Preventing Falls in Older Adults with

Kye Y. Kim, MD and Mark B. Detweiler, MD, MS

With an absence of clear guidelines for in these patients, providers must apply their clinical knowledge and experience to individualize general preventive strategies.

efined as an event that re- tional limitations, can have demen- and have been shown to have higher sults in a person’s uninten- tia rates that rival those in nursing mortality rates after than tional coming to rest on the homes. One recent study estimated community dwelling elders.13 ground, floor, or other lower that 68% of assisted living residents in Falls also are a leading cause of D1 8 level, falls among older adults repre- central Maryland had dementia. head injury in the elderly population. sent a major health concern and are Dementia is considered an inde- It has been estimated that 73% of all responsible for considerable mortality, pendent risk factor for .9 As head injuries in people older than age morbidity, and reduced functioning. many as 30% of patients with early- 65 are the result of falls.14 Older peo- More than one third of community stage dementia and up to 75% of pa- ple are at increased risk for subdural living, older adults (aged 65 years tients who are institutionalized with bleeds even with less severe injuries, and older) fall each year,1,2 and for dementia experience a fall during a as their bridging veins are more vul- half of this population the falls are one-year period.10 Even with these nerable to tearing due to the brain recurrent.3 For individuals living in troubling statistics, there is limited atrophy. In fact, subdural hematomas long-term care facilities, the incidence information available about the risk are common consequences of falls in of falls and fall-related injuries is ap- factors and prevention strategies the aging population.15,16 proximately three times the rate for unique to older adults with demen- After experiencing a fall, elderly community dwelling, older adults.4 tia. This article discusses the fall- people often develop an anxiety to a Dementia is prevalent both in long- related clinical issues in patients potential future fall. One study indi- term care settings (such as nursing with dementia, paying particular atten- cated that approximately one third homes and assisted living facilities) tion to those who reside in nursing of 487 community dwelling, elderly and among older individuals. The homes and assisted living facilities. adults developed a fear of falling after prevalence increases with advancing sustaining a fall and experienced a age and institutionalization—sky- Consequences OF FallS in greater increase in balance, gait, and rocketing from 3% to 11% in com- older adults cognitive disorders over time—which munity dwelling adults aged 65 and Falls and their related consequences ultimately resulted in a decreased older to 47% in the oldest, institu- are a leading cause of death in older level of mobility.17 tionalized groups in some studies.5,6 adults.11 According to the CDC’s The financial aspect of fall-related Rovner and colleagues found that Web-Based Injury Statistics and injuries is of serious significance. The 67% of 454 patients consecutively Query Reporting System (which total cost of fall-related injuries for admitted to one nursing home had a compiles data from the National people aged 65 and older was $19.2 dementia syndrome.7 Assisted living Center for Injury Prevention and billion in 2000,18 and this cost is facilities, though typically depicted Control), in 2005, nearly 16,000 expected to reach at least $32.4 billion as residential settings for cognitively people aged 65 and older died from by 2020.19 Indirect costs—related to intact older people with minor func- injuries related to falls. And some 1.8 labor, equipment, or quality of life— million older adults were treated in are not included in these figures. Ad- Dr. Kim and Dr. Detweiler are both geriatric psy- hospital emergency departments for ditionally, with the risk of legal action chiatrists at the Salem VA Medical Center, Salem, fall-related injuries, with more than being highest in patients whose falls VA. In addition, Dr. Kim is a professor in the de- partment of psychiatry and neurobehavioral sci- 433,000 of them admitted. are associated with serious injury, the ences at the University of Virginia, Charlottesville Approximately 2.9% of falls result costs of risk management, legal fees, and Dr. Detweiler is an assistant professor in the in hip fracture.12 Elderly individuals in and settlement awards add to the department of neuropsychiatry and behavioral sciences at Edward Via Virginia College of Osteo- nursing homes have a disproportion- substantial indirect expenses related 20 pathic Medicine, Blacksburg. ately high incidence of hip fracture to falls.

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PRECIPITATING Factors for meta-analysis indicated that digoxin, Table 1. Factors associated falls in dementia type IA antiarrhythmics, and diuret- with fall risk in older Falls in the elderly population gener- ics have been associated weakly with ally are associated with the interaction falls in elders. It also found that older adults with dementia of multiple intrinsic and extrinsic adults taking more than three or four Dementia-specific factors factors (Table 1). Intrinsic factors medications were at increased risk for • Aggressive behaviors include , cognitive decline, recurrent falls.35 • Aspects of a patient’s prior medications, and sensory deficits. Multiple comorbid medical prob- occupation Faulty equipment, restraints, poor lems may contribute to falls. One • Cognitive decline lighting, ill fitting clothing, and im- study found that diabetes mellitus is an • Medications proper shoes are examples of extrinsic independent risk factor for falls among • Physical restraints factors. Such unanticipated medical elderly nursing home residents.36 • Relocation events as , seizures, and cardiac is another con- • Wandering also can precipitate falls. tributor. While research has shown Although most falls do not result that standard measures of visual General factors in serious injury, older people with acuity and visual field size are fair • Diabetes dementia living in nursing homes fall predictors of falls, adequate depth • Environmental hazards, such more often than their counterparts perception and distant-edge-contrast as poor lighting without dementia, leaving them with sensitivity, in particular, appear to be • Impaired gait and balance a higher overall risk of sustaining in- important for maintaining balance • Neurovascular instability jurious falls over time.9 Patients with and detecting and avoiding hazards • Prior falls dementia also are more likely to sus- in the environment.37,38 • Visual impairment tain fractures when falling.21–24 Mus- Along with wandering, relocation cle weakness in the lower extremities has been associated with an increased can couple with the disturbances in risk for falls in older adults with de- Preventing falls equilibrium, limb coordination, and mentia.39,40 In one study, the incidence The goal of fall prevention strate- neurovascular stability that affect of falling doubled after nursing home gies is to develop interventions that older adults with cognitive decline to residents were relocated to a new facil- minimize or eliminate known risk increase their fall risk.25–27 ity.40 The continued use of restraints in or precipitating factors. Strategies for In addition to cognitive decline, long-term care facilities is based on the minimizing fall-related injury also patients with dementia exhibit neu- widely held belief that restraint reduc- should be included, especially for pa- ropsychiatric symptoms, which often tion will lead to fall-related incidents tients with dementia. The first step in result in aggressive behaviors.28–30 and injuries. Capezuti and colleagues developing a prevention program is Aggression generally causes increased reported, however, that physical re- to calculate fall risk. activity, which puts them at high risk straint removal did not cause an in- Multiple assessment tools are avail- for falls. Various psychotropic and crease in falls or subsequent fall-related able for quantifying fall risk. Perell nonpsychotropic agents used to treat injury in older nursing home resi- and colleagues reviewed these scales neuropsychiatric and medical condi- dents.41 The same group of researchers and identified those that can be used tions consistently are associated with also found that the use of bilateral side with confidence as part of an effec- falls.31,32 Notably, despite fewer ex- rails did not appear to reduce signifi- tive fall prevention program.43 Since trapyramidal adverse effects, atypical cantly the likelihood of falls, fall recur- little is known about the fall-related antipsychotics are not associated with rence, or serious injuries.42 factors that are unique to older adults fewer falls than conventional antipsy- Based on our clinical experience, with dementia, however, quantifying chotics.33 Additionally, although the we note that aspects of the prior oc- fall risk and applying appropriate pre- risk of falls among nursing home resi- cupation of a patient with dementia vention strategies in these patients dents taking short-acting benzodiaze- may put him or her at risk for falls. can prove more difficult. For exam- pines is lower than that among those For example, a patient who used to ple, an interdisciplinary, multifacto- taking long-acting agents, these drugs be a plumber may go beneath a sink rial prevention program aimed at less are associated with an increased risk basin, placing himself at risk for a fall cognitively impaired adults in resi- of nocturnal falls.34 Furthermore, a as he attempts to get up. dential care facilities yielded re-

12 • FEDERAL PRACTITIONER • APRIL 2008 PREVENTING FALLS IN DEMENTIA

duced falls and fractures—but not in Table 2. Possible strategies to minimize fall risk and residents with more severe cognitive related injuries in older adults with dementia impairment.44,45 On a positive note, in a popula- Dementia-specific strategies tion-based study, Kallin and col- leagues reported that the factors most • Adequate treatment of neuropsychiatric symptoms strongly associated with falls among • Comprehensive and regular medication review older adults with cognitive impair- • Minimum use of physical restraints ments were: (1) the ability to get up • Toileting program from a chair, (2) previous falls, (3) • Use of bed and chair alarm the need for help when walking, and • Use of hip protector (4) hyperactive symptoms.46 They • Use of mattress only or a low bed concluded that an intervention for General strategies this group probably would have to • Appropriate footwear with good traction include treatment of psychiatric and • Appropriate use of personal safety devices behavioral symptoms, improvement • Establishment of interdisciplinary fall review committee of gait and balance, adjustment of • Exercise programs (both general and specialized ones) 45 drug therapy, and staff supervision. • Fall preventive milieu (adequate lighting, flooring, railing, etc.) In a small study, investigators used • Minimization of potential environmental hazards trained nursing aides to provide • management focused supervision of high risk fall • Staff education about fall risk and interventions patients on a dementia unit and dem- • Use of comprehensive prefall and postfall assessment tools 47 onstrated a decrease in fall severity. • Use of nonslip mat In addition to larger fall preven- tion program undertakings (such as adequate treatment of patients’ neu- of hip protectors are available, in- Conclusions ropsychiatric symptoms and staff cluding energy shunting ones, which Further research into effective fall education), smaller adjustments are made of durable plastic and are prevention strategies for older adults (such as the use of nonslip mats) can designed to divert a direct impact with dementia is needed. Such re- minimize fall risk and related injuries away from the greater trochanter search should focus especially on among residents with dementia in as- onto surrounding soft tissue. Al- stratifying interventions based on sisted living facilities, nursing homes, though soft, absorbing hip pads do levels of cognitive impairment. In and dementia care programs (Table offer some peak force reduction, en- the meantime, clinicians and caregiv- 2). Establishing an interdisciplinary ergy shunting systems are likely su- ers need to employ individualized, committee to review and oversee fa- perior in preventing hip fractures.53 pragmatic strategies based on general cility-wide and patient-specific fall In designing a safer environment guidelines and clinical experience to prevention strategies is one way to for patients at risk for falling, the type reduce fall risk and related injuries. ● streamline the approach. of flooring should be considered. An important step toward fall pre- Simpson and colleagues implicated Author disclosures vention is performing an osteopo- carpeting placed over wood floors as The authors report no actual or poten- rosis evaluation for elderly patients the flooring type associated with the tial conflicts of interest with regard to determined to be at risk for falling. lowest number of fractures.54 this article. Calcium and supplemen- Extensive general guidelines for tation possibly can reduce fracture the prevention of falls in older adults, Disclaimer risk if a fall is sustained.48,49 The use with or without dementia, were is- The opinions expressed herein are those of hip protectors seems to reduce the sued as a joint endeavor between the of the authors and do not necessarily risk of hip fracture effectively and has American and British Soci- reflect those of Federal Practitioner, been found to be cost saving among eties and the American Academy of Quadrant HealthCom Inc., the U.S. patients in nursing home who are at Orthopedic Surgeons Panel on Falls government, or any of its agencies. high risk for falls.50–52 Various types Prevention in 2001.51 This article may discuss unlabeled or

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