causes of fall in geriatric along with physiotherapy prevention and management

1. Fall In Geriatrics, Risk factors,
Assessment, PT Rx
Ref: Duque. G. Osteoporosis in Older Persons
By: Radhika Chintamani
Fall definition: defined as unintentional change in position resulting in coming to rest at a lower
level or to ground.
It is very commonly seen in elderly, because of various reasons. Consequences of fall may be #,
head injury, etc. Here fall may/not be from height, but even d/t loss of balance,
giddiness/hypotension, as concomitant d/t heart disease, slip and fall, etc. They are both
associated with advancing age and an increased risk of disability, dependency, premature
nursing, home admission and mortality.
Vicious cycle of fall:
Epidemiology of Falls:
Even other ages like children, and teen ages like meeting with an accident have greater fall rates,
but in elderly falls are considered very important as minor falls may cause major # d/t
osteoporosis which is seen frequently d/t weakening of bones as age progresses.
Evidence: A study done by Tinneti et al, to assess the age and cause matched for fall risk in
elderly, concluded that 30%/yr for 65yrs, and 40-55%/yr for 80y of aged with main factor being
lower BMD.
Frequent consequences of Falls:
Cause Consequence
Medical Haematoma
Fracture
Chronic pain
Death
Psychological Fear of Falling
Anxiety
Depression
Loss of confidence

2. Social Dependency
Isolation
Placement in Long-term Care
Functional Immobility
Deconditioning
Disability and dependence
Causes and Risk Factors:
Domain Risk factor Assessment tools
Neuromuscular Parkinson gait syndrome
Balance and Gait problem
Lower extremity weakness
Gait Velocity
Get UP and Go
POMA
Medical Dizziness or vertigo
Visual impairement
Peripheral neuropathy
Hip problems or deformity
Cognitive problems or depression
Auditory tests, History and examination
Visual acuity test
NCV
X-rays
Depression scales
Environmental Environmental fall hazards Assessment of environmental fall
hazards
Cardiovascular Orthostatic hypotension
Post-prandial Hypotension
Vaso-vagal syndrome
Carotid sinus hypersensitivity
Measurement of BP: Morning as soon
as he wakes up, bed tilted at 45degs,
supine-to-sit, etc.
Assessment of JVP.
Common causes of falls and abnormal mobility and gait in older adults
Symptom Potential Cause
Difficulty raising from chair Weakness
Osteoarthritis
Instability on first standing Hypotension
Weakness
Instability with eyes closed Problems related to proprioception
Decreased step height and length Parkinsonism
Frontal Lobe disease
Fear of Falling
According to Hierarchy Sensorimotor Level, Level of gait seen in elderly:
Level Deficit/ Condition Gait Characteristics
Low Peripheral sensory ataxia,
vestibular and visual ataxia.
Peripheral motor-deficits owing to
hip problems
Arthritis (antalgic gait, joint
deformity)
Peripheral motor deficits (owing to
myopathic and neuropathic
Unsteady and uncoordinated gait (esp without
visual input)
Avoids WB on affected side
Painful knee flexed
Painful spine produces=short, slow steps.
Decreased lumbar lordosis, and increased
thoracic kyphosis produces=stooped posture.
Proximal motor neuropathy produces= waddling
gait and foot slap.

3. conditions) Distal produces= distal weakness
Middle Spasticty from hemiplegia, or
hemiparesis
Parkinsonism
Cerebellar ataxia
Circumductory gait.
Shuffling gait/festinating gait
Drunked gait
High Cautious gait
Ignition failure
Fear of falling with appropriate postural
response, normal to widened gait base, shortened
stride, Slower turning, and performance improve
with assistance.
Frontal Gait disorders, difficulty initiating gait,
short shuffling steps, but normal wide base,
upright posture and with arm swing.
-Nutt et al
Approaches for assessing falls:
The first approach should include taking a history of previous falls, because this is the most
important predictor for future falls.
A complete fall evaluation should include an assessment of balance and gait, vision acuity, and
documentation of the individual’s medication history. This triad is considered to have a high
predictive value for detecting older adults at higher risk for falls in the community.
A hemodynamic episode such as postural hypotension and vasovagal symptoms, these entities
should also be considered.
Falls after taking certain medications identification of drugs associated to falls (e.g., diuretics,
vasodilators, and benzodiazepines).
Environmental factors that may have contributed to the fall (e.g., a loose carpet, poor lighting, or
a displaced piece of furniture).
Gait can be assessed from either a quantitative or qualitative perspective.
the Get Up and Go consists of rising from a chair, walking 3 m, turning around, walking back to
the start point, and sitting down again. A later modification by Podsialo and Richardson
incorporated a timed component to the performance measure of the test, thus providing extra
information for analysis and clinical interpretation. Because this test was initially created to
evaluate frail elderly with disability, a problem faced when evaluating older persons in the
community is a ceiling effect, because high-functioning older adults generally perform well on
the task. Therefore, for these individuals a cut-off time of 12 seconds has been proposed in order
to detect those vulnerable to suffer future falls.
More complex tests such as the Performed Oriented Mobility Assessment (POMA) test and the
Berg Balance Scale has been described and validated for assessing risk of falling in different
scenarios.
Powerful test that can be used in different settings is the gait velocity test. It has been
demonstrated to be very sensitive test for detecting mobility problems and to predict falls, even
in high-functioning older people. Gait velocity is measured as the time taken to walk a known
and predetermined distance (e.g., the middle 8 m of 10 m) and it is usually timed by a
chronometer (38), with the participants being instructed to “walk at a comfortable and secure
pace.” The only limitation of the gait velocity test appears when it is used in people using
assistive devices. In this situation, changes in the functionality may show less effect on gait
velocity. It has been suggested to use a gait velocity cut off of 1 m/second in community elderly

4. without disability, 0.8 m/second in older persons with disabilities, and 0.6 m/second in older
persons living in nursing homes.
Berg Balance test: To assess for the balance of an individual. Has 8 components, or activities to
be performed.
The more important factors for fracture risk are the history of previous osteoporosis fracture, the
use of psychotropic medication, and the presence of sarcopenia and impaired mobility.
Recent Advances:
PT Rx:
1. The Otago Exercise Programme is a regimen of home exercises using a combination of
strength and balance exercises supplemented with a walking program. It is designed to be
individually prescribed by a trained professional, undertaken 2–3 times per week, and
progressed over time.
Evidence: In the original study, among women aged over 80 years (1), there was a
significant reduction in falls over a 12-month period (between group difference = 0.47,
95% confidence interval [CI] 0.04–0.90). At the end of a second year (with 69% of
intervention and 74% of control group continuing from the original study), the reduction
in falls rates remained significant (relative risk [RR] 0.69, 95% CI 0.49–0.97
2. Group exercise: This is an important concept, as many older people enjoy the
socialization and opportunity to leave the home that a group exercise program offers.
Group exercises may be individualized and tailored to the needs of the older person or
involve all participants undertaking the same exercises and at the same intensity.
Evidence: Barnett et al. found that group-based balance and strength exercises signifi
cantly reduced falls in community-dwelling people (IRR 0.60, 95% CI 0.36–0.99).
3. Reducing Hazards in Home: cient to cause falls. The interaction between an older
person’s physical abilities and their exposure to environmental stressors appears to be
more important.
Evidence: Cumming et al. (37) conducted a study among 530 community-dwellers, most
of whom had been recently hospitalized. The intervention group received a home visit by
an occupational therapist who assessed the home for environmental hazards and
facilitated any necessary home modifi cations. There was no signifi cant reduction in falls
in the intervention group as a whole. There was however a signifi cant reduction in the
rate of falls among those who had fallen in the year prior to the study (RR 0.64, 95% CI
0.50–0.83). Falls in this group were signifi cantly reduced both inside and outside of the
home, suggesting that the home modifi cations alone may not have been the major factor
in the reduction in falls rates.
4. Preventing Hip Fractures With Hip Protectors: Hip protectors are designed to absorb
energy and to transfer load from the bone to the surrounding soft tissues (55). The
original hip protectors (56) incorporated a fi rm outer shell and an inner foam section.
Other versions are made of dense plastic without an outer shell (57). Hip protectors either
fi t into pockets of underwear or are built into underwear.

5. Evidence: A further study in Sweden (58) tested a different model of hip protector and
also found a decreased fracture rate among residents of a randomly selected nursing
home that was offered hip protectors compared with a control nursing home (RR 0.33).