Preventing Falls In The Elderly: Where DPMs Can Have An Impact
What Studies Reveal About Interventions For Fall Prevention
The medical literature contains thousands of articles relevant to fall prevention. Various researchers have developed and tested interventions to address any and all of the aforementioned risk factors. What is perplexing is the fact that treating individual risk factors does not reliably lead to any significant reduction of fall risk in elderly patients. Clearly the prevention of falls is far more complicated than simply identifying risk.
For example, a recent trend in podiatric medicine has been the dispensing of bilateral solid shell ankle-foot orthoses (AFOs) to prevent the risk of falls in elderly patients (see my Podiatry Today DPM Blog at http://goo.gl/7r7dG ). Training sessions and webinars promoting the sale of these braces justify the medical necessity of this intervention because the treatment focuses on musculoskeletal or neuromuscular disorders that have previously been identified to be risk factors for falling. The problem is that treating balance problems, muscle weakness, neuropathy or ankle arthritis with AFOs has never proven to prevent falls in the elderly. In short, AFOs have never been included in any credible published study of an independent or multifaceted fall prevention program.
The most recent Cochrane review of community-based fall prevention trials was published in 2008.26 This 254-page document surveyed over 4,000 references and selected 111 randomized controlled trials of 53,000 participants. This review paper made the following conclusions about fall prevention programs.
• 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.
Costello and colleagues also observed that multifactorial fall prevention programs are not always successful.27 These authors reviewed 781 published studies and concluded that only such programs that target individuals with a previous fall are successful. Researchers also 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.