Fall prevention

February 25, 2020   |   Evidence in Integrative Healthcare
“Ashes, ashes we all fall down.”

Thought by some to refer to the Black Plague in the 14th Century, Snopes.com notes, “ ‘Ring Around the Rosie’ is simply a nursery rhyme of indefinite origin and no specific meaning, and someone, long after the fact, concocted an inventive “explanation” for its creation.” The Black Plague aside, falling down is a significant public health problem that integrative healthcare providers should be aware of and can help to prevent. The greatest concern, and most of the evidence, is focused on older adults, hospital in-patients, and nursing home residents, but injury from a fall can affect anyone.

Falling is usually the most serious for older persons. Fall injuries that lead to death occurs at an alarming rate of about 62 per 100,000 falls in those 75-84 years but rising to over 250 per 100,000 in those over 85. More than 90% of hip fractures in the elderly are often associated with falling. Fracture of the hip in this group predicts death within 6 months in about 25% of cases. Fall injury is also more common in patients under the age of 5. Across all populations, falls account for nearly 25% of “external” injuries. Major injuries including head trauma, fracture, and dislocation occur in about 5-15% of falls. Falls are the 3rd leading cause of injury for ages 18-35.

While most falls do not result in serious injury, even among the high-risk elderly, one fall predicts the future risk of another one. The medical history in all age groups should include inquiry about a history of falls, a risk assessment for falls and relevant risks should be addressed in treatment planning.

Risks of falling increase with age, but patients of any age in many circumstances can be at risk. Healthy and active younger patients often fall during athletic participation, running, hiking, skiing, etc. Walking while multi-tasking (talking, texting, cell phone) has been shown to be associated with falls. And all persons are at risk of a fall on slippery surfaces, tripping over an obstacle, or moving about in the dark.

Many medications can increase the risk of a fall. A thorough medication history may reveal risk of falling. Psychoactive medicines like benzodiazepines, sleeping pills, antidepressants, seizure medications, narcotic pain relievers, and even some OTC sleep aids and antihistamines can increase the risk of a fall due to drowsiness.

Temporary physical impairments such as a sprained ankle or knee can lead to loss of balance and cause a fall. Foot problems, poor footwear or numbness as associated with diabetes can lead to a fall. Dizziness, light-headedness and syncope (fainting) can result in a fall with a potential for injury. Bowel and bladder problems that cause urgency and rushing to a bathroom can be a problem. Excess alcohol consumption can slow reaction time and cause unsteadiness prompting a fall. Educating patients about these risks can prevent a fall.

Winter weather with its ice and snow can increase the risk of falling and in all age groups. When snow falls, so can people. Common sense measures such as wearing appropriate clothing, foot gear and taking extra caution are all commonly recommended. Traction devices such as ice walkers and Yak Traks reduce the risk of a slip and fall, but be careful wearing them inside. Use a walking pole. Keeping walkways and paths clear can make getting about easier. Spread sand, gravel or kitty litter on icy paths. Carry a baggie of it with you. Be extra careful getting into and out of vehicles.

Fall prevention certainly begins with awareness of modifiable risk factors like medication usage or temporary physical impairments. Among older adults, the evidence points to strength and balance training. A 2017 systematic review in BMJ (free full text) considered 18 clinical trials with over 3800 older adults and concluded that “Tai Chi is effective for preventing falls in older adults.”

The CDC STEDI initiative is an evidence based approach to screening, assessment, and intervention to prevent falls in older adults. Many elements of the initiative can be of use with any age group. A check list for risk assessment is at https://www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf.  Tools for functional fall risk assessment include the 30-Second chair stand, the 4-stage balance test, the timed up and go test, and measuring orthostatic blood pressure. Again, these assessments and tools are primarily directed to older adults, however they can be relevant to patients of any age.