Fall Risk Assessment

Preventing Falls In The Elderly: Where DPMs Can Have An Impact

Author(s):
Douglas H. Richie, DPM, FACFAS

Over the past two decades, podiatric medicine has become a vital member of the healthcare team treating important health issues around the world. For example, the role of the podiatric physician in the team approach to treating the diabetic foot has elevated our profession to a level of esteem where we are on a par with any medical specialty.1
One in three adults over the age of 65 falls each year and half of these people fall multiple times.2,3 The Centers for Disease Control and Prevention report that falls are the leading cause of injury-related deaths in people over the age of 65.4 In 2000, the cost of treating non-fatal fall related injuries was $19 billion and is expected to double by 2020.5,6
Most of our elderly patients experience a decline in balance and muscle strength. The combination of this decline with visual and vestibular compromise increases the risk of falling. What, if anything, can we as podiatric physicians do about this?

Helfand voiced a call to attention for podiatric physicians to realize their role in fall prevention in 1966.11 Few paid notice, especially outside the podiatric profession. Beginning in 1991, the emergence of significant research conducted by a group of Australian podiatrists started a movement that has now placed podiatry in an esteemed position in the role of fall prevention in the elderly.12 As a profession, American podiatric physicians owe a debt of gratitude to Lord and Menz as well as all of their students and collaborators for their monumental contributions to our understanding of foot health and fall prevention in the elderly. Their findings have elucidated four general areas of podiatric risk factors which are toe deformity, range of motion and toe flexion strength, foot pain and footwear.

What Studies Reveal About Interventions For Fall Prevention

The medical literature contains thousands of articles relevant to fall prevention. Various researchers have developed and tested interventions to address any and all of the aforementioned risk factors. What is perplexing is the fact that treating individual risk factors does not reliably lead to any significant reduction of fall risk in elderly patients. Clearly the prevention of falls is far more complicated than simply identifying risk.

For example, a recent trend in podiatric medicine has been the dispensing of bilateral solid shell ankle-foot orthoses (AFOs) to prevent the risk of falls in elderly patients (see my Podiatry Today DPM Blog at http://goo.gl/7r7dG ). Training sessions and webinars promoting the sale of these braces justify the medical necessity of this intervention because the treatment focuses on musculoskeletal or neuromuscular disorders that have previously been identified to be risk factors for falling.

The most recent Cochrane review of community-based fall prevention trials was published in 2008.26 This 254-page document surveyed over 4,000 references and selected 111 randomized controlled trials of 53,000 participants. This review paper made the following conclusions about fall prevention programs.

  • Exercise programs may target strength, balance, flexibility or endurance. Programs that contain two or more of these components reduce the rate of falls and number of people falling. Exercising in supervised groups, participating in tai chi and carrying out individually prescribed exercise programs at home are all effective.
  • Multifactorial interventions assess an individual person’s risk of falling and then carry out or arrange referral for treatment to reduce the risk. Some studies have shown multifactorial interventions to be effective but other studies have shown such interventions to be ineffective.
  • Taking vitamin D supplements probably does not reduce falls, except in people who have a low level of vitamin D in the blood. Interventions to improve home safety do not seem to be effective, except in people at high risk for falling, such as those with severe visual impairment.
  • Wearing an anti-slip shoe device in icy conditions can reduce falls.
  • Some medications increase the risk of falling. Ensuring that medications are reviewed and adjusted may be effective in reducing falls. Gradual withdrawal from some types of drugs for improving sleep, reducing anxiety and treating depression may reduce falls.
  • Cataract surgery reduces falls in people having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition that may result in changes in heart rate and blood pressure.

Costello and colleagues also observed that multifactorial fall prevention programs are not always successful.27 These authors reviewed 781 published studies and concluded that only such programs that target individuals with a previous fall are successful. Researchers also noted that an exercise program combined with balance training was the single treatment intervention that had a benefit for patients with and without a previous history of falling. Costello and co-workers also recommended that a medication and vision assessment with appropriate health practitioner referral should be included in a fall screening examination.

References
1. Rogers LC, Andros G, Caporusso J, Harkless LB, Mills JL Sr, Armstrong DG. Toe and flow: essential components and structure of the amputation prevention team. J Am Podiatr Med Assoc. 2010; 100(5):342-8.
2. Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: A 1-year prospective study. Arch Phys Med Rehabil. 2001; 82(8):1050-56
3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988; 319(26):1701-7.
4. Centers for Disease Control and Prevention. Falls among older adults: An overview. Available at: http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html. Accessed February 25, 2011.
5. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006; 12(5):290-95.
6. Schneider EL, Guralnik JM. The aging of America. Impact on health care costs. JAMA. 1990; 263(17):2335-40.
7. Falls prevention for the elderly. Balzer K, Bremer M, Schramm S, Lühmann D, Raspe H. GMS Health Technol Assess. 2012; 8:Doc01. Epub 2012 Apr 12.
8. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010; 21(5):658-68.
9. Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J Am Geriatr Soc. 1994; 42(3):269-74.
10. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009; 169(21):1952-60.
11. Helfand AE. Foot impairment—an etiologic factor for falls in the aged. J Am Pod Assoc. 1966; 56(7):326–330.
12. Lord SR, Clark RD, Webster IW. Postural stability and associated physiological factors in a population of aged persons. J Gerontol. 1991; 46(3):M69–M76.
13. Menz HB, Lord SR. Foot problems, functional impairment, and falls in older people. J Am Podiatr Med Assoc. 1999; 89(9):458–467.
14. Menz HB, Lord SR. Foot pain impairs balance and functional ability in community-dwelling older people. J Am Podiatr Med Assoc. 2001; 91(5):262–268.
15. Menz HB, Lord SR. The contribution of foot problems to mobility impairment and falls in older people. J Am Geriatr Soc. 2001; 49(12):1651–1656.
16. Menz HB, Morris ME, Lord SR. Foot and ankle characteristics associated with impaired balance and functional ability in older people. J Gerontol A Biol Sci Med Sci. 2005; 60(12):1546–1552.
17. Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a prospective study. J Gerontol. 2006; 61A(8):866–870.
18. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Toe weakness and deformity increase the risk of falls in older people. Clinical Biomechanics. 2009; 24(10):787–791.
19. Munro BJ, Steele JR. Foot-care awareness. A survey of persons aged 65 years and older. J Am Podiatr Med Assoc 1998; 88(5):242–248.
20. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Foot pain, plantar pressures, and falls in older people: a prospective study. J Am Geriatr Soc. 2010; 58(10):1936–1940.
21. Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and risk of falls in older adults. J Am Geriatr Soc. 2004; 52(9):1495–1501.
22. Sherrington C, Menz HB. An evaluation of footwear worn at the time of fall-related hip fracture. Age Ageing. 2003; 32(3):310-4.
23. Menz HB, Morris ME, Lord SR. Footwear characteristics and risk of indoor and outdoor falls in older people. Gerontology. 2006; 52(3):174–80
24. Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR. Optimizing footwear for older people at risk of falls. JRRD. 2008; 45(8):
25. Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci. 2010; 65(8):896–903.
26. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Sys Rev 2009; 15(2):CD007146.
27. Costello E, Edelstein J. Update on falls prevention for community-dwelling older adults: Review of single and multifactorial intervention programs. J Rehab Res Dev. 2008; 45(8):1135-52.
28. Tinetti ME. Preventing falls in the elderly. New Eng J Med. 2003; 348(1):42-49.
29. Spink MJ, Menz HB, Fotoohabadi MRf, E Wee, Landorf KB, Hill KD, Lord SR. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomized controlled trial. BMJ 2011; 342:d3411.
For further reading, see Dr. Richie’s DPM Blogs “How Can DPMs Prevent Falls In The Elderly?” at http://tinyurl.com/6238jq9 , “The Truth About AFOs And Fall Prevention” at http://goo.gl/7r7dG or “Still Looking For Documentation That AFOs Effectively Prevent Falls” at http://tinyurl.com/cjjcvko .

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