FALLING IN THE ELDERLY

Every year, one-third to one-half of the population age 65 and over experience falls¹. Half of the elderly people who fall do so repeatedly². Falls are the leading cause of injury in older adults and the leading cause of accidental death in those over age 85^1,3. Five percent of falls lead to a fracture. Falls cause approximately 300,000 hip fractures annually. By the year 2000 there will be an estimated 350,000 fractures⁴. The United States spends an estimated $20.2 billion annually for the treatment of fall-related injuries. The majority of the cost is for the treatment of hip fractures, which average $35,000 per patient⁴. Although 25% of hip fracture patients will make a full recovery, 40% will require nursing home admission and 50% will require a cane or walker for ambulation. Twenty percent will die each year⁴.

The number of older persons with fall-induced injuries is increasing at a rate that cannot be explained by demographic changes alone and strong preventative measures should be adopted to control the increasing burden of these injuries, according to a study published in the Journal of the American Medical Association⁹

Identifying & Managing Elderly Fallers

Debra J. Rose, Ph.D. & Leslie Allison, M.S., P.T., N.C.S.

A Significant Health Concern
Falls are prevalent, dangerous, and costly. Even falls that do not result in injury can have serious consequences. Psychological trauma and fear-of-falling produce a downward spiral of self-imposed activity reduction which leads to loss of strength, flexibility and mobility, thereby increasing the risk of future falls².

However, falls are not a normal part of aging. Current research indicates that elderly fallers are different than their healthy, age-matched counterparts^5,6,7. Some have medical diagnoses such as diabetes or Parkinson's disease that contribute to falling, but many have no diagnoses at all that would explain their falls. This is because they do not have one large problem within a single system that would "earn" them a diagnosis. Instead, they often have many small problems across multiple systems, which interact to produce instability⁵. Each of these impairments is a risk factor for falls. Individually, none of these factors would cause a fall, but in combination they can. The more risk factors a person has, the greater the likelihood that they will fall².

As falls are not a normal part of aging, they may be preventable to a large degree. Risk factors for falls have been identified and there are many screening tools available to determine the presence of balance and mobility disorders. While "low-tech" or non-technology assessments provide a gross idea of who may be at risk, they do not identify impairments within specific body systems or why that problem exists. In addition, these tools are not sensitive to changes that may occur through interventions. NeuroCom balance evaluation and rehabilitation systems can assist professionals and/or providers in the identification of the risk factors associated with falling and can provide objective quantifiable assessments of underlying impairments, as well as functional capacity.

Components of a multidimensional geriatric balance assessment⁸:

Dimension of Balance	NeuroCom, a division of Natus Assessment	Alternative Assessment
Sensory Reception and Organization	Sensory Organization Test (SOT) Modified Clinical Test of Sensory Interaction on Balance (mCTSIB)	Clinical Test of Sensory Interaction on Balance
Volitional Postural Control	Limits of Stability Test (LOS)	Functional Reach and Reach in Four Directions
Nonvolitional Postural Control	Motor Control Test (MCT) Adaptation Test	Postural Stress Test
Peripheral Motor Impairments	Performance Assessments: Weight Bearing, Sit-to-Stand, Step-Up-and-Over, Forward Lunge	Manual Muscle Testing Joint Range of Motion

The training capabilities available on NeuroCom^®, a division of Natus® systems also help the clinician minimize risk factors, increase balance skills and reduce the probability of falls. The treatment objective for elderly fallers is to reduce the risk of falls. This is accomplished by (1) reduction or elimination of as many risk factors as possible, and (2) when certain risk factors are permanent, education and home/lifestyle modification.

Risk factor reduction goals that can be directly addressed using NeuroCom systems:

Reduction of excessive postural sway when holding still
Reduction of extraneous postural sway during goal directed movements
Expanded limits of stability
Increased symmetry of limits of stability
Improved perception of body position in space
Improved use of ankle, hip and stepping strategies
Decreased dependence on visual cues
Increased use of available sensory inputs for postural control
Improved ability to survive balance perturbations
Improved upper body control and head stability

Risk factor reduction goals that are indirectly addressed through upright exercise on NeuroCom systems:

Increased lower extremity strength
Increased foot and ankle flexibility
Increased endurance for standing activities
Increased awareness of and self-confidence in balance abilities

The Opportunity

The implications are that, by reducing falls, it may be possible to save lives and money, while maintaining a higher quality of life for elderly people. This information encourages professionals to be pro-active in their approach to unstable elderly clients, to offer services which can help identify and treat those at risk for falls, such as a Fall Risk Reduction Program or as one component of a Balance Center. NeuroCom balance evaluation and rehabilitation systems offer highly effective, and efficient, means for cost-effectively managing elderly patients at risk for falls to a positive functional outcome.

References:

Coogler, C.E. (1992). Falls and imbalance. Rehab Management, April/May, p.53.
Tinetti, M.E. & Speechley, M. (1989). Prevention of falls among the elderly. The New England Journal of Medicine, 320 (16), 1055-1059.
Pocinki, K.M. (1990). Studies aim at reducing risk of falls. P.T. Bulletin, February 21, p.13.
American Academy of Orthopaedic Surgeons (1998). Don't let a FALL be your last TRIP.
Horak, F.B., Shupert, C.L., & Mirka, A. (1989). Components of postural dys-control in the elderly: a review. Neurobiology of Aging, 10, 727-738.
Whipple, R. & Wolfson, L.I. (1989). Abnormalities of balance, gait, and sensori-motor function in the elderly population. In Duncan, P.W. (Ed.), Balance: Proceedings of the APTA Forum, American Physical Therapy Association, Alexandria, VA, 61-68.
Lizardi, J.E., Wolfson, L.I. & Whipple, R.H. (1989).Neurological dysfunction in the elderly prone to fall. Journal of Neurological Rehabilitation, 3 (3), 113-116.
Rose, D.J. (1997) Balance and mobility disorders in older adults: assessing and treating the multiple dimension of balance. Rehab Management
Pekka K., et al. Fall-induced injuries and deaths among older adults. 1999 JAMA, vol. 28, no. 20.

Additional References:

Nevitt, M.C. (1997). Falls in the elderly: Risk factors and prevention. In Masdeu, J.C., Sudarsky, L., & Wolfson, L. (Eds) Gait disorders in aging. Falls and therapeutic strategies. Philadelphia, PA: Lipincott-Raven, 13-36.
Di Fabio & Seay, R. (1997). Use of the "fast evaluation of mobility, balance, and fear" in elderly community dwellers: Validity and reliability. Physical Therapy, 77, 9, 904-915.
El-Kashlan, H.K., Shepard, N.T., Asher, A.M., Smith-Wheelock, M., & Telian, S. (1998). Evaluation of clinical measures of equilibrium. Laryngoscope, 108, 311-319.
Clark, S., Rose, D.J., & Fujimoto, K. (1997). Generalizability of the limits of stability test in the evaluation of dynamic balance among older adults. Archives of Physical Medicine and Rehabilitation, 78, 1078-1084.
Newton, R.A. (1997). Balance screening of an inner city older adult population. Archives of Physical Medicine and Rehabilitation, 78, 587-591.
Rose, D.J. & Dickin, C. (1998). Changes in functional performance as a function of age and fall risk. (Manuscript in progress).
Rose, D., Clark, S. (In Review). Can the control of bodily orientation be significantly improved in a group of older adults wit a history of falls? Submitted to Journal of gerontology: Medical Sciences, June 1998.
Whipple, R. (1997). Improving balance in older adults: identifying the significant training stimuli. In Masdeu, J.C., Sudarsky, L., & Wolfson, L. (eds.) Gait disorders in aging. Falls and therapeutic strategies. Philadelphia, PA: Lipincott-Raven, 355-79.
Shumway-Cook A., Gruber W., Baldwin M., Liao S. (1997). Effect of Multidimensional Exercises on Balance, Mobility, and Fall Risk in Community-Dwelling Older Adults. Physical Therapy, 77, 46-57.
Rose, D. (1997). A Multi-level Approach to the Study of Motor Control and Learning. Allyn & Bacon, Needham Heights, MA.