

People of all age groups experience ground level falls, but in the older population, aged 65 or above, a fall can lead to a serious injury and long-term disability. Multiple factors can cause falls, and it is believed that a complex interaction between postural responses, musculoskeletal, neuromuscular, and cardiopulmonary systems, balance, sensory activity, and environmental factors increases susceptibility to falls. This course will provide a brief overview of the causes of falls, steps to assess risks for falls, and the mechanics of ambulation.

Course Objectives

Upon completion of the independent study, the learner will be able to:

  • Define falls as described by the World Health Organization (WHO)
  • Recognize risk factors for falls
  • Understand the mechanics of ambulation
  • Understand the components of a fall risk assessment
  • Explain the proper use of crutches and walkers for improved mobility

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
AmbulationThe ability to walk without the need for any kind of assistance.
BalanceAn even distribution of weight enabling someone or something to remain upright and steady:
Cardiopulmonary SystemsConsists of two body systems: the cardiovascular and respiratory system. 
Cognitive ImpairmentProblems with language, memory and thinking.
DorsiflexionThe action of raising the foot upwards towards the shin. 
FallTo balance and collapse.
GaitManner of walking.
Gluteus MaximusThe largest and most superficial muscle of the buttocks that extends and rotates the thigh.
Gluteus MediusA large fan-shaped muscle located in the posterior hip, extending from the ilium to the proximal femur.
Gluteus MinimusActs as a flexor, abductor (swinging the leg out away from the body), and rotator (turning the leg in toward the body).
IliopsoasA major hip flexor that also helps to move the spine
Musculoskeletal SystemAn organ system that gives people the ability to move using their muscular and skeletal systems.
Neuromuscular SystemThe interaction of nerves and muscles that enables movement and other functions.
Quadriceps FemorisA group of four muscles that extend the knee and flex the hip.
Rectus FemorisOne of the four muscles that make up the quadriceps group in the front of the thigh.
Sensory ActivityAn activity that stimulates at least one of the senses.
Tensor Fascia LataA muscle of the thigh that helps in moving and stabilizing the hip and knee.
Introduction

People of all age groups experience ground level falls, but in the older population, aged 65 or above, a fall can lead to a serious injury and long-term disability.1 According to the Center for Disease Control (CDC), 1 out of 4 elderly people fall each year, but only half of them seek medical attention.2 More than 3 million older adults are treated in emergency departments for fall injuries or are hospitalized because of a fall injury.2

Despite their common occurrence, falls can be detrimental to health; thus, every measure should be taken to reduce and prevent falls. This course will discuss the causes of falls, steps to assess risks for falls, and the mechanics of ambulation.

Incidence of Falls

According to the World Health Organization (WHO), a fall is described as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”4 Falls can be fatal or non-fatal; most are non-fatal.4 However, an estimated 684,000 fatal falls occur annually, with 80% of cases coming from low to middle-income countries.4

According to the CDC, falls are most common among individuals aged 65 or above and are one of the leading causes of death in that age group.2,3 Falls can lead to serious injuries and are an economic burden on patients, hospitals, and society. In the United States, over the last 5 years, the rate of falls increased by 30% for older adults, and if this rate continues, the estimated number of deaths by fall will increase to 7 per hour by 2030.2

It is also important to mention that ground level falls are accountable for 38 million disability-adjusted life years (DALYs) lost yearly.4 Falls result in longer disabilities than most other disability causes, such as burns, drownings, poisonings, and transportation injuries, resulting in substantial financial costs.4

Causes for Falls

Multiple factors can cause falls, and it is believed that a complex interaction between postural responses, musculoskeletal, neuromuscular, and cardiopulmonary systems, balance, sensory activity, and environmental factors increases susceptibility to falls.5 The multifactorial nature of falls makes it difficult to identify who is most at risk.5 Let’s review the most common causes and risk factors of falls in all age groups.

Age

Age is a major fall risk factor in young children and older adults. Children under 2 years of age are at increased risk of falls because of their curious behavior, evolving developmental stages, and increasing independence to explore their surroundings.4 Insufficient parental supervision is the main cause of children’s falls, but many factors contribute to this cause, such as single parenthood, poor socioeconomic status, and hazardous surroundings.4

Adults aged 65 or older are also at a higher risk for falls.3,4 Older adults have the highest risk of death or serious injuries from falls, and it increases with age.4 The main reasons are the cognitive, physical, and sensory changes associated with age.4 On some level, hazardous environments unsuitable for adults also contribute to falls.4

Gender

Although the rate of falls is the same in both genders, it has been noted that men are more likely to die from fall related injuries than women.4 The reasons for increased risk in men is due to hazardous environments within occupations, and risk-taking behaviors.4

Lifestyle

Lifestyle, job type, and the environment also play a major role in fall risks. Safety hazards or unsafe workplaces with insufficient safety equipment can lead to falls and injuries.3

Health Conditions

Multiple health conditions have been identified that contribute to falling, such as:1,2,3,4

  • Cardiac or neurological-related disabling conditions
  • Diabetes
  • Heart disease
  • Use of poor footwear
  • Vitamin D deficiency

Musculoskeletal Conditions

Musculoskeletal conditions and pain are commonly associated with increased age.6 These conditions  can lead to a reduced quality of life, impaired functionality and mobility, and persistent pain. Including physical activity in a daily routine is recommended.6 However, these conditions make it difficult to incorporate an active lifestyle. The loss of independence, gait and balance problems, and functional decline all contribute to an increased risk of falls.6

Gait and Balance Disorders

Gait and balance disorders are among the most common causes of falls in adults.6 Balance is maintained through complex interactions between the physiological and cognitive elements that enable an individual to respond rapidly and precisely. Both these elements are affected with age progression.6

It is true that changes in gait may be a sign of aging; however, it is also true that gait changes may be caused by underlying conditions as they increase in severity; thus, healthcare professionals should conduct an extensive assessment to eliminate all other possibilities.6 Gait and balance disorders lead to loss of independence, decreased mobility, and poor life quality, but early detection and prevention can reduce these symptoms.6

Cognitive and Emotional State

Cognitive impairment is also a strong risk factor for falls, and one that is difficult to manage.6 Cognitive impairment or dementia increases fall prevalence. How? Cognitive disorders are associated with functional decline, which increases the risk of falls. If a cognitively impaired individual falls, their chances of hospital admission, reduced activity increase.6 However, if detected early, different interventions can be employed, such as physical therapy, strength training exercises, and using mobility aids.6 Moreover, lack of sleep, disorientation, unconsciousness, or impaired alertness also contribute to falls.3

Physiology

Vision

Visual impairment is an important and overlooked risk factor for falls.6 Vision decline increases with age and is associated with a greater risk of falling. 6 Improving visual impairment can lead to a decreased risk; however, many studies support the contrary. For instance, a study concluded that the falling rate of the visually intervened was higher than in the control group.6 This is because of changes in activity, less caution during ambulation, and increased exposure to hazards within the environment after the intervention.6

In addition to vision, lower body weakness, imbalance, and hearing impairment increase fall risk.3

Pharmaceutical Agents

The use of multiple medications or medications that affect the neurological system can lead to gait and balance changes that can increase the risk of falls.6 Common examples include hypnotics, sedatives, tranquilizers, muscle relaxants, and antidepressants.1,3,6 Healthcare professionals should questions patients regarding their current medications use, and review the medications  as they could affect memory, response time, and cognition, especially in older adults.6

Mechanics of Ambulation

In medical terms, ambulation refers to the ability to walk independently, without the need for any assistance. It is often used to describe patients’ goals after a major surgery or physical therapy. But before reaching these goals and walking freely, must work with healthcare professionals and use assistive devices when necessary.

To understand how falls affect gait and balance, one must first understand the mechanics of mobility and ambulation. They are influenced by multiple elements, such as the musculoskeletal system, the nervous system, and environmental factors. However, the three main components include gait, balance, and posture.

Walking is a complex mechanism that involves the coordinated effort of the hips, knees, and feet.7 An individual’s walk consists of a repeated gait cycle.7,8 A gait cycle consists of the following two stages: 7,8

  • Stance stage – Accounts for 60% of the cycle and consists of four motions which can be divided into heel-strike, support, and toe-off.
  • Swing stage – A phase that is divided into swing acceleration and deceleration and placement of the heel for the next step.

The following is the underlying mechanics of ambulation:7,8,9

  • Heel-strike – During this stage, the feet touch the ground heel first, and three muscle sets are involved in the process.8 The gluteus maximus decelerates the forward motion of the lower limbs by acting on the hip; then, the quadriceps femoris enables the legs to stay extended at the knee, whereas the thighs are flexed at the hips. Lastly, the heel position for the strike is maintained by the anterior compartment of the leg.8
  • Support – At this stage, the entire foot meets the ground, and multiple muscle sets support the force passing through the leg. For instance, the quadriceps femoris supports weight by stabilizing the knee. Then, balance is maintained by foot invertors and evertors. The gluteus minimus, gluteus medius, and tensor fascia lata contract and abduct the knee, ensuring to counter the imbalance created by having all the weight on one leg.
  • Toe-off – At this stage, the feet leave the ground – heels first, toes last.8 The hamstring muscles act at the hip to extend the thigh. Then, the quadriceps femoris maintains the knee’s extended position. While the posterior compartment of the leg enables the foot to move in a downward motion, away from the body, also known as plantar flexion.
  • Leg lift – The swing stage of the gait cycle, where once the feet leave the ground, the lower limb is raised for the swing. In this stage, the iliopsoas and rectus femoris flex the thigh and drive the knee forward. The hamstring muscles then flex the leg at the knee joint, and the anterior compartment of the leg raises the foot upwards to the shin, commonly known as dorsiflexion.
  • Swing – In this stage, the raised leg is propelled forward to complete a single cycle. The thigh is flexed at the hip, and the iliopsoas and rectus femoris resist gravity as the lower extremity is pulled downwards. The quadriceps femoris positions the foot for landing by extending it at the knee, while the anterior compartment of the leg maintains dorsiflexion to prepare the foot for landing.
  • Once the feet touch the ground, the heel-strike stage occurs, and the gait cycle is repeated. Physiotherapists analyze each phase of the gait cycle to determine if there are any underlying neurological or musculoskeletal issues affecting gait and balance. A safety assessment is conducted to evaluate the patient’s strength, tolerance level, and current mobility status to develop a customized ambulation plan and determine the required assistance.
Steps to Assess Fall Risk

To implement effective interventions and preventive measures to reduce falls in older adults, the healthcare professional must first assess the patient and identify modifiable risk factors.10 The CDC recommends annual screening of older adults for fall risks. This should involve the patient’s history of falls, concerns about falling, and any walking or balance impairment self-reported.10 However, it should be noted that a fall risk assessment may be  limited, because all decisions are made on a patient’s self-reported measures, which can be useful but lack psychometric robustness.10 There are multiple fall risk assessment tools available, most of which require trained staff and time and thus have their limitations. Despite this, patient screening plays a pivotal role in effective management. According to a Cochrane Systematic Review, there is a 24% reduction in the rate of falls if clinical assessment and individualized treatment after identifying risk factors, combined with follow-ups, is provided by a healthcare professional.11

The following are the steps to assess fall risk in older adults:

History

The healthcare professional should inquire about the patient’s history regarding falls and the associated circumstances, because the risk of repeated falls significantly increases if a patient has fallen previously within the year.6 The following is information that a healthcare professional may gather:6

  • The number of times the patient has fallen previously and the associated circumstances.
  • Specific questions about known risk factors for falls.
  • Inquiring about environmental hazards, such as electrical cords, poor lighting, slippery stairs, rugs, cluttered areas, etc.
  • Consulting other family members regarding the functional history of the patient and their ability to perform routine daily life activities.6
  • Inquiring about premonitory symptoms or use of assistive devices, glasses, location, activity, footwear, or anything related to the fall.
  • Perform a medication reconciliation and check if the patient is taking the following classes of medications:
    • Antidepressants
    • Antihypertensives
    • Antipsychotics
    • Diuretics
    • Nonsteroidal anti-inflammatory drugs
    • Sedative hypnotics

These classes of medications all can lead to gait and balance impairment.11 The possible solution is to reduce the dose or immediately stop a medication contributing to fall risk and find alternative interventions for other conditions.11

Physical Examination

The following are the key components to assess fall risk in older adults:6

  • Vision
  • Cognition and depression – Includes assessment of tone, tremors, coordination, cognition, and depression.
  • Ambulatory aids or shoes – The shoes should be comfortable, fit nicely, offer wide support and stability, and should be lightweight.
  • Joint deformities – Check for bruises, swelling, deformities, or any active or passive motion limitation in the lower limb joints and spine. These limitations alter the normal gait pattern and the body’s center of gravity, leading to more energy consumption in the gait and balance cycles. Common problems include hip extension, tight hamstrings, and iliopsoas, and limiting knee.
  • Focused neuro exam – Conducted to assess deficits, such as weakness or sensory impairments that reveal underlying treatable problems.
  • Functional performance – Includes assessing the gait, which involves the balance, stance, velocity, stride length, symmetry, and antalgic movements. If the gait is normal, the patient should be asked to perform various tests or variations, such as tandem or backward walking, walking on toes, and unipedal stance.6 Other formal functional diagnostic tests include:
    • 30-Second Chair Stand test
    • Berg Balance Scale
    • Functional Reach Test
    • Performance-Oriented Mobility Assessment
    • Timed Up and Go Test
  • Posture – Any posture that alters the body’s center of gravity contributes to falls, such as a forward shift of the head with limited neck extension or excess kyphosis.
  • Vital signs – Check for orthostatic hypotension, and heart rate and rhythm.
Ways to Reduce Fall Risks

Fall-Proof the Home

Most falls occur at home, where someone is unaware of the potential risk factors. It is important to fall-proof the home to prevent future falls. A healthcare professional may suggest the following changes: 12

  • Bathroom
    • Place grab bars inside and outside the tub or near toilets.
    • Place non-skid carpets, mats, or strips on potential wet surfaces.
  • Bedroom
    • Have a landline or phone on the bedside table.
    • Place a nightlight to help with navigation.
  • Stairway
    • Place handrails on both sides of the stairs.
    • Use carpets or non-slip strips to offer friction.
    • Do not place mats or rugs at the top or foot of the stairs.
    • Ensure there is proper lighting during the day and at night.
  • Kitchen
    • Complete all cutting, chopping, and preparation tasks while being seated to prevent fatigue or weakness.
    • Keep frequently used utensils and pots within reach.

Incorporate Exercise and Strength Training

Staying physically active is important for increasing flexibility, strength, endurance, and balance.6 Older adults are usually recommended for physical activities and exercise to prevent age-related muscle mass and bone loss. Exercise should be introduced gradually, in a step-by-step manner, with gradually increasing intensity.6

Exercise has a positive impact on reducing the rate of falls. According to a meta-analysis, a 21% fall reduction rate was observed in community-dwelling older adults who exercised regularly.6 Effective exercise plans include multiple-component exercise programs, home-based exercises, and weight-bearing activities.6

Strength exercises should be included, such as yoga or Pilates, which improves balance and strength in the legs.1,2  To be effective, all physical activity should be: 10

  • Focus on improving balance
  • Moderate to high challenge and should progress in difficulty level
  • Should be done a minimum of 30 minutes a day or 2 hours weekly.

It is important to note that effects are not apparent immediately, and individuals should consider this as a lifestyle modification to prevent falls.10

Test Vision and Hearing

An individual should consult a healthcare professional to have routine vision and hearing assessments. Contact lenses, glasses, and hearing aids should be worn as prescribed, and an individual be comfortable with the use of  contact lenses and glasses prior to driving.1

Avoid Alcohol

By avoiding or limiting alcohol intake, an individual can prevent falls, as these substances affect the sensorium and balance, which can lead to serious fall related injuries.1

Consult Physical and Occupational Therapists

An individual can consult a physical therapist (PT) to detect deficits. A physical therapist conducts several assessment tests, such as Dynamic Gait Index and Four-Square Step Test to assess gait, strength, and balance deficits.10 A physical therapist can help design an exercise program based on the individual’s age, needs, and functional performance. A 3-month one-on-one fall prevention exercise program with a PT is recommended before transitioning to a community-based exercise program.10 Physical therapists also help determine the need for any assistive devices and teach patients how to use them properly.10

Occupational therapists (OT) help patients assess fall risk at home and incorporate lifestyle changes to eliminate risk factors.10 They plan a new routine based on the individual’s perception of previous falls, associated risk factors, and home and community use patterns.10 Based on this, OTs incorporate physical activity and behavioral changes, like scanning ahead for potential hazards while walking.10

Reduce Medication Burden

It is common practice that older adults are treated by multiple healthcare providers simultaneously with no coordination of care. This leads to polypharmacy and multiple side effects due to unforeseen drug-drug interactions, leading to dizziness, orthostatic hypotension, and sleepiness, all risk factors for falls.6 In such cases, medication reconciliation and adjustments to medications has shown a 39% reduction in the falling rate.6

Other preventive measures include: 1

  • Avoid bad weather or hazardous environments.
  • Stand up slowly.
  • Use assistive devices like canes and walkers to prevent falls. Ensure it is the right size and you know how to use it properly.
  • Wear low-heeled or rubber-soled shoes.
How to Ambulate with Assistive Devices

Assistive devices are used to aid in walking. The most recommended assistive devices include crutches and walkers. Proper usage of both will result in easier walking, reduced accompanying symptoms, and faster recovery.

Crutches

Crutches are used by individuals who cannot bear weight on one or both legs.13 They are used temporarily for recovery from serious injuries, or permanently in older adults with general leg weakness.13 There are two types of crutches; axillary crutches, which start at the axilla and extend to the ground, and forearm crutches, are at the level of the elbow and extend to the ground.13 Both serve different purposes; however, the usage and general considerations are more or less the same.

  • Ensure the crutches are placed between the arms and chest.
  • Ensure that when the crutches touch the ground, there is a shoulder-width distance between them.
  • An individual should consider any of the following four gaits according to preference and capabilities: 13
    • Four-point gait – The right crutch moves forward, and then the left leg follows. Then, the left crutch moves forward, and the right leg follows.
    • Swing-to gait – As support, move both crutches forward at the same time, and then lift and swing the legs forward to the crutches position.
    • Three-point gait – Both crutches move forward simultaneously, then the strong leg moves forward, and the weak leg follows.
    • Two-point gait – The left foot and right crutch move forward together, and then the right foot and left crutch follows.

Walkers

Individuals with balance issues or general leg weakness often use walkers.13 Walkers have a steel frame with four legs and two hand grips. They are movable, lightweight, and easy to use. General considerations for walkers include:13

  • If using a walker without wheels, lift it 5 to 6 inches, place it down, and move forward. For a walker with wheels, simply push it forward, put the brakes, and then move forward.
  • Patient should stand straight using the walker and move one leg forward and then the other.
  • The hand grips should come at the patient’s waist level.
  • The legs should have non-slip rubber covers.
Nursing Considerations

It has been researched that patients that receive nursing interventions during hospital stays benefit from reduced fall risk regardless of age and length of stay. Thus, advanced nurse training is essential. The following are the general guidelines and nursing considerations for reducing falls: 3

  • Avoid universal fall precautions and create an individualized care plan for each patient based on their needs, preferences, and capabilities.
  • Create a safe and comfortable environment for the patient and ensure every essential item is within reach.
  • Encourage patients to get their hearing and vision checked routinely.
  • Lower the bed position and keep the patients as close to the surface as possible to avoid trauma or serious injuries as a cause of falling.
  • Place identifiable markers like wristbands on patients to alert other healthcare providers that they are at risk for falls.
  • Provide close monitoring for at-risk patients and place them close to the nurses’ station.
  • Respond to call lights as quickly as possible.
Conclusion

Falls are a common reason older adults are frequently hospitalized or acquire life-long injuries. Although there is no sure way of preventing falls, individuals can improve their balance, posture, and bone structure by incorporating exercise and strength exercises to their daily routine.1

Establishing an interdisciplinary fall prevention team is also important. Healthcare professionals play a major role in managing and preventing falls by creating awareness and encouraging lifestyle changes among patients, such as improving home support, teaching patients how to use ambulation assistive devices, and encouraging the use of physical and occupational therapy.3

Healthcare professionals should also use a combination of fall assessment tools to determine modifiable risk factors and develop an individualized plan of care based on previous falls and injury risks, which includes transparent reporting and trend analysis, and reassessing the patient for fall risk after interventions are implemented.14

References
  1. National Institute on Aging. Falls and Fractures in Older Adults: Causes and Prevention. National Institute on Aging. Published September 12, 2022. https://www.nia.nih.gov/health/falls-and-fractures-older-adults-causes-and-prevention
  2. ‌Centers for Disease Control and Prevention. Facts about falls. www.cdc.gov. Published 2020. https://www.cdc.gov/falls/facts.html
  3. ‌Wayne G. Risk for Falls – Nursing Diagnosis & Care Plan. Nurseslabs. Published 2022. https://nurseslabs.com/risk-for-falls/
  4. ‌World Health Organization. Falls. World Health Organization. Published 2021. https://www.who.int/news-room/fact-sheets/detail/falls
  5. ‌Lusardi MM, Fritz S, Middleton A, et al. Determining Risk of Falls in Community Dwelling Older Adults. Journal of Geriatric Physical Therapy. 2017;40(1):1-36. doi:https://doi.org/10.1519/jpt.0000000000000099
  6. ‌Cuevas-Trisan, Ramon (2019). Balance Problems and Fall Risks in the Elderly. Clinics in Geriatric Medicine.2019;35(2):173–183.
  7. doi:10.1016/j.cger.2019.01.008    
  8. American Bone Health. The Mechanics of Walking – American Bone Health. americanbonehealth.org. Published June 21, 2021. https://americanbonehealth.org/exercise/the-mechanics-of-walking/#:~:text=The%20mechanics%20of%20walking%20involves
  9. ‌Jones O. Walking and Gaits – Stages – TeachMeAnatomy. Teachmeanatomy.info. Published 2012. https://teachmeanatomy.info/lower-limb/misc/walking-and-gaits/
  10. ‌McKnight J. 4.3.2 Ambulation. ecampusontariopressbookspub. Accessed April 20, 2023. https://ecampusontario.pressbooks.pub/personalcareassistant/chapter/4-3-2-ambulation/
  11. ‌Sun R, Paramathayalan VR, Ratnam R, Jain S, Morrow DG, Sosnoff JJ. 6 – Design and development of an automated fall risk assessment system for older adults. ScienceDirect. Published January 1, 2018. Accessed April 28, 2023. https://www.sciencedirect.com/science/article/abs/pii/B9780128112724000063
  12. ‌Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and Management of Fall Risk in Primary Care Settings. Medical Clinics of North America. 2015;99(2):281-293. doi:https://doi.org/10.1016/j.mcna.2014.11.004
  13. ‌Preventing Falls at Home: Room by Room. National Institute on Aging. Published September 12, 2022. https://www.nia.nih.gov/health/preventing-falls-home-room-room
  14. ‌Assistive devices for ambulation: Clinical skills notes. osmosis.org. https://www.osmosis.org/learn/Assistive_devices_for_ambulation:_Clinical_skills_notes
  15. ‌West GF, Rose T, Throop MD. Assessing nursing interventions to reduce patient falls. Nursing. 2018;48(8):59-60. doi:https://doi.org/10.1097/01.nurse.0000541404.79920.4e
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