Falls

I have talked a great deal about falls and the importance of not falling for seniors. I have always tried to be careful and to follow my own advice. The cold has been extreme in my area, as it has in many others, and we have hummingbird feeders to help the birds survive the winter. These feeders are freezing so we have been following a routine like many others of leaving out one feeder and when it is frozen, replacing it with the one that is not. This allows the food to be available to the hummingbirds throughout the day. 

The birds show up about 8:00 in the morning on a regular basis, so I have been getting up at about 7:00 AM to put out a feeder. To replace or put out the feeder I have to climb a stepladder about 3 steps, but yesterday I noticed the steps were icy. I should have cleaned them, but it was cold, so I left the ice and snow on the steps. Big mistake. At 7:00 AM I was up and took the feeder out to put it up. I climbed up two steps on the stepladder and went to take the third step. Ice is unforgiving and I went down. Lucky for me the 8 cm  (3 inches) of snow broke my fall. I landed on my elbow and side but I kept my head up. The feeder flew across the lawn opening but not breaking. The snow jolted me awake and I swallowed my pride and went and put the other feeder out.

Falls can be dangerous to seniors even minor ones, and I am in a bit of pain but a lesson learned. Even the shortest lack of attention can do you harm. Be safe out there and be careful. I am ok but my pride is wounded but the birds were able to feed this morning.

Seniors’ falls in Canada Second report published by Health Canada

According to this report:

Injury in Canada is a serious public health concern. It is a leading cause of hospitalization for children, young adults and seniors, and it is a major cause of disability and death.

Falls remain the leading cause of injury-related hospitalizations among Canadian seniors, and between 20% and 30% of seniors fall each year.

Falls and associated outcomes not only harm the injured individuals but also affect family, friends, care providers and the health care system.

However, we do know that these personal and economic costs can be avoided through injury prevention activities

Among Canadian seniors, falls remain the leading cause of injury-related hospitalizations, and absolute numbers are on the rise. Falls can lead to negative mental health outcomes such as fear of falling, loss of autonomy and greater isolation, confusion, immobilization and depression. In addition to the negative physical and mental health consequences of falling, there are significant associated financial costs, estimated at $2 billion annually, a value 3.7 times greater than that for younger adults.

Biological or intrinsic risk factors include those pertaining to the human body and are related to the natural aging process, as well as the effects of chronic or acute health conditions. In 2008/2009, 20% of Canadian seniors in the household population reported at least one fall; falling was even more prevalent among older ages (i.e., 80 years and over). The following conditions often associated  with aging are contributors to falling:

a.  acute illness: Symptoms of acute illness such as weakness, pain, fever, nausea and dizziness can increase the risk of falling.102 For example, one study found that infections, in particular urinary tract infections, were a precipitating factor in 8% of falls.82 Furthermore, the effects of medications taken to treat the condition or symptoms can also increase the risk of falling.169

b.  balance and gait deficits: Balance impairments result when there are changes to the normal functioning of the systems underlying postural control, which can involve biomechanical, sensory and cognitive changes.76 Changes to these systems result in context-specific instabilities that may lead to falls.76 Research consistently shows that balance deficits are significantly linked to  risk of falling among older adults.  Similarly, a number of studies have found that variability in one’s  gait (e.g., timing, placement) is a risk factor for falling.

c.  chronic conditions and disabilities: A wide range of chronic conditions can increase an individual’s risk of falls, including neurological disorders such as Parkinson’s disease, diabetes, arthritis, cardiovascular disease, end-stage renal disease, chronic obstructive pulmonary disorder or the effects of a stroke.

a.  These chronic conditions result in physical limitations that affect one’s mobility, gait and balance. For example, in samples of community-dwelling individuals with Parkinson’s disease, estimates show that over 60% of participants fell at least once each year, and the risk of a fracture has been shown to be approximately twice that of comparable older persons who fall. Furthermore, complications related to diabetes, such as neuropathy, retinopathy and nephropathy, likely contribute to an increased risk of falls.

d.  Other chronic conditions include bowel or bladder incontinence and urgency, which can lead to rushing and frequent trips to the bathroom.

a.  A recent meta-analysis conducted by Bloch et al. found a strong link between taking laxatives and falls, such that patients taking laxatives were twice as likely to fall as those not taking them.

b.  Similarly, foot disorders such as corns, bunions, toe deformities, ulcers and general pain can contribute to balance and gait difficulties.

e.   cognitive impairments: For those older people with dementia or other cognitive impairments, the risk of falling and sustaining a fall injury is two to three times that of older people without cognitive impairments. Cognitive impairments affect one’s ability to anticipate and adapt to environmental stimuli to maintain or restore balance. In addition, researchers are beginning to explore the link between dementia, gait instability and delirium, has also been shown to increase the risk of falls. Delirium may result from acute infection, medication, dehydration, sensory impairment, emotional distress etc. Research has found that normal age-related cognitive changes can also affect balance, for example, through delays in switching attention from an ongoing cognitive task to the task of responding to an unexpected loss of balance.

f.   low vision: Changes to vision, such as decreases in visual field sensitivity, acuity, contrast sensitivity and stereopsis, are associated with aging and increase the risk of falls. For example, a systematic review of risk factors found that older adults with low vision were 2.5 times more likely to fall than older adults without visual deficits. Indirectly, changes in vision are linked to a decrease in physical activity, which is another risk factor for falling. Low vision can impede one’s ability to walk safely because one cannot detect hazards

g.  muscle weakness and reduced physical fitness: Decreases in muscle strength and endurance can leave one unable to prevent a slip, trip or stumble from becoming a fall. The panel of the American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons found muscle weakness to be the most important risk factor, increasing the risk of a fall by four to five times. Furthermore, weakness in the lower extremities was found to be a risk factor for fall- related hip fractures.

Falls can and should be prevented

 Did you know that falls remain the leading cause of injury-related hospitalizations among Canadian seniors? I was surprised to read that between 20% and 30% of seniors fall each year. Falls and associated outcomes not only harm the person that falls, but when a person falls, it also affects family, friends, care providers and the health care system. However, we do know that these personal and economic costs can be avoided through injury prevention activities.

Among Canadian seniors, falls remain the leading cause of injury-related hospitalizations, and absolute numbers are on the rise. Falls can lead to negative mental health outcomes such as fear of falling, loss of autonomy and greater isolation, confusion, immobilization and depression. In addition to the negative physical and mental health consequences of falling, there are significant associated financial costs, estimated at $2 billion annually, a value 3.7 times greater than that for younger adults.156

Results from the data analysis in the Seniors’ Falls in Canada SECOND Report indicates that:

·        self-reported injuries due to falls are increasing, specifically by 43% between 2003 and 2009/2010. The majority of falls resulted in broken or fractured bones, and over one-third of fall-related hospitalizations among seniors were associated with a hip fracture.

·        Fracture-induced physical limitations augment the need for support on the part of older adults themselves and their caregivers and increases pressure on Canadian health care systems.

·        When hospitalization data are examined, the results show that seniors who are hospitalized for a fall remain in hospital an average of nine days longer than those hospitalized for any cause. This discrepancy highlights the disproportionate health care costs of fall-related injuries in comparison to other causes of hospitalization. Even more worrying is that the number of deaths due to falls increased by 65% from 2003 to 2008.

Each older person may face a unique combination of risk factors according to his or her life circumstances, health status, health behaviours, economic situation, social supports and environment. Factors that put seniors at risk of falls include chronic and acute health conditions, balance or gait deficits, sensory factors, inadequate nutrition, social isolation, as well as factors related to the built and social environment.

Falls among seniors are preventable; however, addressing this growing public health problem is a shared responsibility. Progress in the prevention of falls and their resulting injuries requires continued collaboration, among governments, health care providers, non-government organizations, care associations and services, as well as Canadians themselves. Over the years, Canada has laid a foundation for good health and well-being across the life course. However, as our population ages, focused efforts on fall prevention will be required to maintain and improve the quality of life and well-being of seniors and to ensure that they continue to contribute and participate in society

Factors associated with an increased risk of falling among older adults

I make fun from time to time of the commercial on TV that talks about the dangers of getting seniors up and downstairs. The solution they say, “is just don’t fall.” That is easier said than done according to Seniors’ Falls in Canada, SECOND Report published in 2014 by Health Canada. In this report, they examine in a lot of detail why seniors fall, and the costs associated with when senior’s fall, on our society Here is some of what they have to say

Most falls occur as a result of compounding factors that combine and overwhelm an older person’s ability to maintain or regain his or her balance. These factors typically represent a complex interaction of biological, behavioural, environmental and socio-economic conditions termed “risk factors”. Research has identified numerous conditions that differentiate between older persons who fall and those who do not fall. Each older person may face a unique combination of risk factors based on life circumstances, health status, health behaviours, economic situation, social supports and the environment. Understanding what puts a person at risk of falling is a critical step in reducing falls and fall-related injuries among older Canadians.

The broad set of conditions that have been demonstrated to increase the risk of falling among older persons can be categorized as biological/ intrinsic, behavioural, environmental and social/ economic. These risk factors do not exist in isolation but are instead complex and interactive.

The order in which the following risk categories are presented is not based on their relative importance but, instead, in accordance with their presentation in Scott, Dukeshire, et al., and then specific factors are addressed alphabetically.

Appendix B

 Biological/ Intrinsic

• Impaired mobility

• Balance deficit

• Gait deficit

• Muscle weakness

• Advanced age

• Chronic illness/disability:

• Cognitive impairment

• Stroke

• Parkinson’s disease

• Diabetes

• Arthritis

• Heart disease

• Incontinence

• Foot disorders

• Visual impairment

Behavioural

•      History of falls

•      Fear of falling

•      Multiple medications

•      Use of:

•      Antipsychotics

•      Sedative/hypnotics

•      Antidepressants

•      Excessive alcohol

•      Risk-taking behaviours

•      Lack of exercise

•      Inappropriate footwear/clothing

•      Inappropriate assistive devices use

•      Poor nutrition or hydration

•      Lack of sleep

Social & Economic

•      Low income

•      Lower level of education

•      Illiteracy/language barriers

•      Poor living conditions

•      Living alone

•      Lack of support networks and social interaction

•      Lack of transportation

•      Cultural/ethnicity

Environmental

•      Poor building design and/or maintenance

•      Inadequate building codes

•      Stairs

•      Home hazards

•      Lack of:

§  Handrails

§  Curb ramps

§  Rest areas

§  Grab bars

§  Good lighting or sharp contrasts

•      Slippery or uneven surfaces

•      Obstacles and tripping hazards

New research exercise and falls

Falls are a problem for seniors and those who love them. On December 28, 2018 a review was published of the research that looked at the impact of exercise on falls among seniors. The research was a Meta-analysis called Association of Long-term Exercise Training With Risk of Falls, Fractures, Hospitalizations, and Mortality in Older Adults and it was written by Philipe de Souto Barreto, PhD.

Dr. Barreto, asked the question “What is the association of long-term (≥1 year) exercise with the risk of falls, fractures, hospitalizations and death in older adults?” 

In this meta-analysis of 40 long-term randomized clinical trials of 21 868 participants, exercise significantly decreased the risk of being a faller and injurious faller but did not significantly reduce the risk of fractures. Long-term exercise, particularly moderate intensity, multi-component training with balance exercises, performed 2 to 3 times per week, appears to be a safe and effective intervention for reducing the risk of being a faller/injurious faller in seniors. Exercise did not, however, diminish the risk of multiple falls, hospitalization, and mortality

This meta-analysis showed that long-term exercise had modest but significant association with reduced risk of becoming a faller and an injurious faller, but not a faller with multiple falls, in older adults. Moreover, exercise was associated with a nonsignificant reduction in the risk of sustaining a fracture. Exercise benefits occurred without increasing the risk of mortality and hospitalization.

Furthermore, this study further extends current knowledge by examining for the first time the association of exercise with the risk of being a faller with multiple falls. However, multiple falls were not reported in some of the largest, well-conducted original studies.

The study consistently found that exercise decreased the risk of injurious falls by about 26%. Regarding fractures, the study contributes to this still not well-established field by showing that exercise seems to protect against fractures; although the primary finding was not statistically significant. The positive results suggest that long-term exercise might lead to a reduction in the risk of fractures. 

The study found that vigorous-intensity is as safe as moderate-intensity exercise. Exercise frequency of between twice and thrice a week was associated with decreased mortality, whereas more than 3 times per week was associated with increased risk of being a faller; therefore, the best exercise frequency seems to be 2 to 3 times per week.

The association between exercise frequency and risk of becoming faller might be dependent on the fall-related vulnerability of the population, with higher risks in more vulnerable participants; indeed, among studies with exercise frequency of 4 or more times per week. It is possible that the dose-response idea implying that “more exercise is always better” might not fully apply for the most vulnerable older adults. The potential mechanisms involved require further investigation, but it could be related to overtraining: excessive exercise leads to diminished immunity and energy metabolism according with animal models and is associated with reduced calorie intake, worse sleep, and negative psychological patterns in young and middle-aged adults. 

The findings on the best exercise frequency, suggests that the best exercise regimen for protecting older people against diverse adverse events would be moderate-intensity, multi-component training comprising balance exercises, performed 2 to 3 times per week; a session duration of 30 to 60 minutes (average of 50 minutes, according to studies on injurious falls analysis) should be safe and effective. Exercise is associated with a modest decrease in the risk of becoming a faller, an injurious faller, and potentially sustaining a fracture in older adults.