The Fall Prevention Program Manual
Roberta A. Newton,
Professor of Physical Therapy
College of Allied Health Professions
Department of Physical Therapy
3307 North Broad Street
Philadelphia, PA 19140-5101
HRSA/Bureau of Health Professions
Grant No. 5 D37 AH00523
©Newton, RA, Fall Prevention Project, October 1997
Fall Prevention Program
Falls are the second leading cause of accidental
death in the United States. Seventy-five percent of these falls occur in the older adult
population. One third of the older adults who fall, sustain a hip fracture
and are hospitalized, die within a year. Falls not only affect the quality
of life of the individual but also influence the caregiver and family. Health care costs
for falls and rehabilitation average 70 billion dollars a year!
Even if the fall does not result in hospitalization, fear of falling becomes a major factor. Fear leads to inactivity and loss of confidence. This, in turn produces a cycle of fear, loss of self-confidence, and inactivity, thereby decreasing the quality of life and increasing the risk of falls.
Some health care individuals state that only one-third of the community-dwelling older adults fall each year, which is a relatively small number. Therefore they question the expenditure of the dollars for fall prevention. However, the argument can be countered by the fact that fall prevention programs may preserve and possibly improve the quality of life for even one individual. Second, we do not know the long-term health care benefits and reduction in costs for the general population. Some studies are beginning to demonstrate a cost-savings; that is, if the older adults are provided with a series of educational programs and environmental modifications, then the health care costs are reduced. Our knowledge as health care professionals may be able to reduce falls through volunteer efforts. The improving of one persons quality of life and possibly decreasing fall-risk factors is worth the time. The following information is by no means either a comprehensive or a "sure-fire" plan to prevent falls, but it is one possible method to help increase awareness regarding falls and fall prevention.GOALS
The suggestions and ideas in this manual are offered without knowledge of the state regulations for your professional licensure. Health care individuals may be able to provide lectures without referring to their professional identity.
A variety of avenues can be used. For example,
programs at senior centers, church groups, or YMCA and
YWCA activity groups. For local radio or TV talk-shows on
health related topics, also consider talks and appearances.
Information to present is based on the audience and your experience. Being able to identify with similar-aged individuals is an asset. Generally, the recommendations you will suggest are probably those you and the older adults are already doing. The presentation will bring these activities to a new level of awareness.
Several key areas to be considered when preparing a presentation are as follows:
Fear can lead to loss of self-confidence and inactivity. Fear is not only associated with falling down but also with getting up once having fallen.
If no one is available to call for assistance,
then the person
may have to get up on own or move to a different location to
call for assistance. Before moving, the person should be aware
if anything hurts or is possibly broken. Then move along the floor to a stable piece of
furniture such as a chair or sofa. Using the object as a support, first move into a
side-sitting position. If
need be, rest a few minutes, then kneel using the object as support. Then put one foot flat on the floor and push up into the chair. This last step is probably the hardest because of the strength required to do this movement. Once in the chair, the person should probably rest. The rest period will also help with orientation. Demonstrate how you would get up from the floor.
Activity is one key to reduce the risk of falls. With activity there is a good degree of self-confidence. If an individual has not been active, then he or she should check with a physician for possible limitations. Activity needs to be enjoyable to the individual, such as gardening, walking, water aerobics, Tai Chi. Tai Chi is rapidly becoming a very popular group activity for maintaining balance and activity levels. The type of activity is personal choice, because some people prefer individual activity and some prefer group activity. Just getting out of the house may be of great benefit.
A set of exercises for the frail, home-bound person or for anyone interested in a low-impact activity program is found in Appendix A.
A properly fitted cane, walker, or assistive device should be in good condition. Individuals may carelessly use a variety of objects to substitute for a cane; for example, use an umbrella that is not stable or does not have a rubber tip. Although viewed as a stigma of old age, a cane may prevent a fall. It should be noted that a learning curve does occur with the use of a cane because it is another object that needs to be manipulated. Some individuals need time to adjust to an assistive device before it becomes second nature.
Only a few internal factors are listed here;
traumatic injuries are not discussed.
Visual acuity decreases with age. Therefore, periodic eye exams or checkups are recommended. Be aware that either old prescriptions or new prescriptions can alter the visual field and cause falls. Also, clean glasses daily.
Changes in contrast sensitivity occur. This is related to the ability to detect and discriminate objects in the environment. One way to accommodate this is to increase the lighting (wattage).
Decline in depth perception occurs as a decreased
to judge distances and relationships among objects in the visual field. Stairs, carpets with patterns, and curbs are risk factors for individuals with such declines in depth perception. The person may have difficulty estimating the height of the step and therefore misplace the foot. Or,
the person may think that the carpet is uneven and alter balance and walking to accommodate the misperception.
The ability to recover from a sudden exposure to a bright light or glare decreases. When moving from a dark to bright lighted environment or the reverse, the person should pause a second to allow the eyes to accommodate to the change in light.
Periodic checkups are recommended. Because we rely on sound for orientation in the environment, a person may not be as quickly aware of a potentially hazardous situation when hearing is decreased.
Over 75% of older adults have foot pain. Foot pain is caused by, but not limited to, thin heel pad, corns, bunions, dry and cracked skin, ingrown or over grown toe nails, and sores. Foot pain can cause a change in the biomechanics or alignment of the body, thereby increasing the risk for falls.
Another potential risk factor for falls is decreased sensation in the feet. This is more noticeable in the person with diabetes, but gradually occurs with the aging process. Sensation can be tested on the person using a Q-tip or something soft and brushing it on the sole of the foot. It is not recommended to use a sharp object (eg, tip of a pen).
Recommended topics here would include daily foot inspection for red areas, sores, condition of toe nails; application of cream; avoidance of abrasive substances such as pumice stone or acid to reduce calluses or corns; and, shoe inspection for worn areas.
Also noteworthy is the condition of the person’s currently worn shoes and slippers. Ill-fitting or badly worn foot wear can lead to tripping and falling or sprains and strains. This problem is especially hazardous when combined with ill-fitting clothing that drags on the floor.
A handout on selection of shoes is found in Appendix B
Four or more medications is a risk factor for falls. Single or multiple medications (polypharmacy) can cause side effects such as dizziness, drowsiness, or low blood pressure. We recommend that prescription medicines and regularly taken over-the- counter medications be checked by the physician or pharmacist
A gradual decline in balance abilities and speed of gait occurs with age. These two are linked with activity level. One cause of tripping and stumbling is the anterior tibialis muscle, which dorsiflexes the ankle and toes to clear the toes during walking. With age, it becomes a little out of sync in its timing with other muscles in the leg. As a result, the timing of toe clearance is a little off and the toe may catch on the floor. During walking, toe clearance is approximately 1 cm. Be sure exercises (Appendix A) include one to maintain or strengthen the dorsiflexors in more frail or inactive older adults.
Gait speed also decreases and the person may not have sufficient time to cross the street; or may have to hurry to perform various activities. To have to walk faster, particularly when it is associated with anxiety, can cause a fall.
Remaining active and participating in leisure and social activities helps maintain balance and gait. (See a variety of activities that are listed under Activity).
Both high and low blood pressure can cause a person to become unsteady.
When moving from one position to another, such as either from the bed to sitting or from a chair to standing, the person should pause for a couple of moments to let the blood pressure adjust and to orient to the new position.
Falls are generally not the result of a single factor but rather a combination of both internal and external factors. Assessing the home is one method to reduce some detrimental external factors. Approaches can be done room by room or by elements (eg, lighting, clutter, spills). Both inside and outside assessments should be included. The brochures in Appendix C offer many topics and can be used to assist the presentation. They can be copied for the participants. When recommending changes, cost and desire to change are the two factors to consider.
Moving furniture is generally not recommended
unless it poses a definite fall-risk hazard. We have "cognitive maps" of our
environment; that is, we are able to maneuver in
our home environment with eyes closed. We tend to know where objects are and tend not to
run into things. Do not recommend that older adults rearrange things unless absolutely
necessary. When furniture is moved, a new cognitive map needs to be formed, and it takes
time to develop that new map. We also have cognitive maps for
our external environment, the map being stronger for
those places we visit more frequently and less strong for
the places we visit less frequently and when a person goes into the hospital, some of the confusion arises because the person does not have any cognitive map of the surroundings.
Example of recommendations for indoors follows.
General considerations include using night lights, keeping a flashlight by the bed, and using a cellular phone.
Flooring: avoid shiny floors having the appearance of being wet because they can cause unstable changes in the gait pattern, such as lowering the center of gravity by slightly flexing the knees. Although this is an appropriate adjustment to a potential hazard, it is an alteration of the typical posture of the individual. Can we convince public places to have duller looking floors? Be aware that raised door sills or any uneven flooring may cause falls. Try to make these potential hazards stand out in some obvious way.
Carpeting: when carpeting on the stairs and landing is the same color, mark the last step with tape or a color (not in the walk path) to differentiate the floor from the step and to alert the person to the bottom step. Be aware that geometric patterns on rugs can cause visual conflict problems, making the floor appear to be uneven.
Throw Rugs: eliminate the use of throw rugs, if
possible. Older adults, however, do have attachments to throw rugs.
If the person cannot be convinced to remove the rugs,
then increase their adherence to the floor by using tape
or a rubber mat.
Bathroom: ensure that the necessary functional aids are available to allow safety in getting on and off the toilet and in and out of the tub or shower. This includes safety while in the tub or shower.
Clutter: get rid of as much extraneous clutter on the floors and in pathways as possible, including extension cords, stacks of papers and magazines, and boxes.
Check the following areas for potential hazards and make recommendations for change accordingly.
Uneven sidewalks, terrain, or curbs requiring repair or highlighting. Need for additional lighting.
Gravel or debris on sidewalks requiring better
maintenance or preventive barriers. Handrails that are not available
where needed, that are not structurally secure, and that
are not suitable for height and grasp of person. All such problems are usually solvable.
Pets that get under foot, jump on people, or lie in pathways. (Also check for same indoors). Training may be needed for control methods and awareness.
When walking is required in crowded areas, calling
for an increased level of assistive devices and a protective plan
to stay near a wall.
Collection of hazardous materials (eg, snow, ice,
mud, and oil spills) needing periodic removal and clean up.
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Visit us and have older adults visit us at our WEB site:
Special thanks to the grant staff:
Sherry K. Tanksley-Bolden, BS, Program Coordinator
Ed Beasley, MEd, MS, Instructional Media Specialist.
Low Impact Activity Program
APPENDIX BFEET AND SHOES
|English||In-Home Safety Check||Check It Out!|
|Spanish||In-Home Safety Check||Check It Out!|
|French||In-Home Safety Check||Check It Out!|
|German||In-Home Safety Check||Check It Out!|
|Italian||In-Home Safety Check||Check It Out!|
|Polish||In-Home Safety Check||Check It Out!|
|Russian||In-Home Safety Check||Check It Out!|
|Vietnamese||In-Home Safety Check||Check It Out!|
|Chinese||In-Home Safety Check||Check It Out!|
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Last revised 3/30/04 RAN