Monday, October 23, 2017

Stay on your feet: Falls prevention in seniors

Did you know approximately one third of our senior citizens, aged 70 and over, fall each year? An estimated one in ten of these falls, result in injury. Most of us take for granted the odd fall and trip. Stumbling over a stair or tripping on the sidewalk is more of an inconvenience than a major trauma. However research has shown falls in independent community dwelling older adults can be a threat to their health and well being. Unintentional injury caused by falls is the sixth leading cause of death in people aged 65 and older. More than 1300 seniors die annually in Australia as a direct result of a fall. Experts believe as much as seventy per cent of all falls are preventable. The cost of hospital care rises each year as a result of falls injury. Research shows the overwhelming cause of falls is trips or slips. Misplaced steps, such as standing in a hole; legs giving way; or loss of balance, although reported are less likely causes in the majority of injuries. Falls are more likely to occur at home and outdoors more likely than indoors. People are usually alone when they fall and most occur during the afternoon.

More falls are reported during the colder months. The frequency of falls is the same over flat surfaces and rough ground. Most people reported being in a hurry, not looking where they are going, and or carrying something heavy when the event occurred. Hurrying was by far the most likely cause of tumbles with slippery surfaces, wet floors and unseen objects, contributory factors. The older the faller the more likely fractures and soft tissue injuries would result. Although there is no gender difference in the number of falls, men do slip more and women trip. Males fall more in cold weather where as there is no similar pattern for women. Men are more likely to fall outdoors than indoors and most will consciously try to avoid further falls by changing their behaviour. This pattern is not the same for women. Recurrent fallers may be more likely to suffer fall related injuries than first time fallers. Fear of falling is more prevalent in older women and has been linked to their curtailment of daily activities. As we grow older our walking patterns change. Feet are placed further apart for stability and each foot spends more time on ground contact. Body sway increases and our angle of toe clearance becomes lower. This makes the foot more susceptible to catching unseen objects and hence sets the body out of balance.

Age related changes to the visual system may also contribute. Common changes of ageing like diminished vascular tone with increased venous pooling may result in orthostatic hypotension. This means when a person gets up from sitting for example they may feel giddy and in some cases faint. Although falls can result this is not considered a main contributor in healthy older adults. Anyone can fall but those living with long term conditions such as heart conditions, diabetes, Parkinson’s disease, arthritis, osteoporosis, high/low blood pressure, depression and dementia do have an increase the risk of falling. Sore feet can also lead to unsteadiness, poor posture and imbalance. Things which contribute include: muscle or joint stiffness, poor vision, pain and lack of energy and or concentration. Inattentiveness or not taking time is also contributory factors. Consequently most falls are preventable and the more care you take the less likely you will have a fall. Diseases that reduce strength such as cardiac disease and diseases which reduce flexibility, such as arthritis increase the risk of falls. Incontinence (especially urgency) is another factor. One major contributor to falls in community dwelling elderly is footwear. Many people were wearing slip-on type slippers when their fall occurred. Vigorous individuals are more likely to fall in the presence of environmental hazards and on stairs suggesting frailer people may correct the environmental hazards or routinely avoid hazardous situations. Active elders are more likely to fall due to over balance whereas less active elders are not as prone. Falls are related to changes in how an individual uses the environment (in a rush or inattentive) or difficulty or discomfort experienced when using the environment i.e. such as sitting or reaching. There was a preponderance of left sided falls and more involving backward than forward movement. bedroom, lounge and kitchen are common places where falls take place. Stairs and steps account for approximately 10% of all falls.

Ageing brings change to the way we walk. We begin to slow down spending more time with both feet on the ground. There is a marked increase in body sway which promotes instability. The angle of toe clearance gets smaller and the lower angle of the foot at take off, the easier it is to catch unseen objects. These changes are made more obvious with arthritis or painful knees, hips, neck and spine. Balance problems and blood pressure also add considerably to the safety of walking as does failing eyesight and sore feet.

Prevention includes maintaining a healthy lifestyle, keeping physically fit, being mentally alert as well as being involved in a social network. Most falls are caused by personal issues such as life style; physical and mental state; and environmental hazards. Reduce falls risk by staying mobile and improve movement in joints. Be active and strengthen muscles. Improve walking patterns and balance and monitor your medications. Physical activity helps maintain leg and hip strength and ankle flexibility. It also improves bone strength and slows osteoporosis. Regular exercise increases cardiovascular stamina, assists joint movement and stability as well as improve balance, co-ordination and walking patterns. Increased energy levels helps maintains a healthy weight and improve sleep patterns. Putting together 30 minutes per day is enough. If you have a medical condition chat to your doctor first.

The best kinds of activity are those which use all parts of the body like walking, swimming and dancing. So too is active gardening, housekeeping and walking the dog. There are many walking groups like Walk there today  to find thirty. Activites which focus on balance include: tai chi, yoga, pilates; and for strength training and fitness try aerobics or acqua-aerobics.

According to experts both foot strength and flexibilty decline with age and falls are common in older people. A recent randomized controlled trial of a multifaceted podiatric medical intervention demonstrated a 36% reduction in the fall rate over 12 months. Reseachers evaluated the acceptability of and levels of satisfaction with this intervention in the older people who participated in the trial. Participants were allocated to the intervention group (which included a home-based program of foot and ankle exercises, assistance with the purchase of safe footwear when necessary, and provision of prefabricated foot orthoses) and asked to complete a structured questionnaire 6 months after they had received the intervention. The questions addressed participants’ perceptions of their balance and foot and ankle strength, the perceived difficulty of the exercise program, and the degree of satisfaction with the footwear and orthoses provided. Of 153 participants, 134 (87.6%) attended the 6-month follow-up assessment and completed the questionnaire. Most participants perceived improvements in balance (62.7%) and foot and ankle strength (74.6%) after 6 months of performing the exercises, and 86.6% considered the difficulty level of the exercises to be “about right.” Most participants reported that they were somewhat or very satisfied with the footwear (92.3%) and orthoses (81.6%) provided. The multifaceted podiatric medical intervention used in this trial was generally perceived to be beneficial and demonstrated high levels of satisfaction among participants. Further research is now required to evaluate the feasibility of implementing the intervention in a range of clinical practice settings.

Established guidelines for falls prevention now recommend that older adults have their feet examined by a podiatrist as a precautionary measure.

Tencer et al (2009) reported certain measurable properties of shoes were found to be significantly related to risk of falls in older adults. Footwear characteristics such as shoe type, heel height, heel counter height, heel width, critical tipping angle, method of fixation, heel counter stiffness, sole rigidity and flexion point, tread pattern and sole hardness have all been subject to research in the prevention of falls. Other footwear features such as heel collar height, sole hardness, and tread and heel geometry are also considered influential aspects likely to influence balance and gait. Shoe measurements related to lateral stability (heel height and width, critical tipping angle), foot position sense (heel-collar height, sole thickness, and sole flexibility), and the shoe/surface interface (fore-sole material, shoe-to-ground coefficient of friction, sole contact area) have all been subject to extensive research in a bit to prevent falls.

Wearing shoes with low heels and large contact area may help older adults reduce the risk of a fall in everyday settings and activities. Other studies undertaken to determine the relationships between footwear characteristics and the falls risk of indoor and outdoor incidents in older people have revealed no significant association (Menz, Morris and Lord (2009). Instead they found indoor falls were associated more with going barefoot or wearing socks only. They found falls were associated more with going barefoot or wearing socks only indoors. Menant et al (2008) found elevated heels of 4.5 cm height did significantly impair balance in older people. The potential benefits of wearing shoes with a hard sole or a high heel-collar on balance in older people warrant further research in ambulatory tasks. Based on findings of a systematic literature review, older people should wear shoes with low heels and firm slip-resistant soles both inside and outside the home. Further findings suggest older adults are slower terminating gait rapidly than their younger counterparts and that footwear is likely to influence whole-body stability during challenging postural tasks on wet surfaces. Whilst the characteristics of shoes have been shown to influence balance in older people, the relationship between footwear and slips, trips and falls is still unclear. According Menant et al (2008) the relationship between changes to the somatosensory feedback from foot and ankle combined with modifying frictional conditions at the shoe/floor interface many be related. To date however no one is sure which shoe features are beneficial or detrimental to balance in older people. According to Chari et al (2009) athletic and canvas shoes (sneakers) were the styles of footwear least associated with falls in older adults during everyday activities. Going barefoot or in stocking feet was associated with sharply increased risks . Bare feet might provide better slip resistance than socks or stocking feet but previous studies have associated barefoot mobilisation with increased falls in the elderly.

Menant et al (2008) have also proffered elevated heels of 4.5 cm height did significantly impair balance in older people and researchers generally agree the potential benefits of wearing shoes with a hard sole or a high heel-collar on balance in older people warrant further research in ambulatory tasks. Based on findings of a systematic literature review, older people should wear shoes with low heels and firm slip-resistant soles both inside and outside the home. Further findings suggest older adults are slower stopping gait rapidly than their younger counterparts and that footwear is likely to influence whole-body stability during challenging postural tasks on wet surfaces. It is evident that bare feet provide better slip resistance than non-slip socks and therefore might represent a safer foot condition. However, previous studies have associated barefoot mobilisation with increased falls. However it is generally accepted wearing good fitting shoes should be encouraged. In another study Chari et al (2009) discovered wearing athletic and canvas shoes (sneakers) were the styles of footwear associated with lowest risk of a fall in older adults during everyday activities.

* Wear a shoe which suits your activity.
* The most expensive shoes are not always the best for your feet.
* Good fit is the most important feature when choosing a shoe.
* Choose footwear which is enclosed at the front and back, fits properly and
supports the foot to allow you to walk comfortably and naturally.
* Flatter shoes with broad heels increase ground contact and give greatest stability. High and narrow heels reduce body stability.
* Pointed heel shapes may be less stable on wet surfaces

If you fall

Don’t panic
Do not get up in a hurry
Call for help if hurt
Inform your doctor at your next visit. Sore Feet
Many people accept sore feet come with age but that is not always true. A high percentage of first time fallers have foot problems. The vast majority are women and many recurrent fallers are more likely to suffer foot problems. A routine vist to the podiatrist can put paid to more recurring foot ailments.

Monitor your medications and eyesight
Make a list and know what medication you are prescribed form your doctor and what they are for. All medicines have side effects and sometimes these can affect balance. Talk to your GP or pharmacist if you experience:
• Drowsieness
• Dizzieness
• Light headedness
• Unsteadyness
• Blurred or double vision
• Difficulty thinking clearly

Have your medicines reviewed regularly and check for any interactions with no prescribed drugs you may be taking .

Eat healthy
• Eat a wide variety of nutritious foods
• Drink alcohol in moderation

Stop smoking

Poor balance accounts for upt to 25% of falls among elderly people. . Factors that can effect balance include:

• Loss of muscle strength
• Reduced joint mobility and stability
• The side effects of some medicines
• Ear problems
• Sudden movements particularly rising quickly (postural hypertension)
• Post hip and knee replacement

Common hazards inside include:
• Slippery floors
• Clutter or obstacles on the floor
• Loose mats or scatter floors
• Different floor surfaces

Hazard outside are:
• Uneven paths
• Clutter
• Poorly lit areas
• Wet surfaces

What to do if you fall
  • Don’t panic
  • Check for serious injury
  • Get up slowly and safely
  • If seriously injured call for help / ambulance

Further Reading
Chari S, Haines T, Varghese P and Economidis A. (2009) Are non-slip socks really 'non-slip'? An analysis of slip resistance BMC Geriatrics 2009, 9:39doi:10.1186/1471-2318-9-39.
Koepsell TD, Wolf ME, Buchner DM, Kukull WA, LaCroix AZ, Tencer AF, Frankenfeld CL, Tautvydas M, Larson EB. Footwear style and risk of falls in older adults.
Menz H.B., Morris M.E., & Lord S. R. (2009) Footwear Characteristics and Risk of Indoor and Outdoor Falls in Older People Gerontology.
Menant JC, Steele JR, Menz HB, Munro BJ, & Lord SR. (2008) Effects of Footwear Features on Balance and Stepping in Older People. Gerontology. 2008 Feb 4 [Epub ahead of print]
bMenant JC, Steele JR, Menz HB, Munro BJ, Lord SR. Optimizing footwear for older people at risk of falls. J Rehabil Res Dev. 2008;45(8):1167-82.
cMenant JC, Steele JR, Menz HB, Munro BJ, Lord SR. (2009) Rapid gait termination: Effects of age, walking surfaces and footwear characteristics.Gait Posture. 2009 Apr 7. [Epub ahead of print]
Tencer AF, Koepsell TD, Wolf ME, Frankenfeld CL, Buchner DM, Kukull WA, LaCroix AZ, Larson EB, Tautvydas M. Biomechanical properties of shoes and risk of falls in older adults.
Menz H B, Spink MJ, Landorf K B, Hill KD and Lord S R (2013 ) Older People’s Perceptions of a Multifaceted Podiatric Medical Intervention to Prevent Falls J Am Podiatr Med Assoc 103(6): 457–464.
Reviewed 22/10/2017

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