Falls and Fall Prevention _ _____________________________________________________________________
worldwide, after road traffic injuries [7]. Because the number of falls is so high, the resultant loss of disability-adjusted life years (DALYs) is significant—more lives lived with disability than results from transport injury, drowning, burns, and poisoning combined [7]. Not only is the individual economic burden related to falls and fall injuries increasing, healthcare system costs have skyrocketed. Approximately 40% of the total DALYs lost due to falls globally occurs in children [7]. The Centers for Disease Control and Prevention (CDC) conducts surveillance of falls in the United States, including the incidence rate of reported falls by state. While there is vari- ability in the fall rate per state, those with the highest recorded number of falls among older adults are California, Texas, and Florida [3]. CDC surveillance data indicate that about 30 million falls occur annually across the country, of which 37% require medical attention. Of those individuals needing medical treatment, many also need to restrict their activity for a minimum of one day. These data show that, on average, there are 8 million fall injuries per year in the United States [3]. Falling imposes an economic hardship not only for individual patients but also the healthcare system in general. Approxi- mately 800,000 patients each year are hospitalized because of fall-related injuries. According to National Council on Aging estimates, the 2015 cost of nonfatal falls was documented at $50 billion [4]. The cost related to fall treatment is expected to reach an estimated $101 billion by 2030. Fatal falls incur nearly $754 million in healthcare costs alone [4]. Individual groups at highest risk of falling are those 65 years of age and older, young children, and women; men are at higher risk of death associated with falls [7]. FALLS AMONG OLDER ADULTS As noted, falls are a common occurrence in the frail older adult population, causing injuries that may result in disability, institutionalization (e.g., long-term care facility admission), or even death. Older adults are particularly prone to falling because of age-associated, gradual onset of lower body muscle weakness, disturbances of gait, and balance deficits. More than 14 million, or 1 in 4, older adults in the United States report falling every year. About 30% of falls result in injury severe enough to require medical attention; of these, approximately 50% require treatment for bone fracture. The most common skeletal fracture sites are the hip, spine, forearm, leg, pelvis, arm, and hand. Hip fractures from falling occur at the rate of about 1 per 100 falls in older adults, a serious complica- tion that requires hospitalization, surgery, and often results in long-term disability. Even in the absence of injury, many older people who fall then develop a fear of falling, which may prompt additional restriction of physical activity, leading to further loss of physical fitness and agility, thereby increasing the risk of falling.
INTRODUCTION The ability to remain upright on the varied terrain of the physi- cal world, whether at rest or in motion, depends on the inter- play of multiple faculties: awareness, vision, memory, balance, coordination, strength, and agility. These faculties are acquired and honed during youth and undergo an inexorable erosion during old age. Simple maneuvers, once negotiated effortlessly and with little conscious attention, become unpredictable and less reliable as one grows older. Witness an older man hurry- ing up a flight of stairs. At first nothing appears amiss, when suddenly the toe of his right shoe fails to clear the ledge of the next step and he trips forward in disbelief—this has never hap- pened before. Imperceptible quadriceps atrophy and gradual general deconditioning likely accounts for the failure lifting the advancing foot just far enough to clear the step. Consider an older woman descending the same staircase cautiously, less sure whether she can negotiate every step-down safely, unaware that her hesitancy arises from the subtle changes in vision imposed by cataracts. The strength and agility required to maintain an upright posture while carrying out the usual tasks of work and play dissipate with age. Other factors can also contribute to deficits in the skills necessary to maintain balance and gait, including disorders of the nervous system, infection, muscular weakness/wasting, and intoxication. Injuries sustained by falling, especially falls among older adults, can lead to immediate and long-term sequelae, including death. Health professionals responsible for hospital and long-term facility care have increasingly worked to develop programs that reduce fall risk among inpatients. Given the growing expansion of the aging population, it is equally important that primary care providers pay close attention to risk assessment and fall prevention among community-dwelling older adults. This course will review the epidemiology and scope of falls and fall-related injuries, available clinical guidance for screening and fall risk assessment, and management strategies for fall prevention in community and healthcare settings, emphasizing the fall burden associated with aging. EPIDEMIOLOGY Falls and fall-related injuries are common worldwide and have the heaviest impact in low-income communities and commu- nal settings with a preponderance of older adults. Falls can cause severe injury such as hip fractures and head trauma. Among older adults, injurious falls may heighten the risk for further loss of mobility and early death. The World Health Organization estimates that 37.3 million falls severe enough to require medical attention occur each year and notes that falls are the second leading cause of unintentional injury deaths
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