Keywords:
Accidental Falls - Aged
Palavras-chave
Acidentes por Quedas - Idoso
INTRODUCTION
Falls are a major problem in public health since they are an important cause of morbidity
and mortality. Fall rates vary among older adults according to age, but it is estimated
that 30% of people over the age of 65 fall each year, and that this percentage increases
up to 50% among people over 80[1]-[3], while half of these have recurrent falls[4]. Added to this, falls lead to mild to severe injuries, are the cause of 10-15% of
all emergency department visits, and account for 40% of all injury deaths[3]. Besides physical consequences, falls also can result in psychological sequelae
characterized by fear of falling, insecurity, self-limitation, functional impairment,
and social isolation. This situation compromises the quality of life and increases
the risk of further falls[3].
The maintenance of a good postural balance is a complex task that involves an interaction
to the environment, multiple afferences to the central nervous system, a complex integration,
an efficient motor postural response and a good biomechanical support ([Figure 1]). Therefore, it is easy to understand that a fall can be the result of a problem
in one or more of any of these stages. On the other hand, since there are several
possible problems in this schema, identifying fall risks may be a challenging task.
Furthermore, in most cases there are multiple risk factors involved and the fall cannot
be attributed to a single cause. To evaluate the risk of fall of a patient may be
another challenge, since there are different functional tools, with no consensus in
the literature as to which one should be applied.
Figure 1 Schematic representation of all systems involved in postural balance.
Thus, the aims of this review are to summarize the most relevant information on the
topic “falls in the elderly” and to give a critical view and practical clinical approach
in these cases. For this, the authors will answer the following questions: (1) Which
are the most relevant fall risks in the elderly? (2) What is relevant in the physical
and neurological examination? (3) How can one identify the risk of fall? (4) Which
are the most important interventions to prevent falls? (5) How can new technologies
help the management of older people with risk of fall?
FALL RISKS ASSESSMENT
Publications describe an extensive list of risk factors for falls in the elderly,
and there is a great effort to establish those that are most important, although the
models are still insufficient to predict those patients at risk. The predictive accuracy
of risk factor models for falls is weak compared with models for cardiovascular events,
and one of the main risk factors for falls in the elderly is a previous fall, meaning
there is no proper primary prevention as yet[4]. One of the possible explanations for this is that risk factors for falls are not
static, they can interact with each other, adding to or multiplying their impact[4] ([Figure 2]).
Figure 2 Schematic representation of fall risks domains. The arrows show the interaction between
domains.
Therefore, screening the patient for risk factors for falls may be exhaustive. Epidemiological
studies show dozens of risk factors, and some authors group these in different areas
in order to make the analysis easier ([Table 1]) [3],[5],[6].
Table 1
Fall risks factors grouped in different domains according to different authors.
|
WHO3
|
Lord et al5
|
Kim et al6
|
|
Biological risk factors
|
Psychosocial and demographic
|
General characteristics
|
|
Age Race Gender chronic illnesses (eg, neurologic diseases, arthritis, cancer) physical,
sensory, cognitive, and affective declines
|
Advanced age Female gender Living alone History of falls Inadivity ADL limitations
|
Sex Increased age Living alone Low income
|
|
Balance and mobility
|
Physical function
|
|
Impaired stability when standing Impaired stability when leaning and reaching Inadequate
responses to external perturbations Slow voluntary stepping Impaired gait and mobility
Impaired ability in standing up Impaired ability with transfers
|
Low vision Mobility/balance/gait deficit Impaired ADL Musculoskeletal function Cardiac
function Neurological function Inappropriate footwear Use of assistive devices
|
|
Sensory and neuromuscular
|
|
Visual acuity Visual contrast sensitivity Visual field dependence Reduced peripheral
sensation Reduced vestibular function Muscle weakness Poor reaction time
|
|
Medical
|
Disease factor
|
|
Impaired cognition Depression Abnormal neurological signs Stroke Incontinence Acute
illness Parkinson 's disease Vestibular disorders Arthritis Foot problems Dizziness
|
Stroke Dementia Parkinson’s Dizziness Cardiovascular Hypotension Respiratory Peripheral
neuropathy Diabetes Chronic pain Arthritis Osteoporosis Incontinence
|
|
Behavioral risk factors
|
|
Behavior factor
|
|
Multiple medications lack of exercise excess alcohol usage inappropriate footwear
inattention, multitasking hurrying
|
|
Inadequate diet History of previous falls Fear of falling Lack of exercise Excess
alcohol intake
|
|
Medication
|
Medication
|
|
Psychoactive drugs Antihypertensive Use of four or more medications
|
Psychoactive drugs Cardiovascular drugs Multiple medication use
|
|
Environmental
|
Environmental
|
Environmental
|
|
narrow steps slippery surfaces of stairs looser rugs and insufficient lighting
|
Poor footwear Inappropriate spectacles
|
Brightness of light Carpet Slipperiness Support of community
|
|
Socioeconomic risk factors
|
|
|
|
low income low education inadequate housing lack of social interaction limited access
to health and social care lack of community resources
|
|
|
However, a careful analysis shows that some factors are present in the three lists:
age and sex, medication, medical conditions such as muscle weakness and visual changes,
cognitive changes and depression, lack of physical activity/sedentary lifestyle. Next,
we will comment on fall risks that we consider most relevant.
General characteristics
Falls incidence increases with age, a finding easy to understand since many other
factors (balance problems, polypharmacy, sensory and muscular impairment) are more
common in older people. Women are more prone to falls than men, although fall-related
mortality is higher among older men[3]. Biological difference may contribute to a higher risk in women, as they have a
faster muscle mass sarcopenia than men. On the other hand, men may have a higher fatality
rate, maybe because they only seek medical assistance when they have a severe condition,
and they are more engaged in dangerous and risky activities and behaviors[3].
Falls among older people are associated with living alone[3],[7]. A possible link between living alone and falls is depression, since isolation may
increase depression, which increases the fear of falling, and vice-versa. Fear of
falling can lead to less social interaction, loss of personal contact, and reduction
of daily activity. This in turn reduces mobility and increases isolation and depression,
and consequently increases the risk of falls[7].
Medical conditions
Most authors agree that medical conditions such as stroke, dementia, Parkinson’s disease
and peripheral neuropathy increase the risk of fall[5],[6]. This is probably due to motor or cognitive dysfunctions that affect postural control.
There is a close relationship between gait and cognition, and both can be impaired
in early stages of neurodegenerative disorders. Cognitive impairment is associated
with disturbed gait parameters, falls are more frequent in patients with dementia,
and the number of falls increases with the severity of cognitive disturbance[8].
Other conditions such as cardiovascular diseases may also increase the risk of falls,
although it is not clear if this increase is due to disease itself, or due to the
association with other conditions that occur with cognitive decline[6]. Regarding the association between falls and orthostatic hypotension, this may be
difficult to confirm as it is an intermittent condition, and may not be present at
the consultation but even so may be related to a fall[4],[5]. Vestibular disease, dizziness, foot problems, and arthritis are also thought to
be associated with an increased fall risk, but this has not been proven, probably
due to a lack of evidence[5],[9]. However, elderly patients with multisite pain had a 51% higher chance of fall risk[6]. Pain may cause low balance confidence, reduced self-protection from falls, mobility
limitations and difficulties in activities of daily life and thus increases risk of
fall[6].
Balance, mobility, sensory, neuromuscular, and physical function
Considering the classification of Lord et al, medication and sensory and neuromuscular
domains were associated with 50% greater risk for recurrent falls and balance and
mobility and psychological domain with 30% greater risk[9].
Sensory and neuromuscular domain includes vision problems, peripheral sensation, and
muscle weakness, so it is not a surprise that there exists an association with falls.
Reduced visual acuity, contrast sensitivity, stereo-acuity and visual motion perception
are all visual problems related to increased fall risk[10]. Presbyopia, cataracts, glaucoma, and macular degeneration are common causes of
these visual problems. Furthermore, the use of bifocal and multifocal lenses worsens
depth perception and sensitivity to contrast, increasing the risk of falling mainly
when going up and down stairs outdoors[11].
In elderly people with no neurological diseases, there may be a decrease of sensory
afferences. The proprioceptive change occurs by axonal degeneration and a decrease
in sensory fiber density and degeneration of chondrocytes on the cartilaginous surface
due to articular degenerative disease. With a loss of proprioceptive sensation, the
individual has greater difficulty when walking in environments with insufficient lighting,
which increases the risk of falls[12].
Elderly people lose 1 to 2% of muscle mass and strength each year. This process, called
sarcopenia, is more pronounced in women after the age of 60 and is probably one of
the reasons for a higher female incidence of falls[12].
Poor balance is one of the most important risk factors for falls, and the more difficult
the balance task and the poorer performance of the task, the higher the risk of a
fall[5]. Balance is also a complex ability and may also be linked to mobility and psychological
aspects in the fall-risk assessment, as shown above. There is a corresponding relationship
between falls, depression, mobility, and balance. The worse the balance and mobility,
the higher the chance of depression and falls, while a fall increases the chance of
depression, reduced mobility and poor balance[13].
Although supplementation of vitamin D may lower the risk of falls (see below), vitamin
D deficiency is not included as a risk factor, since it is not a fall risk itself,
but rather weakens the musculoskeletal system and thus may be associated with falls[6].
Medication
Polypharmacy (four or more drugs) or the use of specific classes of medication are
important risk factors for falls[5],[6],[9]. Special care should be taken with psychoactive drugs (antidepressants, sedatives,
opioids), anti-hypertensives (diuretics, b-blockers, vasodilators), skeletal muscle
relaxants and antihistamine medication[14],[15].
The particular situation of a patient prone to falls and with depression may be challenging,
as depression and the use of antidepressants are both fall risks. In this case, if
clinical conditions allow, the antidepressant should be withdrawn[16].
Behavioral and environmental factors
An important behavioral risk factor is the lack of physical activity. This is easy
to understand, as physical activity is important for maintaining good health. It contributes
to good muscular power and prevents functional decline[3].
Regarding environmental factors, although they are usually included in the list, there
is some consensus that they do not cause falls by themselves, rather there is an interaction
of external hazardous features and intrinsic risk factors[3],[5],[9]. In this context, the most common environmental factors cited are slippery surfaces,
loose rugs, insufficient lighting, and inappropriate footwear.
PHYSICAL AND NEUROLOGICAL EXAMINATION AND ASSESSMENT TOOLS
PHYSICAL AND NEUROLOGICAL EXAMINATION AND ASSESSMENT TOOLS
The aims of a physical and neurological examination and the use of assessment tools
are different, and the physician should bear this in mind. Through a physical and
neurological examination, it is possible to identify the risk factors, and to evaluate
the functional status of all systems involved with balance (musculoskeletal, muscle
strength, coordination, sensibility, visual and vestibular function, cognition). On
the other hand, by using one or more assessment tools the objective is to evaluate
the mobility or balance function status and to identify the risk of fall. Thus, a
complete evaluation should contemplate both aspects.
Physical and neurological examination
As mentioned above, a physical and neurological examination should focus on a physiological
approach, rather than a disease-oriented approach[17]. As an example, the examiner must evaluate and identify possible visual problems
such as poor visual acuity or visual contrast sensitivity rather than making a diagnosis
of cataracts or glaucoma. With this in mind, all necessary systems for good balance
and mobility must be examined: muscular strength and tonus, coordination, proprioception,
visual function, vestibular function and cognition in special executive functions[14],[17]. A simple evaluation of gait can also be helpful, observing velocity, stride length,
antalgic movements and balance[14].
The examiner must also note that a marked deficit in one of these systems may alone
explain a fall or disequilibrium. Nevertheless, most elderly patients have only mild
to moderate deficits, and the combination of multiple impairments is in most cases
the reason for falling[17].
Fall risk assessment tools
Once the patient has been examined and physical and neurological deficit has been
identified, the physician can use one or two assessment tools to verify mobility,
balance and the fall risk.
Review papers about fall risk assessment list up to 28 different functional measurement
tools[18],[19], and to make an analysis of all these tools is not our objective. Among all these
tools, a few are often used and cited and are easy to perform in a practical and clinical
approach and will be further discussed ([Table 2]). Although there is no consensus on which tests should be used, there is some agreement
that an ideal evaluation should incorporate more than one test[18],[20].
Table 2
Assessment tools frequently used to identify risk of fall.
|
Single measure tools
|
|
Test
|
Purpose
|
Instructions
|
Interpretation
|
Cut-off for falls
|
|
Functional reach test21
|
Measures the maximum distance a person can reach forward while standing in a fixed
position
|
The patient is instructed to stand next to a wall and position the arm that is closer
to the wall (but not touching) at 90 degrees of shoulder flexion with a closed fist.
The assessor Instructs the patient to “Reach as far as you can forward without taking
a step.” The location of the 3rd metacarpal is recorded at beginning and ending position,
and the scores are the difference between these values. Three trials are done, final
score is the average value of the best 2 results.
|
Smaller distances = worse performance
|
< 18,5cm22
|
|
Gait velocity24
|
Measures the walking speed in a comfortable, natural speed
|
A distance of 3-10 meters is measured, with or without an addition distance for acceleration
and deceleration. Individual is timed once the foot touches the initial path and is
stopped once it reached the end of the path (without the acceleration and deceleration
distance). Two trials are measured
|
Higher gait velocity = better functional mobility Normal functional mobility = gait
speed > 1,0m/sec
|
<0,7m/s26 <1,0 m/s20
|
|
Berg Balance Scale27
|
Assesses balance
|
14 items, that include static and dynamic balance tasks Each item points 0-4 Total
scale score 0-56
|
Higher scores = better performance
|
45-49 points29
|
|
Timed up and Go (TUG)30
|
Assesses balance, mobility, walking ability
|
The patient sits on a standard armchair, and is instructed to stand up, walk on a
comfortable speed along a l3 meters line, turn around at the line, walk back to the
chair, and sit down. The test ends when the patient’s buttocks touch the seat.
|
Shorter time = better performance
|
>11 sec20 >13 sec18
|
|
miniBEST test31
|
Assesses balance, mobility, walking ability
|
14 items, that include dynamic balance tasks, walking tasks and TUG. Each item point
0-2 Total score 0-28
|
Higher scores = better performance
|
>19 points33 17-25 points32 (age dependent)
|
These assessment tools can be divided into single-performance tests (gait velocity
and functional reach test) and multidimensional performance tests (timed up and go,
Berg balance test, miniBEST test).
The objective functional reach test (FRT) is intended to evaluate how far the person
can lean forward without taking a step or losing balance. Normal values are above
18,5cm [21] and values below that point are associated with an increased risk of fall[22].
Although walking may be seen as an easy task, it is quite a complex one and is considered
a useful sign of functional mobility, as the slower the gait, the greater the chance
of adverse events[23]. To measure gait velocity is very simple, but a few pitfalls must be mentioned:
(1) the distance must be 3-10 meters, and longer distances give more reliable measures,
(2) a small distance for acceleration and deceleration can be used, but the velocity
must be measured only in a predetermined line; (3) the patient must be specifically
instructed to walk at a comfortable, normal speed[24]. Normal gait speed is different for different ages, and older adults have a slower
velocity[25], thus cut-off values for risk of fall range from 0.7m/sec to 1.0m/sec[20],[26].
There is some controversy regarding the usefulness of the Berg balance scale[27] for assessing fall risk in the elderly[28],[29], and a ceiling effect has been reported[28], but this is still one of the most cited tools. A recent review and meta-analysis
observed that cut-off for risk of fall between 45 and 49 points had a good predictive
validity in sensitivity[29].
The timed up and go test[30] has long been used and a vast number of modifications such as walking as fast as
possible, walking distances greater than three meters, additional cognitive or motor
tasks have been described[18]. Normal values increase with age and range from eight seconds in people aged 60-69
to 12 seconds in those aged 80-89[25]. Thus, the cut-off for fall risk also shows variations from 11-13sec[18],[20].
Through the mini-Balance Evaluation Systems Test (miniBESTest) scale it is possible
to evaluate the performance in 14 tasks related to four aspects of dynamic balance:
anticipatory adjustment, compensatory response, sensory organization, and gait. Each
of the items can be graded between 0 and 2 points, the highest score being related
to a better functional status[31]. Since older adults have a poorer performance and lower score, the cut-off values
for fall risk in adults from 60 to above 90 range from 17 to 25 points[32],[33].
INTERVENTIONS TO PREVENT FALLS
INTERVENTIONS TO PREVENT FALLS
As falls in older people are multifactorial, relating to behavioral, environmental,
socio-economic, and biological factors, efforts to prevent falls in the elderly should
not be isolated. The prevention of falls in the elderly is supported by the Active
Aging policy. According to the World Health Organization, Active Aging is “the process
of optimizing opportunities for health, participation and security in order to enhance
quality of life as people age”. The determinant factors of Active Aging are gender,
culture, access to health and social services, behavioral determinants, physical environment,
personal, social, and economic determinants[3]. Once functional capacity is impaired in the older age, fall prevention measures
should be instituted to reduce falls and the complications resulting from them.
Based on the knowledge of risk factors for falls previously discussed, several studies
have analyzed the effectiveness of simple and multiple interventions. Theoretically,
for each fall risk factor there would be a prevention intervention. However, many
risk factors are non-modifiable and prevention is limited. In this situation, promoting
the understanding of these non-modifiable factors that result in falls can help to
raise the awareness of older people and care providers that they should be more cautious
in hazardous situations[5].
The interventions are often based on known modifiable risk factors for falling and
many studies have evaluated the effectiveness of different interventions for the prevention
of falls in the elderly. Many systematic reviews and meta-analysis studies have analyzed
the effectiveness of different intervention programs to reduce the risk of falls,
including single, multiple, and multifactorial interventions. Although studies have
shown promising results, interventions have varied isolated or combined strategies
resulting in data heterogeneity and difficulty in generalizing positive results[34].
Therefore, it has been necessary to develop a standardization through a taxonomy and
common data collection system. Gillespie et al. categorized the interventions using
the fall prevention classification system developed by the Prevention of Falls Network
Europe (ProFaNe)[35],[36] ([Table 3]).
Table 3
Components of fall prevention.
|
Intervention
|
|
|
Exercises (supervised, unsupervised, or both)
|
gait; balance and functional training; strength/resistance exercises; flexibility
exercises; 3D training (e.g. Tai Chi); general physical activity; endurance training
or others.
|
|
Medication (review and target)
|
vitamin D and calcium supplementation.
|
|
medication withdrawal, dose reduction or increase, substitution or provision (antihypertensives,
cardiovascular agents, drugs used in diabetes, anti-parkinson drugs, anti-dementia
drugs, antidepressants, antipsychotic/neuroleptic drugs, anxiolytics/hypnotics/sedatives,
other)
|
|
Surgery
|
cataract extraction, pacemaker provision, podiatric surgery or others.
|
|
Management of urinary incontinence
|
e.g. assisted toileting, bladder retraining, prompted voiding, pelvic floor exercises,
antispasmodics
|
|
Fluid or nutrition therapy
|
Fluid therapy to restore the volume and composition of the body fluids to normal with
respect to water- electrolyte balance. Nutrition therapy to improve health status
of an individual by adjusting the quantities, qualities, and methods of nutrient intake.
|
|
Psychological individual or group
|
Cognitive (behavioural) interventions and others.
|
|
Environment/Assistive technology
|
Furnishings and adaptations to homes and other premises, aids for personal mobility,
aids for communication, information and signalling, body worn aids for personal care
and protection, social environment.
|
|
Social environment
|
staff ratio, staff training, service model, telephone support, caregiver training,
home care services, others.
|
|
Knowledge
|
pamphlets, information, booklets/sheets, videos, lectures.
|
The interventions to prevent the fall risk in older people are classified into three
major groups[37]:
-
Single intervention;
-
Multifactorial interventions: two or more interventions are given to a person according
to the individual risk factor profile (e.g., the intervention exercise and home-hazard
modification is applied to one person, whereas home-hazard modification and medication
modification may be performed in another);
-
Multiple interventions: two or more interventions are applied to all individuals participating
in the fall prevention program (e.g., supervised exercise and vitamin D supplementation).
Thus, we will discuss the different prevention interventions to be performed alone
or in combination ([Table 4]).
Table 4
Modifiable and non-modifiable fall risk factors and possible interventions to prevent
falls.
|
Risk factor
|
|
Intervention
|
|
Non-modifiable conditions
|
Age Female gender
|
Raising awareness of the increased risk of falls
|
|
Medical conditions
|
Chronic diseases
|
Improving the individualized management of chronic diseases
|
|
Depression
|
Improving the individualized management of depression Exercises
|
|
Pain
|
Improving the individualized management of pain
|
|
Impaired cognition
|
Improving the individualized management of impaired cognition Cognitive training,
computerized version of cognitive training Exercises
|
|
Visual impairment
|
Treatment with corrective lenses or surgery Exercises
|
|
Balance impairment
|
Gait; balance and functional training; strength/resistance exercises; flexibility
exercises; 3D training (e.g. Tai Chi); general physical activity; endurance training
or others.
|
|
Medication
|
Polipharmacy
|
Medication review (withdrawal, dose reduction or increase, substitution, provision):
anti-hypertensives, cardiac effects, hypoglycemic medications, skeletal muscle relaxants,
antihistamine medications and mainly psychoactive drugs
|
|
Supplementation
|
Vitamin D plus calcium
|
|
Behavioral
|
Living alone History of falls ADL limitations
|
Raising awareness of the increased risk of falls Possible change of living arrangements
Aids for walking assistance: walking-sticks, walking-frames, wheelchairs
|
|
Inactivity
|
Exercise, education
|
|
Environmental
|
Narrow steps
|
Advise for the use of appropriate footwear
|
|
Slippery surfaces of stairs
|
Installation of safety features, correction or removal of hazards
|
|
Looser rugs
|
Correction or removal
|
|
Insufficient lighting
|
Correction of ambient lighting
|
Interventions in non-modifiable conditions
For risk factors that have no scope for correction, such as advanced age and female
gender, intervention strategies must be performed with the individual and caregivers
raising awareness of the increased risk of falls[5].
Medical conditions
Many clinical and neurological conditions can contribute to the increased risk of
falls. Intervention should be instituted as soon as the fall risk assessment is performed,
regardless of a lack of evidence, in order to reduce the number of falls. In systematic
review studies, for example, improving the management of chronic diseases, depression,
and pain has been shown to potentially have much more effect on quality of life than
on reducing falls, although this has not been tested[37].
Cognitive training (non-physical practice) can improve physical performance of older
adults during single-task and dual-task walking (for example, walking while talking).
It can be performed using a computerized version of cognitive training with a suggested
session duration of 45 minutes or less. A shorter period of cognitive training helps
to improve an acceptance of this intervention[38].
A vision assessment and treatment with corrective lenses or surgery, in combination
with exercises, is strongly associated with reduction in injurious falls. The same
is observed when multiple interventions are combined including exercises, vision assessment
and treatment, environmental modification, and vitamin D supplementation[2].
Exercises
Interventions with exercises are the most studied in prevention of falls and they
have shown a reduction in both the rate of falls and the number of people who have
falls. No difference was observed between groups of individuals with a high risk of
falling or not. In all types of exercises the outcomes were better in reducing falls
when interventions were performed by health professionals compared with interventions
by trained instructors who were not health professionals[39]. The main categories of exercise programs associated with high-certainty evidence
of fall reduction are balance and functional exercises. Interventions with multiple
categories of exercises, mainly programs including balance and functional exercises
plus resistance exercises, probably reduce falls (moderate-certainty evidence) though
it was uncertain whether exercises classified as 3D (Tai Chi or similar) using the
ProFaNE taxonomy reduced the rate of falls (very low-certainty evidence)[40]. Despite the latter interventions showing less evidence, the great heterogeneity
observed in the systematic review studies does not allow a precise evaluation of these
data.
Fall prevention interventions with exercise lasting less than six months were not
effective in reducing the risk of falling. When these programs have a longer duration,
lasting from six to 12 months or 12 months, the fall risk is reduced in 33% and 36%,
respectively[41]. Similarly, the beneficial effects of different programs of exercises in fall risk
in older people are related to the frequency of intervention. These effects were shown
with a frequency of three to five times a week[42].
Medication
Medication review is a necessary intervention that includes different actions (withdrawal,
dose reduction or increase, substitution, provision) targeted to specific classes
of drugs, mainly those that cause hypotension, cardiac effects, hypoglycemic medications,
skeletal muscle relaxants, antihistamine medications and mainly drugs acting on the
central nervous system[3],[5].
Regarding vitamin D supplementation, randomized controlled trials showed inconsistent
findings, positive or negative, according to dosage of vitamin D[43],[44]. However, the effectiveness of vitamin D supplementation for the prevention of falls
is related to the basal serum levels of 25(OH)D in the elderly. Trials with vitamin
D supplementation in older people with concentrations less than 20ng/mL demonstrated
beneficial effects on preventing falls[45]. Unlike isolated vitamin D supplementation in fall prevention, the combination of
vitamin D and calcium showed a 12% reduction in the risk of falls and benefits to
musculoskeletal function and bone metabolism[45],[46].
Behavioral and environmental interventions
Fall prevention education promotes fall risk awareness and knowledge facilitating
engagement in behavior and lifestyle changes, such as physical activity. Although
the target of this intervention is the elderly, in order that it can attain positive
results, it must be applied to both the elderly, caregivers, health professionals
and the wider communities in which the older people live[3].
Environmental interventions are related to the adaptations of homes, walking aids
and aids for personal protection and changes in social environment mobility. Adaptation
of homes refers for example to ambient lighting, suitability of beds, chairs, attention
to rugs and slippery surfaces, and other factors. Walking-sticks, walking-frames,
wheelchairs, orthopedic footwear are some aids for walking assistance and personal
protection[3].
TECHNOLOGY IN FALL DETECTION AND PREVENTION
TECHNOLOGY IN FALL DETECTION AND PREVENTION
With advances in technology, researchers have developed techniques for detecting and
preventing falls in the elderly, and some will be briefly discussed.
Fall detection devices
Fall detection systems are used in order to establish whether an older person has
had a fall through an alarm sent to health professionals, and so the consequences
of falls are minimized. These systems continuously monitor older individuals using
devices to find the fall prediction. These can be divided into three categories[47],[48]:
-
wearable devices consist of accelerometers, gyroscopes, magnetometers, etc. The posture
and movement sensors process the information and decide if it is a fall or not. The
decision is communicated to the pre-selected caregivers. The disadvantages of these
devices are that they are intrusive and can be an extra burden to some individuals.
Moreover, there is the risk of device displacement during everyday activities and
less accurate results;
-
camera-based devices, placed at selected locations around the individual for continuous
monitoring. The major disadvantages of these systems are their limited coverage and
that they compromise the user’s privacy;
-
ambience devices that are a series of sensors strategically installed close to the
individual, such as a wall, floor, bed, etc. The data are processed, and an algorithm
decides whether there is a fall or not and then the caregivers are notified.
Fall preventing devices
For the future, there are many machines learning algorithms still under development
based on the data collected by sensors and data processing to identify and prevent
falls.
Today a system of fall injury prevention is already available: the wearable airbag.
This multisensory smart wearable belt detects collision with the ground surface. With
a response time of 0.133 second it triggers two large-size airbags that lessen the
fall impact. The limiting factors are the high cost and its effectiveness has not
been evaluated on a large scale[49].
Fall intervention devices
Fall intervention devices are used to improve the knowledge, mobility, and balance
in older people. However, there is still no evidence that using these technology-based
applications prevent falls[49]. The main examples of these technologies are: exergame and VR system; robot personal
coaching system for fall education and walking-aid cane robot for real-time assessment
of mobility and support to the user.
In conclusion, falls are a major problem in public health with physical and psychological
consequences, compromising the quality of life and increasing the risk of further
falls.
Several risk factors for falls that can be grouped in different domains (psychosocial,
demographic, medical, medication, behavioral, environmental) and the clinical evaluation
of an older adult prone to falls must include identification of these risk factors
through history and examination. Furthermore, identification of risk of fall must
be done through an assessment tool such as gait velocity, functional reach test, timed
up and go, Berg balance test, miniBEST test. Fall prevention strategies can be single
or multiple, and physical activity is the most cited. Technologies can be used to
detect and prevent falls. Thus, a systematic approach to the older patient at risk
of fall is feasible and may impact fall prevention.
