FALLS AND FALL INJURIES
Content
FALLS AND FALL INJURIES:
ARE MORE COMMON THAN STROKES AND CAN BE JUST AS SERIOUS SECONDARY TO THE CONSEQUENCES OF FALLING ARE PREVENTABLE LEAD TO PROBLEMS INCLUDING WALKING, GETTING AROUND, PERFORMING ACTIVITIES OF DAILY LIVING. ADULTS THAT ARE 70 YEARS AND OLDER: 3 IN 10 FALL EACH YEAR. 2 IN 10 WHO NEED HEALTH CARE AFTER BEING IN THE HOSPTIAL FALLING A FALL (SUB ACUTE) WILL FALL WITHIN THE FIRST MONTH OF BEING BACK AT HOME 1 IN 10 WILL SUFER A SERIOUS FALL INJURY – A BROKEN BONE OR HEAD INJURIES 5 OUT OF 10 HAVE PROBLEMS GETTING UP OFF THE FLOOR WITHOUT HELP FOLLOWING A FALL 90% OF HIP FRACTURES ARE CAUSED BY FALLS. 50% WILL GET AROUND THE SAME THEY DID PRIOR TO THE HIP FRACTURE CAUSED BY A FALL **INFORAMTION FROM MARY TINNETI, MD WEBSITE AFTER FILLING OUT THE YES/ NO FORM IF YOUR NUMBER OF HEALTH PROBLEMS IS : CHANCE OF FALLING IS: 0 1 IN 10 PERSONS WILL FALL 1 2 IN 10 WILL FALL 2 3 IN 10 WILL FALL 3 6 PEOPLE IN 10 WILL FALL 4 OR MORE 8 PEOPLE IN 10 WILL FALL
Falls Among Older Adults: An Overview
How big is the problem?
More than one third of adults 65 and older fall each year in the United States (Hornbrook et al. 1994; Hausdorff et al. 2001). • Among older adults, falls are the leading cause of injury deaths. They are also the most common cause of nonfatal injuries and hospital admissions for trauma (CDC 2005). • In 2005, 15,800 people 65 and older died from injuries related to unintentional falls; about 1.8 million people 65 and older were treated in emergency departments for nonfatal injuries from falls, and more than 433,000 of these patients were hospitalized (CDC 2005). • The rates of fall-related deaths among older adults rose significantly over the past decade (Stevens 2006).
•
What outcomes are linked to falls?
Twenty percent to 30% of people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. These injuries can make it hard to get around and limit independent living. They also can increase the risk of early death (Alexander et al. 1992; Sterling et al. 2001). • Falls are the most common cause of traumatic brain injuries, or TBI (Jager et al. 2000). In 2000, TBI accounted for 46% of fatal falls among older adults (Stevens et al. 2006). • Most fractures among older adults are caused by falls (Bell et al. 2000). • The most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand (Scott 1990). • Many people who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, and increasing their actual risk of falling (Vellas et al. 1997). • In 2000, direct medical costs totaled $0.2 billion ($179 million) for fatal falls and $19 billion for nonfatal fall injuries (Stevens et al. 2006).
•
Who is at risk?
Men are more likely to die from a fall. After adjusting for age, the fall fatality rate in 2004 was 49% higher for men than for women (CDC 2005). • Women are 67% more likely than men to have a nonfatal fall injury (CDC 2005). • Rates of fall-related fractures among older adults are more than twice as high for women as for men (Stevens et al. 2005). • In 2003, about 72% of older adults admitted to the hospital for hip fractures were women (CDC 2005). • The risk of being seriously injured in a fall increases with age. In 2001, the rates of fall injuries for adults 85 and older were four to five times that of adults 65 to 74 (Stevens et al. 2005) • Nearly 85% of deaths from falls in 2004 were among people 75 and older (CDC 2005). • People 75 and older who fall are four to five times more likely to be admitted to a longterm care facility for a year or longer (Donald et al. 1999). • There is little difference in fatal fall rates between whites and blacks, ages 65 to 74 (CDC 2006).
•
After age 75, white men have the highest fatality rates, followed by white women, black men, and black women (CDC 2005). • White women have significantly higher rates of fall–related hip fractures than black women (Stevens 2005). • Among older adults, non–Hispanics have higher fatal fall rates than Hispanics (Stevens et al. 2002).
•
How can older adults prevent falls?
Older adults can take several steps to protect their independence and reduce their risk of falling. They can: Exercise regularly; exercise programs like Tai Chi and Balance Training Exercises that increase strength and improve balance are especially good. o Ask their doctor or pharmacist to review their medicines–both prescription and over-the counter–to reduce side effects and interactions. o Have their eyes and ears checked by an EENT doctor/ Audiologist at least once a year. o Improve the lighting in their home. o Reduce hazards in their home that can lead to falls.
o
What is CDC doing to prevent falls among older adults?
CDC supports research and dissemination on ways to help prevent falls among older adults. To read about these activities, follow the link to CDC Fall Prevention Activities. CDC has also developed brochures and posters, in partnership with the CDC Foundation and MetLife Foundation, to educate older adults and those who care for them about preventing falls and the injuries that result.
CDC Falls Prevention Activities
Research Studies
Studies of AoA-funded Fall Prevention Programs In June 2007, CDC developed an interagency agreement with the Administration on Aging (AoA). AoA currently provides 24 states with three-year grants that are designed to mobilize the aging, public health, and non-profit networks at the state and local level. The purpose of these grants is to accelerate translation of research into practice by introducing evidence-based disease and disability prevention programs at the community level. Of the 24 AoA grants, four evidence-based fall prevention models are being implemented: Matter of Balance (10 states and increasing); Stepping On (one state); Tai Chi (one state); and Step by Step (one state). It seems likely that other grantees will add fall prevention programs during the next three years. Under this interagency agreement, CDC is conducting three activities related to older adult falls:
•
•
Supporting the collaborative initiative by the National Council on Aging (NCOA), the Arch stone Foundation, the Home Safety Council, and other partners to address the growing problem of falls and fall-related injuries among adults aged 65 years and older. The Falls Free Coalition, formed in 2004 as a result of this initiative, includes more than 55 organizations and employs a collective approach to promoting a national fall prevention action plan. Assessing the long-term impact of Matter of Balance, a program designed to reduce fear of falling; increase self efficacy and a sense of control in relation to fall risk; increase physical and social activity and consequently prevent older adult falls.
•
Estimating the average implementation and maintenance costs and comparing these costs across three AoA-funded fall prevention programs: Matter of Balance, Moving for Better Balance, and Stepping On.
Dane County Safety Assessment for Elders (SAFE) study research project From October 2002 to September 2005, CDC funded the Wisconsin Department of Health, in collaboration with the University of Wisconsin, to conduct a randomized controlled trial to assess the effectiveness of a comprehensive fall intervention among community-dwelling older adults (i.e.: adults living independently rather than in an assisted living facility or in a nursing home) aged 65 years and older and at high risk of falling. The intervention included:
• • • •
Conducting individualized health assessments in participants’ homes to identify fall risk factors. Reducing risk through changes in medical conditions, vision, medication use, behavior, physical functioning, home environment, and social support. Facilitating sustained fall prevention efforts through follow-up, social support, and links to existing medical care and human service networks. Educating physicians throughout the community about fall prevention.
The goal was to decrease fall rates by 35 percent. The key outcome measures were falls and related hospitalizations, and length of nursing home stays. The study found that, compared to physician and therapist education alone, a multi-factorial individualized intervention in addition to physician and therapist education did not reduce the rate of falls among this population. No More Falls! From October 2001 to September 2004, CDC funded the California Department of Health Services to evaluate a multifaceted fall prevention intervention that was integrated into a public health program already established for older adults in the community. Study participants were 552 seniors attending Preventive Health Care for the Aging (PHCA) clinics in urban San Diego county and rural Humboldt county. The intervention included four elements:
• • • •
Education about fall risk factors Referrals to community exercise programs to increase strength and balance Medication review, and Home modifications to reduce fall hazards.
The goal was to reduce the incidence of falls requiring hospitalization by 10 percent. Results showed that this intervention did not reduce falls in this population. Reducing falls among older adults by adding a fall intervention to an existing health promotion program remains challenging. Further research is needed on effective methods to deliver multifaceted fall interventions to healthy older adults in community settings. Washington State older adults fall prevention study The State of Washington Department of Community Health was funded in October 2002 for three years to evaluate the effectiveness of a best practices model for senior fall prevention in a community setting. The study was a 12-month, randomized controlled trial of a fall prevention intervention among community-dwelling seniors aged 65 years and older and was tailored for each individual. It was implemented in senior centers and housing through a partnership between a local YMCA and the Northwest Orthopedic Institute, and in a community hospital. The study population included 453 participants.
Participants in the intervention group received an exercise program to improve strength, balance, and mobility; an education program on how to avoid falls and reduce fall risk factors; medication review and modification; referral for medical care management for selected fall risk factors; and a home hazard assessment and reduction of environmental hazards. Outcome measures were falls, balance and gait, and functional status. Falls among the intervention group were reduced 25% although this was not statistically significant. However, the intervention group showed significant improvement in measures of physical functioning. Effect of medication changes on the short-term risk of falls in long-term care In October 2004, researchers at Johns Hopkins University were funded to study the effect of medication changes on the risk of falls among residents of three nursing homes who fell during 2002–2003. The study used a case-crossover design to capture medication changes that occurred one to 9 days before the fall. The measure of effect was the odds ratio of falling after a start, stop, or dose change in medication in the case time period compared to the control time period. The results indicated that the short-term risk of single and recurring falls was three times higher in the two days following a medication change (odds ratio = 3.0, 95% CI=1.1, 25.9). The study outcomes may be used to develop similar fall risk studies in other clinical settings; identify high-risk times for falls related to medication changes; and to develop intensive, short-term interventions for vulnerable residents after medication changes. Preventing falls through enhanced pharmaceutical care Researchers at the University of North Carolina, Chapel Hill are conducting a randomized, controlled clinical trial to evaluate the effectiveness of a fall prevention program delivered by community pharmacists. The study focuses on community-dwelling older adults aged 65 years and older who have experienced a fall within the past year and are currently using either four or more prescription medications or at least one medication that acts on the central nervous system. A community pharmacist will conduct an in-depth consultation with those in the intervention group about their current medications. The control group will receive a series of monthly informational materials about preventing and treating health problems associated with aging and on lifestyle behaviors important for maintaining health. Data on falls will be collected through monthly falls calendars. All participants will be followed for one year.
Translating Research into Programs
Dissemination of a community Tai Chi fall prevention program Previous research findings have demonstrated that Tai Chi exercise can improve balance and decrease falls among older adults. However, it is not clear whether the general community can readily implement or adopt this type of training. CDC funded a researcher at Oregon Research Institute in October 2005 for three years to translate his evidencebased Tai Chi intervention into a user-friendly resource package for communities to be used with adults 60 years and older who are physically mobile, with or without assistive devices. A 12-week Tai Chi program for adults aged 60 and over, Moving for Better Balance, was developed and has been implemented in six local senior centers (140 people). The program consists of one-hour classes given twice a week. Participants are contacted 12 weeks after program ends to find out whether they’re continuing to practice Tai Chi. Dr. Li and his colleagues are evaluating the program’s feasibility and acceptability Based on feedback from senior service providers and seniors in the program, a user-friendly program package is being developed that includes:
•
Instructor’s manual
• •
Instructor supplements, and Participant’s course book.
The results of this translation and dissemination research will provide an effective, evidence-based fall prevention package for older adults that can be implemented in a community setting. This research will also provide important public health information about the most effective dissemination strategies for program reach, adoption, feasibility, and acceptability. Resulting publication: Li F, Peter Harmer P, Mack KA, Sleet D, Fisher KJ, Kohn MA, Lisa M. Millet LM, Xu J, Yang T, Sutton B, Tompkins Y. Tai Chi: Moving for Better Balance—Development of a Community-Based Falls Prevention Program. Journal of Physical Activity and Health 2008;5:445-455. Understanding factors that influence hip protector use among community-dwelling older adults In February 2004, CDC funded researchers at the University of North Carolina Injury Control Research Center to evaluate the acceptability of hip protectors among community-dwelling seniors. The goal of this project was to identify perceived barriers to hip protector use and to develop methods to promote their acceptability and use among community-dwelling older adults. Using focus groups and interviews, the researchers explored reactions to and attitudes about hip protectors among community-dwelling older adults. A different group of participants was interviewed and then given four pairs of hip protectors, instructed in their use, and asked to wear each one for a week. Participants were interviewed again after one week to determine their attitudes toward various aspects of the hip protectors including ease of use and care, comfort and fit, and physical difficulties and/or illnesses. The study found that participants initially felt that comfort, convenience and protection were all important factors. However, after trying the different hip protectors, seniors were more likely to say that protection was most important. Seniors’ perceptions of their own fall risk also influenced their views on wearing hip protectors. CDC will use these findings to develop ways to make hip protectors more acceptable to community-dwelling older adults. Resulting publication: Blalock SJ, Demby KB, Karen L. McCulloch KL, Stevens JA. Seniors' Perceptions of Using Hip Protectors to Reduce Fracture Risk [Letter to the Editor] JAGS 2008 (in press). Fall risk perception and risk assessment project Researchers at the Veterans Affairs Greater Los Angeles Healthcare System are conducting a study to learn about older people’s perceptions of their own risk for falls. They also want to understand whether older people are willing and able to implement specific strategies to reduce their fall risk. This project was funded in 2005 through a grant to the VA Greater Los Angeles Healthcare System, a partner in the Fall Prevention Center of Excellence. * In Phase I of the project, researchers conducted focus groups of 8 to 10 older adults at senior centers in Los Angeles County to learn about their knowledge of and beliefs about fall risk and fall prevention. The groups discussed perceived risk factors for falls, prevention efforts, barriers to performing recommended protective behaviors, and how to increase the chances that older adults would adopt changes to reduce their risk. In Phase II, a second set of focus groups discussed whether a newly developed self-assessment brochure was easy for older people to use. The goal was to create a user-friendly education tool and to test its validity as a risk predictor by comparing the risk scores from the brochure with an independent physician’s risk evaluation carried out on the same day.
In Phase III, researchers will revise the brochure, test its validity among a large group of community seniors, and then test its predictive accuracy by conducting follow-up phone interviews after 3 and 6 months to determine if the self-assessment tool was both useful and accurate.
Dissemination
Dissemination research on fall prevention: Stepping On in a Wisconsin community In Sept 2007, CDC funded a researcher at the University of Wisconsin for four years to adapt the Australian program, Stepping On, for the U.S. while at the same time maintaining fidelity to the original program. Dr. Mahoney and her colleagues will be evaluating uptake, reach, feasibility, fidelity, adherence, and outcomes related to implementation. In this project, the research team will examine issues such as:
• • •
The feasibility of implementing this program in rural compared to urban settings; Uptake of the program by different community organizations in different settings, such as parish nurses, senior housing and senior centers; How effective this program is when delivered by a professional without a health degree.
Evaluating dissemination of a fall prevention program for older adults The 11,500 senior centers throughout the United States serve as gathering places for older adults and offer both information and support for their clientele. As such, they are potentially powerful mechanisms for delivering injury control interventions to community-dwelling older adults. This project, begun in October 2005 by the Injury Control Research Center at the University of North Carolina, will assess the perceived needs for, and barriers to, adopting and implementing Safe Steps, a fall prevention program in senior centers. It will also compare the effectiveness of two enhanced dissemination strategies with a mail-out strategy to promote senior center and older adult adoption and implementation of Safe Steps; identify organizational-level factors that predict increased adoption and implementation of Safe Steps by senior centers; and identify individual-level factors that predict increased adoption and implementation by older adults. The aims of the project will be examined by conducting a needs assessment with a national sample of 510 senior centers. Researchers will also use a randomized, controlled trial of 180 senior centers equally randomized as Safe Steps via a mail-out; Safe Steps with a training component aimed at assisting senior center staff in program delivery; or Safe Steps with a dissemination strategy to address the barriers identified in the needs assessment. Successful project outcomes will lead to more effective dissemination and increased adoption and implementation of the Safe Steps program to prevent older adult falls. Learning about factors that contribute to successful dissemination of an injury program will also prove useful for other interventions targeting this population. Estimating the health care costs of older adult fall-related injuries In 2003, economists at the Research Triangle Institute in North Carolina worked with CDC to estimate the direct medical costs of falls among adults ages 65 years and older in the United States. The study found that, in 2000, direct medical costs totaled $0.2 billion for fatal falls and $19 billion for nonfatal fall-related injuries. Of the nonfatal injury costs, 63% ($12 billion) were for hospitalizations, 21% ($4 billion) were for emergency department visits, and 16% ($3 billion) were for treatment in outpatient settings. Medical expenditures for women, who made up 58% of the older adult population in 2000, were two to three times higher than for men for all medical treatment settings. Fractures accounted for just 35% of nonfatal injuries, but 61% of costs. Fall-related injuries among older adults, especially among older women, are
associated with substantial economic costs. The magnitude of this economic burden underscores the critical need to implement cost-effective fall interventions. Resulting publications: Finkelstein EA, Chen H, Miller TR, Corso PS, Stevens JA. A comparison of the case-control and casecrossover designs for estimating medical costs of non-fatal fall-related injuries among older Americans. Medical Care 2005;43:1087–91. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290–5.
Fall prevention: 6 ways to reduce your falling risk
Falls put you at risk of serious injury. Prevent falls with these fall-prevention measures.
By Mayo Clinic staff
The odds of falling each year after age 65 in the United States are about one in three. Fortunately, most of these falls aren't serious. Still, falls are the leading cause of injury and injury-related death among older adults. You're more likely to fall as you get older because of common, age-related physical changes and medical conditions — and the medications you take to treat such conditions. You needn't let the fear of falling rule your life. Many falls and fall-related injuries are preventable with fall-prevention measures. Here's a look at six fall-prevention approaches that can help you avoid falls.
Fall-prevention step 1: Make an appointment with your doctor
Begin your fall-prevention plan by making an appointment with your doctor. You and your doctor can take a comprehensive look at your environment, your health and your medications to identify situations when you're vulnerable to falling. In order to devise a fall-prevention plan, your doctor will want to know:
What medications are you taking? Include all the prescription and over-the-counter medications you take,
along with the dosages. Or bring them all with you. Your doctor can review your medications for side effects and interactions that may increase your risk of falling. To help with fall prevention, he or she may decide to wean you off certain medications, especially those used to treat anxiety and insomnia.
Have you fallen before? Write down the details, including when, where and how you fell. Be prepared to
discuss instances when you almost fell but managed to grab hold of something just in time or were caught by someone.
Could your health conditions cause a fall? Your doctor likely wants to know about eye and ear disorders
that may increase your risk of falls. Be prepared to discuss these and how comfortable you are walking — describe any dizziness, joint pain, numbness or shortness of breath that affects your walk. Your doctor may then evaluate your muscle strength, balance and walking style (gait).
Fall-prevention step 2: Keep moving
If you aren't already getting regular physical activity, consider starting a general exercise program as part of your fallprevention plan. Consider activities such as walking, water workouts or tai chi — a gentle exercise that involves slow and graceful dance-like movements. Such activities reduce your risk of falls by improving your strength, balance, coordination and flexibility. Be sure to get your doctor's OK first. If you avoid exercise because you're afraid it will make a fall more likely, tell your doctor. He or she may recommend carefully monitored exercise programs or give you a referral to a physical therapist who can devise a custom exercise program aimed at improving your balance, muscle strength and gait. To improve your flexibility, the physical therapist may use techniques such as electrical stimulation, massage or ultrasound. If you have inner ear problems that affect your balance, balance retraining exercises (vestibular rehabilitation) may help. These involve specific head and body movements to correct loss of balance.
Fall-prevention step 3: Wear sensible shoes
Consider changing your footwear as part of your fall-prevention plan. High heels, floppy slippers and shoes with slick soles can make you slip, stumble and fall. So can walking in your stocking feet. Instead:
Have your feet measured each time you buy shoes, since your size can change. Buy properly fitting, sturdy shoes with nonskid soles. Avoid shoes with extra-thick soles. Choose lace-up shoes instead of slip-ons, and keep the laces tied. Select footwear with fabric fasteners if you have trouble tying laces. Shop in the men's department if you're a woman who can't find wide enough shoes.
If bending over to put on your shoes puts you off balance, consider a long shoehorn that helps you slip your shoes on without bending over.
Fall-prevention step 4: Remove home hazards
As part of your fall-prevention measures, take a look around you — your living room, kitchen, bedroom, bathroom, hallways and stairways may be filled with booby traps. Clutter can get in your way, but so can the decorative accents you add to your home. To make your home safer, you might try these tips:
Remove boxes, newspapers, electrical cords and phone cords from walkways. Move coffee tables, magazine racks and plant stands from high-traffic areas. Secure loose rugs with double-faced tape, tacks or a slip-resistant backing. Repair loose, wooden floorboards and carpeting right away. Store clothing, dishes, food and other household necessities within easy reach. Immediately clean spilled liquids, grease or food. Use nonskid floor wax.
Use nonslip mats in your bathtub or shower.
Fall-prevention step 5: Light up your living space
As you get older, less light reaches the back of your eyes where you sense color and motion. So keep your home brightly lit with 100-watt bulbs or higher to avoid tripping on objects that are hard to see. Don't use bulbs that exceed the wattage rating on lamps and lighting fixtures, however, since this can present a fire hazard. Also:
Place a lamp near your bed and within reach so that you can use it if you get up at night. Make clear paths to light switches that aren't near room entrances. Consider installing glow-in-the-dark or
illuminated switches.
Place night lights in your bedroom, bathroom and hallways. Turn on the lights before going up or down stairs. This might require installing switches at the top and bottom
of stairs.
Store flashlights in easy-to-find places in case of power outages.
Fall-prevention step 6: Use assistive devices
Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help, too. All sorts of gadgets have been invented to make everyday tasks easier. Some you might consider:
Grab bars mounted inside and just outside your shower or bathtub. A raised toilet seat or one with armrests to stabilize yourself. A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Buy a hand-held
shower nozzle so that you can shower sitting down.
Handrails on both sides of stairways. Nonslip treads on bare-wood steps.
Ask your doctor for a referral to an occupational therapist who can help you devise other ways to prevent falls in your home. Some solutions are easily installed and relatively inexpensive. Others may require professional help and more of an investment. If you plan on staying in your home for many more years, an investment in safety and fall prevention now may make that possible.
ARE MORE COMMON THAN STROKES AND CAN BE JUST AS SERIOUS SECONDARY TO THE CONSEQUENCES OF FALLING ARE PREVENTABLE LEAD TO PROBLEMS INCLUDING WALKING, GETTING AROUND, PERFORMING ACTIVITIES OF DAILY LIVING. ADULTS THAT ARE 70 YEARS AND OLDER: 3 IN 10 FALL EACH YEAR. 2 IN 10 WHO NEED HEALTH CARE AFTER BEING IN THE HOSPTIAL FALLING A FALL (SUB ACUTE) WILL FALL WITHIN THE FIRST MONTH OF BEING BACK AT HOME 1 IN 10 WILL SUFER A SERIOUS FALL INJURY – A BROKEN BONE OR HEAD INJURIES 5 OUT OF 10 HAVE PROBLEMS GETTING UP OFF THE FLOOR WITHOUT HELP FOLLOWING A FALL 90% OF HIP FRACTURES ARE CAUSED BY FALLS. 50% WILL GET AROUND THE SAME THEY DID PRIOR TO THE HIP FRACTURE CAUSED BY A FALL **INFORAMTION FROM MARY TINNETI, MD WEBSITE AFTER FILLING OUT THE YES/ NO FORM IF YOUR NUMBER OF HEALTH PROBLEMS IS : CHANCE OF FALLING IS: 0 1 IN 10 PERSONS WILL FALL 1 2 IN 10 WILL FALL 2 3 IN 10 WILL FALL 3 6 PEOPLE IN 10 WILL FALL 4 OR MORE 8 PEOPLE IN 10 WILL FALL
Falls Among Older Adults: An Overview
How big is the problem?
More than one third of adults 65 and older fall each year in the United States (Hornbrook et al. 1994; Hausdorff et al. 2001). • Among older adults, falls are the leading cause of injury deaths. They are also the most common cause of nonfatal injuries and hospital admissions for trauma (CDC 2005). • In 2005, 15,800 people 65 and older died from injuries related to unintentional falls; about 1.8 million people 65 and older were treated in emergency departments for nonfatal injuries from falls, and more than 433,000 of these patients were hospitalized (CDC 2005). • The rates of fall-related deaths among older adults rose significantly over the past decade (Stevens 2006).
•
What outcomes are linked to falls?
Twenty percent to 30% of people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. These injuries can make it hard to get around and limit independent living. They also can increase the risk of early death (Alexander et al. 1992; Sterling et al. 2001). • Falls are the most common cause of traumatic brain injuries, or TBI (Jager et al. 2000). In 2000, TBI accounted for 46% of fatal falls among older adults (Stevens et al. 2006). • Most fractures among older adults are caused by falls (Bell et al. 2000). • The most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand (Scott 1990). • Many people who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, and increasing their actual risk of falling (Vellas et al. 1997). • In 2000, direct medical costs totaled $0.2 billion ($179 million) for fatal falls and $19 billion for nonfatal fall injuries (Stevens et al. 2006).
•
Who is at risk?
Men are more likely to die from a fall. After adjusting for age, the fall fatality rate in 2004 was 49% higher for men than for women (CDC 2005). • Women are 67% more likely than men to have a nonfatal fall injury (CDC 2005). • Rates of fall-related fractures among older adults are more than twice as high for women as for men (Stevens et al. 2005). • In 2003, about 72% of older adults admitted to the hospital for hip fractures were women (CDC 2005). • The risk of being seriously injured in a fall increases with age. In 2001, the rates of fall injuries for adults 85 and older were four to five times that of adults 65 to 74 (Stevens et al. 2005) • Nearly 85% of deaths from falls in 2004 were among people 75 and older (CDC 2005). • People 75 and older who fall are four to five times more likely to be admitted to a longterm care facility for a year or longer (Donald et al. 1999). • There is little difference in fatal fall rates between whites and blacks, ages 65 to 74 (CDC 2006).
•
After age 75, white men have the highest fatality rates, followed by white women, black men, and black women (CDC 2005). • White women have significantly higher rates of fall–related hip fractures than black women (Stevens 2005). • Among older adults, non–Hispanics have higher fatal fall rates than Hispanics (Stevens et al. 2002).
•
How can older adults prevent falls?
Older adults can take several steps to protect their independence and reduce their risk of falling. They can: Exercise regularly; exercise programs like Tai Chi and Balance Training Exercises that increase strength and improve balance are especially good. o Ask their doctor or pharmacist to review their medicines–both prescription and over-the counter–to reduce side effects and interactions. o Have their eyes and ears checked by an EENT doctor/ Audiologist at least once a year. o Improve the lighting in their home. o Reduce hazards in their home that can lead to falls.
o
What is CDC doing to prevent falls among older adults?
CDC supports research and dissemination on ways to help prevent falls among older adults. To read about these activities, follow the link to CDC Fall Prevention Activities. CDC has also developed brochures and posters, in partnership with the CDC Foundation and MetLife Foundation, to educate older adults and those who care for them about preventing falls and the injuries that result.
CDC Falls Prevention Activities
Research Studies
Studies of AoA-funded Fall Prevention Programs In June 2007, CDC developed an interagency agreement with the Administration on Aging (AoA). AoA currently provides 24 states with three-year grants that are designed to mobilize the aging, public health, and non-profit networks at the state and local level. The purpose of these grants is to accelerate translation of research into practice by introducing evidence-based disease and disability prevention programs at the community level. Of the 24 AoA grants, four evidence-based fall prevention models are being implemented: Matter of Balance (10 states and increasing); Stepping On (one state); Tai Chi (one state); and Step by Step (one state). It seems likely that other grantees will add fall prevention programs during the next three years. Under this interagency agreement, CDC is conducting three activities related to older adult falls:
•
•
Supporting the collaborative initiative by the National Council on Aging (NCOA), the Arch stone Foundation, the Home Safety Council, and other partners to address the growing problem of falls and fall-related injuries among adults aged 65 years and older. The Falls Free Coalition, formed in 2004 as a result of this initiative, includes more than 55 organizations and employs a collective approach to promoting a national fall prevention action plan. Assessing the long-term impact of Matter of Balance, a program designed to reduce fear of falling; increase self efficacy and a sense of control in relation to fall risk; increase physical and social activity and consequently prevent older adult falls.
•
Estimating the average implementation and maintenance costs and comparing these costs across three AoA-funded fall prevention programs: Matter of Balance, Moving for Better Balance, and Stepping On.
Dane County Safety Assessment for Elders (SAFE) study research project From October 2002 to September 2005, CDC funded the Wisconsin Department of Health, in collaboration with the University of Wisconsin, to conduct a randomized controlled trial to assess the effectiveness of a comprehensive fall intervention among community-dwelling older adults (i.e.: adults living independently rather than in an assisted living facility or in a nursing home) aged 65 years and older and at high risk of falling. The intervention included:
• • • •
Conducting individualized health assessments in participants’ homes to identify fall risk factors. Reducing risk through changes in medical conditions, vision, medication use, behavior, physical functioning, home environment, and social support. Facilitating sustained fall prevention efforts through follow-up, social support, and links to existing medical care and human service networks. Educating physicians throughout the community about fall prevention.
The goal was to decrease fall rates by 35 percent. The key outcome measures were falls and related hospitalizations, and length of nursing home stays. The study found that, compared to physician and therapist education alone, a multi-factorial individualized intervention in addition to physician and therapist education did not reduce the rate of falls among this population. No More Falls! From October 2001 to September 2004, CDC funded the California Department of Health Services to evaluate a multifaceted fall prevention intervention that was integrated into a public health program already established for older adults in the community. Study participants were 552 seniors attending Preventive Health Care for the Aging (PHCA) clinics in urban San Diego county and rural Humboldt county. The intervention included four elements:
• • • •
Education about fall risk factors Referrals to community exercise programs to increase strength and balance Medication review, and Home modifications to reduce fall hazards.
The goal was to reduce the incidence of falls requiring hospitalization by 10 percent. Results showed that this intervention did not reduce falls in this population. Reducing falls among older adults by adding a fall intervention to an existing health promotion program remains challenging. Further research is needed on effective methods to deliver multifaceted fall interventions to healthy older adults in community settings. Washington State older adults fall prevention study The State of Washington Department of Community Health was funded in October 2002 for three years to evaluate the effectiveness of a best practices model for senior fall prevention in a community setting. The study was a 12-month, randomized controlled trial of a fall prevention intervention among community-dwelling seniors aged 65 years and older and was tailored for each individual. It was implemented in senior centers and housing through a partnership between a local YMCA and the Northwest Orthopedic Institute, and in a community hospital. The study population included 453 participants.
Participants in the intervention group received an exercise program to improve strength, balance, and mobility; an education program on how to avoid falls and reduce fall risk factors; medication review and modification; referral for medical care management for selected fall risk factors; and a home hazard assessment and reduction of environmental hazards. Outcome measures were falls, balance and gait, and functional status. Falls among the intervention group were reduced 25% although this was not statistically significant. However, the intervention group showed significant improvement in measures of physical functioning. Effect of medication changes on the short-term risk of falls in long-term care In October 2004, researchers at Johns Hopkins University were funded to study the effect of medication changes on the risk of falls among residents of three nursing homes who fell during 2002–2003. The study used a case-crossover design to capture medication changes that occurred one to 9 days before the fall. The measure of effect was the odds ratio of falling after a start, stop, or dose change in medication in the case time period compared to the control time period. The results indicated that the short-term risk of single and recurring falls was three times higher in the two days following a medication change (odds ratio = 3.0, 95% CI=1.1, 25.9). The study outcomes may be used to develop similar fall risk studies in other clinical settings; identify high-risk times for falls related to medication changes; and to develop intensive, short-term interventions for vulnerable residents after medication changes. Preventing falls through enhanced pharmaceutical care Researchers at the University of North Carolina, Chapel Hill are conducting a randomized, controlled clinical trial to evaluate the effectiveness of a fall prevention program delivered by community pharmacists. The study focuses on community-dwelling older adults aged 65 years and older who have experienced a fall within the past year and are currently using either four or more prescription medications or at least one medication that acts on the central nervous system. A community pharmacist will conduct an in-depth consultation with those in the intervention group about their current medications. The control group will receive a series of monthly informational materials about preventing and treating health problems associated with aging and on lifestyle behaviors important for maintaining health. Data on falls will be collected through monthly falls calendars. All participants will be followed for one year.
Translating Research into Programs
Dissemination of a community Tai Chi fall prevention program Previous research findings have demonstrated that Tai Chi exercise can improve balance and decrease falls among older adults. However, it is not clear whether the general community can readily implement or adopt this type of training. CDC funded a researcher at Oregon Research Institute in October 2005 for three years to translate his evidencebased Tai Chi intervention into a user-friendly resource package for communities to be used with adults 60 years and older who are physically mobile, with or without assistive devices. A 12-week Tai Chi program for adults aged 60 and over, Moving for Better Balance, was developed and has been implemented in six local senior centers (140 people). The program consists of one-hour classes given twice a week. Participants are contacted 12 weeks after program ends to find out whether they’re continuing to practice Tai Chi. Dr. Li and his colleagues are evaluating the program’s feasibility and acceptability Based on feedback from senior service providers and seniors in the program, a user-friendly program package is being developed that includes:
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Instructor’s manual
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Instructor supplements, and Participant’s course book.
The results of this translation and dissemination research will provide an effective, evidence-based fall prevention package for older adults that can be implemented in a community setting. This research will also provide important public health information about the most effective dissemination strategies for program reach, adoption, feasibility, and acceptability. Resulting publication: Li F, Peter Harmer P, Mack KA, Sleet D, Fisher KJ, Kohn MA, Lisa M. Millet LM, Xu J, Yang T, Sutton B, Tompkins Y. Tai Chi: Moving for Better Balance—Development of a Community-Based Falls Prevention Program. Journal of Physical Activity and Health 2008;5:445-455. Understanding factors that influence hip protector use among community-dwelling older adults In February 2004, CDC funded researchers at the University of North Carolina Injury Control Research Center to evaluate the acceptability of hip protectors among community-dwelling seniors. The goal of this project was to identify perceived barriers to hip protector use and to develop methods to promote their acceptability and use among community-dwelling older adults. Using focus groups and interviews, the researchers explored reactions to and attitudes about hip protectors among community-dwelling older adults. A different group of participants was interviewed and then given four pairs of hip protectors, instructed in their use, and asked to wear each one for a week. Participants were interviewed again after one week to determine their attitudes toward various aspects of the hip protectors including ease of use and care, comfort and fit, and physical difficulties and/or illnesses. The study found that participants initially felt that comfort, convenience and protection were all important factors. However, after trying the different hip protectors, seniors were more likely to say that protection was most important. Seniors’ perceptions of their own fall risk also influenced their views on wearing hip protectors. CDC will use these findings to develop ways to make hip protectors more acceptable to community-dwelling older adults. Resulting publication: Blalock SJ, Demby KB, Karen L. McCulloch KL, Stevens JA. Seniors' Perceptions of Using Hip Protectors to Reduce Fracture Risk [Letter to the Editor] JAGS 2008 (in press). Fall risk perception and risk assessment project Researchers at the Veterans Affairs Greater Los Angeles Healthcare System are conducting a study to learn about older people’s perceptions of their own risk for falls. They also want to understand whether older people are willing and able to implement specific strategies to reduce their fall risk. This project was funded in 2005 through a grant to the VA Greater Los Angeles Healthcare System, a partner in the Fall Prevention Center of Excellence. * In Phase I of the project, researchers conducted focus groups of 8 to 10 older adults at senior centers in Los Angeles County to learn about their knowledge of and beliefs about fall risk and fall prevention. The groups discussed perceived risk factors for falls, prevention efforts, barriers to performing recommended protective behaviors, and how to increase the chances that older adults would adopt changes to reduce their risk. In Phase II, a second set of focus groups discussed whether a newly developed self-assessment brochure was easy for older people to use. The goal was to create a user-friendly education tool and to test its validity as a risk predictor by comparing the risk scores from the brochure with an independent physician’s risk evaluation carried out on the same day.
In Phase III, researchers will revise the brochure, test its validity among a large group of community seniors, and then test its predictive accuracy by conducting follow-up phone interviews after 3 and 6 months to determine if the self-assessment tool was both useful and accurate.
Dissemination
Dissemination research on fall prevention: Stepping On in a Wisconsin community In Sept 2007, CDC funded a researcher at the University of Wisconsin for four years to adapt the Australian program, Stepping On, for the U.S. while at the same time maintaining fidelity to the original program. Dr. Mahoney and her colleagues will be evaluating uptake, reach, feasibility, fidelity, adherence, and outcomes related to implementation. In this project, the research team will examine issues such as:
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The feasibility of implementing this program in rural compared to urban settings; Uptake of the program by different community organizations in different settings, such as parish nurses, senior housing and senior centers; How effective this program is when delivered by a professional without a health degree.
Evaluating dissemination of a fall prevention program for older adults The 11,500 senior centers throughout the United States serve as gathering places for older adults and offer both information and support for their clientele. As such, they are potentially powerful mechanisms for delivering injury control interventions to community-dwelling older adults. This project, begun in October 2005 by the Injury Control Research Center at the University of North Carolina, will assess the perceived needs for, and barriers to, adopting and implementing Safe Steps, a fall prevention program in senior centers. It will also compare the effectiveness of two enhanced dissemination strategies with a mail-out strategy to promote senior center and older adult adoption and implementation of Safe Steps; identify organizational-level factors that predict increased adoption and implementation of Safe Steps by senior centers; and identify individual-level factors that predict increased adoption and implementation by older adults. The aims of the project will be examined by conducting a needs assessment with a national sample of 510 senior centers. Researchers will also use a randomized, controlled trial of 180 senior centers equally randomized as Safe Steps via a mail-out; Safe Steps with a training component aimed at assisting senior center staff in program delivery; or Safe Steps with a dissemination strategy to address the barriers identified in the needs assessment. Successful project outcomes will lead to more effective dissemination and increased adoption and implementation of the Safe Steps program to prevent older adult falls. Learning about factors that contribute to successful dissemination of an injury program will also prove useful for other interventions targeting this population. Estimating the health care costs of older adult fall-related injuries In 2003, economists at the Research Triangle Institute in North Carolina worked with CDC to estimate the direct medical costs of falls among adults ages 65 years and older in the United States. The study found that, in 2000, direct medical costs totaled $0.2 billion for fatal falls and $19 billion for nonfatal fall-related injuries. Of the nonfatal injury costs, 63% ($12 billion) were for hospitalizations, 21% ($4 billion) were for emergency department visits, and 16% ($3 billion) were for treatment in outpatient settings. Medical expenditures for women, who made up 58% of the older adult population in 2000, were two to three times higher than for men for all medical treatment settings. Fractures accounted for just 35% of nonfatal injuries, but 61% of costs. Fall-related injuries among older adults, especially among older women, are
associated with substantial economic costs. The magnitude of this economic burden underscores the critical need to implement cost-effective fall interventions. Resulting publications: Finkelstein EA, Chen H, Miller TR, Corso PS, Stevens JA. A comparison of the case-control and casecrossover designs for estimating medical costs of non-fatal fall-related injuries among older Americans. Medical Care 2005;43:1087–91. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290–5.
Fall prevention: 6 ways to reduce your falling risk
Falls put you at risk of serious injury. Prevent falls with these fall-prevention measures.
By Mayo Clinic staff
The odds of falling each year after age 65 in the United States are about one in three. Fortunately, most of these falls aren't serious. Still, falls are the leading cause of injury and injury-related death among older adults. You're more likely to fall as you get older because of common, age-related physical changes and medical conditions — and the medications you take to treat such conditions. You needn't let the fear of falling rule your life. Many falls and fall-related injuries are preventable with fall-prevention measures. Here's a look at six fall-prevention approaches that can help you avoid falls.
Fall-prevention step 1: Make an appointment with your doctor
Begin your fall-prevention plan by making an appointment with your doctor. You and your doctor can take a comprehensive look at your environment, your health and your medications to identify situations when you're vulnerable to falling. In order to devise a fall-prevention plan, your doctor will want to know:
What medications are you taking? Include all the prescription and over-the-counter medications you take,
along with the dosages. Or bring them all with you. Your doctor can review your medications for side effects and interactions that may increase your risk of falling. To help with fall prevention, he or she may decide to wean you off certain medications, especially those used to treat anxiety and insomnia.
Have you fallen before? Write down the details, including when, where and how you fell. Be prepared to
discuss instances when you almost fell but managed to grab hold of something just in time or were caught by someone.
Could your health conditions cause a fall? Your doctor likely wants to know about eye and ear disorders
that may increase your risk of falls. Be prepared to discuss these and how comfortable you are walking — describe any dizziness, joint pain, numbness or shortness of breath that affects your walk. Your doctor may then evaluate your muscle strength, balance and walking style (gait).
Fall-prevention step 2: Keep moving
If you aren't already getting regular physical activity, consider starting a general exercise program as part of your fallprevention plan. Consider activities such as walking, water workouts or tai chi — a gentle exercise that involves slow and graceful dance-like movements. Such activities reduce your risk of falls by improving your strength, balance, coordination and flexibility. Be sure to get your doctor's OK first. If you avoid exercise because you're afraid it will make a fall more likely, tell your doctor. He or she may recommend carefully monitored exercise programs or give you a referral to a physical therapist who can devise a custom exercise program aimed at improving your balance, muscle strength and gait. To improve your flexibility, the physical therapist may use techniques such as electrical stimulation, massage or ultrasound. If you have inner ear problems that affect your balance, balance retraining exercises (vestibular rehabilitation) may help. These involve specific head and body movements to correct loss of balance.
Fall-prevention step 3: Wear sensible shoes
Consider changing your footwear as part of your fall-prevention plan. High heels, floppy slippers and shoes with slick soles can make you slip, stumble and fall. So can walking in your stocking feet. Instead:
Have your feet measured each time you buy shoes, since your size can change. Buy properly fitting, sturdy shoes with nonskid soles. Avoid shoes with extra-thick soles. Choose lace-up shoes instead of slip-ons, and keep the laces tied. Select footwear with fabric fasteners if you have trouble tying laces. Shop in the men's department if you're a woman who can't find wide enough shoes.
If bending over to put on your shoes puts you off balance, consider a long shoehorn that helps you slip your shoes on without bending over.
Fall-prevention step 4: Remove home hazards
As part of your fall-prevention measures, take a look around you — your living room, kitchen, bedroom, bathroom, hallways and stairways may be filled with booby traps. Clutter can get in your way, but so can the decorative accents you add to your home. To make your home safer, you might try these tips:
Remove boxes, newspapers, electrical cords and phone cords from walkways. Move coffee tables, magazine racks and plant stands from high-traffic areas. Secure loose rugs with double-faced tape, tacks or a slip-resistant backing. Repair loose, wooden floorboards and carpeting right away. Store clothing, dishes, food and other household necessities within easy reach. Immediately clean spilled liquids, grease or food. Use nonskid floor wax.
Use nonslip mats in your bathtub or shower.
Fall-prevention step 5: Light up your living space
As you get older, less light reaches the back of your eyes where you sense color and motion. So keep your home brightly lit with 100-watt bulbs or higher to avoid tripping on objects that are hard to see. Don't use bulbs that exceed the wattage rating on lamps and lighting fixtures, however, since this can present a fire hazard. Also:
Place a lamp near your bed and within reach so that you can use it if you get up at night. Make clear paths to light switches that aren't near room entrances. Consider installing glow-in-the-dark or
illuminated switches.
Place night lights in your bedroom, bathroom and hallways. Turn on the lights before going up or down stairs. This might require installing switches at the top and bottom
of stairs.
Store flashlights in easy-to-find places in case of power outages.
Fall-prevention step 6: Use assistive devices
Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help, too. All sorts of gadgets have been invented to make everyday tasks easier. Some you might consider:
Grab bars mounted inside and just outside your shower or bathtub. A raised toilet seat or one with armrests to stabilize yourself. A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Buy a hand-held
shower nozzle so that you can shower sitting down.
Handrails on both sides of stairways. Nonslip treads on bare-wood steps.
Ask your doctor for a referral to an occupational therapist who can help you devise other ways to prevent falls in your home. Some solutions are easily installed and relatively inexpensive. Others may require professional help and more of an investment. If you plan on staying in your home for many more years, an investment in safety and fall prevention now may make that possible.
