interventions

by Rein Tideiksaar, PhD

Interventions Aimed at Preventing Falls
The ultimate goal of any fall prevention or reduction strategy is to reduce the risk of falls and fall-related injuries while preserving the elder's mobility, functional independence and autonomy. Given that most falls result from a dynamic interaction between intrinsic and extrinsic factors, a multidisciplinary approach incorporating a variety of strategies is likely to be the most beneficial.

Medical Management
Because falls may be caused by underlying diseases, adverse medication effects, and resulting disabilities, all elders with falls should be referred to their primary care providers for evaluation. Diagnosing and treating risk factors, such as visual disorders, gait and balance impairment, muscle weakness, cognitive impairment, postural hypotension, cardiovascular irregularities, discontinuing inappropriate or excessive medication and changing medication, and managing existing chronic diseases are of great benefit in reducing fall risk. In addition, investigating and then treating osteoporosis by administering Vitamin D, calcium supplementation and bone strengthening medications, and instituting weight-bearing exercises helps to reduce the risk of injurious falls.

Rehabilitative Strategies
Rehabilitative strategies include therapeutic exercise, wearing proper footwear, and utilizing appropriate ambulation devices to assist with mobility. Elders with impaired mobility resulting from medical disorders and/or deconditioning may benefit from a trial of exercises. Exercise programs can be grouped into two broad categories: general physical activity (walking, aerobic movements, and other endurance exercises), and specific physical activity (training geared specifically towards increasing balance and strength). To be effective, exercise should be tailored to the elder's physical capabilities and needs. Although exercise has many proven benefits, the optimal type, duration and intensity of exercise for falls prevention remains unclear. Tai Chi Chuan is a promising type of balance exercise which also helps to reduce fear of falling; its contribution to fall prevention requires further evaluation.

Paying attention to shoe type and fit is important, as it can either interfere with or support safe gait and balance. Stability is improved with shoes that have a thin and firm sole, rather than footwear with thicker soles, such as sneakers or running shoes. Thin soles provide better proprioceptive feedback, which helps to support balance. Thick soles can result in tripping, especially in those individuals with shuffling gait.

For those elders with gait and balance disorders, canes and walkers can be used to maintain or improve mobility. Ambulation devices, such as a cane or walker, increase the elder's standing and walking base of support and stability. The devices furnish proprioceptive feedback through the handle, and shift the load on weight-bearing joints (such as hips, knees, ankle, or foot) to the upper limb. Furthermore, devices provide the elder with a visual presence of support that can instill confidence during ambulation, and thereby may help to reduce fear of instability and falls.

Environmental Strategies
The aim of environmental interventions is to, first, identify and eliminate hazardous conditions and, second, simplify or maximize mobility tasks for the older individual. For example, if impaired transfers are identified in an individual, the goals would be to support safe bed and toilet transfers. Environmental modifications put in place might include:

Maintain an appropriate bed height -- one which allowed the individual to sit on the edge of the bed with knees flexed at 90 degrees and feet planted firmly on the floor.
Equip the individual's bed with a transfer bar (a sturdy half side rail may be used as an alternative) to support safe transfers.
Install toilet grab bars to support toilet transfers.
Provide a bedside commode to support safe toileting activities.

Hazardous environmental conditions, such as low seats, poor illumination, slippery floors, faulty stairways, can increase fall risk by interfering with safe mobility. Likewise, elders with diminished functional capacity due to chronic neuromuscular diseases may experience difficulty maneuvering around unsafe environments, which can place them at fall risk. The home and institutional environment can be modified to maintain safe mobility and/or compensate for individual functional problems (in other words, removing hazards and/or supporting mobility with durable medical equipment).

Definitive studies that demonstrate the advantages of environmental modifications in reducing falls are lacking; nevertheless, conducting an environmental safety assessment to identify unsafe activities and environments is a reasonable approach, particularly if targeted to such specific functional impairments as bathroom grab bars for the elder with balance impairment. Additionally, it is important to provide community-living elders and their caregivers with alternate ways to eliminate or minimize dangers posed by unsafe furnishings and environmental conditions. Information on possible sources of financing for environmental modifications is pertinent.

Injury Reduction
Strategies aimed at injury reduction include hip protector garments and personal emergency response systems (PERS). More than ninety percent of hip fractures are caused by direct trauma against a hard surface following a fall. Shock-absorbing plastic pads placed in pockets on the sides of underwear cushion the femur and pelvis against impact. Hip protectors are highly effective in preventing hip fracture. The downside of hip protectors is noncompliance. Some elders choose not to wear them for a variety of reasons, such as denial of injury risk, discomfort, and inconvenience especially when toileting. Hip protectors are likely to be more acceptable to those individuals who are at risk for a second hip fracture.

For those people who live alone, the fear of not being able to get up from the floor following a fall can be especially traumatic. About twenty percent of falls experienced by community-dwelling elders result in lie times of one hour or more. Personal emergency response systems (PERS) are electronic devices designed to provide frail older persons with a means to summon assistance in the event of a fall, and thus prevent a lengthy lie time. They increase the elder's feelings of security and confidence as well as allay family fears regarding the safety of their loved one.

Conclusion
Preventing falls among community-dwelling elders is a complex process that is highly dependent upon educating both patients and health care professionals about falls and risk reduction strategies, identifying those most at risk of falling, and coordinating appropriate risk reduction strategies through an organized process of care.

Posted October 2005