DPMs Impact Fall Prevention

Preventing Falls In The Elderly: Where DPMs Can Have An Impact

The importance of fall prevention is underscored by the volume of research published on this subject by a wide range of medical specialists and scientists. Systematic reviews of the subject of fall prevention reveal over 5,000 articles that cover all aspects of epidemiology, pathophysiology, biomechanics and intervention. Despite the impressive amount of published research, there are many unanswered questions about identifying and treating elderly patients at risk of sustaining a traumatic fall.

What Are The Risk Factors For Falling?

The ability of a human to remain upright during stance and gait requires an intricate, fascinating system of neuromuscular control, which operates at multiple levels in the body. Sensory input is derived primarily from three levels: the visual system, the vestibular system (parts of the inner ear and brain that help control balance and eye movements) and the somatosensory (conscious perception of touch, pressure, pain, temperature, position, movement, and vibration, which arise from the muscles, joints, skin, and fascia) system of the extremities, which include the muscle stretch receptors, the joint mechanoreceptors and pressure receptors on the plantar (bottom) surface of the foot. Processing of the sensory input occurs centrally at the brain stem and cerebral cortex to coordinate muscular activation for ambulation and maintenance of upright stance. The neurological mechanism to recover from slipping or tripping requires proper muscle reaction time, muscle strength and adequate joint range of motion of the extremities.

With multiple levels of input and output from the central nervous system to provide us with proper muscular activation to respond to unexpected hazards, it is easy to see how numerous risk factors associated with aging can predispose people to traumatic falls. The medical literature has identified many independent risk factors for falling.

Listed in descending order of strength of scientific evidence, the risk factors include:

  • previous falls
  • balance impairment
  • decreased muscle strength
  • visual impairment
  • polypharmacy (more than four medications) or psychoactive drugs
  • gait impairment and walking difficulty
  • depression
  • dizziness or orthostasis
  • functional limitations
  • age older than 80 years
  • female sex
  • incontinence
  • cognitive impairment
  • arthritis
  • diabetes
  • pain

More than one risk factor increases the risk of falling. With no risk factors, the risk of falling is 8 percent and grows to 78 percent with four risk factors.  More alarming is the finding that the risk of falling quadruples for a patient within two weeks of discharge from the hospital.

Medications that physicians commonly prescribe for elderly patients can negatively affect all aspects of neuromuscular control of the body during gait. Identifying certain drugs that can independently increase the risk is more difficult. In general, an increased risk of falling is associated with the following medications: serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents, benzodiazepines, anticonvulsants and class IA antiarrhythmic medications. Withdrawal of these medications becomes a complicated issue when considering fall prevention. Many times, the condition patients are taking the medication for is itself a risk factor for falling.

A Closer Look At Lower Extremity Risk Factors For Falling

Most elderly patients experience a decline in balance and muscle strength. The combination of this decline with visual and vestibular compromise increases the risk of falling. The following is a closer look at lower extremity risk factors for falling.

Toe deformity 

While previous studies have reported an association of “foot problems” with an increased risk of falls in the elderly, Menz and Lord were the first to attempt to measure the effects of specific foot deformities on balance and functional abilities in older people. Then these researchers were able to make a connection between foot health and fall risk by showing that people with a history of multiple falls had a significantly higher foot problem score than those who had not fallen.

These foot problems included (in order of prevalence):

  • Bunion or hallux valgus of the great toe
  • Lesser toe (all other toes but the great toe) deformities
  • Plantar (bottom of the foot) calluses and corns on the toes.

The presence of foot problems was associated with decreased performance on functional ability tests such as stair ascent and alternate stepping. This suggested that certain forefoot deformities could compromise balance in elderly patients during dynamic gait.

Range of motion and toe flexion strength

A series of studies have demonstrated certain physiologic or clinical markers from a foot examination that could be clues to fall risk in the elderly. The first paper on this subject showed that ankle flexibility, plantar tactile sensitivity and toe plantarflexor strength were significant and independent predictors of balance and functional test performance, explaining up to 59 percent of the variance in these measures.

Expanding on these findings, Menz and co-workers developed a series of standardized tests for foot problems and then correlated the results with the risk of falling in elderly patients in a prospective study.  This was the most important study at that time because it validated that the previously identified risk factors of reduced ankle flexibility, more severe hallux valgus deformity and reduced plantar tactile sensitivity were associated with a significantly increased risk of falling among elderly patients. Two of these foot and ankle characteristics, toe plantarflexor weakness and disabling foot pain, were significantly and independently associated with fall risk. This important study validated previous notions about the importance of adequate ankle joint range of motion and the ability to grasp with the toes to maintain balance.

Foot pain

Previous studies have shown that foot pain is associated with a risk of falling in men and women residing in a retirement village. Since foot pain occurs in up to 54 percent of community dwelling elderly people, the relationship between foot pain and risk of falling can be significant. Providing interventions for older individuals with foot pain and high plantar pressures may result in a reduced risk of falling. These interventions could include footwear with better cushioning under areas of high pressure as well as podiatric care, which includes lesion debridement or orthotic treatment.

Footwear

The role of shoes in the risk of falls is the subject of extensive study. Some of the findings have been surprising based upon our understanding of proprioception (The unconscious perception of movement and spatial orientation arisingfrom stimuli within the body itself.) and sensory feedback from the feet to provide balance and postural control. While most would expect that going barefoot would provide better balance in comparison to wearing shoes, research has indicated the opposite result when looking at the frequency of falls in the elderly.

A study by Koepsell and co-workers showed that walking barefoot or simply wearing socks indoors resulted in an 11-fold increased risk of falling in comparison to wearing shoes.

Other studies have validated this finding that slippers, in comparison to shoes, lead to an increased risk of falling.

Not all shoes are protective for falls in the home. Menz and others have identified the following characteristics of shoes that are associated with increased risk of falling:

  • wearing shoes with inadequate fixation (no laces, straps, or buckles)
  • increased heel height (greater than 4.5 cm)
  • narrow heel (less than 20 percent width of the heel)
  • reduced contact area of the sole and smooth tread

What You Should Know About Testing To Assess Fall Risk

Often, these tests are time performed to determine a patient’s risk for falling.

Tiedemann and co-workers have developed a fall risk assessment tool, which an external study validated and proved reliable. This assessment discriminates between those who have had multiple falls and those who have not had multiple falls with an accuracy of 72 percent. This compares well with other similar assessments for identifying those with multiple falls and exceeds the predictive ability of other popular tests including the Timed Up and Go test and the Functional Reach test. Here are the key points of the assessment.
1. There is a test of low (10 percent) contrast visual acuity measured at a distance of 3 m.
2. The assessment has a tactile sensitivity test at the ankle using a single Semmes–Weinstein-type pressure monofilament.
3. For the near tandem stand test, the participant stands with his or her eyes closed and with bare feet in a near tandem position. The feet are parallel and separated laterally by 2.5 cm. The heel of the front foot is 2.5 cm anterior to the great toe of the back foot.
4. In the sit-to-stand test, participants rise from a standard height (43 cm) chair five times as fast as possible with their arms folded.
5. The alternate step test involves placing the whole foot (shoes removed) onto a step that is 18 cm high and 40 cm deep. Patients alternate with the right and left feet for a total of eight repetitions as quickly as possible.

What Studies Reveal About Interventions For Fall Prevention

Clearly the prevention of falls is far more complicated than simply identifying risk.

  • Exercise programs may target strength, balance, flexibility or endurance. Programs that contain two or more of these components reduce the rate of falls and number of people falling. Exercising in supervised groups, participating in tai chi and carrying out individually prescribed exercise programs at home are all effective.
  • Multifactorial interventions assess an individual person’s risk of falling and then carry out or arrange referral for treatment to reduce the risk. Some studies have shown multifactorial interventions to be effective but other studies have shown such interventions to be ineffective.
  • Taking vitamin D supplements probably does not reduce falls, except in people who have a low level of vitamin D in the blood.
  • Interventions to improve home safety do not seem to be effective, except in people at high risk for falling, such as those with severe visual impairment.
  • Wearing an anti-slip shoe device in icy conditions can reduce falls.
  • Some medications increase the risk of falling. Ensuring that medications are reviewed and adjusted may be effective in reducing falls. Gradual withdrawal from some types of drugs for improving sleep, reducing anxiety and treating depression may reduce falls.
  • Cataract surgery reduces falls in people having the operation on the first affected eye.
  • Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition that may result in changes in heart rate and blood pressure.

Researchers noted that an exercise program combined with balance training was the single treatment intervention that had a benefit for patients with and without a previous history of falling. Costello and co-workers also recommended that a medication and vision assessment with appropriate health practitioner referral should be included in a fall screening examination.

What One Landmark Study Showed About A Multifaceted Intervention Program To Reduce Falls

For the first time, a multifaceted intervention implemented by podiatric physicians showed a significant effect in reducing falls in a community-based elderly population. This randomized, prospective controlled trial studied 305 elderly individuals with disabling foot pain who also had an increased risk of falls. The experimental group received the following interventions: a foam, prefabricated foot orthosis customized to offload painful calluses in the forefoot, advice on footwear, a subsidy for footwear, a home-based program of foot and ankle exercises, a fall prevention education booklet, and routine podiatry care for 12 months. The control group received routine podiatry care for 12 months.

This multifaceted program resulted in a reduction of falls by 36 percent over a 12-month period. This compared favorably with other previous programs that have included tai chi as well as cataract surgery. Secondary benefits for the intervention group were significant improvement of strength and range of motion of the ankle as well as improvements in balance. The researchers felt that the exercise program was the key component to the multifaceted intervention. This program included ankle joint stretching, ankle strengthening and toe flexor tendon strengthening. It is important to note that isolated balance training and any measure to improve balance were not part of the exercise program.

Any podiatric physician in this country can implement the components of this multifaceted intervention. Obstacles may be the fact that Medicare does not reimburse footwear and foot orthoses unless the patient has diabetes and qualifies under certain criteria.

Patients can implement exercise programs focusing on the foot and ankle at home if podiatrists or qualified physical therapists provide the appropriate training.

In Conclusion

Restricted ankle joint range of motion, foot pain and weakness of the toe flexor muscles are key independent risk factors for falling in the elderly. Recognition of these factors, in combination with previously identified general systemic factors, will allow the podiatric physician to make appropriate referrals while implementing several proven interventions within their own practices that can reliably reduce the risk of falls in elderly patients.

 

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