By Sarah Schwaller, MPH, ISECN Regional Coordinator for North America (USA)
Population aging is a major worldwide trend. This shift in distribution of population towards older ages brings many opportunities but also important health implications. Older adult falls and fall-related injuries are key health issues affecting the health and well-being of older adults, their families, and society as a whole.1 Falls prevention is a relevant topic for health promotion professionals since we can play key roles in addressing this important public health topic and championing theory and evidence-based approaches for falls prevention in our communities.
Falls are a growing global public health problem due to our aging populations. It is estimated that each year, 37.3 million individuals seek medical care due to a fall injury and 424,000 fatal falls occur worldwide. Older adults (65+) suffer the greatest number of fatal falls.2 According to the U.S. Centers for Disease Control, 1 in 3 adults 65+ fall each year in the U.S. and every 11 seconds, an older adult is treated in an emergency room for a fall.3
Falls and fall-related injuries are also very costly. In the U.S., fall injuries rank among the top 20 most costly medical conditions; an average hospitalization for a fall injury costs more than $30,000. Last year, direct medical costs totaled $637.5 million for fatal fall injuries.4 The total cost of non-fatal fall injuries were $31 billion, which CDC Health Scientist, Elizabeth Burns, points out is nearing the financial burden of cancer which cost Medicare $36 billion in 2015. The cost of falls is expected to surge to $67 billion by 2020, as the population ages.5
Risk Factors and Prevention
Older adult falls risk factors are known and some are modifiable. Most falls occur as a result of a combination of environmental, biological, socioeconomic and behavioral risk factors.
Risk factors include a history of one or more falls within the last year, functional, cognitive, neurological or visual impairment, use of assistive devices, inappropriate footwear, osteoporosis, cardiovascular disease, chronic illness, postural hypotension, gait or balance abnormality, poor muscle strength, use of certain medications, and urinary incontinence. Hazards such as slippery surfaces, inadequate lighting, pets, inadequate safety equipment in the home and outdoor environments can also pose risks to older adults. 6 Depression, social isolation, and fear of falling can increase fall-risk in older adults as well. Protective factors primarily include behavioral changes and environmental modification both in the home and public environment.7
Just as falls are often caused by multiple factors, prevention must also be multi-factorial. Health promotion efforts focus on addressing modifiable risk factors – addressing and improving lower body weakness, mobility problems, walking aid use, multiple or unsafe medications, Vitamin D deficiency, foot problems and home hazards. Interventions vary based on fall risk levels and screening is key.
Primary prevention targets older adults who have no issues with walking or balance, no recent falls and/or an absence of other risk factors. Interventions focus on enhancing physical health through fall prevention programs or community fitness programs and preventing new fall risk factors from developing. Prevention may include medication reconciliations, vision testing, and home safety reviews to reducing environmental risks.6
Secondary and tertiary prevention may include the aforementioned interventions, in addition to referrals for physical or occupational therapy, and advanced fall prevention programs such as OTAGO instead of community-based exercise programs. Individuals may be assessed to determine their need for assistive devices and changes may be made to address inappropriate footwear or problems. Postural hypotension management or referrals to neurological specialist may be made when necessary. 6
Health promotion strategies for fall prevention are focused at multiple levels targeting seniors, caregivers, health care providers, community gatekeepers, Emergency Medicine Services (EMS) and policymakers. The Office of Disease Prevention and Health Promotion recommends that evidence-based falls prevention interventions be delivered in community settings by community providers and aging services.8 Popular evidence-based programs include Matter of Balance, Tai Ji Quan: Moving for Better Balance, Stepping On, The Otago Exercise Program, among others.9 At the healthcare level, Centers for Disease Control (CDC) released the STEADI Initiative for Health Care Providers that provides education, tools and materials for health care providers to reduce fall risks among patients. It features videos and online webinars, patient materials, and guidance for integrating screening and interventions into clinical practice. According to STEADI, for every 5,000 health care providers who adopt STEADI over a 5-year period, as many as 6 million patients could be screened, 1 million more falls could be prevented and $3.5 billion in direct medical costs could be saved.10
Evidence-based program highlight – A Matter of Balance
A Matter of Balance is one of several evidence-based programs for falls prevention. In several cities in Texas, aging services, academic institutions and health care organizations collaborate to offer A Matter of Balance program. AMOB, developed by MaineHealth, is a structured group intervention delivered over 8 weeks. It highlights practical strategies to reduce the fear of falling and increase activity levels. Program participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, make home modifications to reduce fall risk factors, and exercise to increase strength and balance. 11
The importance of fall prevention is gaining more attention in the U.S. yet there are still many barriers. The recent White House Conference on Aging, Fall Prevention Summit in 2015, soon-to-be released updated CDC Preventive Services Task Force report on the issue, STEADI initiative and leadership from the National Council on Aging are all recent positive steps towards reducing falls and fall-related injuries. However, changing mindsets and the belief that ‘falls are an inevitable part of aging’ is challenging as is integrating fall risk screening into standard practice in clinical settings. Older adults face many barriers to engage in fall prevention programs and make the necessary changes recommended by their primary care providers. Moving forward, it is important for falls prevention efforts to be integrated, collaborative and comprehensive, addressing multiple risk factors at individual, community, organization and policy levels.