The most important thing you can do now, is to establish a physical activity routine. I don't mean jogging or weight lifting. That's why I don't call it exercise. Walking a few times a week and practicing gentle yoga or Tai Chi regularly will do. I'm not asking you to do this for weight loss, because that probably won't happen, but I'm asking you to do this for balance and strength. This is for you, and your parents, and people in this age group you care about. You don't have to read the entire paper that follows this introduction. I think the epidemiology part of it in the beginning will carry you through the prevention part, and don't worry about the conclusion. It's admittedly lame, but that's the kind of language they look for in an academic paper. Concentrate on the prevention part!
Epidemiology of Unintentional Falls in the Elderly Population in the United States
Falls are the leading cause of death from unintentional injuries in the elderly population in the United States. In 2013, a total of 45,942 persons aged 65-85+ died from unintentional injuries in the United States. 55.4% of these deaths were caused by falls. In comparison, motor vehicle and traffic accidents, the second leading cause of unintentional injury, caused only 6,333 (13.8%) of deaths in this population (Cdc.gov, 2015).
Young children and athletes have higher incidence of falls, but lower incidence of injuries. Elderly people are more susceptible to injuries because of high prevalence of clinical diseases such as osteoporosis and age-related physiological changes such as slowed protective reflexes. Once injured, they are slower to recover and are at risk for deconditioning. Post-fall anxiety syndrome, a fear of falling again, may lead them to be less active, and they may become weaker and more deconditioned, which further increases their risk of falling and getting injured (Rubenstein, 2006).
According to Centers for Disease Control (CDC), one out of three adults aged 65 or older fall each year but less than half of them will talk to their healthcare providers about it. 40% of elderly people aged 65 or older who live at home will fall at least once each year, and 1 in 40 of them will be hospitalized. About half of those who were hospitalized after a fall will still be alive a year later. The rates of falls and their consequences rise with age and double for persons older than 75. Elderly people who live in long-term care facilities have even higher rates of falls, and they tend to suffer more serious injuries such as fractures and lacerations (Rubenstein, 2006).
Falls are the leading cause of fatal and nonfatal injuries. In 2013, 2.5 million nonfatal falls among older adults were treated in emergency rooms and more than 734,000 of those were hospitalized. Twenty to thirty percent of fall injuries resulted in moderate to severe injuries such as lacerations, hip fractures, and head traumas. Half of the falls that resulted in death were due to traumatic brain injury. Most fractures among the elderly are caused by falls, and the most common are fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand (Cdc.gov, 2015).
Men are more likely to die from falls than women. After adjusting for age, the death rate from falls for men is approximately 40% higher than for women. Older whites are 2.7 times more likely to die from falls as older blacks, and older non-Hispanics have higher fatal fall rates than Hispanics. White women have significantly higher rates of hip fractures than black women People 75 and older who have fallen, are four to five times more likely to be admitted to a long-term care facility for a year or longer, than people 65 to 74 (Cdc.gov, 2015).
Costs of Fatal and Nonfatal Falls in the Elderly Population
The direct medical costs of falls, adjusted for inflation, were $34 billion in 2013 (Cdc.gov, 2015). Direct costs are patient and insurance company payments for the treatment of fall related injuries. Direct medical costs include fees for hospitals, doctors and other medical professionals, nursing home care, rehabilitation, home care, prescription drugs, medical equipment and home modifications. Medical costs for women, who make up 60% of the older adult population, are two to three times higher than the costs for men. The most common and costly fall related injuries are fractures, especially hip fractures, because they usually require hospitalization and surgery. About one-third of nonfatal injuries, result in fractures and account for about 61% of nonfatal costs. Two-thirds of the cost of nonfatal injuries, are spent on hospitalizations and 20% on emergency department treatment (Cdc.gov, 2015).
Stevens, Corso, Finkelstein & Miller (2006) point out that direct medical costs, while substantial, do not represent the full financial burden and economic impact of fall related injuries. Costs associated with lost wages and housework for the injured and their caregivers and for expenses not covered by insurance, reduced quality of life and decreased functional capacity are difficult to quantify.
Causes and Risk Factors for Falls in the Elderly Population
Rubenstein (2006) summarized 12 of the largest retrospective studies that carefully evaluated elderly persons after a fall and specified a “most likely” cause. The most frequently cited cause in these studies was accidental or environment related, ranging from 30 to 50 % of falls. The next most common cause cited was the broad category of gait problems and weakness, ranging from10 to 25%, followed by dizziness, ranging from10 to 30%. “However, many falls attributed to accidents really result from the interaction between identifiable environmental hazards and increased individual susceptibility to hazards from accumulated effects of age and disease.” (Rubenstein, 2006). Older people are less able to adjust their posture or compensate to avoid a fall after an unexpected trip or slip (Rubenstein, 2006). Rubenstein further points out that both, prospective, and retroactive epidemiological studies, have been performed to identify specific risk factors that put elderly individuals at increased risk for falling. Rubenstein notes that due to the multifactorial nature of falls, identifying risk factors is more useful than classifying specific causes for falls retroactively. After comparing 16 controlled studies analyzing individual risk factors for falls, Rubenstein identified muscle weakness and problems with gait and balance as the most important risk factor, and concluded that most identified risk factors identified in these studies are “amenable to improvement” and that falls can potentially be prevented with interventions targeted at these risk factors. A widespread and promising risk factor reduction strategy is to improve strength, gait and balance (Rubenstein, 2006).
The causes for falls in the community are multi-factorial. Interventions to prevent falls must also be multi-factorial and must be carried out by a multidisciplinary team of skilled professionals, aided by family and caregivers of the elderly persons living in the community.
CDC recommends that elderly people exercise regularly to improve leg strength and balance, with increasingly challenging exercises. Tai Chi programs are recommended. Elderly persons are advised to be knowledgeable about the medications they are taking and to identify prescription and over-the-counter medicines that can potentially cause dizziness or drowsiness. Eyes should be checked regularly, at least yearly and prescription eyeglasses should be updated, to maximize vision. Make homes safer by reducing clutter and tripping hazards and ensuring adequate lighting in the home. Add grab bars to make tub, shower and toilet use safer and add railings to stairs (Cdc.gov, 2015).
The American Geriatrics Society recommends that all elderly people be screened and assessed for their risk of falling. They should be asked if they have fallen in the past year, and if they have difficulties with walking and balance. If they report a fall, they should be asked about the circumstances of the fall and should be evaluated for problems with gait and balance. Older persons who report multiple falls, who have trouble with gait and balance, or who have sustained an injury due to a fall should have a multifactorial fall risk assessment, which should be performed by trained clinicians (Americangeriatrics.org, 2015).
The multifactorial fall risk assessment begins with a focused history, which includes history of falls, description of circumstances, frequency, any symptoms at the time of the fall and injuries in addition to review of the medical history for acute and chronic medical conditions such as osteoporosis, urinary incontinence and cardiovascular disease, which are relevant risk factors. All medications should be reviewed. The physical examination should include assessment of gait and balance, mobility, neurological function, muscle strength, cardiovascular status, visual acuity and feet and footwear. The functional assessment should include assessment of activities of daily living (ADL) skills and use of mobility aids such as canes and walkers. Finally, an environmental assessment to include home safety should be conducted (Americangeriatrics.org, 2015). The home safety assessment should be done by an Occupational Therapist (OT) and might be covered by Medicare if the person has been injured in a fall previously. The OT can inspect the home and suggest modifications to the home environment to prevent falls. In addition, an OT can evaluate a person’s ability to perform ADLs and suggest safer modifications (Stevens, Mahoney & Ehrenreich, 2014).
CDC’s STEADI (Stopping Elderly Accidents, Deaths & Injuries) is made up of tools and educational materials for health care providers. STEADI’s purpose is to help healthcare providers identify patients at risk for a fall, identify modifiable risk factors, and offer effective interventions. STEADI directs medical providers to ask patients if they have fallen in the past year or if they feel unsteady or worried about falling. Next, the provider is to review medications and stop, switch or reduce dosages of drugs that increase fall risk. Finally, the medical provider is to recommend Vitamin D supplements of at least 800 IU/day with calcium (CDC) CDC’s STEADI website offers screening and clinical support tools, instructional videos, online training, case studies and tips for talking with patients and free educational materials for patients and their friends and families. In the future, STEADI will offer online continuing education classes on how to incorporate STEADI into clinical practice and clinical decision support modules for electronic health records systems (Epic, and GE Centricity) which will prompt providers during patient visits to screen for fall risk and initiate appropriate interventions (Cdc.gov, 2015).
Minimizing Injuries from Falls
Stevens, Mahoney & Ehrenreich (2014) examined the circumstances and outcomes of falls experienced by high risk community-dwelling adults in Dane County (Wisconsin) and found that a fall in the bathroom was two and a half times more likely to result in an injury than a fall in the living room. Most injuries in the bathroom occurred when people were getting in or out of a tub or shower or when sitting down, standing up, or using the toilet. Stevens et al., recommend improving safety in the bathroom and suggest getting assistance from another person for bathing, and installing raised toilet seats on toilets, and installing non-skid tub or shower mats, and grab bars around tubs and toilets. In addition, they recommend storing toiletries on easy-to reach shelves, and wearing shoes with non-slip soles.
Once an elderly person has fallen, prompt emergency medical services could be activated by medic alert devices that are worn on the body by elderly people who live alone.
Fall related injuries in the population aged 65 and older of the United States are a serious public health issue, causing significant morbidity and mortality and economic cost. Life expectancy in the United States continues to increase, and rates of unintentional falls in the elderly will continue to increase also, unless people at risk are identified and screened promptly and systematic fall prevention becomes a routine part of the comprehensive care of the older adult. More research is needed to identify risk factors and efficacy of prevention methods to inform focused public health prevention strategies.
Americangeriatrics.org. (2015). Clinical Practice Guideline: Prevention Of Falls In Older Persons Summary Of Recommendations > Guidelines & Recommendations > Clinical Practice > Health Care Professionals > The American Geriatrics Society. Retrieved 27 April 2015, from http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations
Cdc.gov (2015). CDC - Older Adult Falls - Costs of FallsÂ Among Older Adults - Home and Recreational Safety - Injury Center. Retrieved 27 April 2015, from http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html
Cdc.gov, (2015). CDC - STEADI - Older Adult Falls - Home and Recreational Safety - Injury Center. Retrieved 27 April 2015, from http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html
Rubenstein, L. (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age And Ageing, 35(Supplement 2), ii37-ii41. doi:10.1093/ageing/afl084
Stevens, J., Corso, P., Finkelstein, E., & Miller, T. (2006). The costs of fatal and non-fatal falls among older adults. Injury Prevention, 12(5), 290-295. doi:10.1136/ip.2005.011015
Stevens, J., Mahoney, J., & Ehrenreich, H. (2014). Circumstances and outcomes of falls among high risk community-dwelling older adults. Injury Epidemiology, 1(1), 5. doi:10.1186/2197-1714-1-5