Interventions for those at High Fall Risk
Naturally, the purpose of estimating fall risk is to determine when individuals need interventions to prevent future falls. But what then? In this final installment of our series, we’ll review some of the most common and/or effective interventions used to reduce fall risk, from the generic to the specific.
Generic Preventive Interventions
Things get left on the floor, something is just out of reach, we become startled, a door or drawer is stuck -- and then it happens. One way to reduce fall-risk is to eliminate the potential disturbances that most frequently precede a fall. This includes removing slipping and tripping hazards, putting frequently used objects within easy reach (e.g., dishes, food), and adjusting the position of furniture (e.g., the coffee table) according to the most common paths they will take. These are low or no-cost. If you’re willing to invest a little bit more, you can add features to the home environment to reduce the risk. Increasing the home lighting brightness and adding night lights will help highlight potential hazards. Installing effective stair treads and handrails will enhance stair climbing. Grab-bars in the bathroom shower or beside the toilet provide assistance in standing and being seated. Installing a handheld shower head with hose and adding a plastic chair to the shower also allows a sit-down shower, which for some is helpful. A bath mat and raised toilet seat make the bathroom environment safer as well.
When it comes to fall risk fashion, sensible footwear and clothing are key. The goal is to not let either trip you up. Footwear should fit well, not loosely. If the insole or outsole is wearing out, replace the shoes. If laces are coming undone, consider Velcro. Slippers may be comfy for padding around the house, but…well the name says it all. Same with flip-flops. Now, non-slip socks sound promising, but one recent survey article suggests that there is little evidence to support them reducing fall risk (in hospitalized older adults) and instead they recommend footwear. Clothing that is easier to put on and remove or pull down for bathroom visits is preferable. Properly fitting clothes rather than loose-fitting ones may prevent them from getting hooked or caught.
Specific Targeted Interventions
“What makes someone at risk of falling?” If we can answer that question for a certain individual, then we can look beyond the generic interventions and actually tailor solutions to their situation. The previous two blogs in this series discussed strategies for assessing overall fall risk and inherently offer some insight regarding individual underlying problems. Questionnaires can reveal medication and illness history and certain functional performance tests (low or high-tech) can help pinpoint weaker aspects of a person’s mobility. Let’s take a brief tour of some of the underlying fall risk problems, with a focus on functional performance, and look at some of their associated interventions.
As noted in our last blog, slower walking speed is correlated with fall risk. It stands to reason that interventions that improve walking will reduce this risk factor. In the literature, gait enhancing interventions that focused on exercise or resistance training slightly increase preferred gait speed (0.07—0.13 m/s, according to two survey articles), which could substantially decrease fall risk for certain individuals. It has also been argued that exercises that build walking “skill” by approximating certain aspects or types of movements in walking are more beneficial than exercises for strength, endurance, and flexibility of impaired systems.
Regarding gait variability, a pole-striding exercise (walking with poles) was found to reduce step-time variability in one study. In a separate study, a 12-week combined resistance, balance, and endurance exercise regimen led to significant reduction of gait variability. Some curious research has been explored as well. One line of research has looked into using external cues such as music or metronomes and mental (internal) singing, reducing gait variability in some cases. In another line of research, one study applied subtle random vibrations to the sole of the foot during walking and saw a decrease in gait variability among individuals with higher degrees of gait variability. Unfortunately, it would appear that the mental singing and underfoot vibrations would need to be applied whenever one walks.
Older adults with foot pain or flat foot have substantially increased odds of falling according to a study involving 1375 participants. One multifaceted intervention applied to a group of older adults with foot pain involved “…foot orthoses, advice on footwear, a subsidy for footwear, a home-based program of foot and ankle exercises, a falls prevention education booklet…” over the control group (both groups received routine podiatry care for 12 months). The group with the extra interventions saw 36% fewer falls. A survey article on the topic agreed that multifactorial podiatry interventions significantly reduce fall rates, whereas “single component podiatry interventions demonstrated no significant effects on falls rate.”
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Above normal postural sway is another sign of instability and fall risk. Exercise-based interventions to reduce postural sway have included balance exercises, resistance exercises, and multi-component exercises. A survey article of these three types of interventions revealed definite reduction of sway for balance exercises in both eyes-open and eyes-closed postural sway testing, whereas resistance and multi-component exercises did not affect the sway measures they examined (COP velocity/path length, COP area). One postural sway fall risk metric looks at the ratio of sway between eyes closed and eyes open. The closer this ratio is to 1, the more similar the eyes open case is to the eyes closed case. Eyesight normally provides another mental input with which to stabilize postural sway. Thus, if this ratio is low, one possible explanation is that the individual’s eyesight is poor and needs correction. Finally, textured insoles have been used to provide more sensitivity to the foot and may be helpful if available.
Postural hypotension, the dizzying effects of sitting up from lying down or standing from sitting too quickly (because of a drop in blood pressure), substantially increases the odds of someone falling, according to a recent survey article. Common interventions include the use of compression stockings to improve blood flow, specialized medications, and lifestyle changes: drinking more fluids, avoiding alcohol, elevating the head of the bed, and increasing the amount of salt in your diet (if the doctor allows), to name a few. Getting up or out of bed slowly, squatting rather than bending at the waist, exercising gently (e.g., clench and unclench hands) before and after getting up, and avoiding standing for long periods are a few ways to reduce the momentary symptoms, and thus falls.
Depending on the severity of the impairments discussed above, remediation by generic interventions or specifically targeted exercise, education, or other means may not be enough to reduce the fall risk to a level where the individual, family, and clinician are comfortable. A clinician may prescribe a cane or walker, etc. to provide the extra stability needed. Of course, let’s not forget vigilance, common sense, and human assistance, especially when navigating more treacherous terrain. Like most things in life, if we put our thinking caps on, there’s a lot we can do to reduce fall risk. Knowing the source of instability, we can go even further.
Now, it’s time for your feedback. What unique fall risk interventions have you encountered? Are there any you’ve used that were particularly effective? Please leave your thoughts in the comments section below.
The Mayo Clinic on Fall Prevention, describing primarily generic preventive interventions:
The Regional Geriatric Program of Eastern Ontario (Canada) on Fall Risk Assessment and Intervention, a broad and rich source of fall risk information, including exercise-based interventions: