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Falls Prevention

Hello and welcome back again to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy related. As community physiotherapists seeing our patients in their homes, one of the major reasons that we see people is because they have been having falls. So, I thought in this blog we would have a look at falls, what a fall is, who tends to fall, why people fall and what you can do to reduce the risk of falling.

What is a fall?

Before looking at why people fall and what you can do about we need to look at what a fall actually is. Now, I know this sounds like a very simple thing and clearly everyone knows what a fall is but as physiotherapists when we talk to our patients many of them despite having fallen many times, deny that these were falls! So what is a fall? Well, one definition is:

“Coming to rest on the ground or another lower level”

Personally, I like this definition of a fall because it is simple and clear and we can all understand that if at any time we end up (involuntarily) on the floor or at a lower level such as sitting on a step or a low couch then we have fallen.

As a physiotherapist, one of the main questions that I ask of any patient is: “have you had any falls in the last 12 months?” To which many of my patients (who have had multiple falls) answer “no”! They are not being dishonest, they simply don’t recognise that those times they “tripped” and ended up on the floor or got their foot caught and had to grab onto the couch and then ended up on the floor or hanging of the couch were falls.

Who Tends To Fall?

Okay, so now have defined what a fall is and we understand that if at any time you end up on the floor or slumped on the couch after tripping, you have fallen. We now need to look at who falls and who is at most risk of falling:

Although there are a range of factors that influence why people fall, it is reasonable to say that the risk of falling increases as we age and drastically increases as people enter old age. There is a large body of evidence and statistics that shows as we age there is a greater risk of falling. We will look later on at why it is the case that older people tend to fall more than younger people but for now it is important to note that older people and especially the very elderly have a much higher risk of having a fall. The following statistics are illuminating:

Every year 30% of those people aged over 65yrs will have a fall. Now, for those people who are thinking that 65 is actually quite young, this should be an eye opener!
Every year 50% of those aged over 80yrs will have a fall of some kind, now this really is a sobering statistic and highlights the absolute link between aging and falling. Another statist
60% of people with dementia will fall at some point in a year. As a physiotherapist visiting care homes and seeing many patients with dementia I suspect that this is actually an underestimate of how many falls they have.

Lastly, an important point is that older people who fall are at a significant risk of falling again. After a fall that causes a hospital admission within six months after discharge 40% of people will fall again! As a physio I often explain to patients and relatives that once a person has a fall there is a high likelihood that it will happen again as in the main, people do not fall unless there is a background cause.

Why Are Falls A Problem?

So, now we have an idea of who tends to fall, it is important to consider why falls and falling are a problem. If you are young, fit and strong then this may not seem obvious to you and you may remember many times where you have been playing football or some other sport and have ended up on the ground after a trip. You probably then got up, dusted yourself off and felt no ill effects other than a bruise or two. Well, this is what happens when you are young and strong but as we age falling and ending up on the ground tends to have more of an effect and at some point the risk of injury becomes much greater.

To consider why having a fall is a problem when you are older, some statistics can illuminate the issues. Of those who have a fall each year, 40-60% will be injured (resulting in some need for medical attention – possibly a GP visit or a trip to minor injuries). 15% of those who fall will have a serious injury – this could include a broken bone and a lengthy hospital stay. 5% of falls result in a broken hip – this almost always requires a major operation such as a hip replacement and of those who have a hip replacement after a fall 1/3 can no longer live independently and 25% have passed away after 6mths. If a person with dementia falls and breaks their hip then they have a 71% chance of being dead within 6 months! Falls are the leading cause of mortality due to injury in the over 75s in the UK.

Clearly, from the statistics above, falls are a significant risk factor for any individual older person and especially those over 75 but it is also worth thinking about whether falls are a problem for society more generally. Every time, someone visits their GP practice to speak to a doctor or get checked out by a nurse after they have had a fall they are taking up a limited resource of general practice appointments and increasing the burden on the healthcare system. To be clear, if you have a fall and feel that you have been injured you must seek medical advice.

Hospital stays and major operations are incredibly expensive and a massive drain on the resources of the NHS and if there is a way of reducing the number of falls each year then this would make a huge difference to performance of the NHS.

Why Do People Fall?

Having established what a fall is, who falls and why falls are a problem we need to take a deep dive into why people fall over. This seems like such a simple thing – for example don’t people just trip over accidentally? Well, yes they do but there is actually quite a lot more to it than just that. We need to break down the factors that influence a fall:

Environmental Factors

The place and surroundings that someone lives in is commonly one of the key factors in why they fell and also it is one of the easiest factors that can be changed and controlled and if you are the relative of an elderly person I would strongly recommend that you look closely at the place they are living in. A family home that was appropriate for a person when they were young and fit is very often wholly inappropriate when they have aged and become weaker. There are a number of factors within the home that are crucial for having (or avoiding) falls:

Trip Hazards

If you look around someone’s home and you see a multitude of leads, rugs and items on the floor that they could stumble across then you are looking directly at trip hazards. Now, if you have a young family and are perfectly fit then it is absolutely normal that your home will look this way (and there may well be a range of toys on the floor!). However, if you are elderly and your balance is not the best then you need to have as few trip hazards as possible. Rugs on the floor may look nice but when you are older and you tend to shuffle your feet then a rug is a trip hazard just waiting for you to catch your foot on. As a physiotherapist this is one of the first things I try to address with anyone who has either had a fall or looks at risk of a fall and if you are a relative this is a relatively quick and simple way of reducing the risk of your family member falling.

Doorways and Steps

A large number of PVC doors/entrances into and out of properties have a “sill” that you have to step over and commonly elderly patients of mine who are using a stick or a walker find this challenging. It is often a good idea to consider either “flattening” this out somehow or putting a hand rail at this point so they can step over safely. Many people’s properties also have a quite unnecessary series of “steps” when the kitchen or dining room is on a slightly different level. If these steps can be removed this is clearly the best solution but if not a hand rail again is very handy in reducing the likelihood of a loss of balance. In general, if you are worried about your elderly relative having a fall then having flat access to all areas of their property including the shower etc is undoubtedly the best option to reduce falls.

Poor Lighting

Many people are very conscious of rising energy prices and keep their lights off in order to reduce bills which is clearly very sensible. However, for many elderly people with poor balance, poor eyesight and a high falls risk this is a false economy as it massively increases the risk of falling due to not seeing an obstacle. Many times, as a physio, I go into a patient’s home and find it dark and poorly lit and immediately ask them to turn the main lights on as quite clearly they would not be able to see the trip hazards in the home.

Poor Footwear

This is an extremely common issue that we come across as physiotherapists seeing our patients at home. Many of our patients have old, worn out slippers that provide no support and are clearly a reason that they are likely to fall. Having good supportive footwear can make a significant difference to a person’s risk of falling.

Lack of Appropriate Walking Aids

As a physio I see many people that have for many years been denying that they need a walking aid such as a stick or frame and have instead been “furniture walking” around their property and have stopped going outside almost entirely. Often these patients have had multiple falls and on assessment it is clear that they need some form of walking aid such as a stick or walker and when questioned about this they will often state that “a stick is for an old person”! Having an appropriate walking aid that provides a bit of support and helps with balance can quite often dramatically improve someone’s walking and reduce their risk of falling.

Non-Environmental Factors

As well as the situation that someone is living in and their footwear and clothing etc, there are also a number of other factors that can be reasons why a person will fall. Some of these factors are more easily altered than others:

Eyesight

Your eyes are one of the main ways in which your body maintains a good sense of balance, they also enable you to see any trip hazards and avoid falling over. There are a number of reasons for poor vision and some of them can be helped with quite easily such as having appropriate glasses or having clean glasses. Sometimes patients do not realise that they have poor eyesight as it has changed over a number of years and it is worth having regular tests for this.

Toilet Urgency

As we age there is a tendency to need the loo a bit more often and especially in the night. Waking up in the middle of the night and stumbling to the toilet urgently in the dark is a common way in which many people end up having a fall. Also may elderly people find that they struggle to get themselves to the toilet quick enough in the day time and then begin to panic and then have a fall because of this.

Postural Hypotension

Hypotension is a medical phrase simply meaning low blood pressure and sometimes (especially in the elderly) as we move from lying to sitting or sitting to standing there is a drop in blood pressure which can make you feel faint. Anyone, who has jumped out of bed in the middle of the night and then felt woozy or faint as they go to the loo will be experiencing postural hypotension (a drop in blood pressure due to a change in posture).

Medication Issues

As people age we tend to begin to take more and more medication and for the elderly their list of medicines can often be quite extensive. As a physiotherapist I always ask for a medication list and talk through what the person is taking and why. Sometimes, these medications have not been reviewed properly and there are issues with how they interact and this can cause the patient to feel unwell or for their blood pressure to drop.

Poor Balance

For a variety of reasons as people age their balance (which may never have been great) worsens and eventually gets to a point where they begin to feel very unsteady and at risk of falling over. Having good balance and the ability to correct a slip or a trip is one of the key ways in which we avoid falling.

Muscle Weakness

Closely linked to a worsening of balance is a general weakening of strength in the elderly. This is due to a process called “sarcopaenia” which simply means a loss of muscles mass. This happens gradually over time as we age and is quite hard to see until it gets to a critical point. There are a variety of physiological processes involved such as changes in hormone levels but also there is the effect of a general lowering in activity levels as people get older which causes them to lose muscles mass.

A Neurological Condition

In this article we have tried to mainly address why people with no major conditions have a fall but there are some neurological conditions out there such as having had a stroke, Parkinson’s Disease or MS that make having a fall much more likely.

Okay, I think we have now covered all of the major reasons that people have falls and certainly we have covered all of the reasons that we as physiotherapists encounter as reasons that people falls. Now, it is time to take a look at how you can prevent and reduce the risk of falls

Falls Prevention:

So, it is all well and good understanding why falls are a problem, who is most likely to fall and why people fall but for most people reading this article the main thing you will want to know is what to do about a person who is falling and can you help them?

The answer to this question is almost universally: “yes, you will be able at the least to reduce their risk of falling but you probably won’t be able to eliminate it.” Below are our top recommendations in order to quickly reduce the risk of you or your relative having a fall:

Reduce trip hazards at home: this is a quick and easy solution. Simply go around the property and de-clutter. Make sure there are no leads sticking out and no rugs on the carpets etc.. Just look around and see if you think someone could trip over something. Also try and make sure there are good wide spaces to walk along and that you don’t need to squeeze past things that might trip you up. Sounds simple because it is but this is one of the quickest and most effective ways in which you can reduce the risk of having a fall.
Have a medication review at least once per year: your pharmacist will be happy to arrange this and in fact every GP practice should be doing this routinely. But if your elderly relative is on a large number of medicines and these have been altered and they are not feeling well it is very worthwhile getting this checked. There is a large amount of evidence that suggests that lots of people in the UK are on inappropriate medication.
Buy decent footwear: another very simple one! If you see that your grandfather is hobbling around in worn out, collapsing and flopping slippers then these need changing. Having supportive footwear can make a huge difference to how stable someone feels and their falls risk.
Have an eyesight test: at least once per year you or your relative should have an eyesight check. This means that your relative will be able to clearly see any obstacles or trip hazards in the home and thus reduce the falls risk.
Get your blood pressure checked at rest and standing: this is simple to do and just involves having a blood pressure monitor on and checking your blood pressure in sitting and then repeating this after standing up. If there is a significant drop in the numbers then you need to contact the GP. Disclaimer: this advice does not replace seeking medical advice if you think that you or your relative is having low blood pressure causing them to feel faint.
Make sure your home is well lit: along with having good vision, having a well lit property where your relative can easily see where they are going and avoid tripping over any obstacles is a quick way of reducing falls risk.
Don’t Drink 2 Hours Before Bed: to avoid waking up in the middle of the night, desperate for the toilet and then stumbling and having a fall, just don’t drink anything for 2 hours before you wish to go to sleep. Now, this doesn’t mean you should dehydrate yourself, it simply means that if you keep well hydrated throughout the day, then you should be fine to not drink for a few hours before bedtime.
Get a walking aid: if your relative is having falls or looks unsteady then almost certainly they will need a walking aid. Having an appropriate aid will significantly reduce their likelihood of having a fall.
Have flat access throughout the property: now, this is probably the most challenging of all ways of reducing falls risk and may involve a lot of discussion with your relative about moving house if you can’t easily make the property flat throughout (no unnecessary steps up or down into the kitchen or downstairs toilet for example.) This is something as physiotherapists we often come across and generally involves difficult conversations about whether that large family home with stairs and multiple levels is appropriate for someone that has balance issues and is falling.
Have an assessment by a physiotherapist: in my opinion, along with all of the other quick fixes above, having an assessment by a physiotherapist can be one of the most effective ways in which you can reduce the falls risk. Here at ThreeSpires Physiotherapy we have a large amount of experience of helping people who are having falls and we can look at all the factors that are causing a person to fall and come up with a clear plan to reduce this risk.
Do some strengthening exercises: as discussed above getting weaker can lead to having falls and as such doing some basic strengthening exercises can really help. These can quite easily be done at home and we have a whole article about this.
Do some balance exercises: as with strength, falls are highly linked to reduced balance and even if you think that you are never going to be a tight rope walker improving your balance even just a little bit can often make a big difference to the likelihood of falling. Check out our article here for ideas on how to improve your balance.

Conclusion

So, what can we conclude from all of this about falls:

Well, firstly falls are a significant problem and if you fall you are highly likely to get injured. We should attempt to reduce the risk of falling and the risk of a serious injury and hospital stay. As with most things, unfortunately age plays a role and the older you get the more likely you are to fall, so you should keep an eye on your elderly relative and how they are moving. If you have had a fall you are much more likely to fall again and as such if your relative has had a fall then you urgently need to look at all the factors we have listed in this article about falls. Prevention of falling is the key and means that you can avoid all of the injuries and reductions in quality of life associated with having a fall. There are a whole range of things that you can do to help but in terms of exercises strengthening and balance exercises are very important.

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