Fall prevention

Generation-specific healthcare against the backdrop of demographic change

Jakob Tiebel

The changes to age distribution in society are accompanied by an exponentially increasing demand for health services. The reason for this is the increased incidence of age-associated diseases, which are facilitated by advanced age, last for a long time and are difficult or impossible to cure. The shifts in the morbidity spectrum create new demands, especially in the specialist disciplines of rehabilitation and physical medicine [32].

Health policy faces the challenge of making appropriate use of increasingly scarce resources in order to be able to guarantee high-quality and at the same time affordable healthcare in the future [2,32,36].

In this context, preventive measures aimed at preventing severe health impairments and the need for long-term care in old age are becoming increasingly important [2,32,33]. In particular, this also includes measures to promote mobility and fall prevention, as with increasing loss of mobility, there is increased risk of falling and also of fall-related injuries [2,32,33,34].

Falling in old age and its consequences

n Germany alone, 4-5 million elderly people fall every year. About one third of seniors over the age of 65 living in a private home environment fall on average once a year. Among those over 80, the rate is higher than 50 percent [26,27,35]. People who have an increased risk of falling related to age usually experience repeated falls over time [24].

Up until they experience their first fall, seniors usually still live alone and largely independently in their familiar surroundings. However, they become increasingly unsteady on their feet. Basic everyday activities such as getting up from an armchair or moving from the hob to the fridge pose an unpredictable risk [2,29]. In about half of all cases, falls in the private home environment do not initially result in serious physical injuries. In 30-40 percent of cases, minor injuries such as bruises, abrasions and haematomas occur [2,27,35].

Up until they experience their first fall, seniors usually still live alone and largely independently in their familiar surroundings.

Falls are usually trivialised by those who experience them, as they generally wish to remain in their familiar environment and are afraid that an increasing loss of mobility means they will have to leave. The subjective assessment of the individual risk of falling usually differs greatly from the results of objective examinations. If a fall is minor, a doctor is rarely consulted because “nothing bad happened” [29]. Afterwards, however, those affected are greatly unsettled and increasingly isolate themselves. They no longer leave the house for fear of falling again. This decreased activity accelerates age-related muscle wasting [2,29].

When people lose confidence in their own motor skills, it is usually not only their physical activity that suffers, but also their diet. The nearest supermarket may be quite far away, which means that grocery shopping becomes less frequent [2,29]. Prolonged impaired nutrition leads to a critical reduction in muscle mass and function, which, in conjunction with the progressive physical ageing process and an increasing decline in mobility, results in a clinical presentation of sarcopenia [40].

Sarcopenia is characterised by a progressive and generalised loss of motor neurones, muscle mass and strength. In particular, fast type II muscle fibres atrophy, which are important for adequate support, protection and positioning reactions. Anabolic resistance also develops. This means that anabolic stimuli increase muscle protein synthesis only to a reduced extent and the muscles regenerate less effectively. The elderly tire quickly and often have reduced motivation due to increasing physical weakness [41].

The connection between sarcopenia and an increased risk of falling is confirmed in a review paper by Feuchter [12]. The results show that sarcopenia is associated with a significantly higher rate of falls as well as a significantly higher risk of falling. Both fear of falling and fall-related injuries such as fractures are significantly increased in people with sarcopenia [12]. Frailty is also closely linked with sarcopenia. Frailty describes a decrease in functional reserves and the resulting reduced resilience of elderly bodies to endogenous and exogenous disruptive factors [4,40].

Frailty is determined by physical, psychological and sociological factors [40]. The definition of Fried et al. has become widely accepted, according to which frailty is characterised by physical weakness, rapid fatigue, slowed walking speed, reduced activity and unintentional weight loss [13]. The diagnosis is made when at least three of these five criteria are met. Sarcopenia and frailty are closely linked both pathophysiologically and clinically and are highly relevant to the functionality and mobility of older people [40].

In the presence of sarcopenia and frailty, the individual risk of falling increases many times over [6]. But those affected usually do not seek help because they are ashamed. Ultimately, it is only a matter of time before another fall occurs, resulting in more serious injuries [18,29,30].

Significance of falls and fall-related injuries in health economics

When considering the health economics perspective, a relevant example is the femoral neck fracture, which in 90% of cases in the very elderly results from low-energy trauma during a fall (in most cases from a standing position, sideways onto the hip or onto an extended or splayed leg), with pre-existing polymorbidity [3,22,23,28]. The fracture causes the affected person a lot of pain, and the leg can no longer be actively moved as a result. The treatment of choice is surgery, and in many cases falls result in a permanent dependency on care [33,37].

Half of those affected by a fall-related femoral neck fracture still suffer from a loss of mobility one year after the event. They can no longer climb stairs, use the toilet independently or walk outdoors [19]. A hip fracture thus represents a drastic change in the social and qualitative aspects of life [25]. This is because the fracture perpetuates a vicious cycle of immobilisation and lack of activation. Those affected hardly dare to get out of bed because they have completely lost confidence in their body and no longer consider themselves to be capable. An increased fear of falling leads to generally avoidant behaviour [37].

In the presence of sarcopenia and frailty, the individual risk of falling increases many times over.

For about a quarter of those affected, this means that, despite follow-up rehabilitation, they cannot initially return to their own homes and have to be cared for at least temporarily as inpatients [3]. In addition to the health problems, the economic and social significance of the disease becomes obvious here. In about 40% of all those affected, it can be assumed that a hip fracture will lead to a permanent dependency on care. This means that every fifth patient with a hip fracture has to move to a nursing home [5].

Treatment of hip fractures alone represents a considerable challenge for the healthcare system and the supportive community due to the need for care so often associated with them [22,42]. In Germany, the immediate treatment costs nationwide are in the billions, not including the long-term costs. Analyses by Weyler and Grandjour from [43] show that hip fractures cause direct costs of 2.77 billion euros annually from a societal perspective.

Against the backdrop of rising incidences due to increasing ageing in society, this is expected to increase to 3.85 billion by 2030 [43].

The importance of measures to promote mobility and prevent falls in ageing people from a health economics perspective results from the assumption that mobility losses, falls and fall-associated injuries and the associated financial burdens for the health care system are avoidable [2,33,34].

It is assumed that up to 30 percent of healthcare costs could be saved if prevention and health promotion were pursued more consistently [42].

Prophylactic strategies to promote mobility and prevent falls

It seems obvious that the treatment of falls should no longer be considered only in terms of surgical and non-surgical care for fall-related injuries and fractures. In particular, it must be based on a systematic strategy to avoid falls, i.e. fall prevention [9,23]. Weyler & Grandjour [43] conclude that effective preventive measures need to be identified to avoid hip fractures in particular.

After decades of health policy being primarily focused on curative medicine, there are now increasing efforts to make more intensive use of the potential of prevention, which has now been clearly proven medically, and to systematically expand it [17,42].

“This development is to be welcomed, as the available evidence shows that a focus on curative care (“repair medicine”) not only perpetuates inefficiencies, but also leads to treatment burdens for patients, premature illness and death. This can be avoided by an early and effective prevention and health promotion strategy” [17].

Prevention should be seen as an effective strategy to unlock the health potential of the population and to contribute to reducing health inequalities and demands on the healthcare system [17,42]. Thus, prevention contributes to improved wellbeing and quality of life on both the individual and societal levels [17].

In general, a distinction can be made between three forms of prevention: primary, secondary and tertiary prevention. Primary prevention pursues the goal of preventing the recurrence of a disease (promotion of mobility in old age). It serves to reduce the incidence of disease (avoiding falls) by minimising known risk factors (lack of exercise, balance disorders). Since a large proportion of falls in old age are caused by loss of mobility, primary measures should aim to increase physical activity. These can start long before a first fall occurs. Secondary prevention is geared towards early detection and containment of an emerging disease or disease risks in order to improve the chances of treatment (implementation of fall prevention screening programmes, wearing hip protectors). Tertiary prevention attempts to reduce the medical or psychosocial consequences of specific diseases and to prevent relapses (return home while ensuring independence, preventing new falls) [42].

Goals and possibilities of fall prevention programmes

Understandably, investing in preventive strategies requires choosing appropriate interventions based on the available evidence [42]. National and international guidelines recommend a wide range of options to promote mobility and prevent falls [2,7,11,8,20]. A range of informal and formal tests and measurement tools are used to assess the degree of mobility and the risk of falls [2,33]. The choice of appropriate preventive measures depends largely on individual limitations and risk factors, which is why a specific prevention programme is usually always preceded by a differentiated assessment of existing mobility limitations and fall risks [2,33,34]. The results of the diagnosis lead to a multimodal prevention programme consisting of a combination of appropriate individual interventions adapted to the identified risk factors [2,37].

Table 1 provides an overview of the most common fall risk factors from the American Geriatrics Society’s guideline on fall prevention [1]. The risk factors were identified on the basis of selected evidence and prioritised in a quantitative analysis using the relative risk (RR, for prospective studies) or odds ratio (OR, for retrospective studies) [42].

Table 1.
Identified fall risk factors based on selected evidence [42].

Risk factor	Significant/Total	M RR/OR	95% CI
Muscular weakness	10/11	4.4	1.5-10.3
History of falls	12/13	3.0	1.5-10.3
Gait disturbance	10/12	2.9	1.3-5.6
Use of walking aids	8/8	2.6	1.2-4.6
Visual disturbances	6/12	2.5	1.6-3.5
Arthritis	3/7	2.4	1.9-2.9
ADL deficits	8/9	2.3	1.5-3.1
Depression	3/6	2.2	1.7-2.5
Cognitive impairment	4/11	1.8	1.0-2.3
Age >80 years	5/8	1.7	1.1-2.5

Figure 1 shows that interventions to prevent falls are as diverse as the risk factors that can cause them. A distinction is made between personal, environmental, behavioural and fracture prevention measures [42].

Figure 1. Spectrum of interventions for fall prevention [42] (own illustration).

• Personal interventions
  • Implementation of training programmes
  • Eyesight check
  • Medication review
• Environment-related interventions
  • Adaptation of the home environment
  • Removal of tripping hazards in the home
• Behaviour-related interventions (information & training)
  • Safe behaviour in the home
  • Sturdy non-slip footwear
• Fracture prevention measures
  • Hip protectors (to prevent hip fractures)
  • Measures geared towards pathophysiological causes (e.g. administration of medication)

A large number of the interventions described that have been proposed to reduce the frequency and risk of falls have now been investigated for their effectiveness. The first high-quality reviews of prevention programmes that aimed, among other things, to improve physical fitness, identify risks and make structural changes to the living environment are provided by the Cochrane reviews published in 1997 and 2003 [14,15]. At the beginning of the 21st century, almost all fall prevention programmes initially proved to be ineffective, so interest shifted over the years primarily to the application of fracture prevention measures [10,14,15]. The aim was not to prevent the falls themselves, but their consequences (e.g. through hip protectors, vitamin D supplementation) [42].

The importance of training programmes in the context of fall prevention

It remains the case that much of the available advice on promoting mobility and preventing falls is based on studies with limited scientific evidence. The low quality is mainly due to methodological weaknesses in the studies and lack of comparability of the results. In addition, there is a lack of research results on the effectiveness of individual measures specific to setting and target group.

However, subject to these limitations, current research suggests that training programmes to promote motor functions should be a core element of multimodal prevention programmes, as they are crucial in maintaining older people’s mobility and reducing the risk of falls. It should be noted,
however, that positive effects can be expected especially in seniors who are still spry and possess a minimum of functional abilities [2].

For example, in the most recent version of its guideline on the prevention of falls in older adults, the US Preventive Services Task Force (USPSTF) points to the superiority of exercise programmes to promote motor functions (recommendation grade B) compared to other multimodal intervention programmes (recommendation grade C) and vitamin D supplementation (recommendation grade D). The authors conclude that older people can best protect themselves from falls and the fractures they cause by exercising regularly. The studies that investigated the effectiveness of exercise in the USPSTF guideline uniformly conclude that seniors are significantly less likely to fall (RR 0.89; 95% CI 0.81-0.97), and the incidence of injuries (incidence rate IRR 0.81; 95% CI 0.73-0.90) and falls (IRR 0.87; 95% CI 0.75-1.00) is reduced overall through regular physical activity and adequate exercise. Multidisciplinary approaches that include cognitive training during physical activity are particularly appropriate for those at increased risk of falling.

It remains the case that much of the available advice on promoting mobility and preventing falls is based on studies with limited scientific evidence.

A review by Sharrington and colleagues published in early 2019 also examined the effectiveness of exercise in preventing falls in older people living independently [31]. The authors searched the literature for relevant reports of randomised controlled trials until May 2018 and were able to include a total of 108 of them (23,407 subjects) in a meta-analysis. The studies come from 25 countries. On average, the participants were 76 years old and 77 percent were female. The evidence regarding the effect of fall prevention exercises is highly reliable. The authors conclude that exercise programmes significantly reduce both the rate and number of falls among older people living at home. Exercises reduce the number of falls by about a quarter (23% reduction). This means that if 850 out of 1,000 seniors fall within a year, exercise programmes can prevent about 195 of these falls. It is interesting that the effects were the same regardless of whether the seniors already had an increased risk of falling or not. This speaks in favour of starting preventive measures as early as possible. In addition, exercise programmes reduced fall-related fractures by about a quarter (27% reduction). Further studies are needed to verify the results [31].

The THERA-Trainer senso can be used for targeted cognitive-motor training in older people.

Step training improves reaction time, balance and reduces falls in older people

In a systematic review from 2017, Okubo et al. summarise the evidence for the effectiveness of step training programmes [21]. The results suggest that both reactive and volitional stepping exercises reduce the number of falls in older adults by about 50%. This clinically significant reduction is mainly due to improvements in reaction time, gait, balance and balance recovery.

Van het Reve & de Bruin [39] were also able to show that it is precisely the combination of strength-balance training with specific cognitive training that has a positive effect on walking, gait initiation and divided attention during motor tasks. The results are confirmed by numerous other studies, which have already shown that cognitive-motor training improves executive functions and effectively reduces falls.

The THERA-Trainer senso can be used for targeted cognitive-motor training in older people. A variety of scientifically validated training programmes and progressive algorithms ensure individual and continuous progress. The system also provides assessments for testing cognitive and motor functions, which have been reviewed in collaboration with ETH Zurich to ensure that they meet quality criteria. The performance metrics thus provide a reliable and meaningful overview of the physical and cognitive condition.

The combination of strength-balance training with specific cognitive training has a positive effect on walking, gait initiation and divided attention during motor tasks.

The THERA-Trainer senso includes special training software that guides and motivates users to achieve their goals. Each programme is designed to work towards a specific goal and is constantly adapting to the abilities of the participants. This not only strengthens cognitive-motor functions, but also sustainably promotes the joy of movement.

Prevention should be seen as an effective strategy to unlock the health potential of the population and to contribute to reducing health inequalities and demands on the healthcare system.

 

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Jakob Tiebel
studied Applied Psychology with a focus on Healthcare Management and has clinical expertise through previous therapeutic work in neurorehabilitation. He researches and publishes on theory-practice transfer in neurorehabilitation and is the owner of Native.Health, a digital health marketing agency.