WHO Global Report on Falls Prevention in Older Age

Ageing and Life Course, Family and Community Health

PAGE 1 Ageing and Life Course, Family and Community Health

WHO Global Report on Falls Prevention in Older Age WHO Library Cataloguing-in-Publication Data

WHO global report on falls prevention in older age.

1.Accidental falls - prevention and control. 2.Risk factors. 3. Population dynamics. 4.Aged. I.World Health Organization.

ISBN 978 92 4 156353 6 (NLM classification: WA 288)

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PAGE ii Who global report on falls prevention in older age

Contents

Chapter I Magnitude of falls – A worldwide overview 1 1. Falls 1 2. Magnitude of falls worldwide 1 3. Population ageing 3 4. Main risk factors for falls 4 5. Main protective factors 6 6. Costs of falls 6 7. References 7

Chapter II Active ageing: A Framework for the Global Strategy for the prevention of falls in older age 10 1. What is 'Active Ageing'? 10 2. References 12

Chapter III Determinants of Active Ageing as they relate to falls in older age 13 1. Cross-cutting determinants: Culture and gender 13 2. Determinants related to health and social services 14 3. Behavioural determinants 15 4. Determinants related to personal factors 16 5. Determinants related to the physical environment 18 6. Determinants related to the social environment 18 7. Economic determinants 19 8. References 19

Chapter IV Challenges for prevention of falls in older age 20 1. Changing behaviour to prevent falls 20 2. References 25

Chapter V Examples of effective policies and interventions 26 1 Policy 26 2. Prevention 29 3. Practice – Interventions 32 4. Concluding remarks 33 5. References 33

Chapter VI WHO falls prevention model within the Active Ageing framework 35 1. The need 35 2. The foundation 37 3. Three pillars of the WHO Falls Prevention Model 39 4. The way forward 47

PAGE i Acknowledgements

This global report is the product of the conclusions reached and recommendations made at the WHO Technical Meeting on Falls Prevention in Older Age which took place in Victoria, Canada in February 2007. The report includes international and regional perspectives on falls prevention issues and strategies and is based on a series of background papers that were prepared by worldwide recognized experts. The papers are available at: http://www.who.int/ageing/projects/falls_pre- vention_older_age/en/index.html

The report was developed by the Department of Ageing and Life Course (ALC) under the direction of Dr Alexandre Kalache and the coordination of Dr Dongbo Fu who was closely assisted by Ms Sachiyo Yoshida. ALC would like to thank three institutions for their financial and technical support: the Division of Aging and Seniors, Public Health Agency of Canada; the Department of Healthy Children, Women and Seniors, British Columbia Ministry of Health and the British Columbia Injury Prevention and Research Unit.

The contribution and input of the following experts are gratefully acknowledged: Dr W. Al-Faisal (Syria), Ms Lynn Beattie (U.S.A), Dr Hua Fu (China), Dr K. James (Jamaica), Dr S. Kalula (South Africa), Dr B. Krishnaswamy (India), Dr Nabil Kronfol (Lebanon), Dr P. Marin (Chile), Dr Ian Pike (Canada), Dr Debra J. Rose (U.S.A.), Dr Vicky Scott (Canada), Dr Judy Stevens (U.S.A), Prof. Chris Todd (the United Kingdom), Dr G. Usha ( India ) and Dr Wojtek J. Chodzko-Zajko (U.S.A.).

Editing, layout and printing of the report was managed by Mrs Carla Salas-Rojas (ALC).

PAGE ii Who global report on falls prevention in older age

Chapter I. Magnitude of falls – A worldwide overview

1. Falls (5-7). The frequency of falls increases with age and frailty level. Older people who are Falls are prominent among the exter- living in nursing homes fall more often nal causes of unintentional injury. They than those who are living in community. are coded as E880-E888 in International Approximately 30-50% of people living in Classification of Disease-9 (ICD-9), and as long-term care institutions fall each year, W00-W19 in ICD-10, which include a wide and 40% of them experienced recurrent range of falls including those on the same falls (8). level, upper level, and other unspecified falls. Falls are commonly defined as “in- The incidence of falls appears to vary advertently coming to rest on the ground, among countries as well. For instance, a floor or other lower level, excluding inten- study in the South-East Asia Region found tional change in position to rest in furni- that in China, 6-31% (9-13) while another, ture, wall or other objects”. found that in Japan, 20% (14) of older adults fell each year. A study in the Region of the a) Problems in defining falls. Americas (Latin/Caribbean region) found The adoption of a definition is an the proportion of older adults who fell each important requirement when studying year ranging from 21.6% in Barbados to 34% falls as many studies fail to specify an in Chile (15). operational definition, leaving room for b) Fall injury rates. interpretation to study participants. This results in many different interpretations The rate of hospital admission due to falls of falls. For example, older people tend to for people at the age of 60 and older in describe a fall as a loss of balance, whereas Australia, Canada and the United Kingdom health care professionals generally refer to of Great Britain and Northern Ireland (UK) events leading to injuries and ill health (1). range from 1.6 to 3.0 per 10 000 population. Therefore, the operational definition of a fall Fall injury rates resulting in emergency with explicit inclusion and exclusion criteria, department visits of the same age group is highly important. in Western Australia and in the United Kingdom are higher: 5.5-8.9 per 10 000 population total. 2. Magnitude of falls worldwide a) Frequency of falls.

Approximately 28-35% of people aged of 65 and over fall each year (2-4) increasing to 32-42% for those over 70 years of age

PAGE 1 c) Need of medical attention. d) Fall mortality rates.

Falls and consequent injuries are major Falls account for 40% of all injury deaths public health problems that often require (27). Rates vary depending on the country medical attention. Falls lead to 20-30% of and the studied population. Fall fatality mild to severe injuries, and are underlying rate for people aged 65 and older in United cause of 10-15% of all emergency depart- States of America (USA) is 36.8 per 100 ment visits (18). More than 50% of injury- 000 population (46.2 for men and 31.1 for related hospitalizations among people women) (28) whereas in Canada mortality over 65 years and older (19). The major rate for the same age group is 9.4 per 10 000 underlying causes for fall-related hospital population (29). Mortality rate for people admission are hip fracture, traumatic brain age 50 and older in Finland is 55.4 for men injuries and upper limb injuries. and 43.1 for women per 100 000 population (30). The duration of hospital stay due to falls varies; however it is much longer than other Figure 1 (page 3) shows fatal falls by 5-year injuries. It ranges from four to 15 days in age group and sex (31). Fatal falls rates Switzerland (20), Sweden (21), USA (22), increase exponentially with age for both Western Australia (23), Province of British sexes, highest at the age of 85 years and Columbia and Quebec in Canada (24). In over. Rates of fatal falls among men exceed the case of hip fractures, hospital stays that of women for all age groups in spite extend to 20 days (25). With the increas- of the fewer occurrences of falls among ing age and frailty level, older person are them. This is attributed to the fact that men likely to remain in hospital after sustaining suffer from more co-morbid conditions a fall-related injury for the rest of their life. than women of the same age (28). A similar Subsequently to falls, 20% die within a year difference in mortality between men and of the hip fracture (26). women has been reported following hip fracture. The incidence of hip fracture is In addition, falls may also result in a post- greater among women while hip fracture fall syndrome that includes dependence, mortality is higher among men (32). One loss of autonomy, confusion, immobiliza- study found that men reported poorer tion and depression, which will lead to a health and a greater number of underlying further restriction in daily activities. conditions than women, which substantially increased the impact of hip fracture and consequently increased the risk of mortality (33). Or is it not that men who fall have more co-morbidity than other men in general.

PAGE 2 Who global report on falls prevention in older age

Figure 1. Fatal falls rate by age and sex group

Fatal falls rates Men 200 Women

153.2 150

106.4 100 63.9 50 34 41.4 16 19 5.4 10.6 9.5 0 65-69 70-74 75-79 80-84 85+ Age group

In the U.S.A. 2001 Source : National Council on Ageing, 2005 (31)

3. Population30 ageing with a decreasing proportion of younger population. The triangular population pyra- "Population ageing is a triumph of human- mid of 2005 will be replaced with a more 24 ity but also a challenge to society" (34). cylinder-like structure in 2025. Worldwide, the number of persons over a) Impact of population ageing on falls. 60 years is growing18 faster than any other age group. The number of this age group Falls prevention is a challenge to popula- was estimated to be 688 million in 2006, tion ageing. The numbers of falls increase in projected to grow12 to almost two billions magnitude as the numbers of older adults by 2050. By that time, the population of increase in many nations throughout the older people will6 be much larger than that world. Falls exponentially increase with of children under the age of 14 years for age-related biological change, therefore a the first time in human history. Moreover, 0 pronounced number of persons over the age the oldest segment0-9 of population,65-69 aged 80 of 80 years will trigger substantial increase and over, particularly prone to falls and its of falls and fall injury at an alarming rate. In consequences is the fastest growing within fact, incidence of some fall injuries, such as older population expected to represent 20% fractures and spinal cord injury, have mark- of the older population by 2050 (35). edly increased by 131% during the last three Figure 2 illustrates the population pyramid decades (36). If preventive measures are not in 2005 and 2025. It highlights the growing taken in immediate future, the numbers of proportion of older population in parallel injuries caused by falls is projected to be 100% higher in the year 2030 (36).

PAGE 3 This applies to many developing countries dimensions: biological, behavioural, envi- where currently close to 70% of the elderly ronmental and socioeconomic factors. population lives, and where population Figure 3 encapsulates the risk factors and ageing is occurring rapidly. “Unlike the the interaction of them on falls and fall- developed world that became richer before related injuries. As the exposure to risk getting older, developing countries are factors increases, the greater becomes the getting older before becoming richer” (37). risk of falling and being injured. This is reflected in the fact that health in older age is neglected in some developing a) Biological risk factors countries. Falls prevention is one of the issues that have not been given a sufficient Biological factors embrace characteristics attention. For instance, there is a lack of of individuals that are pertaining to the epidemiological data in many regions of the human body. For instance, age, gender and developing world. race are non-modifiable biological factors. These are also associated with changes due to ageing such as the decline of physical, 4. Main risk factors for falls cognitive and affective capacities, and the Falls occur as a result of a complex interac- co-morbidity associated with chronic ill- tion of risk factors. The main risk factors nesses. reflect the multitude of health determinants that directly or indirectly affect well-being. Those are categorized into four

Figure 2. Global population pyramid in 2005 and 2025

Age group Males Females 80+ 70-74 2025 2005 60-64 50-54 40-44

30-34

20-24 10-14

0-4 400000 300000 200000 100000 0 100000 200000 300000 400000 Population in thousands Source : UN, 2004 (35)

PAGE 4 Who global report on falls prevention in older age

Figure 3. Risk factor model for falls in older age

Behavioural risk factors -Multiple medication use -Excess alcohol intake -Lack of excercise -Inappropriate footware

Biological risk factors Environmental risk factors Falls and -Poor building design -Age, gender and race -Slippery floors and stairs fall-related -Chronic illnesses (e. g. Parkinson, -Looser rugs Arthritis, Osteoporosis) -Insufficient lighting injuries -Physical, cognitive and affective -Cracked or uneven sidewalks capacities decline

Socioeconomic risk factors -Low income and education levels -Inadequate housing -Lack of social interactions -Limited access to health and social services -Lack of community resources

The interaction of biological factors with c) Environmental risk factors behavioural and environmental risks increases the risk of falling. For example, Environmental factors encapsulate the the loss of muscle strength leads to a loss interplay of individuals' physical conditions of function and to a higher level of frailty, and the surrounding environment, includ- which intensifies the risk of falling due to ing home hazards and hazardous features some environmental hazards (see Chapter 3 in public environment. These factors are for further information). not by themselves cause of falls – rather, the interaction between other factors and their exposure to environmental ones. b) Behavioural risk factors Home hazards include narrow steps, slip- Behavioural risk factors include those pery surfaces of stairs, looser rugs and concerning human actions, emotions or insufficient lighting (29). Poor building daily choices. They are potentially modifi- design, slippery floor, cracked or uneven able. For example, risky behaviour such as sidewalks, and poor lightening in public the intake of multiple medications, excess places are such hazards to injurious falls alcohol use, and sedentary behaviour can (see Chapter 3 for further information). be modified through strategic interventions for behavioural change (see Chapter 3 and 4 for further information).

PAGE 5 d) Socioeconomic risk factors 6. Costs of falls

Socioeconomic risk factors are those The economic impact of falls is critical to related to influence social conditions and family, community, and society. Health- economic status of individuals as well as care impacts and costs of falls in older age the capacity of the community to challenge are significantly increasing all over the them. These factors include: low income, world. Fall-incurred costs are categorized low education, inadequate housing, lack of into two aspects: social interaction, limited access to health and social care especially in remote ar- Direct costs encompass health care costs eas, and lack of community resources (see such as medications and adequate services Chapter 3 for further information) e.g. health-care-provider consultations in treatment and rehabilitation.

Indirect costs are societal productivity 5. Main protective factors losses of activities in which individuals or family care givers would have involved if Protective factors for falls in older age are he/she had not sustain fall-related injuries related to behavioural change and environ- e.g. lost income. mental modification. Behavioural change to healthy lifestyle is a key ingredient to This section briefly shows an overview of encourage healthy ageing and avoid falls. health service impacts and costs of falls in Non-smoking, moderate alcohol consump- some developed countries. This is due to tion, maintaining weight within normal the lack of data in developing countries. range in mid to older age, playing an ac- a) Direct health system costs ceptable level of sport protect older people from falling (38). Furthermore, self-health The average health system cost per one fall behaviour (e.g. proper level of simple … injury episode for people 65 year and older in walking) is integral to healthy ageing and Finland and Australia was US$ 3611 (origi- independence. nally AUS$ 6500 in 2001-2002) and US$ 1049 One example of the environmental modi- (originally in €944 in 1999) respectively (23, fications is home modification. It prevents 40). older persons from hidden fall hazards in daily activities at home. The modification includes installation of stairway protective devices such as railings, grab bars and slip-resistant surfacing in the bathroom and provision of lighting and handrails (39). Age-friendly design in public environment is also critical factor to avoid falls among older adults. (see Chapter 5 for further information).

PAGE 6 Who global report on falls prevention in older age

Among different cost items, hospital 7. References inpatient services cost is the greatest cost, accounting for about 50% of total cost of 1. Zecevic AA et al. (2006). Defining a fall and falls (19, 22, 23). The cost of hospital inpa- reasons for falling: Comparisons among the tient services includes the emergency and views of seniors, health care providers, and the research literature. The Gerontologist, 46:367- general holding ward cost, of those admit- 376. ted to either the general holding ward or to 2. Blake A et al.(1988). Falls by elderly people at hospital. The second highest is the long- home: prevalence and associated factors. Age term care costs, contributing to 9.4% to 41% Ageing, 17:365-372. of all health system costs (23, 25). 3. Prudham D, Evans J (1981). Factors associated with falls in the elderly: a community study. The average cost of hospitalization for fall re- Age Ageing, 10:141-146. lated injury for people 65 year and older range 4. Campbell AJ et al. (1981). Falls in old age: a study of frequency and related clinical factors. from US$ 6646 in Ireland to US$ 17 483 in the Age Ageing, 10:264-270. USA (22, 41). This cost are projected to in- 5. Tinetti ME, Speechley M, Ginter SF (1988). crease to US$ 240 billion by year 2040 (42). Risk factors for falls among elderly persons Where the cost of a visit to an emergency living in the community. New England Journal of Medicine, 319:1701-1707. department varies widely across countries, 6. Downton JH, Andrews K (1991). Prevalence, ranging from US$ 236 in the USA (based characteristics and factors associated with on data collected in 1998) (22) to US$ 2472 falls among the elderly living at home. Aging (Milano), 3(3):219-28. in Western Australia (based on data col- 7. Stalenhoef PA et al. (2002). A risk model for lected in 2001-2002) (23). the prediction of recurrent falls in community- dwelling elderly: A prospective cohort study. b) Indirect costs Journal of Clinical Epidemiology, 55(11):1088- 1094. In addition to the substantial direct costs 8. Tinetti ME (1987). Factors associated with outlined above, falls incur indirect costs that serious injury during falls by ambulatory are critical to family e.g. the loss of produc- nursing home residents. Journal of the American Geriatrics Society, 35:644-648. tivity of family caregivers. The average lost 9. Wannian Liang, Ying Liu, e.a. Xueqing Weng earnings could approximate US$ 40 000 per (2004). An epidemiological study on injury of annum in the United Kingdom (25). Even the community-dwelling elderly in Beijing. Chinese Journal of Disease Control and when family caregivers are more morally Prevention, 8(6):489-492. and culturally accepted, falls remain a sig- 10. Suzhen L, Jiping L, Y C (2004). Body function nificant burden to household economy. and fall-related factors of the elderly in community. Journal of Nursing Science, 19(6):5-7.

PAGE 7 11. Weiping M, Lihua Y (2002). Analysis of risk 23. Hendrie D et al. (2003). Injury in Western factors for elderly falls. Chinese Journal of Australia: The health system costs of falls Behavioural Medical Science, 11(6):697-699. in older adults in Western Australia. Perth, 12. Gang L, Sufang J, YS (2006). The incidence Western Australia, Western Australian status on injury of the community-dwelling Government. elderly in Beijing (in Chinese). Chinese Journal 24. Herman M, Gallagher E, Scott VJ (2006). of Preventive Medicine, 40(1):37. The evolution of seniors' falls prevention in 13. Litao L, Shengyong W, Shong Y (2002). A British Columbia. Victoria, British Colombia, British Columbia Ministry of Health http:// study on risk factors for falling down in elderly www.health.gov.bc.ca/library/publications/ people of rural areas in Laizhou city. Chinese year/2006/falls_report.pdf, accessed 27 August Journal of Geriatrics, 21(5):370-372. 2007). 14. Yoshida H, Kim H (2006). Frequency of falls 25. The University of York (2000). The economic and their prevention (in Japanese). Clinical cost of hip fracture in the U.K., Health Calcium, 16(9):1444-1450. Promotion, England. 15. Reyes-Ortiz CA, Al Snih S, Markides KS 26. Zuckerman JD (1996). Hip fracture. New (2005). Falls among elderly persons in Latin England Journal of Medicine, 334(23):1519- America and the Caribbean and among elderly 1525. Mexican-Americans. Revista Panamericana de Salud Pública, 17(5-6):362-369. 27. Rubenstein LZ (2006). Falls in older people: epidemiology, risk factors and strategies for 16. Stevens JA, Sogolow ED (2005). Gender prevention. Age Ageing, 35-S2:ii37-ii41. differences for non-fatal unintentional fall related injuries among older adults. Injury 28. Stevens JA et al. (2007). Fatalities and Injuries Prevention, 11(2):115-119. From Falls Among Older Adults, United States, 1993-2003 and 2001-2005. Journal of 17. Gregg EW et al. (2000). Diabetes and physical the American Medical Association, 297(1):32- disability among older U.S. adults. Diabetes 33. Care, 23(9):1272-1277. 29. Division of Aging and Seniors, PHAC. Canada 18. Scuffham P, Chaplin S, Legood R (2003). (2005). Report on senior's fall in Canada. Incidence and costs of unintentional falls in Ontario, Division of Aging and Seniors. Public older people in the United Kingdom. Journal of Health Agency of Canada. Epidemiology and Community Health, 57:740- 744. 30. Kannus P et al (2005). Fall-induced deaths among elderly people. American Public Health 19. Scott VJ (2005). Technical report: Association, 95(3):422-424. hospitalizations due to falls among Canadians age 65 and over. In Report on Seniors' falls in 31. National Council on Ageing (2005). Falls Canada. Canada, Minister of Public Works and among older adults: risk factors and prevention Government Services. strategies. In Fall free: promoting a national falls prevention action plan. J.A. Stevens Eds.. 20. Seematter-Bagnoud L et al. (2006). Healthcare utilization of elderly persons hospitalized after 32. Fransen M et al. (2002). Excess mortality or a noninjurious fall in a Swiss academic medical institutionalization after hip fracture: men center. Journal of the American Geriatrics are at greater risk than women. Journal of the Society, 4(6):891-897. American Geriatrics Society, 50(4):685-690. 21. Bergeron E et al. (2006). A simple fall in the 33. Hernandez JL et al. (2006). Trend in hip elderly: not so simple. Journal of Trauma, fracture epidemiology over a 14-year period 60(2):268-273. in a Spanish population. Osteoporosis International, 17: 464-470. 22. Roudsari B et al. (2005). The acute medical care costs of fall-related injuries among the 34. World Health Organization (2002). Active U.S. older adults. Injury, 36(11):1316-1322. Ageing: A Policy Framework. Geneva.

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35. United Nations (UN) (2004). World Population 40. Nurmi I., Luthje P (2002). Incidence and Prospects: The 2004 Revision. New York, USA. costs of falls and fall injuries among elderly 36. Kannus P et al. (2007). Alarming rise in the in institutional care. Scandinavian Journal of number and incidence of fall-induced cervical Primary Health Care, 20(2):118-122. spine injuries among older adults. Journal of 41. Carey D, Laffoy M (2005). Hospitalisations due Gerontology: Biological Sciences and Medical to falls in older persons. Irish Medical Journal, Sciences, 62(2):180-183. 98(6):179-181. 37. Kalache A, Keller I (2000). The greying world: a 42. Cummings SR, Rubin SM, Black D (1990). challenge for the 21st century. Science Progress, The future of hip fractures in the United 83(1):33-54. States. Numbers, costs, and potential effects 38. Peel NM, McClure RJ, Hendrikz JK (2006). of postmenopausal estrogen. Clinical Health-protective behaviours and risk of Orthopaedics and Related Research, fall-related hip fractures: a population-based (252):163-166. case-control study. doi: 10.1093/ageing/afl056. Age Ageing, 35(5):491-497. 39. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49(5):664-672.

PAGE 9 Chapter II. Active Ageing: a framework for the global strategy for the prevention of falls in older age

The WHO's Active Ageing policy offers a gender and culture, which are cross-cut- coherent framework on which to develop a ting, and six additional groups of comple- strategy for the prevention of falls in older mentary and interrelated determinants: age worldwide. 1. access to health and social services, a) What is 'Active Ageing'? 2. behavioural, Active Ageing is the process of optimizing opportunities for health, participation and 3. physical environment, security in order to enhance quality of life 4. personal, as people age. 5. social, and Active Ageing depends on a variety of influences or determinants that surround 6. economic. individuals, families and communities as expressed in Figure 1 below. They include

Figure 4. The determinants of Active Ageing

Gender

Health and Economic social services determinants

Behavioural Active determinants Social Ageing determinants

Personal determinants Physical environment

Culture

Source: Active Ageing: A Policy Framework, WHO, 2002 (http://www.who.int/ageing/publications/active/en/index.html)

PAGE 10 Who global report on falls prevention in older age

Figure 2. Maintaining functional capacity over the life course

Early life Adult life Older age Growth and Maintaining highest Maintaining independence development possible level of function andpreventing disability

Range of function in individuals

Disability threshold* Functional capacity Functional

Rehabilitation and ensuring the quality of life

Age

Source: Active Ageing: A Policy Framework, WHO, 2002

In addition, there are the underlying 'bio- of decline is largely determined by factors logical' factors which can play a significant related to lifestyle behaviours, as well as ex- role as preventing individuals from falls ternal social, environmental and economic and consequent injuries or, conversely, can factors. From an individual and societal act as risk factors. All of these determi- perspective, it is important to remember nants, and the interplay between them, play that the speed of decline can be influenced an important role in affecting how high or and may be reversible at any age through low is the risk of falling and/or if a fall oc- individual and public policy measures, such curs, the risk of sustaining serious injuries. as promoting an age-friendly living environment. An example of particular impor- These determinants have to be understood tance within the context of falls, relates to from a life course perspective which rec- bone mass. Good nutrition and optimum ognizes that older persons are not a homo- levels of physical activity throughout child- geneous group and that individual diver- hood and adolescence are critical for the sity increases with age. This is expressed development of healthy bones. As individu- in Figure 2 (next page), which illustrates als age they experience a gradual decline in that functional capacity (such as muscu- bone mass. Once again, healthy life styles lar strength and cardiovascular output) can slow down the process. For post meno- increases in childhood to peak in early pausal women in particular, such life styles adulthood and eventually decline. The rate

PAGE 11 are crucially important to counterbalance • Drop off and pick up bays close to build- the hormonal factors that can precipitate ings and transport stops are provided for the onset of osteoporosis. For some sec- handicapped and older people. ondary prevention through drug-therapy becomes an indispensable form of intervention for avoiding bone fractures as a conse- 2. References quence of even relatively minor traumas. 1. World Health Organization. Active Ageing – Active ageing is a lifelong process. Thus, A Policy Framework. Geneva: World Health Organization, 2002. age-friendly environments with barrier- free buildings and streets, adequate public transportation and accessible sources of information and communication enhance the mobility and independence of younger as well as older persons who present the risk of developing disabilities. Secure neighbourhoods allow children, younger women and older persons to venture out- side in confidence to participate in physi- cally active leisure and in social activities – contributing to preventing falls at all ages, particularly at old age. The operative word in a society committed to active ageing is enablement – for instance through initiatives such as:

• Affordable parking is available.

• Priority parking bays are provided for older people close to buildings and transport stops.

• Priority parking bays are provided for people with disabilities close to buildings and transport stops, the use of which are monitored.

PAGE 12 Who global report on falls prevention in older age

Chapter III. Determinants of Active Ageing as they relate to falls in older age

Approaching falls in older age within the Cultural preferences are also reflected in framework of the determinants of Active the design of public and private spaces Ageing help us to develop effective inter- – such as shining floors and steps or ventions and policies. The following section staircases without appropriate railings. summarizes what is known about how the Culture also contributes to the stigma of determinants of Active Ageing affect falls requesting help where that is needed or in older age. even unavoidable – for instance, where 1. Cross-cutting determinants: negotiating architectonic barriers that culture and gender should not be there in the first place but, if they are, asking for help should a) Culture come naturally rather than a reason for Cultural values and traditions determine embarrassment. to a large extent how a given society views b) Gender older people and falls in older age. While falls are more common among older Culturally driven expectations affect how women than men fall-related mortality people view older persons and falls in older is higher among older men. Policies and age. In some cultures, social participation programmes on falls prevention need to in older age is not seen as a virtue: the reflect a gender perspective. perception is that old people are meant “to rest”. In practice, this results in some older As is outlined in Chapter 1, women are people adopting sedentary life often in more likely than men to fall and sustain isolation due to the resignation from social, fracture (1), resulting in twice more hos- economic and cultural participation, with pitalizations and emergency department a resulting increase in the risk of falling. visits than men (2). However, fall-related Furthermore, in many societies, falls in mortality disproportionately affects men. older age are perceived as "an inevitable The difference in falls in older age may stem natural part of ageing" or "unavoidable from the gender-related factors, such as accidents". All these contribute to falls women being inclined to make greater use prevention not to be considered as a matter of multiple medications and living alone of priority on governmental agendas - (3). In addition, biological difference also leading to a loss of financial provisions contributes to greater risk, for instance, required to develop surveillance systems, appropriate interventions and clinical diagnostic techniques, as well as treatment regimens for falls and fall-related injuries.

PAGE 13 women's muscle mass declines faster than 2. Determinants related to health that of men, especially in the immediate and social services few years after menopause. To some extent Health and social services providers are by and this is gender-related as women are less large unprepared to prevent and manage falls likely to engage into the practice of muscu- in older age. lar building physical activity though the life course e.g. sports. Falls in older age has been a neglected public health problem in many societies, Health seeking behaviour differs according particularly in the developing world. Many to gender. Culturally-oriented expectations health and social services providers are to gender roles affect behaviour when seek- unprepared to prevent and manage falls in ing medical care. Male higher fatality rates older age as they lack sufficient knowledge may be due in part to the tendency of men to treat the conditions that predispose their not seeking medical care until a condition consequences and complications. becomes severe, resulting in substantial delay to the access to prevention and man- Falls in older age are often iatrogenic agement of diseases. Further, men are more conditions – that is, induced by incorrect likely to be engaged in intense and danger- diagnoses and treatments. Examples in- ous physical activity and risky behaviours clude over-prescription of medications that – such as climbing high ladders, cleaning cause side effects and interactions among roofs or ignoring the limits of their physical the drugs, inadequate dosage and lack of capacity. warning to make older people aware about their effects. Various policy options and falls prevention strategies for men and women based on Appropriate training programmes cover- gender differences in locations, circum- ing knowledge and skills in falls prevention stances and events preceding falls and fall- and management should be a priority in related injuries are needed. primary heath care (PHC) settings, where increasing number of patients are older people. PHC practitioners should be well versed in the diagnosis and management of falls and fall-related injuries. In addition, social services that ensure the accessibility of older people to falls prevention programmes are critical.

PAGE 14 Who global report on falls prevention in older age

3. Behavioural determinants b) Healthy eating a) Physical activity Eating a balanced diet rich in calcium may decrease the risk injuries resulting from falls in Regular participation in moderate physical older people. activity is integral to good health and maintaining independence, contributing to lowering risk Eating a healthy balanced diet is central to of falls and fall-related injuries. healthy ageing. Adequate intake of protein, calcium, essential vitamins and water are Regular participation in moderate physi- essential for optimum health. If deficien- cal activity is integral to good health and cies do exist, it is reasonable to expect that maintaining independence. It prevents weakness, poor fall recovery and increase onset of multiple pathologies and func- risk of injuries will ensure. Growing evi- tional capacity decline. Moderate physi- dence supports dietary calcium and vita- cal activities and exercise also lowers risk min D intake improves bone mass among of falls and fall-related injuries in older persons with low bone density and that it age through controlling weight as well as reduces the risk of osteoporosis and falling contributing to healthy bones, muscles, and (6). No dairy and fish consumption were as- joints (4). Exercise can improve balance, sociated with a higher risk of falling. Older mobility and reaction time. It can increases persons with low dietary intake of calcium bone mineral density of postmenopausal and vitamin D may be at risk for falls and women and individuals aged 70 years and therefore fractures resulting from them (7). over (5). Use of excessive alcohol has been shown to Moreover, it should be noticed that partici- be a risk factor of falls. Consumption of 14 pation in vigorous physical activities – for or more drinks per week is associated with instance intensive running in older age an increased risk of falls in older adults (7). may increase the risk of falls. Promoting appropriate physical activities or exercises to improve strength, balance, and flexibility is one of the most feasible and cost-effective strategies to prevent falls among older adults in the community. Activities such as outdoor walking or mall walking indoors is the most feasible and accessible way of exercising that improves strength, balance and flexibility leading to a reduction on the risk of falling. Other kind of effective physical activities and exercises are mentioned in Chapter 5.

PAGE 15 c) Use of medicines Wearing poor fitting shoes is also a risk taking behaviour. Walking in socks without Older people tend to take more drugs than shoes or in slippers without a sole increases younger people. Also as people age, they the risk of slipping indoor. Appropriate develop altered mechanisms for absorbing shoes are particularly important – avoiding and metabolizing drugs. If older persons high heels, thin and hard soles, or slippers don't take medications as directed by health of unsuitable size and that do not stick professionals, their risk of falling can be closely to the feet. affected in several ways. Effects of uncon- trolled medical conditions and of medication because of non-adherence can provoke or generate altering alertness, judgement, 4. Determinants related to personal factors and coordination; dizziness; altering the balance mechanism and the ability to a) Attitudes recognize and adapt to obstacles; and in- People's attitudes influence their behaviours. creased stiffness or weakness (7). Attitudes affect how people interpret and cope When prescribing new drugs to these older with falls in older age. patients health professionals should fully Older people's attitudes greatly influence ascertain other drugs being taken, includ- whether they will avoid fall-related risk- ing self-prescribed medicines. taking behaviours when they participate d) Risk-taking behaviours in activities of daily living. If older people perceive falls as a normal consequence of The ordinary choices people make and the ageing expressed as "seniors will always actions they take may increase their chance of fall" their attitudes may halt preventive falling. measures.

Some risk-taking behaviours increase the Attitudes of policy-makers determine to risk of falling in older age. Those behav- a large extent the amount of resources iours include climbing ladders, standing on allocated to falls prevention and develop- unsteady chairs or bending while perform- ment and enforcement of related policies. ing activities of daily living, rushing with Awareness and attitudes of health profes- little attention to the environment or not sionals to falls are essential to increased in- using mobility devices prescribed to them centive in providing appropriate services for such as a cane or walker (8). preventing and managing falls in older age.

PAGE 16 Who global report on falls prevention in older age

Professionals who design public transporta- c) Coping with falls tions, such as buses and subway systems, The ability of coping with falls of both older often do not make them age-friendly, people and health professionals can lower neglecting the risk of falls for older people. the risk and consequences of falling. For example, in some developing countries, buses are designed with not enough Falls are particularly difficult to manage in seats and rails and the steps to climb into PHC settings because health professionals them are too high. As a consequence, older lack enough knowledge and skills. Building people incur the risk of falling because they coping skills of health professionals to pre- have to stand or do not have the strength vent and manage falls needs to be empha- to climb into the buses in the first place sized. For example, health professionals are and cannot properly hold on for support. recommended to teach patients at risk of Moreover, the steps on the public buses falling how to get up from the floor; unfor- are often too high to older people and they tunately clinical experience suggests that might fall when getting into the bus. this is rarely done (9). b) Fear of falling Physical and mental management of falls Fear of falling is frequently reported by by older people and their family members older persons. Older people are usually un- is also important. Therefore, training older der the fear of falling again, being hurt or people at high risk to avoid falling needs to hospitalized, not being able to get up after be encouraged. a fall, social embarrassment, loss of inde- d) Ethnicity and race pendence, and having to move from their homes. Fear can positively motivate some Although the relationship between falls and seniors to take precautions against falls and ethnicity and race remains widely open for can lead to gait adaptations that increase research, Caucasians living in the USA have stability. For others, fear can lead to a de- higher risk of falling. In addition, for both cline in overall quality of life and increase men and women, the rate of hospitaliza- the risk of falls through a reduction in the tion for fall-related injuries is some two to activities needed to maintain self-esteem, four times higher among the Whites than confidence, strength and balance. In addi- Hispanics and Asians/Pacific Islanders, and tion, fear can lead to maladaptive changes about 20% higher than African-Americans in balance control that may increase the (10). It is also clear differences observed risk of falling. People who are fearful of between Singaporeans of Chinese, Malay falling also tend to lack confidence in their and Indian ethnic origins, and between ability to prevent or manage falls, which native Japanese older community dwellers increases the risk of falling again (7). and Japanese-Americans and Caucasians. Native Japanese people have much lower rates of falls than Japanese-Americans and Caucasians.

PAGE 17 5. Determinants related to the Factors related to the public environment physical environment are also frequent causes of fall in older age. Even walking on a familiar route can lead Factors related to the physical environment are to falls as a consequence of poor building the most common cause of falls in older age. design and inadequate consideration. Most Physical environment plays a significant problematic factors are cracked or uneven role in many falls in older age. Factors sidewalks, unmarked obstacles, slippery related to the physical environment are the surfaces, poor lighting and lengthy distanc- most common cause of falls in older people, es to sitting areas and public restrooms. responsible for between 30 to 50% of them (11). A number of hazards in the home and public environment that interact with other 6. Determinants related to the social risk factors, such as poor vision or balance, environment contribute to falls and fall-related injuries. Social connection and inclusion are vital to For example, stairs can be problematic – health in older age. Social interaction is in- studies show that unsafe features of stairs versely related to the risk of falls. can be frequently identified including uneven or excessively high or narrow steps, Isolation and loneliness are commonly slippery surfaces, unmarked edges, dis- experiences by older people particularly continuous or poorly-fitted handrails, and among those who lose their spouse or live inadequate or excessive lighting. alone. They are much more likely than other groups to experience disability and Since approximately half of falls occurs the physical, cognitive, and sensory limita- indoor, the home environment is critical tions that increase the risk of falls. for avoiding them. A high particular risk to falls was found in homes with irregular Isolation and depression triggered by lack sidewalks to the residence, loose carpets on of social participation increase fear of fall- the kitchen and bathroom floors, loose elec- ing, and vice versa. Fear of falling can in- trical wires, and inconvenient doorsteps. crease the risk of falls through a reduction Poor surroundings around home such as in social participation and loss of personal garden paths and walks that are cracked or contact - which in turn increase isolation slippery from rain, snow or moss are also and depression. Providing social support dangerous. Entrance stairs and poor night and opportunities for older people to par- lighting can also pose risks. ticipate in social activities to help maintain active interaction with others may decrease their risk of falls.

PAGE 18 Who global report on falls prevention in older age

7. Economic determinants 8. References Older people with lower economic status, 1. Stevens JA et al. (2006). The costs of fatal especially those who are female, live alone or in and non-fatal falls among older adults. Injury rural areas face an increased risk of falls. Prevention, 12(5):290-295. 2. Hendrie D et al. (2003). Injury in Western Studies have shown that there is a rela- Australia: The Health System Cost of Falls tionship between socioeconomic status in Older Adults in Western Australia. Perth, Western Australia. Western Australian and falls. Lower income is associated with Government. increased risk of falling (12). Older people, 3. Ebrahim S, Kalache A (1996). Epidemiology in especially those who are female, live alone Old Age. London, Blackwell BMJ Books. or in rural areas with unreliable and insuffi- 4. Gardner MM, Robertson MG, Campbell AJ (2000). Exercise in preventing falls and fall cient incomes face an increased risk of falls. related injuries in older people: A review of Poor environment in which they live, their randomised controlled trials. British Journal of poor diet and the fact of not being able to Sports Medicine, 34:7-17. access health care services even when they 5. Day M et al. (2002). Randomised factorial trial of falls prevention among older people have acute or chronic illness exacerbates living in their own homes. BMJ, doi:10.1136/ the risk of falling. bmj.325.7356.128. 6. Tuck SP, Francis RM (2002). Osteoporosis. The negative cycle of poverty and falls in Postgraduate Medical Journal, 78:526-532. older age is particularly evident in rural 7. Division of Aging and Seniors (2005). Report areas and in developing countries. The fall- on senior's fall in Canada. Ontario. Public Health Agency of Canada. related burden to health system will keep 8. Gallagher EH, Brunt H (1996). Head over increasing unless resources and money are heels: A clinical trial to reduce falls among the allocated in order to provide proper PHC elderly. Canadian Journal on Aging, 15:84-96. and opportunities to older people for social 9. Simpson JM, Salkin S (1993). Are elderly people at risk of falling taught how to get up participation. It is never too late to break again? Age Ageing, 22: 294-296. this vicious cycle. 10. Ellis AA, Trent RB (2001). Hospitalized fall injuries and race in California. Injury Prevention, 7:316-320. 11. Rubenstein LZ (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing, 35-S2:ii37-ii41. 12. Reyes CA et al. (2004). Risk factors for falling in older Mexican Americans. Ethnicity & Disease, 14:417-422.

PAGE 19 Chapter IV. Challenges for prevention of falls in older age

1. Changing behaviour to prevent • it is within their ability to do so; falls • they have the resources to implement The background papers that underlie this change (including physical, psychologi- report refer to a considerable body of cal and social capital resources); evidence indicating the effectiveness of a • number of interventions for falls preven- the changes are perceived as being of tion. These include strength and balance benefit to them; and training, environmental modification and • the benefit outweighs the cost or effort medical care aimed at removing or reduc- in overcoming barriers. ing specific risk factors by for example review of medications and reduction of For example, the older person may care for polypharmacy. The systematic reviews, grandchildren, and thus using time to do evidence syntheses and meta-analyses are exercises to maintain or improve physical well referenced in the briefing papers to be function may appear in the immediate term found at the following WHO URL: a poor use of time or impossible if it con- flicts with childcare responsibilities. Thus, http://www.who.int/ageing/projects/falls_ the programme will need to be tailored to prevention_older_age/en/index.html fit with these responsibilities, or the person Crucial to the success of such interventions must be persuaded that a long-term gain is changing the beliefs, attitudes and behav- (maintaining independence and seeing iour of older people themselves, the health the grandchildren grow up) outweighs the and social care professionals who provide short-term 'pain'. Most importantly, the services, and the wider communities in society in which older people live must which older people live. For example, a value them and be willing to allocate re- fifteen-week balance and exercise class will sources to the maintenance of their health only have an effect if the older person goes and well-being. Expression of valuing older to the sessions, undertakes the exercises as people must include allocation of adequate prescribed, and continues to practice after resources towards helping people to age completion of the course. People will only well and take part in activities that have the change their lifestyles if: potential to prevent falls.

PAGE 20 Who global report on falls prevention in older age

This chapter is based heavily on a se- At present, advice from family members ries of recommendations made by the and health professionals tends to empha- Psychological Aspects of Falling Group size avoiding risk rather than engaging in (1, 2), Work Package 4 of the Prevention of activities to improve strength and bal- Falls Network Europe (ProFaNE) and fuller ance (3-5). Informing the general popula- evidence for the recommendations has tion about the benefits of easy-to-provide been published (1, 2). These recommenda- interventions such as strength and balance tions should be sufficiently general to be training activities should influence older applicable to populations other than the people’s views and counteract fatalistic European population for which they were views that falling is a consequence of ageing originally developed. (6). Exercise may be generally recognized as important for maintaining fitness and a) Raise awareness in the general popula- strength, but its importance in maintaining tion of a number of interventions that could good balance and function needs to be bet- improve balance and prevent falls. ter publicized. It is likely that the approach To make choices people need to have at will prove effective for both high and least basic information about benefits of lower-risk populations (7). Although the taking part in activities aimed at preven- effectiveness of less intensive interventions tion. But information alone is not enough, at a population level is currently unknown it needs to be framed so that it promotes it would seem likely that they will provide realistic positive beliefs about the possibili- benefit. Exercises that improve strength ties for preventive action if any change is and balance should be recommended for all likely to follow. Many older people seem older people (7-9). to assume that falls prevention consists of Emphasis must be on the positive advan- activity restriction or the use of aids and tages of undertaking interventions such as home modifications. Research suggests balance and exercise training, rather than that many older people are ignorant that on reduction of risk of falls since the latter fall risks can be reduced because there is is generally viewed negatively and of little a fatalistic acceptance of falling that may relevance by many older people. Uptake contribute to low uptake of falls prevention may be encouraged by promoting greater interventions. awareness among older people, their Campaigns need to raise general aware- families and health professionals of how ness and should not be aimed only at older undertaking specific physical activities may people. The opinions of others, including contribute to improving balance and reduc- health professionals and family, influence ing falls risk. older people’s decisions.

PAGE 21 b) When offering or publicizing interventions, Uptake of falls prevention interventions promote benefits that fit with a positive self- may be enhanced by emphasizing the identity. positive benefits that are likely to accord with desirable self images for older people, It seems that many older people do not in addition to those that reduce fall risks. acknowledge falls, for example because of Examples of such benefits include increased fear of: independence, greater confidence, ability to • negative stereotyping; take an active part in society and support younger generations. • beliefs that falls are an inevitable and c) Utilize a variety of forms of social encour- unavoidable consequence of ageing; and agement to engage older people • embarrassment about loss of control. Uptake may be encouraged by the use of Falls prevention advice is often perceived as personal invitations to participate (from being for other ‘disabled or elderly people’. a health professional or other authority Programmes that are perceived to impact figures) and positive media images and negatively on self-image are likely to be peer role models to illustrate the social ac- unattractive while those, which are viewed ceptability, safety and multiple benefits of as improving skills or characteristics val- taking part. Uptake and adherence may be ued by older people, are likely to be more encouraged by ongoing support from fam- popular. In interviews older people say that ily, peers, professionals and social organiza- they would participate in falls-prevention tions. A wide range of social influences are initiatives to be proactive in managing their known to impact on health-related behav- own health needs, maintain independence iour, including encouragement, approval and improve confidence (4, 5). Older people and social support from health profession- value strength and balance training activi- als and other sources (10). Role models ties for their potential to: should provide examples of successful ac- complishment of health-related goals (11). • maintain functional capabilities and Concern about social disapproval poses a thus avoid disability and dependence; barrier to undertaking physical activity, • enhance general health, mobility and while social support, positive media images appearance; and and real-life examples of ordinary older people doing exercise can promote greater • be interesting, enjoyable and sociable (4, 5). physical activity (12-14). These characteristics are all compatible with a positive identity and should be encouraged.

PAGE 22 Who global report on falls prevention in older age

Social factors play a key role in people’s de- d) Ensure that the intervention is designed to cisions whether to participate in falls pre- meet the needs, preferences and capabilities vention interventions (15, 16). In European of the individual. countries a personal invitation from a Review of evidence generally suggests that trusted health professional is an important a tailored personal approach – even for motivation for taking up an intervention, group contexts – can greatly improve the and approval and encouragement from chance of older people engaging with and family, friends and health professionals maintaining an intervention programme influence initial and continued participa- (1-2). There is a need to consider the tion (5). Participation in group activities individual’s lifestyle, values, religious and is influenced by anticipated and actual cultural beliefs, which may be associated positive and negative social contacts with with ethnicity and gender-specific factors. members and leaders of the group. A major Environmental determinants such as the barrier is the perception that falls preven- wealth of the society in which the older tion is only for very old and frail people and person lives; their place of residence and not relevant to oneself (3-5). Inversely, old availability and access to services should and frail people may see health promoting also be contemplated. Interventions need activities as strenuous and only suitable for to be presented in ways that are tailored to people who are younger and fitter (6). Since the cultural preferences of older people and seeing prevention activities as appropriate be realistic within the resources available. for someone like oneself is the foremost Group sessions with trained-balance and predictor of intention to undertake these strength-exercise instructors for example, activities (3, 17) it may be valuable to use are relatively low-tech affordable interven- media pictures and peer role models to tions that should be within the means of promote a positive social image of strength many societies. Although more research is and balance training. The latter is as a suit- necessary, there is growing evidence that able activity for those who are still fit and many older people may prefer exercises active, in order to maintain their mobility delivered at home with some professional and independence, while emphasizing that guidance (4, 12). it can still be a safe and effective method of falls prevention for those at higher risk of falling.

PAGE 23 Cost-effective ways of catering for these f) Draw on validated methods for promoting preferences at a public health level should and assessing the processes that maintain be considered when developing a policy. adherence, especially in the longer term. The evidence-based principles of balance These could include encouraging realistic and strength training could be presented as positive beliefs, assisting with planning and part of a set of activities that are recogniz- implementation of new behaviours, build- able and accepted within specific cultures. ing self-confidence, and providing practical For example, while exercises, which pro- support. There is substantial evidence for mote physical strength and balance, may a range of techniques for changing health- be presented within T'ai Chi Ch'uan based related behaviour but it is most effective to practice appropriately in China, a more combine a variety of such approaches (10). suitable presentation of exercises, which Potentially important ingredients include: promote physical strength and balance in India, may be based on yogic practices. • creating a supportive partnership rela- Dance may provide a vehicle for adequate tionship with the therapy provider (see exercises in a number of cultures. How recommendations 3 and 5); exercises are best presented will need to • be developed locally and should be tested providing with good practical support before large-scale roll out of a programme (access and appropriate supervision); in a country. • promoting the belief that the interven- e) Encourage self-management rather than tion is necessary and effective; dependence on professionals by giving older • building confidence in being able to people an active role. carry out the intervention; There is strong theoretical rationale in the • developing skills for generating and psychology literature generally to suggest maintaining new behaviours (e.g. goal- that participation and adherence will be setting, planning, self-monitoring, and maximized if the older person can choose self-reward); and or modify the intervention (1-2). While some form of supervision will be necessary • tailoring interventions to individual to ensure safety and appropriate compo- needs (see recommendation 4). nents, the older person should be enabled, wherever possible, to select among:

• different interventions;

• different formats of the same intervention; or

• a range of intervention goals.

PAGE 24 Who global report on falls prevention in older age

2. References 10. World Health Organization (2003). Adherence to long-term therapies: evidence for action. Geneva. 1. Yardley L et al. Recommendations for 11. Bandura A (1997). Self-efficacy: the exercise of promoting the engagement of older people in control. New York, WH Freeman. preventive health care. Manchester, ProFaNE, 12. King AC et al. (2000). Personal and Workpackage 4 (http://www.profane.eu.org/ environmental factors associated with physical directory/display_resource.php?resource_ inactivity among different racial-ethnic groups id=1121, accessed 27 August 2007). of US middle-aged and older-aged women. 2. Yardley L et al. (2007). Recommendations for Health Psychology, 19:354-364. promoting the engagement of older people in 13. King AC, Rejeski WJ, Buchner DM (1998). activities to prevent falls. Quality and Safety in Physical activity interventions targeting older Health Care, 16(3):230-234. adults: A critical review and recommendations. 3. Yardley L, Todd C. (2005). Encouraging American Journal of Preventive Medicine, positive attitudes to falls in later life. London, 15:316-333. Help the Aged. 14. Ory M et al. (2003). Challenging aging 4. Yardley L et al. (2006). Older people's views stereotypes: strategies for creating a more of advice about falls prevention: a qualitative active society. American Journal of Preventive study. Health Education Research, 21:508-517. Medicine, 25:164-171. 5. Yardley L et al. (2006). Older people's views of 15. Commonwealth Department of Health and falls-prevention interventions in six European Aged Care (2001). National Falls Prevention countries. The Gerontologist, 46:650-660. for Older People Initiative "Step out with 6. Simpson JM, Darwin C, Marsh N (2003). What confidence". Canberra, Commonwealth of are older people prepared to do to avoid falling? Australia. A qualitative study in London. British Journal 16. McInnes E, Askie L (2004). Evidence review of Community Nursing, 8:152-159. on older people's views and experiences of falls 7. Chang JT et al. (2004). Interventions for the prevention strategies. Worldviews on Evidence- prevention of falls in older adults: systematic Based Nursing, 1:20-37. review and meta-analysis of randomised 17. Yardley L et al. (2007). Attitudes and beliefs clinical trials. British Medical Journal, that predict older people’s intention to 328:680-683. undertake strength and balance training. 8. Kannus P et al. (2005). Prevention of falls and Journals of Gerontology Series B, Psychological consequent injuries in elderly people. Lancet, Sciences and Social Sciences, 62B:119-125. 366:1885-1893. 9. Skelton D, Todd C (2004). What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe, Health Evidence Network report, (http://www.euro.who.int/ document/E82552.pdf, accessed 27 August 2007).

PAGE 25 Chapter V. Examples of effective policies and interventions

As discussed in previous sections, the 1. Policy effect of a fall on an older person can be a devastating event, resulting in chronic To effectively address the growing problem pain, loss of independence and a reduced of falls in an ageing society, healthy public quality of life. Moreover, the cumulative policies are needed to provide vision, effect of falls and resulting injuries among set priorities and establish institutional older persons in most countries has the po- standards. Such policies should facilitate tential to reach epidemic proportions that capacity building unique to each setting by would consume a disproportionate amount supporting the generation of new research, of health care resources. Healthy public encouraging broad collaboration and policies and proven prevention strategies maximizing availability of resources. are needed to provide the infrastructure Falls and resulting injuries among older and support essential for the integration persons are public health problems in of fall prevention evidence into practice. all regions of the world that are facing The complex and multifactorial nature of the impact of an ageing population. The fall risk among a rapidly ageing and grow- good news is that evidence exists to ing population demands a proactive and show that most falls are both predicable systematic approach to prevention that and preventable. There are also good integrates policy, preventive measures and examples to show that this evidence practice. can be applied to sustainable changes • Policy should provide the infrastructure in practice when supported by healthy and support essential to a comprehen- public policies. Examples of such policies sive and integrated approach to falls are more commonly seen in developed prevention. countries where healthy public policies have established capacity for effective • Prevention evidence is needed to sup- falls prevention through good leadership, port the effective application of proven intersectoral collaboration and education. interventions. Moreover, these are the countries that have first experienced population ageing and • Practice is where evidence is applied ac- have had the necessary financial resources cordingly to the standards and proto- to implement such policies. cols set by policy.

PAGE 26 Who global report on falls prevention in older age

a) Leadership community-service providers, researchers, community planners, policy-makers and Government agencies responsible for health many other potential partners for creat- and social services for older persons are ing integrated falls prevention activities. well placed to provide leadership by es- Strategies for developing and maintain- tablishing a policy-making infrastructure, ing collaboration include the formation of collaborating to set priorities and targets, focused fall-prevention coalitions. and overseeing and supporting national and regional efforts to reduce falls and related Many recommendations from the Falls Free injuries. Coalition National Action Plan are now

Leadership

An example of such leadership is seen in Canada, where a turning point in policy development for falls prevention occurred in 1999 when a policy-maker in the Province of British Columbia (B.C.) Ministry of Health, set in place a collaborative process for priority setting to reduce falls and fall-related injury rates for the province. The process involved an analysis of regional data on the scope and nature of the problem combined with meetings of regional stakeholders to identify priority areas for change. The final product was a comprehensive report of fall-related morbidity and mortality, a review of the literature on fall-risk factors and proven prevention strategies, and 31 priority recommendations for policy and prevention (1, 2). The process of meaningful involvement by the stakeholders in the formation of these recommendations was pivotal to the success of this leadership model. Since release of this report, there has been substantial growth in the number of falls prevention programmes and a significant reduction in fall-related deaths and hospitalizations among older persons in B.C. (3).

b) Collaboration

A good leader will recognize that the most included in a recently passed USA Senate important collaborators in developing ef- Committee Falls Prevention Bill, with US$ 8 fective falls prevention policies are those million of authorized spending for fall-risk most directly impacted by the issue – older screening and multifactorial prevention persons at risk of falling, those who care strategies (5). Another example using an for them, and those who provide services to electronic network for reaching a broad older adults. This comprehensive approach audience is found in Europe. serves to include health-care providers,

PAGE 27 Falls Free Coalition An example of an effective coalition is the Falls Free Coalition coordinated in the USA; a collective of representatives of national organizations and state coalitions working to reduce the growing number of falls and fall-related injuries among older adults (17). With support from the Archstone Foundation and Home Safety Council non-profit organizations, members of the Falls Free Coalition first convened in 2004 to write the Falls Free National Action Plan (4). The plan outlines key strategies and action plans for fall prevention to address the following five priority areas: • physical mobility; • medications management; • home safety; • environmental safety in the community; and • cross-cutting issues, such as advocacy, policy, links to health care systems and integration of interdisciplinary activities. More information about the National Action Plan, and the Coalition and its bimonthly newsletter may be found at www.healthyagingprograms.org.

c) Education

Along with good leadership and collabora- • are responsible for the design and con- tion, education is an essential strategy for struction of housing and public spaces building the necessary capacity for effective used by older persons. fall prevention policy and practice. Such To be effective, education must be part of education is needed by those who: a larger strategy for falls prevention that • are at risk of falling; reflects current evidence, adult learning principles and integration of learning to • provide health and social services to practice. An example of an education pro- those at risk; and gramme that reflects these principles is the Canadian Falls Prevention Curriculum.

ProFaNE

The Prevention of Falls Network Europe (ProFaNE) is a European community-funded thematic network to promote effective practice in falls prevention among older persons (6). With over 1100 website members from over 30 countries, an active discussion board, and nearly 900 resources, ProFaNE disseminates good practice by making all its resources publicly available at www.PROFANE.eu.org.

PAGE 28 Who global report on falls prevention in older age

The Canadian Falls Prevention Curriculum© (7), funded by the Population Health Fund of the Public Health Agency of Canada is designed to provide community leaders and those who provide health and social services to older persons with the necessary skills to design, implement and evaluate evidence-based falls prevention programmes. To ensure relevance to the target audience the process for the development, testing and dissemination of the curriculum actively involves partners representing older persons, policy-makers, educators, researchers and health and social service providers. See www. injuryresearch.bc.ca for further information.

2. Prevention

There has been a substantial increase in the and disease-related conditions and the indi- past decade in research on the prevention vidual’s interaction with their social and of falls among older persons. Considerable physical environment (9). It is also known evidence now exists that most falls among that risk is greatly increased for those with older persons are associated with identifi- multiple risk factors (11). There is good evi- able and modifiable risk factors and that dence to show that some interventions are targeted prevention efforts are shown to be more effective than others and those when cost-effective (9, 10, 11, 12). Most falls and tailored to individual risk profiles in com- resulting injuries among older persons are munity, residential and acute care settings shown to result from a combination of age are most effective.

Fallproof © Fallproof© is a comprehensive balance and mobility training programme designed for physical activity instructors and health professionals to build the necessary skills to reduce the risk of falling among community-based older adults (8). Based on a sound understanding of the physiology of ageing, adult learning theory and falls-prevention evidence, this programme provides instruction for the practical application of mobility and balance assessment and intervention.

PAGE 29 a) Community Within a multifactorial approach, the components of successful health interven- For older persons living in the community, tions focus on post-fall clinical assessment evidence shows that health and environ- followed by treatment involving a multi- ment risk-factor assessment with interdisciplinary-team approach. The following ventions based on assessment results, is medical conditions are most often reported highly effective in reducing falls among as target areas for fall reduction: community-dwelling older persons who are cognitively intact (13, 14). Components • cardiac dysrhythmias and orthostatic of successful multifactorial approaches hypotension; include: • reducing the number of medications, • balance and gait training with appropri- particularly those that contribute to ate use of assistive devices; postural hypotension or sedation;

• environmental risk assessment and • addressing gait and balance problems modification; with appropriate assistive devices;

• medication review and modification; • rehabilitation for weakness and mobility problems; • managing visual problems; • vitamin D and calcium supplementa- • providing education and training; tion; and • addressing foot and shoe problems; and • treatment of correctable vision, particu- • addressing orthostatic hypotension and larly early cataract surgery (9, 10). other cardiovascular problems (12, 13, Environmental screening and modification 14). programmes are shown to be most effective Exercise is shown to be an important when they involve a multidisciplinary team component of a multifactorial intervention, and are targeted to those with a history particularly when applied consistently for of falling or known-risk factors (14). The ten weeks or longer (12). However, little precise components of successful home is known about the cost effectiveness of modification are not clearly understood. exercise programmes for older persons and Most programmes target the removal more research is necessary to determine hazards such as loose rugs, clutter electrical the optimal type, duration, frequency and cords, unstable furniture and installation intensity of those programmes (15). of bathroom grab bars, raised toilet seats, handrails on both sides of stairways and the use of personal alarm systems to call for help when necessary (9).

PAGE 30 Who global report on falls prevention in older age

Evidence also exists to show that education Components of successful multifactorial and self-management programmes when interventions include: staff training and used on their own without measures to guidance, changes in medication, resident implement change are not effective in the education, environmental assessment and community setting (12). modification, supply and repair of aids, exercise, and use of hip protectors (12, 17, 10). While less effective that multifactorial approaches, there are a number of single- A single intervention shown to be effective factor interventions shown to have a strong in residential settings is the use of vitamin effect in reducing falls among community- D and calcium supplements. Other single dwelling older persons. Single interven- strategies that show promise include: tions that are most strongly recommended • gait training and advice on appropriate include: exercise, home hazard assessment use of assistive devices; and modification, withdrawal of psychotropic medications, and cardiac pacing for • review and modification of medications, fallers with carotid sinus hypersensitivity particularly psychotropics; (13, 14). • nutritional review and supplementation; As a single intervention strategy, the exer- • cise approach shown to be most effective is staff education programmes; individually tailored muscle strength and • exercise programmes; balance retraining prescribed by a trained- health professional. • environmental modification;

Group exercise programmes are shown • post-fall problem-solving sessions; and to be less effective than individually pre- • the use of hip protectors (12, 17). scribed exercises with the exception of a group programme using the Tai Chi There is no evidence to support the ef- intervention – a form of Chinese martial fectiveness of interventions to reduce falls arts (16). among residents with cognitive impair- b) Residential settings1: ments (17).

As with community settings, multifactorial approaches are shown to be the most effect- prevention strategy in residential settings.

1 Residential setting: refers to nursing homes, care homes or long-term facilities

PAGE 31 2 c) Acute care settings : 3. Practice – Interventions

No evidence exists to support the effec- Practice settings are where falls preven- tiveness of multifactorial interventions in tion evidence is translated into feasible, acute care settings (14). The use of physical affordable and sustainable interventions. or pharmaceutical restraints commonly Practitioners are well placed to link the used with the intention of reducing falls application of evidence to organizational is shown not to be effective. Conversely, policies and to identify gaps that need to there is moderate evidence to support an be addressed before successful adoption is increased risk of injury from a fall with possible. An effective tool for enacting the the use of restraints (12). Alternatives to translation of evidence into practice is the restrains (lower bed, mats on floor, train- development of a clinical practice guide- ing on exercise and safe transfers) have line. An example of an effective guideline moderate evidence for their effectiveness is produced by the Registered Nursing (12). Other interventions that have been Association of Ontario (RNAO), Canada. tested but lack strong supporting evidence In less developed countries the translation include: hospital discharge risk assessment of falls prevention evidence to practice is and planning, exercise programmes, envi- made difficult by competing demands for ronmental modifications, use of bed alarms urgent health-care issues and shortages of and the use of identification bracelets health-care providers. In addition, before (18, 19). Some evidence exists to support effective adoption of evidence to prac- facilitated home assessments for those at tice, more studies are necessary to better high risk for falling when discharged from understand the unique contributors to hospital (10). falls among older people in less developed countries, including the influence of diet,

2 Acute care setting: refers to hospitals or rehabilitation hazardous environments, the lack of acces- units sible safety equipment and transportation, and the role of inadequate health services.

The RNAO Prevention of Falls and Fall Injuries in the Older Adult Best Practice Guideline

The RNAO Prevention of Falls and Fall Injuries in the Older Adult Best Practice Guideline was designed for long-term and acute-care nurses to enhance their skills and abilities for risk assessment and prevention. The purpose of this guideline is to increase all nurses’ confidence, knowledge, skills and abilities in the identification of adults within health- care facilities at risk of falling and to define interventions for the prevention of falling (20).

PAGE 32 Who global report on falls prevention in older age

Injury outcomes among older persons 5. References in less developed versus more developed countries also need to be explored, particularly given that hip fractures are being 1. Scott VJ, Peck S, Kendall P (2004). Prevention of falls and injuries among the elderly: a special described as an “orthopedic epidemic” in report from the office of the provincial health less developed countries [Baker et al;1992: officer. Victoria, British Colombia, Provincial cited in (21)]. Health Office, B.C. Ministry of Health. 2. British Columbia Injury Research and Prevention Unit (BCIRPU) (2006). Vancouver, British Columbia, (http://www.injuryresearch. bc.ca/, accessed 27 August 2007). 4. Concluding remarks 3. Herman M, Gallagher E, Scott VJ (2006). The Given recent rapid population ageing evolution of seniors' falls prevention in British worldwide, without concerted action by Columbia. Victoria, British Columbia, B.C. Ministry of Health, (http://www.health.gov. policy-makers, researchers and practitio- bc.ca/library/publications/year/2006/falls_ ners, the economic and societal burden of report.pdf, accessed 27 August 2007). falls will increase by epidemic proportions 4. National Council on Aging (NCOA) Center for healthy aging model health programs in all parts of the world over the next few for communities (2007). Washington, decades. The complex and multifactorial DC, Center for Health Aging (http:// nature of falls in older age demands a pro- healthyagingprograms.org/content. asp?sectionid=69, accessed 27 August 2007). active and systematic approach to preven- 5. Fall Prevention Center of Excellence. Falls Free tion. Healthy public policies and proven (2007). Washington, DC, Center for Healthy prevention strategies that are tailored to Aging (http://www.stopfalls.org/, accessed 27 August 2007). target populations are essential for the successful integration of fall-prevention evidence into practice for effective fall-risk identification and reduction.

PAGE 33 6. Prevention of Falls Network Europe, ProFaNE 15. Gardner MM, Robertson MC, Campbell AJ. (2007). Manchester, GB, ProFaNE (http://www. (2000). Exercise in preventing falls and fall profane.eu.org/, accessed 27 August 2007). related injuries in older people: a review of 7. Scott VJ et al. Canadian Falls Prevention randomised controlled trials. British Journal of Curriculum©, Vancouver, British Columbia. Sports Medicine, 1(34):7-17. B.C. Injury Research and Prevention Unit, 16. Wolf SL et al. (2003). Selected as the best paper (unpublished data). in the 1990s: Reducing frailty and falls in 8. Rose, DJ (2003). Fallproof! A comprehensive older persons: An investigation of tai chi and balance and mobility training program. computerized balance training. Journal of the Windsor, Ontario, Human Kinetics. American Geriatrics Society, 51(12):1794-1803. 9. Rubenstein LZ (2006). Falls in older people: 17. Kannus P et al. (2000). Prevention of hip epidemiology, risk factors and strategies for fracture in elderly people with use of a hip prevention. Age Ageing, 35-S2:ii37-ii41. protector. New England Journal of Medicine, 343(21):1506-1513. 10. Rubenstein LZ et al. (2006). The summary of the newly updated ABS/BGS guideline: 18. Hill K et al. (2000). An analysis of research on Evidence based practice guideline for the preventing falls and falls injury in older people: prevention of falls in older persons. Chicago: community, residential care and hospital American Geriatrics Society Plenary settings (2004 update). Canberra, Australia, Symposium, May 4, 2006. National Ageing Research Institute for the Commonwealth Department of Health and 11. Tinetti ME, Speechley M, Ginter SF (1988). Aged Care. Risk factors for falls among elderly persons living in the community. New England Journal 19. Oliver D, Hopper A, Seed P (2000). Do hospital of Medicine, 319(26):1701-1707. fall prevention programs work? A systematic review. Journal of the American Geriatrics 12. Skelton D, Todd C (2004). What are the main Society, 48(12):1679-1689. risk factors for falls amongst older people and what are the most effective interventions 20. Registered Nurses’ Association of Ontario to prevent these falls? Copenhagen, WHO (2005). Prevention of falls and fall injuries in Regional Office for Europe, Health Evidence the older adult. Toronto, Ontario, Registered Network report (http://www.euro.who.int/ Nurses’ Association of Ontario (www.rnao. document/E82552.pdf, accessed 27 August org/bestpractices/PDF/BPG_Falls_rev05.pdf, 2007). accessed 27 August 2007). 13. Chang JT et al. (2004). Interventions for the 21. Barss P et al. (1998). Injury prevention: An prevention of falls in older adults: systematic international perspective. Epidemiology, review and meta-analysis of randomised surveillance, and policy. New York, Oxford, clinical trials. British Medical Journal, Oxford University Press. 328:680-683. 22. World Health Organization (2002). Active 14. Gillespie LD et al. (2004). Interventions ageing: A policy framework. Geneva. for preventing falls in elderly people. Cochrane Database of Systematic Reviews, (4):CD000340.

PAGE 34 Who global report on falls prevention in older age

Chapter VI. WHO Falls Prevention Model within the Active Ageing Framework

This chapter provides a summary of the ageing proposes strategies, interventions, preceding section of this document and and programmes that recognize the rights, presents the WHO Falls Prevention model needs, preferences and contributions of within the Active Ageing Framework (see older people – and these are reflected in Figure 6 below). This model describes a this model. cohesive, multisectoral approach to falls prevention that is built on the WHO Active Ageing Policy Framework – a proactive 1. The need and flexible public health policy grounded in the principles of health promotion and Although population ageing is one of disease prevention. Thus, the model recog- humanity’s greatest triumphs, it also nizes the importance of a commitment to presents today's societies with one of their active ageing strategies and programmes most significant challenges. Worldwide, that are designed to enhance the health, the proportion of people age 60 and over is participation, and security of older people growing faster than any other age group. By (see Chapter 2). The WHO vision of active 2050, the number of persons over the age of

Figure 6. Falls Prevention for Active Ageing

Falls Prevention for Active Ageing COMMUNITY *OUFSWFOUJPO "TTFTTNFOUCommunity and "XBSFOFTTOlder Persons individual risk Behaviour change determinants $6-563& (&/%&3Family/caregivers Individual level Health and Youth social services Environmental level Community Behavioural Health sector Personal Health and social services level Physical Government environments Media Social Economics EDUCATION CAPACITY BUILDING TRAINING Healthy Public Policy Surveillance Resources Research

PAGE 35 60 years is expect to increase to more than and social costs. This would result in the in- two billion with 85% of them living in de- appropriate use of resources, which are still veloping countries. Global ageing will place needed to address other health and social increased economic and social demands challenges. There is a need to shift the pub- worldwide. However, the ageing population lic health paradigm from one that focuses should not be viewed as a threat or a crisis. on “finding and fixing” acute problems to a On the contrary, the WHO Active Ageing more systematic, coordinated, and compre- Framework recognizes that older persons hensive strategy designed to prevent, treat, are precious and invaluable resources who and manage the growing number of NCDs make an extraordinarily important contri- worldwide. The WHO Falls Prevention bution to the fabric of all societies. Model is an example of such a systematic, coordinated, and comprehensive strategy A major factor behind the global ageing and designed to reduce the burden of one of the increase in life expectancy observed the most significant causes of age-related in most countries has been the impressive injuries and non-communicable conditions development of public health practices and associated with old age. policies that have greatly reduced prema- ture deaths through the partial control of The extensive reviews of the scientific many previously fatal-infectious diseases. literature summarized in earlier sections of The worldwide development and imple- this report underscore the reality that falls mentation of PHC practices and the control among older people are a large and increas- of communicable diseases are important ing cause of injury, treatment costs and components of the WHO mission. This un- death in virtually all regions of the world. finished agenda has now been followed by The WHO Active Ageing Framework a shift in the global burden of disease from recognizes that the injuries sustained as a the management of acute conditions to consequence of a fall in old age are almost addressing the steady increase in noncom- always more severe than when that occurs municable diseases (NCDs). As individuals earlier in life. and societies age, NCDs are increasingly For injuries of the same severity, older becoming the leading causes of morbidity, people experience more disability, longer disability and mortality in all regions of the hospital stays, extended periods of rehabili- world. tation, a higher risk of subsequent depen- Fortunately, many NCDs can be prevented dency as well as a higher risk of dying. The through the application of appropriate good news is that many fall-related injuries health promotion and disease-prevention are preventable. There is now compelling strategies. The WHO Active Ageing evidence that risk-factors for falling can Framework recognizes that the failure to be influenced by the implementation of prevent or manage the growth of NCDs ap- targeted intervention strategies designed to propriately will result in enormous human modify the various intrinsic and extrinsic

PAGE 36 Who global report on falls prevention in older age

determinants known to increase the likeli- their caregivers in all aspects of the plan- hood of falling. The WHO Falls Prevention ning, implementation and evaluation. Model provides a comprehensive multi- An effective falls-prevention strategy will sectoral framework for reducing falls and need to acknowledge the cultural reality fall-related injuries among older persons. of the society in which it is to be imple- The model is designed to identify policies, mented. The culture that surrounds all practices and procedures that will: individuals and communities shapes and • build awareness of the importance of influences all of the determinants of ac- falls prevention and treatment among tive ageing. Cultural values and traditions older persons; determine not only how a given society views older people and the ageing process, • improve the assessment of individual, but also the types of prevention, detection environmental, and societal factors that and treatment services that are most likely increase the likelihood of falls; to be successful in a particular country and • facilitate the design and implementation culture. of culturally-appropriated evidence- In order to address the diversity of cultural based interventions that will signifi- determinants, the WHO Falls Prevention cantly reduce the number of falls among Model requires the cross-national, transre- older persons. gional and global sharing of information and ideas. The Active Ageing Framework reminds us that all effective NCD preven- 2. The foundation tion and treatment strategies will need to The WHO Falls Prevention Model within be firmly grounded within the local, na- the Active Ageing Framework cannot suc- tional, and regional reality. These realities ceed unless it is integrated into a healthy- must consider factors such as epidemiologi- public policy that embraces a multisectoral cal transition, rapid changes in the health approach to the prevention, treatment, and sector, globalization, urbanization, chang- management of NCDs. The WHO vision ing family patterns and environmental of healthy and active ageing requires the degradation, as well as persistent inequali- mobilization and commitment of many ties and poverty, particularly in develop- sectors of society including health and ing countries where the majority of older social services, education, employment and persons are already living. labour, finance, social security, housing, The WHO Active Ageing Framework transportation, and both rural and urban recognizes that effective policies and pro- development. Furthermore, all effective grammes designed to combat NCDs in old active-ageing policies and programmes age need to adopt a life course perspective realize the involvement of older people and that acknowledges that most determinants

PAGE 37 of chronic conditions and disabilities have Finally, falls prevention policies and pro- their roots in childhood as well as in young grammes cannot be targeted at only one and middle-aged adult life. If a substantive level of determinants or risk-factors. decrease in the impact of falls on the health Effective strategies will need to acknowl- and quality of life of older persons is to be edge and balance multiple levels of de- achieved, it will be necessary to develop terminants including recognizing the programmes and policies that create sup- importance of individual-level risk factors portive environments, reduce risk factors and responsibilities; the development of and foster healthy choices at all stages of age-friendly and enabling environments; the life course. and the formulation of policies and programmes that maximize participation and Any effective falls prevention strategy inclusion of older persons. will also need to acknowledge the reality that globally, women are at greater The WHO Falls Prevention Model is built risk for falls and fall-related injuries than around three pillars that are highly inter- men. Accordingly, gender issues need to be related and mutually dependent; considered in the development of all poli- (1) Building awareness of the importance of cies, programmes and practices. The WHO falls prevention and treatment; Active Ageing Framework reminds us that in many societies, girls and women have (2) Improving the assessment of individual, lower social status and less access to food, environmental and societal factors that education, meaningful work and health increase the likelihood of falls; and services. Because the consequences of falls disproportionately impact older women it (3) Facilitating the design and implementa- is especially important that these factors be tion of culturally-appropriated evidence- addressed proactively and explicitly within based interventions that will significantly the Falls Prevention for Active Ageing reduce the number of falls among older context. Moreover, it is also important to persons. observe that mortality rates resulting from Making progress in implementing the strat- injuries caused by falls are higher among egies identified in each of these pillars will older men than women of same age for require an ongoing commitment to capac- reasons that are not yet fully understood. ity building, education, and training in all More research in this regard is urgently countries and regions. needed.

PAGE 38 Who global report on falls prevention in older age

3. Three pillars of the WHO Falls Family and caregivers: Both informal and Prevention Model: formal caregivers have a critical role to a) Pillar One - Building awareness of the play in building awareness about the importance of falls prevention: importance of falls and falls prevention. It is especially important to provide fam- There is a need to build awareness of the ily members, peer counsellors and other importance of falls within all sectors of informal caregivers with information and society that are impacted by falls and training on how to identify risk factors for fall-related injuries. Awareness building falls and how to take action to decrease the is not restricted to educating individuals likelihood of falling among those at great- and groups about the significance of falls est risk. It is also critical to ensure that as modifiable risk factors for disabling formal caregivers are fully familiar with the conditions and increased mortality. It also latest evidence related to the assessment, involves education about the increasing prevention, and treatment of falls. This will economic and social costs associated with comprise the incorporation of modules the failure to address falls and fall-risk on falls and fall prevention in professional factors in a systematic manner. Awareness caregiver curricula at all levels, including will need to be built within the following continuing education. Within the develop- constituencies: ing world, it is important to acknowledge Older persons: Any strategy to build aware- the contribution of healers who are knowl- ness of the importance of falls and fall edgeable about alternative and complemen- prevention must begin with older persons tary medicines. These individuals should themselves. Many of them are unaware be encouraged to integrate their special that falls are preventable. In many cultures skills and knowledge with contemporary falling is considered to be a normal, un- evidence-based practice related to falls and avoidable consequence of growing older. fall prevention. The WHO Active Ageing Framework calls Youth and young adults: Any active-ageing for increasing basic-health education and strategy that strives to be effective in reduc- health literacy through a commitment to ing the prevalence of chronic diseases and lifelong learning about health and disease disabling conditions will need to adopt a prevention. By applying such an approach life course perspective. This is especially to educating older adults about falls and important in the area of falls and falls fall prevention, not only would older adults prevention because many of the individual- become more aware of the importance of level determinants, which predispose a paying close attention to fall-related risk person to be at risk for injurious falls, factors and determinants but they would begin to manifest themselves early in life. also be more likely to take action to correct Furthermore, building awareness of the these challenges to their health and inde- importance of falls and fall-related issues in pendence.

PAGE 39 children and youth will increase the likeli- and fall-related injuries. It is important to hood to implementing intergenerational ap- provide incentives and training for health proaches to falls prevention and treatment. and social service professionals. This will increase their awareness and understand- Community: The majority of older persons ing of contemporary research and practices grow old in their own homes and in the so that they are able to counsel healthy communities they have lived in for most lifestyle practices that reduce falls and fall- of their lives. Accordingly, it is important related injuries among men and women of to educate all sectors of these communi- all ages. ties about the importance of a proactive, evidence-based strategy for reducing falls. Government: Raising awareness of the Building awareness of risk factors for falls importance of falls prevention among at the community level is particularly im- government officials at all levels is critical if portant because there is evidence that the the resources and other support needed to structure of the physical environment can implement a comprehensive, multisectoral impact the likelihood of an older person to fall prevention strategy at any of societal fall. It can also make the difference between levels are to be made available. It is impor- independence and dependence for indi- tant to underscore that a commitment to viduals who live in unsafe environments or prevention and treatment of falls is both areas with multiple physical barriers. These cost-effective and the right thing to do. barriers can render older persons more Legislators and government officials should susceptible to isolation, depression, reduced be invited to participate in all aspects of the physical activity, and increased mobility development and implementation of public problems. health policies and practices that focus on health promotion and disease prevention. Health sector:: The WHO Active Ageing Framework recognizes that building aware- Media: The media have an important role ness and changing the attitudes of health to play in promoting a positive image of and social-service providers is paramount ageing, therefore building awareness among to ensuring that their practices enable and them of the significance of falls and falls empower individuals to remain as autono- prevention is paramount. The media can mous and independent as doable for as help by widely disseminating realistic and long as possible. Within the area of falls positive images of active ageing, as well as and falls prevention, health professionals by sharing educational information on falls have a critical role to play in identifying and falls prevention strategies. The media risk factors and determinants for falls, and can also help to confront negative stereo- for recommending culturally-appropriated types about growing old and help to combat evidence base interventions for the preven- persistent ageism. tion, treatment and management of falls

PAGE 40 Who global report on falls prevention in older age

b) Pillar Two – Improving the identification Furthermore, there must be neither age nor and assessment of risk factors and determi- gender discrimination in the provision of nants of falls: services and service providers should treat There is a growing appreciation that a people of all ages with dignity and respect. complex combination of individual-level, Behavioural: : There is a growing apprecia- community-wide, and societal factors influ- tion that a number of important behavioural ence the probability of falls and fall-related factors impact older persons vulnerability to injuries among older persons. Although the falls and their likelihood to seek treatment evidence base regarding how best to iden- or care for falls and fall-related conditions. tify and assess the various risk factors and Many older adults incorrectly believe that determinants for falls is growing, there are it is too late to change their behaviour and many areas where information is lacking adopt a healthy lifestyle in old age. Others and improvements are needed. A system- experience a significant fear of falling that atic multisectoral strategy for reducing falls greatly limits their activity choices, reduces and fall-related injuries will require con- their independence and decreases their certed efforts to improveassessment and engagement in society. It is not sufficient to identify critical determinants in each of the simply educate older adults about the impor- following domains: tance of falls and falls prevention, it is also Health and social services: Convenient and crucial to assess their readiness to change affordable access to health and social ser- their lifestyles and adopt preventative and/ vices can greatly impact an older persons’ or rehabilitative therapies. Any integrated likelihood of experiencing a fall or fall- strategy to reduce falls at the individual and/ related injury. Health and social services or community level will need to acknowl- should be structured in such a way as to edge and assess the critical behavioural de- routinely screen older persons for known- terminants known to impact an individual’s risk factors for falls. Health professionals risk for falling. Attention to these factors should be trained to use evidence-based can significantly increase the chance that a protocols and procedures that help to iden- person will engage in appropriate preventive tify those individuals who are at the great- behaviours such as physical activity, healthy est risk. Suitable follow-up strategies should eating, not smoking and using alcohol and be in place to assist clinicians to recom- medications wisely. These behaviours can in mend culturally-appropriated and afford- turn help to prevent disease and functional able evidence-based treatment programmes decline, extend longevity and enhance qual- when indicated. The WHO Active Ageing ity of life. Framework notes that health and social services need to be integrated, coordinated and cost-effective.

PAGE 41 Personal: There are many personal or indi- attention to environmental risk factors such vidual-level risk factors and determinants as unsafe sidewalks, poorly lit roadways, that can influence an individual’s likelihood and inaccessible or unsafe neighborhoods of experiencing a fall. In any comprehen- can significantly increase the likelihood sive falls prevention programme, effective of falls among older persons. There are evidence-based strategies will need to be also many risk factors within the homes, developed to screen for and identify indi- in which older people live, that place them vidual-level risk factors known to be associ- at an increased risk for falling. In many ated with an increased risk for falling. The countries home-safety visits have proved to specific nature of such screening protocols be effective for identifying environmental will inevitably vary as a function of the re- risks factors that increase the risk of falling. sources and expertise available to perform The need to address environmental deter- these assessments. At the most basic level, minants of falls may be particularly acute evidence-based questionnaires are available in developing countries where many older to screen older persons for key risks fac- persons are forced to live in arrangements tors. Ideally, more comprehensive clinical that are not of their choice, such as with examinations can be used to assess for relatives in already crowded households. In known risk factors such as physical inactiv- many developing countries, the proportion ity, decreased muscle strength, impaired of older people living in slums and shanty balance, poor vision, confusion, inadequate towns is rising rapidly. Older people living or inappropriate medication and/or polyp- in these settlements are at an increased risk harmacy. Accurate identification of indi- for falls and fall-related injuries. vidual-level risk factors and determinants Social: Older persons who have suffered can greatly increase the likelihood of select- from fall-related injuries and others who ing an appropriate prevention or treatment experience a fear of falling can often strategy that is targeted to meet the needs become isolated and disengaged from the of the individual older person. community. Any comprehensive falls Physical environments: There is a growing prevention programme will need to recog- appreciation that the nature and structure nize and acknowledge the critical role that of the physical environment can signifi- social support plays in providing oppor- cantly influence the likelihood of an indi- tunities for older persons to fully partici- vidual to suffer a fall or fall-related injury. pate in society. The WHO Active Ageing The WHO Active Ageing Framework un- Framework recognizes that opportunities derscores the need to ensure that the older- for education and lifelong learning, peace, people physical environments are “age- and protection from violence and abuse are friendly” because this can make a difference key factors in the social environment that between independence and dependence. enhance health, participation and security There is a growing base of knowledge sug- as people age. Loneliness, social isolation, gesting that a systematic assessment of and illiteracy and a lack of education, abuse

PAGE 42 Who global report on falls prevention in older age

and exposure to conflict situations greatly On the one hand, it provides opportuni- increase older people’s risks for disabilities ties for older persons to earn money and and early death. Inadequate social sup- stay active and engaged in the community, port is associated not only with an increase on the other it can place older persons in mortality, morbidity and psychological at increased risk for accident and injury, distress but a decrease in overall health particularly in cases where the worksite is and well-being. Assessment of and atten- hazardous with inadequate facilities and tion to the adequacy of social support in an lighting. older person’s environment is an important In all countries, families provide the major- element of a comprehensive fall-risk assess- ity of support for older people who require ment protocol and can make a difference help. However, as societies develop and between success and failure of an interven- the tradition of generations living together tion strategy. declines, mechanisms that provide social Economic: The economic environment, in protection for older people who are unable which an older person lives, can play a pro- to earn a living and are alone and vulner- found impact on their health and quality of able are needed. National, regional, and life. The WHO Active Ageing Framework local falls-prevention strategies cannot be reminds us that economic factors such as developed independently of these cultural, income, work and social protection need political, and economic realities?. to be considered when developing effec- c) Pillar Three - Identifying and tive strategies in the area of active ageing. implementing realistic and effective All ageing policies must acknowledge the interventions reality of poverty and the impact that a lot of lack of personal resources has on the Falls are complex events that are caused by opportunities available to an older person. a combination of intrinsic impairments and Active-ageing policies need to intersect disabilities which are often compounded with broader schemes to reduce poverty by a variety of environmental hazards. Due at all ages. While all poor people face an to the multifactorial nature of falls risk increased risk of ill-health and disabilities, factors and determinants, numerous stud- older people are particularly vulnerable. In ies have shown that interventions can be many countries and cultures, older people effective in reducing falls in older people by are, by necessity or choice, continuing simultaneously targeting several intrinsic to work in the labour force well into old and extrinsic risk factors or determinants. age. Others participate in unpaid labour Successful multifaceted-intervention pro- through childcare and work within the grammes have included such components home and in the fields. Continued employ- as: ment of older persons can be a “double- edged sword”.

PAGE 43 • medical assessment; maintaining an intervention designed to promote health and/or reduce the risk of • home safety checks and advice; chronic conditions. There is now good evi- • monitoring of prescription medications; dence that incorporating a comprehensive behavioural change strategy into inter- • environmental changes; ventions designed to increase health and well-being can help to maximize recruit- • tailored exercise and physical activity; ment, increase motivation, and minimize • training in transfer skills and gait; attrition. Among the behavioural strategies that have been shown to increase the • assessment of readiness to change be- likelihood that a person will sustain a new haviour; and behaviour are the following: • referral of clients to health-care profes- • Securing social support from family sionals. and friends. Unfortunately, multifactorial falls preven- • Promoting the participant’s self-efficacy tion interventions can be labour-intensive and perceived competence. and expensive both for the individual and the community. For these reasons, deci- • Providing older persons with active sions regarding whether to implement a choices that are tailored to their per- comprehensive, multifaceted falls-preven- sonal needs and preferences. tion intervention, or targeted interven- • Encouraging older persons to commit tions addressing individual risk factors and to an intervention by developing health determinants will need to be made at the contracts and/or goal statements that local or national level. These shown-effec- include realistic and measurable plans tive decisions need to take into account a of action with specified health goals. variety of economic, cultural, and political factors. In the section below, information • Concerns for safety are identified as a about some of the most promising inter- barrier to changing behaviour by many ventions that have been shown to be effec- older adults. Educating participants tive in reducing the incidence of falls and about actual risks of interventions can fall-related injuries in older populations is help to alleviate many of these con- summarized. cerns. Behaviour change: In recent years grow- • Providing regular and accurate perfor- ing attention has focused on the study of mance feedback can assist older adults behavioural factors that increase the prob- in developing realistic expectations ability of an individual in initiating and about their own progress.

PAGE 44 Who global report on falls prevention in older age

• Positive reinforcement strategies in- evidence of the impact of environmental crease the likelihood of maintenance changes on the incidence of falls and the of an activity. Examples of effective-re- number of fall-related injuries is insuffi- inforcement strategies include recruit- cient to draw definitive conclusions, these ment incentives, rewards for reaching interventions show promise and additional targeted goal, and public recognition for research is necessary to shed more light on attendance and adherence. the relationship between environmental changes and both fall risk and actual falls. Environmental modification:There is now good evidence that home-hazard assess- Health management: There is good evidence ment and modification that is profession- that access to appropriate and affordable ally prescribed for older persons with a medical care can significantly impact history of falling is effective in reducing health and quality of life as well as decrease risk. However, the value of home visits the likelihood of developing noncommu- and home-hazard assessments in low-risk nicable diseases. Because older people populations is less clear. Among the factors are more likely to suffer from a variety of addressed in a typical-home visit include chronic conditions, their access to medi- the assessment and improvement of light- cal care is especially important and can ing, the identification and removal of rugs make the difference between early detec- and other trip hazards, and the installation and timely intervention, and delayed tion of railings on staircases in bathrooms and/or non-existent treatment and care. In and toilets. The value of systematic hazard the area of falls prevention, the accurate assessment and intervention has also been identification of individuals at high risk shown to be effective in decreasing falls for falling is an important element in the in retirement homes and seniors centers selection of the evidence-based interven- where large numbers of individuals with tion with the greatest chance of a positive elevated risk live or regularly visit. outcome. There is evidence that identifying patients who attend accident and emer- There is growing interest in examining the gency departments after falls, and referring impact of community level interventions them for subsequent therapy significantly designed to identify and correct environ- reduces subsequent falls. mental hazards that reduce physical and social activity and increase the risk of older persons falling. Among the environmental hazards assessed in environmental audits and “walkability” assessments are: unsafe sidewalks, poorly lit roadways, and inaccessible or unsafe neighborhoods. Although

PAGE 45 Older persons are more likely than younger For healthy older adults at low risk for people to need and use medications. falls, engaging in a broad range of physical Unfortunately, medications are often either activities on a regular basis is likely to be unavailable or over-prescribed in this sufficient to substantially reduce the risk of population. Averse drug-related reactions, falling. polypharmacy, and confusion induced by In contrast, older adults at higher risk for psychotropic medication are all associated falls will benefit from engaging in struc- with an increased risk of falls and fall- tured exercise programmes that systemati- related injuries. Health care strategies that cally target the risk factors amenable to require regular and systematic review of change and are progressed at a rate that is prescription and over-the counter medi- determined by the individual’s capabilities cations have been shown to decrease the and previous experience with physical ac- number of falls in older adult populations. tivity. Older adults identified at the highest Because visual impairments, especially risk for falls will benefit from an individ- poor contrast sensitivity and poor depth ually-tailored exercise programme that is perception, have been shown to be signifi- embedded within a larger multifactorial cant risk factors for falling and fall-induced intervention approach. In these popula- injuries, regular visual examinations with tions, regular strength and balance exer- appropriate follow-up as necessary can be cises, such as, Tai Chi programmes have beneficial in reducing falls in older adults. been shown to be effective in reducing the Physical activity: The WHO Heidelberg risk of both non-injurious and injurious Guidelines for Physical Activity for Older falls. Additional research is necessary to Persons recommend that virtually all older quantify the optimum type, frequency, persons should participate in physical duration, and intensity of exercise needed activity on a regular basis. There are well to produce the maximum benefit. Because established physiological, psychological, regular physical activity provides substan- and social benefits associated with partici- tial health-related benefits and it is cheap, pation in physical activity. Furthermore, safe, and readily available, it is likely that regular physical activity is associated with a physical activity programmes will play a significant decrease in risk for most non- major role in the prevention, treatment, communicable diseases. With respect to and management of falls in most countries falls prevention, regular physical activity and cultures. has been shown to prevent and/or lower an older person’s risk for falling in community and home settings.

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4. The way forward: fectively implemented in all regions and cultures. The degree to which progress The WHO Falls Prevention for Active will be made depends on to the success in Ageing model provides an action plan for integrating falls prevention strategies into making progress in reducing the prevalence the overall health and social care agendas of falls in the older adult population. By globally. In order to do this effectively, it is building on the three pillars of falls preven- necessary to identify and implement cul- tion, the model proposes specific strategies turally appropriate, evidence-based policies for: and procedures. This requires multisectoral 1. building awareness of the importance of collaborations, strong commitment to pub- falls prevention and treatment; lic and professional education, interaction based on evidence drawn from a variety of 2. improving the assessment of individual, traditional, complementary, and alternative environmental, and societal factors that sources. Although the understanding of increase the likelihood of falls; and the evidence-base is growing, there is much that is not yet understood. Thus, there is 3. for facilitating the design and imple- an urgent need for continued research in mentation of culturally-appropriate, all areas of falls prevention and treatment evidence-based interventions that will in order to better understand the scope of significantly reduce the number of falls the problem worldwide. In particular, more among older persons. evidence of the cost-effectiveness of inter- The model provides strategies and solutions connections is needed to develop strategies that will require the engagement of multi- that are most likely to be effective in spe- ple sectors of society. It is dependent on and cific setting and population sub-groups. consistent with the vision articulated in the While this is an ambitious plan, it is attain- WHO Active Ageing Policy Framework. able. A tangible difference in the health and Although not all of the awareness, assess- quality of life of older people around the ment, and intervention strategies identi- world could be achieved by implementing fied in the model apply equally well in all a comprehensive global strategy to reduce regions of the world, there are significant falls. evidence-based strategies that can be ef-

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