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

Author(s): 
Douglas H. Richie, DPM, FACFAS

Given the frequency of falls among senior citizens, this author offers a thorough review of the literature and provides pertinent insights on key podiatric risk factors for falls, testing tips to assess fall risk and interventions that may be beneficial in this patient population.

Over the past two decades, podiatric medicine has become a vital member of the healthcare team treating important health issues around the world. For example, the role of the podiatric physician in the team approach to treating the diabetic foot has elevated our profession to a level of esteem where we are on a par with any medical specialty.1

   At the same time, there is an equally important public health issue that has the same potential for podiatric physicians to make a significant impact but has yet to become part of mainstream podiatric practice. This issue is fall prevention in the elderly.

   One in three adults over the age of 65 falls each year and half of these people fall multiple times.2,3 The Centers for Disease Control and Prevention report that falls are the leading cause of injury-related deaths in people over the age of 65.4 In 2000, the cost of treating non-fatal fall related injuries was $19 billion and is expected to double by 2020.5,6

   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.7 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 and the somatosensory system of the extremities, which include the muscle stretch receptors, the joint mechanoreceptors and pressure receptors on the plantar 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 “feed forward” 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 and pain.8

   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.3 More alarming is the finding that the risk of falling quadruples for a patient within two weeks of discharge from the hospital.9

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