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 Table of Contents  
CONCEPT PAPER
Year : 2022  |  Volume : 18  |  Issue : 4  |  Page : 227-232

Falls are preventable: A multicomponent falls preventive approach for elderly


Department of Nursing, College of Nursing, Swami Rama Himalayan University, Dehradun, Uttarakhand, India

Date of Submission07-Sep-2022
Date of Decision24-Sep-2022
Date of Acceptance07-Oct-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Monika Kankarwal
Department of Nursing, College of Nursing, Swami Rama Himalayan University, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_49_22

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  Abstract 


Indian aging population is increasing steadily and tremendously imposing a major impact on global implications and challenges in medicine and nursing world. The problem faced by the elderly population is numerous and alarming for the nation, society, health-care system, and family caregivers of the elderly. Falls are estimated to be the second-most leading cause of mortality worldwide among elderly and are considered geriatric giants. Falls are the resultant of complex interaction among various risk factors such as biological, behavioral, socioeconomic, environmental, intergenerational bonding, cultural practices, and ethnicity. These risk factors either alone or in combination cause falls among elderly. Falls are very much preventable among elderly at the primordial and primary prevention levels itself. Timely intervention with multicomponent falls preventive approach for the elderly at the community level has resulted not only decrease in the rate of falls and falls-related injuries among them but also proved to be most effective and relevant in terms of cost-effectiveness, time-consumption, and labor intensiveness for the health-care system, families, society, and community.

Keywords: Elderly, falls, multicomponent falls preventive approach


How to cite this article:
Kankarwal M, Prakash K. Falls are preventable: A multicomponent falls preventive approach for elderly. J Indian Acad Geriatr 2022;18:227-32

How to cite this URL:
Kankarwal M, Prakash K. Falls are preventable: A multicomponent falls preventive approach for elderly. J Indian Acad Geriatr [serial online] 2022 [cited 2023 Feb 8];18:227-32. Available from: http://www.jiag.com/text.asp?2022/18/4/227/365775




  Introduction Top


As people aged 60 years and above have increased steadily in India, it is estimated that the elderly population will increase to 12% of the total population by 2025, 8%–10% of which are estimated to be bedridden requiring utmost care. The problems faced by this segment of the population are numerous owing to the social and cultural changes that are taking place within Indian society. Falls are one of the major problems in the elderly and are considered one of the “Geriatric Giants.”[1] Recurrent falls are an important cause of morbidity and mortality in the elderly and are a marker of poor physical and cognitive status.[2] According to the World Health Organization, falls are estimated to be the second-leading cause of mortality worldwide, and it is estimated that 80% of the falls occurring in low- and middle-income countries, of which South East Asia accounts for 60% of fall-related mortalities.[3]

ICD-10-CM Coding Rules W19. XXXA describes falls as circumstance causing an injury, not the nature of the injury. It leads to disability and a loss of independence among elderly. Falls due to slipping and tripping result in injury.[4]


  Risk Factors Related to Fall among Elderly Top


The World Health Organization has developed a risk factor model for falls among elderly, which consists of the complex interaction among biological, environmental, behavioral, and socioeconomic risk factors.[5] Ethnicity, intergenerational bonding, and cultural practices also play a crucial role in determining falls among elderly as shown in [Figure 1].
Figure 1: Various risk factors associated with falls among elderly

Click here to view



  Biological Risk Factors Top


Biological risk factors also considered intrinsic risk factors include both nonmodifiable risk factors which are age, gender, and race and modifiable risk factors which are chronic illnesses, cognitive, affective, and physical decline. A descriptive study conducted by Pitchai et al. on assessment of prevalence, risk factors, circumstances for falls, and level of functional independence among Indian elderly revealed that the fall rate tends to increase with advancement in age with mean age ranging from 71.86 ± 7.49 years among elderly.[6] A review on epidemiology of falls among Indian elderly conducted by Joseph et al. proposed the prevalence rate of falls among elderly people living in Indian community settings ranges from 26% to 37%.[2] The prevalence of falls among women (40.6%) is more common compared to men (31.5%).[7] Elderly with impaired gait, using assistive devices, and having chronic comorbidities such as hypertension, diabetes, Parkinson's, osteoarthritis, poor vision, hearing impairment, urgency of micturition, altered cognitive, and affective conditions such as depression are more prone to falls.[2],[8] Polypharmacy is the consumption of multiple drugs by a person as per clinical suitability of such use, is very much common among the elderly population and results in many negative consequences such as falls and adverse drug reactions in them. Drugs which are commonly prescribed and cause falls in the elderly are antidepressants, diuretics, sedatives, and antihypertensive drugs. Consumption of over-the-counter drug is again a big challenge for the elderly as they result in falls among them due to the lack of awareness about the side effects and interactions among drugs.[8],[9]


  Behavioral Risk Factors Top


Behavioral risk factors also known as extrinsic risk factors include hurrying, rushing, risk-taking behavior, sedentary lifestyle, and alcohol and tobacco consumption, and the previous history of falls is resultant of falls in the elderly population.[10],[11] Surveys have reported that between 30% and 73% of older persons who have fallen acknowledge a fear of falling. This postfall anxiety syndrome can result in self-imposed activity restrictions among the home-living and institutionalized elderly fallers. The loss of confidence in the ability to ambulate safely can result in a further functional decline, depression, feelings of helplessness, and social isolation.[6],[12],[13]


  Environmental Risk Factors Top


Environmental risk factors include poor infrastructure design both inside the house and outside the house. Inside the house, environmental risk factors include poor lighting, clutters, poor staircase design, unsecured mat and floor rugs, nonskid mats, slippery floors, and nonavailability of grab bars in the bathroom. Public factors which result in fall include poor building design, uneven roads, lack of proper lighting on roads, highly crowded areas, etc.[5],[14] Majority of falls occur in the morning (44.9%), inside the house (65.4%), and due to slipping (56.45%).[6] A study conducted by Patil et al. on circumstances and consequences of falls on elderly residing in Indian community settings indicated that the majority of the elderly population wants to finish their household chores, self-care activities, and spiritual rituals early in the morning which results in hurrying, rushing, slipping, and tripping among them which results in falls.[15]


  Socioeconomic Risk Factors Top


Lower socioeconomic status is associated with fall among elderly. The elderly residing in urban areas report less number of falls as compared to the elderly residing in slum and rural areas.[2],[16] A prospective cohort study on Indian elderly dwelling in a community setting by Sasidharan et al. for assessing risk factors for falls concluded that the elderly living alone is at high risk of falls as compared with those elderly who live with their spouse and family members (P = 0.002).[17] A study conducted by Srivastava et al. on poverty among elderly in India intimated that, over 18 million of the elderly lives below the poverty line in India. For the elderly, income reduces and consumption expenditures increase mainly for availing medical facilities, resulting in either reduction of health-care facilities utilization by them or else pushing families onto medical poverty trap.[18] Both direct and indirect costs are associated with falls which is critical for family, community, and society. As direct cost encompasses medication and health-care services associated with falls and indirect cost include losses of societal productivity, and losses of family activities, for example, loss of income which would have been sustained if falls would not have taken place.[5] A study conducted by Burns et al. for assessing the direct costs of fatal and nonfatal falls among elderly residing in the United States from 2012 to 2015 concluded that the USA had experienced increase in substantial economic costs associated with falls. The cost for fatal falls roses from $616.5 million in 2012 to $637.5 million in 2015, and for nonfatal falls, it roses from $30.3 billion in 2012 to $31.3 billion in 2015.[19]


  Ethnicity, Intergenerational Bonding, and Cultural Practices Top


Ethnicity, intergenerational bonding, and cultural practices play a major role in the incidence of falls among elderly. Married elderly experiences less falls and fall-related injuries due to the physical and emotional support they receive from their spouse. Customary activities and religious rituals such as the use of carpet during early morning hours for praying by Islamic elderly, use of oil while bathing by Indian elderly, sitting on the floor with folded legs at the time of prayer by Hindu elderly and then getting up from the floor after prayer, etc., imposes elderly at risk of falling.[10],[20] A ethnography study conducted by Horton et al. for assessing the role of culture and diversity in the prevention of falls among Chinese elderly suggested that Chinese people values more of their independence and feel reluctant using formal health-care services, hide falls from their children and avoid discussing falls with their children.[21] For decades, India is being known for its rich cultural practices, norms, and multigenerational family system where every family member shares common economic resources and responsibilities for household chores, is now facing intergenerational bonding reciprocity in terms of care and support due to modern lifestyle.[22] A study conducted by Goel on falls research is coming of age concluded that despite global advances in the field of falls research, only few studies have been carried out from India in the area of falls among elderly.[23]


  Assessment of Falls among Elderly Top


A physical examination, assessing potential environmental hazards, medication review status of the elderly, knowing falls history and nature of falls, assessing functional limitation, addressing gait and balance abnormalities, and assessing riskiest behavior related with falls among elderly, can be used in the assessment of risk factors associated with falls.[24]


  Physical Examination Top


The physical examination should focus on assessing biological risk factors parameters such as age, gender, chronic illnesses, medication review, orthostatic hypotension, any eye and hearing impairment, and inappropriate use of assistive devices.[5],[24]


  Functional Mobility Assessment Tools Top


Various tools had been identified for assessing functional mobility, gait, and balance abnormalities among elderly such as the Timed up and Go test, berg scale, 30 Second chair test, the one-legged stance assessment, and lateral reach test according to systematic review no single tool alone can predict the accurate risk of falling among elderly, researcher has to use two or more tool for more accurate findings.[25],[26]


  Environmental Risk Factor Assessment Tool Top


Environmental risk factor assessment tool asses all the potential home hazards and individual surrounding environments which impose elderly on the verge of falling. The Home Falls and Accidents Screening Tool and Home Assessment Profile are few standardized tools available.[27],[28]


  Multifactorial Falls Risk Factors Assessment Tools Top


For assessing falls, various multifactorial falls risk screening tool are available such as the Johns Hopkins Fall Risk Assessment Tool, fall risk assessment tool, and CAREFALL Triage Instrument measures falls risk status, history of falls, numbers of falls, recurrent falls, risk factors associated with falls, falls-related injuries, etc.[26],[29]


  Key Elements for Falls Prevention among Elderly Top


Falls are preventable in the elderly. A variety of falls prevention measures are available for preventing falls among elderly which are as follows [Figure 2]:
Figure 2: Key elements associated with falls prevention among elderly

Click here to view


  1. Falls prevention education program,
  2. Single intervention majorly includes exercise as a falls prevention measure,
  3. Enhancing intergenerational bonding, ethnicity, and cultural practices,
  4. Promoting the concept of active aging,
  5. Multifactorial interventions, involve the assessment of two or more modifiable risk factors among elderly for falling, then followed by specific interventions modifying those risk factors,
  6. Multicomponent interventions involve a fixed set of common interventions that are able to target different modifiable risk factors domain.



  Falls Prevention Education Program Top


Education program has significantly enhanced positive fall prevention behavior, increased falls risk factors awareness, and enhanced knowledge among elderly.[30] Education on proper use of assistive devices and environmental modifications such as properly refracted eyeglasses, proper use of walking aids, installation of grab bars in the bathroom, alarm system in the room, removing clutters from the floor, using antiskid mat, proper lightening, and avoiding crowded places have improved independence, functional mobility, and confidence while performing task among elderly.[31] Only a few studies were conducted on behavior risk factor modification which includes awareness regarding annual eye and ear examinations, timely reviewing of medication with physician, consumption of Vitamin D supplementation. In Ottawa, a survey for measuring fall prevention behavior and awareness among elderly suggested that only 44% of the elderly were aware about polypharmacy consumption can increase fall risk, 56% were aware of the importance of reviewing medication timely with their physician can reduce falls among them, and only 34% of elderly consume Vitamin D supplementation.[32]


  Single Intervention Top


Exercise had a great effect in reducing falls among community-dwelling elderly, elderly with Parkinson's disease or cognitive impairment P = 0.004 by improving strength, functional abilities, activity of daily life, mobility, and balance in them.[33],[34] Different types of exercise improves different parameter such as Tai Chi which is a series of gentle exercises and stretches increases flexibility and balance and reduces the rate of falls by 19% and up to 20% among those people who experienced falls previously.[24] Yoga also had gained popularity among people of Western culture as a complement to conventional medical services, during the second half of the twentieth century.[35] On providing preferences among Yoga, Tai Chai, and Otago Exercise Program to elderly people residing in the community, yoga was perceived to be most popular and appropriate for fall prevention among them.[36]


  Enhancing Intergenerational Bonding, Ethnicity, and Cultural Practices Top


Intergenerational bonding is known for establishing a positive relationship between the elderly and youth. Where the elderly contributes in the well-being of youth and vice versa extending sense of purpose, providing opportunities to engage with youth socially and emotionally, and extending benefits to both groups. A review of intergeneration learning program suggested that elderly who participated in intergenerational activities such as reading books for children, playing hand game with them, and children offering knowledge to the elderly about computer and Internet use have resulted in decrease in frailty, falls rate, maintenance of independence, improvement in self-esteem, and mental health promotion among elderly.[37] Ethnicity and culturally appropriate driven falls prevention program should be developed and implemented according to different ethnic and culture-specific groups as cultural diversity affects acceptance of falls prevention program among elderly and ethnicity- and cultural-related factors play a major role in falling among elderly.[20],[21]


  Promoting Concept of Active Aging Top


The WHO has identified the active aging concept as one of the important determinants in preventing falls among elderly. Active aging is a holistic and lifelong process that focuses on the idea of longer activity through optimizing opportunities for health and social services, security, and participation for enhancing the quality of life by the person through the interaction of various interrelated determinants which are behavioral, physical environment, personal, and social and economic determinants surrounded by individuals, families, and communities for its promotion.[5] A research conducted by Rogerson et al. on successful aging in Singapore states that once you start practicing healthy lifestyle, you are at a stage of making better choices for yourself in later life and thus the introduction of active aging concept among elderly ensure longer living, intergenerational harmony, better quality of life, health promotion, financial security/independence, and actively contributing to society.[38]


  Multifactorial Intervention Top


Multifactorial approach includes falls prevention measures that are tailored after assessing individual-based risk factors and according to the need of individual elderly. The multifactorial interventions include, individual-based exercises for muscle strength, balance, and mobility, and education on proper use of mobility aids if using, home/environment modification, medication review, correction of vision/hearing impairment if any, psychological intervention. A meta-analysis review conducted by Lee et al. on the effectiveness of multifactorial interventions in preventing falls among elderly residing in community settings proposed that the elderly who received intervention had significantly reduced fall rate (risk ratio 0.77) and number of people experiencing falls (risk ratio 0.77).[39]


  Multicomponent Intervention Top


Multicomponent approach is a combination package of two or more fixed falls prevention measures that are not individually based. Only a few literature have paid attention to this approach. Multicomponent interventions studied till now majorly include measures on exercise, medication review, urinary continence management, nutritional supplements, environmental modifications, psychological management, and education on assistive device use. It is acknowledged that multicomponent approach which is not individually tailored have more benefit in decreasing falls rate, number of people experiencing fall and depression, and improve balance and mobility. Multicomponent intervention is considered more appropriate measures in delivering services to the elderly at the community level in terms of cost-effectiveness, time –consumption, and labor intensiveness.[40],[41]


  Conclusion Top


Population aging is increasing tremendously imposing a major impact on global implications and challenges. The elderly population is a precious asset of every nation. India being a second-leading country in the elderly population owes to face major challenges in terms of social, cultural, medical, and psychological problems for the elderly. As falls are a geriatric giant, and highly prevalent among elderly causing pain, distress, dismay, disability, morbidity, loss of independence, psychological problem, low self-esteem, and decreased quality of life among them. Falls are a resultant of complex interaction among various risk factors such as behavioral, biological, socioeconomic, environmental, ethnicity, and intergenerational bonding and cultural practices. Falls are preventable among elderly; numerous numbers of fall prevention measures are available globally ranging from single intervention to multicomponent interventions, mainly focusing on exercises, environmental modification, medication review, education on the proper use of assistive devices, and correction of hearing and vision impairment only. Very few studies have focused on socioeconomic, intergenerational harmony, active aging concept, and culturally driven falls prevention measures all together, which will prevent falls among elderly to much greater extent. In India, there is a need of introducing culturally appropriate multicomponent falls prevention intervention to prevent the elderly from falling and fall-related injuries at the community level itself.[10]

Recommendation

  • It is recommended to use the WHO fall risk factor model along with ethnicity, intergenerational bonding, and cultural practices concepts as a basis for the assessment of risk factors related to falls and also for the development of multicomponent interventions
  • It is recommended to develop a culturally driven appropriate need-based multicomponent falls prevention intervention for elderly
  • It is recommended to include the concept of active aging, intergenerational harmony, and socioeconomic parameters while developing multicomponent falls prevention measures for elderly
  • Prepare an evidence-based need-based falls prevention program that will be easily available for ready to use by the government, policymakers, heath-care providers, and society and community people in preventing falls among elderly at the national level.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Risk Factors Rel...
Biological Risk ...
Behavioral Risk ...
Environmental Ri...
Socioeconomic Ri...
Ethnicity, Inter...
Assessment of Fa...
Physical Examination
Functional Mobil...
Environmental Ri...
Multifactorial F...
Key Elements for...
Falls Prevention...
Single Intervention
Enhancing Interg...
Promoting Concep...
Multifactorial I...
Multicomponent I...
Conclusion
References
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