Physiotherapy - Fall Prevention in Geriatric Population

Introduction:

Fall is widespread in the elderly population. Because of a fall, the person might suffer associated injuries such as a fracture of the femur or other musculoskeletal injuries, which may lead to impairment and disability, decrease mobility, and thus reduced community-level participation. If the fall is severe, it will put additional strain on the family members, caregivers, and the patient might be hospitalized, which will put an extra burden on the healthcare system. So, it is important to address this issue for improving the quality of life of this population. Physiotherapy plays a significant role in fall prevention in older adults.

A fall puts a lot of strain on the family, caregivers, and the healthcare system. There are a lot of factors that are considered a risk and may lead to a fall. Proper assessment through subjective examination followed by physical examination is important to identify old-age people at risk of a fall. It has been found in various studies that exercise therapy of multiple types is useful in fall prevention among the community-dwelling geriatric population. Along with exercise behavior modification and environmental modifications also play a vital role in fall prevention in this population. Physiotherapists can teach exercise, educate the old peoples, and make them aware of the importance of fall prevention. They can involve themselves in conducting awareness camps or seminars in the community regarding this issue.

What Causes Falls?

Falls occur due to the discrepancy between an individual's physiological function, environmental requirements, and behavior.

1) Physiological Function - This will include any impairment in vision, proprioception, and vestibular system. Along with it, there are other factors within an individual, which will play a crucial role in maintaining balance and preventing falls. This will include an intact musculoskeletal system, muscle strength, joint integrity, flexibility, proper biomechanics parameters, such as a line of gravity, posture, joint alignment, and the position of the center of gravity. Also, there is the role of higher centers of the brain along with cerebellum and basal ganglia, which plays a crucial role in maintaining one's balance and thus preventing falls. Any disease such as osteoporosis, osteoarthritis, stroke, or Parkinsonism, along with medication effects such as hypotension, alertness, and coordination, may impair one's balance and cause a fall.

2) Environmental Factors - The environment where the person performs any task may be a risk factor that may cause falls, especially in older people. This may include poor lighting, slippery floors, obstacles, such as a rug, wire of extension cords, and stairs without rails.

3) Behavioral Factors - This will include any behavior adopted by an individual that leads to falls—wearing slippery footwear, taking something from a high shelf, walking in a dark room, or room with dim light. Also, performing any high-risk behavior like climbing stairs without holding rails is an example that might put an individual at risk of falling.

Fall Risk Assessment:

The strongest predictor of future falls is the history of a previous fall in the geriatric population. A history of prior falls increases the risk of a fall by five times in this group of people.

Assessment of Physical Function:

It is the next important predictor of falls, which includes the assessment of strength, balance, coordination, sensation, and vision. Also, medication use is a significant risk factor that may cause falls (hypotension due to side effects of medication).

Falls Prevention Strategies:

Various studies have been carried out to identify different interventions by which falls in old peoples can be prevented, and those were found to be effective.

Exercise Therapy:

There is strong evidence suggesting that exercise is effective in preventing falls in community-dwelling older adults. Also, they found out that the 'multicomponent exercise' program seems to be the most effective. It includes gait training, balance training, strength training, yoga, tai chi, flexibility, endurance, and functional task type of training as compared to any single component exercise only. Exercise can be executed in a group or home setting or through online consultation.

Balance Exercises -

• Stand up while holding a chair. Stride standing progress to narrower foot placement, progress to reaching in different directions, standing in hard surface progress to standing on foam. Stepping in different directions with an eye open, then progress to eye closed. More prolonged or faster steps, step over an obstacle.
• Walking practice with eye open and then closed. Decrease base of support (tandem gait), increase step length and speed as improvement in performance occurs, walking in different directions, walking on different surfaces, walking around and over obstacles, heel, and toe walking.
• Stand with an eye open and then closed. Do not use hands to push off, lower chair height as more control comes, softer chair, add weight (vest or belt).
• Heel raises with an arm holding chair. Decrease hand support gradually, hold raise for longer, one leg at a time, add weight (vest or belt).
• Step-ups over stepper or stairs. Forward and lateral. Decrease hand support gradually, increase step height, add weight (vest or belt).
• Half squats sliding down a wall in stride standing. Decrease hand support gradually, hold the squat for more prolonged, move a short distance away from the wall, add weight (vest or belt), one leg at a time.

Multifactorial Interventions:

As there might be multiple causes for falls, it has been found that it is better to identify those factors to prevent falls. Interventions targeting medication dosage, behavior, and type of exercise were found to be very effective in preventing falls. But some studies found out that even single intervention is as effective and cheaper as multiple approaches.

The best strategy by a physiotherapist would be to start with a single exercise prescription for all older adults initially and then add on additional interventions if they find any patients who are at risk of a fall.

The risk-taking behavior of older adults should be addressed. For example, vision and strength, awareness of the environment, and adopting protective behavior, such as using handrails, and walking in a properly lit area to prevent falls. Risk behavior may include climbing, reaching, or bending while performing activities of daily living. In various studies, it has been found that the fall of older adults happened while climbing stairs, standing on unsteady or unstable surfaces, or participating in any vigorous sports activities such as tennis. It was reported that the task was done in a hurry, and concentration and attention were lacking, which resulted in a fall.

The other points which need to be considered are to give education on fall prevention, advice on environmental modification, and the gradual progression of various types of exercise programs. For patients who are hospitalized, physiotherapy sessions should include anticoagulant exercises, breathing exercises, active and passive exercises, that aim at keeping the correct mobility in the joints, the flexibility of the soft tissue, and strengthening the muscles. The aim is to improve strength and balance gradually.

Implications for Physiotherapy Practice:

As research supports that a well-designed exercise program effectively prevents falls in geriatric populations, the physiotherapist should use it to the maximum level. This may be done via-individualized home exercise program, referral to community level or hospital-based group exercise program, or via teleconsultation for people who are present in remote locations. Also, raise awareness regarding the importance of exercise among the old age people in the community by conducting camps, doing a presentation, and writing articles for local newspapers or websites.