There are many definitions for falls. Within most definitions will be an idea that a falling is considered unintentional, to a lower level than before such as the floor or the ground, and it is neither explained either by medical causes such as blood pressure or a stroke, nor caused by an overwhelming external force. A simple and widely accepted version often used in used in research defines a fall as "An unexpected event in which the participant comes to rest on the ground, floor or lower level."
Falls and poor bone health are major causes of disability and accidental home deaths in the older population. Research into causative factors and prevention of falls show that many of the interventions provided through physiotherapy, or physiotherapy as part of a team, can be administered in different settings, and can modify the risk and help to prevent future falls.
An assessment of bone health alongside a falls assessment can ensure older patients who may have osteoporosis can be identified and receive appropriate treatment to reduce their risk of osteoporosis or fragility fracture following a fall. Likewise there should be access to a falls assessment within bone health services as there is a huge impact on the cost of managing falls related fractures.
Management of Falls
The physiotherapist's role is to work with the interdisciplinary team (whether actual or virtual) and investigate possible falls causes, working holistically to address issues. Management is multifactorial aiming to prevent and minimise future falls risks. Most falls are caused by slipping, tripping, or stumbling, not by dizziness or disorientation. They can occur during walking or standing if the person cannot recover quickly or effectively enough to stop the fall. The 'margin for error' when moving and standing decreases as reflexes slow and strength decreases as can happen if an older person becomes more sedentary or affected by disability, so a weakening of the balance system can no longer be compensated.
Key components of a multifactorial assessment include:
A detailed falls history, medication review, risk factor assessment including osteoporosis, urinary incontinence and cardiovascular disease.
Physical examination including gait and balance, neurological and cognitive function, lower limb strength, visual acuity, feet and footwear.
Functional assessment such as activities of daily living, perceived functional ability and fear of falling.
The physical examination should include assessment of gait, balance, joint range of movement and muscle strength. It is recommended that validated assessment tools are used. Outcome measures such as the Timed Up and Go Test or Berg Balance Scale are used .A fall or potential fall event should be assessed through multi-factorial tools such as the Physiological Profile Assessment (PPA).
Functional ability can be reviewed through subjective questioning of how a person manages personal and domestic activities of daily living; or observation of how the person performs everyday tasks such as standing up from a chair or multi-tasking e.g. walk and carry objects. Poor response in a dual-task setting is a possible prognostic value for multiple falls.
The correct treatment strategy is specific to the impairments and activity limitations observed throughout the assessment. Treatment is also based on evidence of falls factors which physiotherapy intervention can improve/alter. These include complex mobility e.g. as post-stroke, Parkinson's Disease with freezing; co-ordination and balance; flexibility; strength and endurance; fear of falling; confidence; getting up from floor using backward-chaining.
Backward-chaining is the method of preference as it provides a useful step by step method of getting down onto, and then getting back up off the floor. The individual is not allowed to progress to the next step of the chain before they have mastered the one they are on, and it may take several goes before someone frail can get onto / off the floor.
For physiotherapists, exercise (for strength and balance) has been shown to have the most effective outcomes in reduction of falls rates. As the majority of people who attend such programmes relapse into old ways by six months, the physiotherapist should attempt to reinforce and encourage good behaviour, eliciting ideas of what might keep the person motivated both during the course of the programme and into the future.
The balance training is highly challenging, should be individualised & progressive
Exercise should be at least twice a week and for a minimum duration of 6 months
Walking should only be prescribed in addition to a high intensity / high dose programme
It is becoming increasingly recognised that falls prevention requires a change in the person's behaviour and should be approached from a psychological, and not just a physical perspective. This is becoming the focus of health promotion and it is such multidisciplinary intervention that has been proven to be of most effect for fallers.
Community based falls prevention programmes such as the Otago Exercise Programme provide an evidence-based approach to reducing falls (by 35%) in high risk older adults.
New areas in falls prevention include games such as those available through the Nintendo Wii system. The Nintendo Wii allow people to practice at home and to monitor their goals following gains they made from a falls programmes. They were designed to, and are proving a fun way to engage people in intergenerational physical activity, and many rehabilitation units are using these systems to improve physical function. In addition, links between exercise referral schemes are increasing, more people are continuing activity in places such as gyms, that they may never before have had a chance to access. In all these settings, physiotherapists are key in helping people to achieve and maintain fitness levels and thus minimise the risk of falls in older adults.
The scope for prevention can be appreciated by considering some of the common conditions and risk factors predisposing to falls in the elderly. From this, the wide range of preventative measures and treatment possibilities can be appreciated. Falls should be considered a symptom rather than a diagnosis, so that when a patient, usually an elderly person, presents with a history of falls, effort should be made to find the cause or causes.
Strategies to prevent fall occurring:
Exercise regularly. It is important that the exercises focus on increasing leg strength and improving balance, and that they get more challenging over time. Tai Chi programs are especially good.
Ask their doctor or pharmacist to review their medicines-both prescription and over-the counter-to identify medicines that may cause side effects or interactions such as dizziness or drowsiness. Vitamin D supplementation and psychoactive drug withdrawal are also effective.
Have their eyes checked by an eye doctor at least once a year and update their eyeglasses to maximise their vision. Consider getting a pair with single vision distance lenses for some activities such as walking outside.
Make their homes safer by reducing tripping hazards, adding grab bars inside and outside the tub or shower and next to the toilet, adding railings on both sides of stairways, and improving the lighting in their homes.