Falls in the Elderly - Essay Example

Falls among the older population and the consequent injuries suffered are a major public health problem. The reason for this is that besides the enhanced frequency of falls in the elderly, such falls result in mild to severe injuries to the tune of 20 to 30%. This leads to more than 50% injury related hospitalization among the elderly and 10-15% emergency of all emergency department visits (The World Health Organization, 2007). In comparison to hospital stays for other injuries among the elderly, hospital stays due to injuries from falls are much longer. In the United Kingdom hospital admission rates owing to falls to individuals over the age of sixty is between 1.6 to 3.0 per 10,000 of the population and the emergency department visits as a result of falls in the elderly is between 5.5 to 8.9  per 10,000 of the population (The World Health Organization, 2007).

In addition, to high hospitalization rates, falls in the elderly carry the higher risk of mortality, with falls being responsible for about 40% of all deaths from injuries to the elderly (The World Health Organization, 2007). Post-hospitalization complications can also arise in the form of post-fall syndrome that include the elements of dependence, loss of autonomy, immobilization and depression. This reduces the ability to perform daily activities, making them dependent on caregivers from the family. In the United Kingdom, the average earnings per annum lost on this account is $40,000 (The World Health Organization, 2007). The health problem of falls in the elderly is bound to rise in the developed world, due to the rise in proportion of the elderly among the whole population (The World Health Organization, 2007). Evidence from a study conducted in the UK shows that in 1999 there were 647,721 A& E attendance and 204,424 admissions to hospitals owing to injuries due to falls in individuals in the age bracket of sixty years and older. The same study also indicates that economic cost of treatment of these injuries due to falls in the elderly was to the tune of 300,000 British pounds per 10,000 population in the age group of 60-64 years and 1,500,000 British pounds in the more than 74 years age group at prices in the year 2000 (Nagaraj, 2011).

Chapter – 2

2.1.    Causes of falls in the Elderly

As people get older several aspects of the aging process bring about intrinsic causes for falls in the elderly (Hurd, 2007).  At the core of the intrinsic causes for falls in the elderly is reduced stability. Reduced mobility or the development of arthritis can bring about a decrease in the muscle tone or strength of the muscles impacting on the stability of older people (Hurd, 2007).  Changes that occur in gait and postural control also reduce stability in the elderly. With advance in age there is the possibility of decrease in depth perception, hearing ability, proprioception and vision strength that have a negative impact on the stability of an older person (Hurd, 2007). Slower reflexes are a common feature of advancing age and slower refluxes reduce the stability of the elderly (Hurd, 2007).

The age-related factors that cause falls can be classified into changes in postural control, alterations in gait, enhanced prevalence of pathologic conditions that impact on the stability of the individual, increase in conditions that lead to nocturia and impaired cognitive function (Kane, Ouslander & Abraas, 2004). Changes in postural control include decreased proprioception, slower righting reflexes, decrease in muscle tone, increase in postural in postural sway and orthostatic hypotension (Kane, Ouslander & Abraas, 2004). Changes in gait include feet not lifted as high as normal, development of flexed posture and wide-based short stepped gait in males and development of narrow-based waddling gait in women (Kane, Ouslander & Abraas, 2004). The enhanced pathologic conditions that have a negative impact on the stability of the elderly include degenerative joint disease, osteoporosis, fractures of hip and femur, stroke with residual effects, weakening of muscle from disuse and de-conditioning, peripheral neuropathy, disease or deformities in the feet, impairment of vision, impairment of hearing, other specific disease processes like cardiovascular diseases and Parkinsonism (Kane, Ouslander & Abraas, 2004). Examples of conditions that cause nocturia include congestive heart failure and venous insufficiency. Forgetfulness and dementia are the common causes of impaired cognitive functioning that can cause falls. The intrinsic causes are not the only factors that add to the incidence of falls in the elderly. There are also the extrinsic causes and the interaction between the intrinsic and extrinsic causes that enhance the possibility of falls in the elderly (Kane, Ouslander & Abraas, 2004).

Extrinsic causes are responsible for more than fifty percent of the falls in the elderly. Environmental factors are responsible for to a very large extent for the extrinsic causes of halls in older people. The environmental factors most commonly involved are inadequate lighting, throw rugs and frayed carpets, unstable furniture and inappropriate bed and toilet heights (Cavalieri, 2002). Other extrinsic causes involved in falls in the older people include movement of the individual, like transferring the individual from bed to chair or vice versa; shoes that do not fit properly; poor foot care and improper use of walking aids (Joint Commission Resources, 2005). In recent times an additional possible extrinsic cause for falls in the older people has been suggested in the form of use of restraints, which limit the freedom of movement and through that contributes to muscle weakness and reduced physical abilities. In the elderly already susceptible to falls due to intrinsic causes the presence of extrinsic causes only heightens the probability if falls (Joint Commission Resources, 2005).

2.2.    Risk Factors of falls in the Elderly

Advancing age and the place of residence are the foremost risk factors for falls in the elderly (Simon, Everitt & Kendrick, 2005).  One third of individuals over the age of 65 years, residing in the community and half of those over the age of 65 years living in institutions have had an episode of a fall. This highlights the risk factors of advanced age and place of residence (Simon, Everitt & Kendrick, 2005). Any fall episode has a serious negative impact on the confidence level of the individual and places the individual at risk for subsequent falls. This lack of confidence results in restriction of activities, lowering of fitness levels and dependence on others. The more the number of fall events the lower is the confidence level in older people(Simon, Everitt & Kendrick, 2005).  Each of the causes of falls in the elderly is a risk factor for falls in older people. The risk factors of falls in the elderly thus include disorders of gait or stability, visual and cognitive impairment, lower mobility and depression, higher level of dependence, weakness of the lower limbs arising from diseases or conditions, problems of the feet, diseases like stroke or Parkinson’s disease, consumption of alcohol, use of psychotropic drugs, sedatives, diuretics or beta-blockers and environmental factors like loose carpets and slippery floors (Simon, Everitt & Kendrick, 2005). 

The risk factors involved in falls in the elderly in indoor environments are different from the risk factors associated with falls in the elderly in outdoor environments. Only the risk factors of previous fall events, depression and higher education levels are found to be common risk factors among the risk factors for falls in the elderly in indoor and outdoors environments (Kelsey et al, 2010). This difference stems from indoor falls of older people being more associated with the intrinsic causes of disability, diseases and poor health condition and an inactive life style, while falls in older people outdoors are associated with their active lifestyle and therefore attuned more towards the extrinsic factors, like ice underfoot conditions and high winds (Kelsey et al, 2010). More of the older people tend to remain outdoors and the emphasis has been on identifying the risk factors to make the indoor environment less hazardous to reduce the incidence of falls in the older people. However, it is important that the differences in risk factors associated with falls indoors and outdoors are identified, so that the incidence of falls in the more active older people also come into focus in the falls risk assessment and management plans for the elderly (Kelsey et al, 2010).

Chapter – 3

3.1.    Risk Assessment 

There is universal agreement that interventions are necessary to prevent the frequent and costly falls in the elderly. However, there is less agreement and clarity on the best means for preventing falls among older people (Chang et al, 2004). Chang et al, 2004, evaluated the relative effectiveness of interventions used to prevent falls in older adults by comparing a usual care group and a control group. Findings from this study show that multi-factorial risk assessment and management programs based on the risk assessment was the most effective means for preventing falls in the elderly. In addition, the study also found that exercise was an additional effective component in the efforts to reduce falls in older people (Chang et al, 2004).

The National Services Framework (NSF) 2001 for older people, developed by the Department of Health, UK, identifies falls as a major health concern for older people. This lays the foundation for the rationale behind falls risk assessment among the older population being necessary. Evidence points to falls among the older population are common, quite often preventable, frequently not reported and many a time the cause of injury and unwanted restriction in normal activities that lead to an overall reduction in health and quality of life to the individual (Department of Health, 2001). Fall risk assessment has been identified as multidimensional by the NSF and involves risk assessment of the intrinsic and extrinsic risk factors relevant to the involvement. The intrinsic factors in the opinion of the NSF consist of “balance, gait or mobility problems including those due to degenerative joint disease and motor disorders such as stroke and Parkinson's disease; taking four or more medications, in particular centrally sedating or blood pressure lowering medications; visual impairment, impaired cognition or depression and postural hypotension’, while the extrinsic factors in the opinion of the NSF include “poor lighting, particularly on stairs; steep stairs; loose carpets or rugs; slippery floors; badly fitting footwear or clothing; lack of safety equipment such as grab rails and inaccessible lights or windows (Department of Health, 2001).   

The National Institute of Clinical Excellence (NICE) guidelines for prevention of falls in older people recommend that the assessment of risk factors for falls among older people should be multi-factorial and includes the elements of “identification of falls history, assessment of gait, balance and mobility, and muscle weakness; assessment of osteoporosis risk; assessment of the older person’s perceived functional ability and fear relating to falling; assessment of visual impairment; assessment of cognitive impairment and neurological examination; assessment of urinary incontinence; assessment of home hazards; cardiovascular examination and medication review (National Institute of Clinical Excellence, 2004).

In the multi-factorial assessment of risk for falls among elderly people, nursing practice plays an important role (Miller, 2008). Many of the risk assessment information is obtained by observing the older people and the close association between nursing practice and patients, places nursing professionals in an ideal position for such observations. While environmental hazards can be observed at home and assistive devices hazards in institutions are more easily evaluated, more pertinent information on the risks are obtained through the interaction of the individual with the environment or the assistive devices (Miller, 2008). The best assessment is thus derived by nursing professionals paying particular attention to the awareness of the individual and the attention of the individual to the environment. Such observations are particularly useful in finding out the discrepancies between an individual’s perception of abilities and actual demonstration of abilities. Observation also assists in identifying adaptive behaviours, which the individual may not acknowledge orally (Miller, 2008). For example, an individual may state that there is no difficulty experienced in climbing stairs, while observation of the actual climbing of stairs may show that the activity is performed in an unsafe manner. The importance of risk assessment in assisting the objective of preventing falls in older people lies in the multi-factorial aspect involved and the tediousness of the task in the assessment and this has led to the availability of several falls risk assessment tools to assist in the risk assessment process for falls in the older people (Miller, 2008).

3.3.    Risk Assessment Tools

Irrespective of whether the setting is at a healthcare setting or at home, certain risk factors for falls like gait instability, agitated confusion, urinary incontinence or frequency use of sedatives or hypnotics remain the same (Peri, 2007). Simple risk assessment tools are capable of predicting falls with sensitivity and specificity that exceeds 70% (Peri, 2007). Validation of these figures in different settings and routine clinical use still has to be ascertained. However, for greater efficiency in fall intervention strategies stronger and more validated risk assessment tools are necessary (Oliver et al, 2003). The importance of the using the right risk assessment tool is highlighted by evidence from single studies demonstrating that very few of the risk assessment tools effectively predict falls in older people (Peri, 2007).

The effective assessment of falls requires a holistic approach and so the risk assessment tool should be capable of providing an efficient evaluation of all the risk factors associated with falls among the elderly. There are hindrances to this. For instance, it is not easy to determine all the factors that impinge on the stability of an older adult resulting in falls and which are the factors that need to be targeted for reduction in falls among older people. Additional limitations with the risk assessment tools include the wide range of settings in which the risk assessment tools have to be employed and the lack of studies that establish the reliability of the risk assessment tool in all the settings. Furthermore, there is limited focus on the holistic approach for falls risk assessment in the risk assessment, with many of the risk assessment tools focusing on balance and gait evaluation and others focusing on the other risk factors(Gupta, 2008).

 This scenario with falls risk assessment tools makes it difficult to single out any fall risk assessment tool as the appropriate tool for all settings across the wide range factors involved in the falls among older adults. The choice of the falls risk assessment tool depends on the purpose of its use. For example, in the event the falls risk assessment tool is used for screening a high-risk population, then the risk assessment tool must be easy to use and provide the appropriate levels of sensitivity and specificity in predicting falls (Gupta, 2008).