Fall Prevention in the Geriatric Population

Falls are the most significant concern for many older adults because it often means a loss of independence. In addition, falls are the second leading cause of death 65 and older adults.(See Figure 1). For long-term care facilities, falls are a major source of liability. In fact, more than one out of every four older adults falls each year,1 but less than half tell their doctor,² which is critical because falling once doubles the risk of falling again.³

Figure 1. Incidence of falls in older adults: 2018 vs 2030 (projected)

Source: https://www.cdc.gov/injury/

Falls can affect an individual in many ways. Falls not only cause significant morbidity in older adults but also behavioral changes that lead to poor quality of life and fear of mobility, which in turn, lead to complications associated with sedentary lifestyle and increase the risk of falling in future.

Falls are serious and costly. One out of every five falls causes a serious injury, such as broken bones or a head injury.^4,5 Falls are the most common cause of traumatic brain injuries. Each year, 3 million older people are treated in emergency departments for fall injuries.⁶ Over 800,000 patients a year are hospitalized because of a fall injury, which are most often head injuries and hip fractures.⁶

Hip fracture is one of the most serious fall injuries. It is difficult to recover from a hip fracture, and afterward many people are unable to live independently on their own. As the US population ages, the number of hip fractures is likely to increase. Per patient annual direct costs associated with hip fracture was more than $50,000 in 20197; this number could only continue to grow due to increased older population and increased life expectancy. Fall death rates have increased year over year (See Figure 2).

Figure 2. CDC’s Fatal Injury Trends

Source: https://www.cdc.gov/injury/wisqars/fatal/trends.html

The management of falls requires focus on three critical areas: (1) Identify specific fall risks; (2) identify and treat falls; and (3) develop and implement a fall risk reduction plan.

Falls are often caused by complex interplay of more than one risk factor. Risk factors are either extrinsic (environmental) or intrinsic (biological/behavioral).^8,9

Examples of extrinsic risk factors include slippery surfaces, improper footwear, poor lighting, home trip hazards (eg, throw rugs, pets, electrical wires, footstools, broken or uneven steps), and uneven outdoor terrains, including sidewalks and curbs.

Intrinsic risk factors comprise age, sex, obesity, fall history and fear of falling, mobility impairment, sleep disturbances, neurologic disorders, medications¹⁰ orthostatic hypotension, lack of exercise, urinary incontinence, vision problems, vestibular problems, and vitamin D deficiency.

Additionally, there are some modifiable risk factors. People who fall tend to have a greater fear of mobility than those who are physically active.¹¹ Physical and occupational therapy can assist with home assessments and help identify these risk factors. Such therapy can also assist in making exercise a part of a patient’s daily routine and break the cycle of inactivity and sedentary lifestyle. Encouraging exercise and reducing the fear of falling are cost-effective interventions to reduce fall risk, and many payers, including Medicare, pay for these services as covered physical and occupational therapy benefits.

Fall risk identification technologies that also report fall history can play a significant role in fall prevention plans. A patient’s fall history can serve as the foundation for a fall prevention plan. In addition, it is critical to ensure that use of these technologies is patient-centered to increase compliance and to properly allocate resources.

There are three types of interventions to reduce the risks associated with falls: (1) Primary prevention, which involves pre-fall prevention¹²; (2) secondary prevention, which involves early fall detection and fall injury prevention; and (3) tertiary prevention, which involves reduction of morbidity from fall-related injuries. This article explores the primary and secondary prevention for fall as they could be more effective in both cost control and reducing fatal outcomes in comparison to tertiary prevention.

Primary Prevention Goals and Methods

Primary prevention programs aim to identify the risk factors associated with falls to develop strategies that reduce the patient’s exposure to such factors. These programs commonly focus on medication review and reduction, home safety assessment and modification, and chronic disease management. Several technologies are currently used in hospital and long-term care settings for fall prevention.¹³ The following methods can be used for primary prevention¹⁴: Home safety assessment, bed alarms, nurse notification system, movement-detecting sensors, and virtual reality. Each of these is discussed below.

Home safety assessment. Home strategies are the most important aspect of primary prevention that may have a huge impact in reducing the fall rate among older adults.^15,16 These strategies are simple, cost-effective, and minimally time-consuming.¹⁷ Strategies involve removing clutter to reduce tripping hazards, installing handrails and grab bars, ensuring properly fitting-clothing and footwear, providing adequate lighting, avoiding slippery surfaces, limiting going up and down stairs, and moving cautiously when changing positions.^18,19

Incorporating technology into home modifications helps reduce fall risk, such as adding fall detection notification and connectivity to emergency medical services in the event of a fall. There are existing and emerging fall prevention and detection technologies that can be instrumental in comprehensive fall prevention plans. Even with all possible home modifications to minimize fall risk, falls may occur.

Bed alarms. Bed alarms are commonly used in hospital settings to monitor the movements of patients at risk of falling and are often one component of multifaceted fall prevention.²⁰ The bed alarms consist of pressure-sensitive mats that trigger an alarm when a patient gets out of bed.^21,22 It is important to note that bed alarms work effectively when connected to a compatible nurse call system that can differentiate between a high-risk patient leaving his or her bed from a less urgent nurse call from a patient requesting a glass of water, for example. This way the nurse call system can handle the former as high priority and sound an audibly distinct alarm signal. The advantage of the bed alarm system is that it is an easy and efficient way to monitor patients at risk for falls. The disadvantages of such a system are sensitivity (ie, its reliability in detecting bed/chair exits) and specificity (ie, its rate of false alarms).

Bed alarm sensitivity and specificity can be improved by employing software technologies, which are wise enough to filter all the alarms coming from the devices and send only the appropriate alerts to relevant care team members. One such software is the Vocera platform. This software can integrate with hospital technology sources, such as Smart beds and electronic health records to locate a patient’s fall risk score. It can weigh variables and know whether a patient getting out of bed is at risk of falling and to send a secondary alarm notification only if it is relevant.

Nurse notification system. Using the software Cipher Orchid²³, nurses at Sentara health care facilities were able to both create and integrate a fall prevention specific rounding script. The script helped nurses identify fall risks through environmental assets such as a missing yellow armband or a fall mat. If an issue was identified, an automatic alert was sent to the appropriate staff for resolution. The immediacy of the Cipher Rounds alerts significantly improved nurse response time and issue resolution, thereby decreasing fall rates.

Movement-detecting sensors. Movement-detecting sensors are incorporated into clothing or attached to clothing and sound an alert when the patient bears weight or assumes a vertical position. The advantage of these devices is that they are unobtrusive; however, patients with confusion may try to remove them.²⁴ These are some examples of movement-detecting sensors:

• The FallSaver device from NOCwatch International is a credit-card sized patch that is worn in a pouch on the thigh; it is wireless, disposable, waterproof, shockproof, and unobtrusive. The transmitter inside the pouch sends a signal alerting the health care providers when it detects movement. In a study, the device was particularly effective when used by patients with dementia²⁵. The advantages include easy acceptance by the residents and staff, and no adverse effects on residents’ skin integrity. Studies indicate that FallSaver reduced the number of falls among nursing home residents by 91%.¹²
• Nobi, a Belgian Smart lamp, uses graduated motion detection, automatic lighting, smoke detection, fall detection with live communication system, and pairs with a phone app that unlocks the door in the event of an emergency.
• Smart slippers, which were introduced in 2009 by AT&T, have embedded pressure sensors in the sole inserts to transmit foot movements over their data network. A preassigned person (doctor or caregiver) receives updates via email or text message in case of a sudden or abnormal movement.

Virtual reality. A study conducts with people over 60 years, virtual reality was found to be reliable future intervention to reveal balance disturbances that are not visible in normal walking pattern and thus can help in prevent falls. This study demonstrates there is a strong potential for virtual reality to be used as a physical therapy tool, particularly for patients with balance issues.²⁶

Secondary Prevention Goals and Prevention

The goal of secondary prevention is to detect falls early and prevent fall injury. Technologies can be used to alert the health care facilities of the occurrence of falls. Automatic fall detection devices are available to decrease the response time and improve the likelihood of recovery from the falls. Fall detection technologies include fall notification systems, ambient sensors, and video monitoring–based fall detectors. Each of these is discussed below.

Fall notification systems: User-activated alarms. With these alarms, a button is affixed to a bracelet or pendant¹² worn by the user that can be integrated with a wireless transmitter. When pressed, the button activates a medical alert unit connected to a telephone that calls a monitoring center. A center attendant will immediately speak to the user and contact their designated caregiver or health care providers. When selecting a user-activated alarm or pendant-style alarm for residents, consider the device’s range from the phone unit.

These fall alarms are simple and low-cost; however, they are not effective if a person is unable to activate the alarm, takes it off, forgets to activate it, or inadvertently activates false alarms.

Philips Lifeline, and LifeFone, offer this technology to facilities for a nominal monthly monitoring fee.¹² Apple Watch, a popular product on the consumer market,²⁷ has recently (with its 4 and 5 series)28,29 incorporated many features that could help in the prevention and detection of a fall, such as its dedicated fall protection feature and FallSafety Pro app.³⁰ Newer technology in watch could be easy to wear and carry as well However the cost of the newer watches could pose a potential disadvantage.

Fall notification systems: Automatic fall detection device. Automatic fall detection devices include neck pendants, bracelet, and straps that are worn by the user or connected to their belt or pocket. Automatic fall detection devices use accelerometers and gyroscopes to detect sudden fast movements, impacts, and body orientation.^31-33 These detectors must be worn where it will assume the body’s inclination following a fall. Provided the device is fixed to the resident’s clothing at or above the waist, it will measure the body’s inclination within an acceptable tolerance of 10 to 15 degrees and can detect more than 90% of all falls onto a horizontal floor. Again, ensure that the device has an adequate range from the alarm phone unit to meet the resident’s needs. Recent developments in this area include a new focus on Smartphones as the automatic wearable device.³⁴

This type of device is small and inexpensive, but they are only effective when worn correctly whenever the resident is up and about. An alarm, however, may not be triggered if a person’s torso does not assume a horizontal inclination. To be useful, these devices must be worn continuously and often must be secured tightly against the body, which can cause skin integrity problems for older adults and can be especially cumbersome at night.

Ambient sensors. A variety of ambient sensors, sensing that gathers data about one’s surrounding, have been studied. Here are some examples:

• Voice-controlled sensor: The Alexa Smart Home Collection offers a variety of voice-controlled devices to turn on lighting, lock or unlock doors, and allow communication with family.
• Floor vibration sensor³⁵: Floor vibration sensors are currently under development. These sensors are thought to work whereby energy associated with the impact of a fall is picked up via vibration sensors coupled to the floor.¹² The advantage of this sensor type is that it continuously monitors the floor for vibrations produced by activities such as walking, sitting down, and falling. But these sensors can be fooled by heavy furniture.
• Acoustic sensors³⁶: Acoustic sensors are wall-mounted and work by sensing the noises associated with the impact of a fall. They help with early fall detection and thereby help in the recovery from a fall. However, sensors must contend with competing background sounds, such as televisions, that may be set at high volumes by older adults.

Video monitoring–based fall detector. Universities worldwide are conducting research in the development of video-analysis–based fall detection systems, to explore the variations in image processing algorithms and monitoring and transmission systems.¹² Individual activities are tracked using installed cameras and attempt to detect a fall event based on image processing algorithms designed to identify unusual inactivity.

Most video-based fall detection research has focused on single-camera solutions,^31,37,38 but falls that are fully or partially occluded from the camera present a significant challenge to these systems. To help overcome this challenge, multicamera systems can be calibrated and synchronized to work together as a coordinated unit,39 or they can be used as independent fall detectors, with results combined into a single output.⁴⁰ A simpler approach to the challenge of occlusions is to use a ceiling-mounted (rather than a wall-mounted) camera; however, ceiling-mounted installation is challenging in older facilities, where power sources and network connectivity may not be readily accessible. In addition, some patients may become suspicious of or agitated by visible devices. When taking this approach, a sufficiently wide-angle lens must be used to ensure that it entirely covers the room being monitored.

Fluctuations in lighting present another challenge with using traditional cameras. Active near-infrared illumination provides a solution, allowing the cameras to work in darkened rooms. A recent trend in near-infrared illuminated fall detection is the use of depth images produced by the Microsoft Kinect sensor.^41-45 A drawback of this sensor is its limited field of view, which makes its use impractical in a ceiling-mounted location.⁴⁶ Wide-angle lenses exist for the Kinect, but they result in substantially lower-quality depth images.

Secondary Prevention: Post Fall Injury Prevention

Hip protectors. Secondary intervention devices such as hip protectors are effective in reducing a fall’s impact like hip fractures⁴⁷. The advantage of these devices are to reduce the forces transmitted to proximal femur following a fall thereby helping to prevent hip fractures. However, hip protectors are bulky, cumbersome, and must be worn continuously being that falls may happen at any time.

One of the hip protectors on a clinical trial is Tango Belt, a real-time fall protection wearable device that sends notifications to caregivers via WiFi (Figure 3). The Tango Belt is an investigational device, which means it has not been approved by the US FDA.

Figure 3: Tango Belt for Hip Protection

Source: https://www.tangobelt.com/

SmartCells fall protection mats and flooring are made from an impact-reduction material that provides a stable standing surface while reducing fall-related injuries. Researchers from Penn State University developed a flooring system that provides a stable walking surface that also deforms elastically under higher loads, such as the weight and impact of a fallen person. Their analysis of the system found that this flooring could reduce the impact on a person’s femoral neck during impact by 15.2%.⁴⁸ Conversely, the flooring is expensive, and some institutional building codes related to flooring material in assisted living facilities may prevent further testing and use.

Falls account for a significant portion of hospitalization among older patients due to multisystem injury. Several extrinsic and intrinsic factors potentially contribute to falls in this population, and interventions are required to prevent the increasing burden. Advances in material science and information technology would make fall prevention and detection technologies more effective and affordable. It is important to implement policies to identify patients at risk for falls and monitor them remotely or frequently to reduce the incidence of falls. A more cost-effective and comprehensive approach in the prevention of falls can lead to a huge impact on reducing morbidity and mortality in the older population. The projected increase in the incidence of falls among older adults coupled with the widespread development of technology to address prevailing health care issues has created opportunity to tackle the significant health care burden of falls.

Priya Ponnaiyan MD, Uloma Ibe MD • Nader Tavakoli MD, CMD, FAAFP • Richard G. Stefanacci DO, MGH, MBA, AGSF, CMD • Sonia Haider, MD • Heather Langley PT, DPT, BS, LMT2 • Lindsay O’Connor BS, MOTR/L

Affiliations:

Department of Family Medicine, University of Maryland Capital Region Medical Center, Largo, Maryland

Disclosure:

R.S. reported serving as a consultant for TangoBelt; N.T., U.I, P.P., S.H., H.L., L.O., reported no relevant financial relationships

Address correspondence to:

Dr Nader Tavakoli MD, CMD, FAAFP

Chair, Dept of Family Medicine

University of Maryland Capital Region Medical Center

901 Harry S Truman Drive Largo, MD 20774

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