Falls in elderly

1. Falls in the Elderly:
a Physical Therapy
Perspective
Hana Al-Sobayel, MSc, PhD
Physical Therapy
King Saud University

2. Outline





Epidemiology of falls
Clinical significance
Risk factors
Assessment
Falls prevention
Alsobayel - Geriatrics Chair Symposium 2010

3. Falls Epidemiology
Alsobayel - Geriatrics Chair Symposium 2010

4. Alsobayel - Geriatrics Chair Symposium 2010

5. Definition
A fall is an event which results in a person
coming to rest inadvertently on the
ground or floor or other lower level
(WHO)
Alsobayel - Geriatrics Chair Symposium 2010

6. Frequency of falls

28-35% of people aged of 65 and over fall each
year

32-42% for those over 70 years of age

Increase with age and frailty level.
Alsobayel - Geriatrics Chair Symposium 2010

7. Frequency of falls


Older people who are living in nursing homes
fall more often than those who are living in
community.
30-50% of people living in long-term care
institutions fall each year, and 40% of them
experienced recurrent falls
Alsobayel - Geriatrics Chair Symposium 2010

8. Fall mortality rate


Falls account for 40% of all injury deaths
Unintentional falls: #1 leading cause of
death in USA for people above 55 years
of age
(CDC, 2006)
Alsobayel - Geriatrics Chair Symposium 2010

9. Fatal falls rates by age and gender
(National Council on Aging, 2005 in WHO 2007)

10. Clinical Significance
Alsobayel - Geriatrics Chair Symposium 2010

11. Need for medical attention



20-30% of mild to severe injuries
Underlying cause of 10-15% of all
emergency department visits
50% of injury related hospitalizations
among people over 65 years and older
Alsobayel - Geriatrics Chair Symposium 2010

12. Fall-related hospital admission


Hip fracture, traumatic brain injuries and
upper limb injuries
Longer hospital stay compared to other
injuries.
Alsobayel - Geriatrics Chair Symposium 2010

13. Fall-related hospital admission

Hip fractures:

Hospital stay extend to 20 days
 Older
person are likely to remain in hospital
for the rest of their life
 20%
die within a year subsequent to falls
Alsobayel - Geriatrics Chair Symposium 2010

14. Post-fall syndrome






Dependence
Loss of autonomy
Depression
Confusion
Immobilization
Restriction in daily activities.
Alsobayel - Geriatrics Chair Symposium 2010

15. National Crisis
Diseases of civilization
Aging and medical
advances that preserve
and prolong life
High inactivity rates
(MOH statistics 2008)
(Al-Nozha et al. 2007)
Alsobayel - Geriatrics Chair Symposium 2010
High Falls
complications

16. Risk Factors
Alsobayel - Geriatrics Chair Symposium 2010

17. Risk factors
Intrinsic & Extrinsic
(Steinweg, 1997)
Alsobayel - Geriatrics Chair Symposium 2010

18. Risk factor model
(WHO, 2007)

19. Causes of falls in elderly
(Rubenstein, 2006)
Alsobayel - Geriatrics Chair Symposium 2010

20. Risk factors of falls
(Rubenstein, 2006)
Alsobayel - Geriatrics Chair Symposium 2010

21. Falls & Fractures



The strongest determinant of a fracture is the
actual fall rather than bone fragility
Abnormalities in gait and balance are the most
frequent and sensitive risk factors that
predispose to fractures
Physical limitations and physical inactivity reduce
bone strength and increase fracture risk
Alsobayel - Geriatrics Chair Symposium 2010
(Karinkanta et al., 2010)

22. Assessment
Alsobayel - Geriatrics Chair Symposium 2010

23. Self-report scales



Identify high risk individuals:
History of fall within a past time frame
Details on frequency, surrounding
circumstances & injury severity
(Rubenstein et al., 2002)
Alsobayel - Geriatrics Chair Symposium 2010

24. Self-report scales





The Falls Risk for Older People in the
Community Scale (FROP-Com):
Covers 13 risk factors in 26 questions
Dichotomous or ordinal scoring, from 0 to 3
An overall score of falls risk, ranging from 0 to
60, with higher scores indicative of greater risk
Sensetivity = 66% ; Specificity = 65%
(Russell et al., 2008)
Alsobayel - Geriatrics Chair Symposium 2010

25. Single-task performance



Assess postural maintenance or physical
performance
Simple, require minimal time and
equipment
Single domain
Alsobayel - Geriatrics Chair Symposium 2010

26. Single-task performance


Five Times Sit to
Stand/Chair Rise
(FTSS)
Good predictor of
recurrent falls
An individual is
asked to rise from
sitting to standing
with arms crossed
and repeat the
task 5 times
(Buatois et al., 2008)
Alsobayel - Geriatrics Chair Symposium 2010

27. Single-task performance



Stepping: Maximal
Step Length
Significantly
correlated with
measures of
balance & mobility
Good predictor of
frequent falling
Arms crossed on
chest, stepping out
with one leg as far
as possible,
maintaining position
on the other leg,
return to initial
position in one step
(Buatois et al., 2008)
Alsobayel - Geriatrics Chair Symposium 2010

28. Single-task performance


Timed Up & Go
(TUG)
Individuals with
falls slower than
non-fallers
(Shumway-Cook et al., 2000)
Time needed to
get up from a
chair, stand
up, walk 3
meters, return
back to sitting on
the chair
Alsobayel - Geriatrics Chair Symposium 2010

29. Multi-task performance




Comprehensive approach to fall
assessment
Incorporate multiple measures (singletask & questionnaires)
Provide detailed information
Time consuming
Alsobayel - Geriatrics Chair Symposium 2010

30. Multi-task performance

Performance
Oriented Mobility
Assessment
(POMA)
(Tinetti, 1986)


Assess balance &
gait
Direct observation
Score range 0-40
Good inter-rater
reliability
Moderate ability to
differentiate
between fallers &
non-fallers
(Raiche et al., 2000)
Alsobayel - Geriatrics Chair Symposium 2010

31. Multi-task performance

Berg Balance Scale
(BBS)
(Berg et al., 1989)


High inter-rater,
intra-rater, testretest reliability
BBS & history of
falls, best predictors
of falls in community
dwelling individuals
14 mobility tasks
Scored from 0-4
Maximum score of 56
(Shumway-cook et al., 1997)
Alsobayel - Geriatrics Chair Symposium 2010

32. Multi-task performance



Physical
Performance Tests
(PPT)
High inter-rater
reliability
Good predictor of
falls in community
dwelling individuals
7 items
Timed tasks
Scores according to
time
Higher score faster
performance
(Reuben & Sui, 1990)
Alsobayel - Geriatrics Chair Symposium 2010

33. Environment Assessment
Alsobayel - Geriatrics Chair Symposium 2010

34. Prevention
Alsobayel - Geriatrics Chair Symposium 2010

35. Physical Therapy Approach

Must consider individual risk
factors, such as functional limitations or
reduced bone strength, and
environmental hazards.
(Karinkanta et al., 2010)

Multi-component exercise beneficial for
bone health and maintaining functional
ability in older community-dwelling
adults.
(Petridou et al., 2009)
Alsobayel - Geriatrics Chair Symposium 2010

36. Physical Therapy Approach

Whole-body vibration training has shown
potential to improve muscle
performance, balance and bone strength
(Mikhael et al., 2010)

Home hazard assessment and
modification and use of hip protectors
are efficient for frail older adults at the
highest risk of falling.
(Gillespie et al., 2009)
Alsobayel - Geriatrics Chair Symposium 2010

37. Summary
Alsobayel - Geriatrics Chair Symposium 2010

38. 




Elder population at high risk of falls
Fractures mainly results from falls in
elder populations
Risk assessment is integral part of fall
prevention
Physical therapy is required for falls
prevention among elderly
Urgent need for risk assessment and
reduction locally and internationally
Alsobayel - Geriatrics Chair Symposium 2010

39. Alsobayel - Geriatrics Chair Symposium 2010