|
 |
CURRENT ISSUE | BACK ISSUES | SUBSCRIBE | ABOUT |
 |
|
Winter 2002-03 "I've Fallen and...""I've fallen and I can't get up!" How many people do not remember the advertisement that made this cry famous? Perhaps you cannot name the product being sold, but surely you remember the phrase--and even the image of the older woman lying on the floor. Two messages could be gleaned from this scene: The woman might be injured and, even if not, she certainly needed someone's assistance. A fall is often a sentinel event for an older person. A fall might indicate an underlying medical problem or a problem with balance or gait, or it might be a sign of decreasing strength. A fall can result in a serious injury such as a hip fracture. Many older people describe a fall as a dreaded event that could precipitate a cascade of problems that will rob them of their independence. To some, falls are mysterious. An older woman once asked me, "Do you fall and break your hip, or do you break your hip and fall?" What she really was asking was if she had any control over such an event. Could she do anything to prevent a fall? Falls are common and increasingly so with advancing age. As described by Judy Stevens in this issue, falls are a major health problem and the leading cause of injury deaths for older people in this country. Nonfatal injuries from a fall can result in medical complications, hospitalizations, diminished function, and premature admission to a nursing home. Loss of independence seems to be the most dreaded consequence of falling. As a result, many falls are unreported to healthcare providers and hidden from family members. The enlightening paper by Lorrie Willett and Barry Sullivan underscores a frequent occurrence--a request for assistance to get up off the floor but refusal to seek healthcare after a fall. It is not the healthcare that is being refused but rather the decision that could result. "I am afraid that I won't be able to come home again." Of emerging concern is the phenomenon of fear of falling. This fear occurs not only among older people who have fallen but also among those who have never fallen. Most older adults know someone who has fallen or have heard stories of what has happened when someone has had a serious fall. One might argue that a little fear can be helpful. That is, it might encourage one to be cautious or to avoid risky behaviors. However, research has shown the opposite to be true. As discussed in the papers by Helen Lach and Elizabeth Peterson, fear of falling can lead to unnecessarily reduced physical and social activity. This reduction in activity not only has a negative impact on quality of life, it also results in physical deconditioning that can increase the risk of falling. Falls are a complex phenomenon. Risk of falling is due to many interactive factors, both personal and environmental. Similarly, successful interventions to reduce falls--and fear of falling--are also multifactorial. Consistent with this complexity, the papers in this issue provide a multidisciplinary approach to understanding and dealing with the problem. Included are the perspectives of epidemiology, medicine, nursing, psychology, sociology, social work, physical therapy, and occupational therapy. In her article, Judy Stevens provides a comprehensive review of the magnitude and consequences of falls. Her concluding recom- mendations call for development of preventive strategies as well as refinement of current intervention approaches. The paper by Larry Rubenstein and Karen Josephson describes known risk factors for falls and discusses how they should be incorporated into a comprehensive clinical assessment. Rein Tideiksaar focuses on how sensory impairments contribute to increasing risk. The paper by Elizabeth Dugan and Denise Bonds points out that assessment can be complicated by gaps in communication between the patient and physician. The final paper in the first section of this issue addresses the growing public health concern with fear of falling. Helen Lach provides research data to confirm that fear of falling is a common and modifiable cause of increased disability. She describes current approaches to measuring and assessing fear of falling. Given the potential of fear of falling to increase the risk of falls, a good clinical assessment should also assess fear of falling when assessing falls risk. Several papers provide information regarding assessment tools and approaches that can be used in evaluation of people with and without a history of falls. Laurence Rubenstein and colleagues provide an overview of the evidence-based clinical guideline developed by a joint task force of the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons, highlighting the recommendations for assessment. Robert Wagenaar and his colleagues Kenneth Holt, Masa Kubo, and Chia-Ling Ho bring a physical-therapy perspective of nonlinear dynamics to assessing gait in older adults. Three types of fall risk assessment tools are described by Karen Perrell. Categorized as comprehensive medical nursing, and functional mobility assessments, Perrell provides suggestions for choosing an appropriate assessment tool. Similarly, home-safety checklists are reviewed and critiqued by Barbara Kercher and Laurence Rubenstein. A broad range of interventions has been developed to reduce falls risk, reduce fear of falling, or manage repeat falls. The paper by Debra Rose provides an excellent overview of the types of interventions for which efficacy has been tested. In addition to describing the range of interventions, she summarizes the results of studies to date and discusses the practical implications of implementing these interventions. Katherine Berg reviews the principles underlying assessment of balance and describes how balance training can be incorporated into a falls intervention program. The paper by Elizabeth Peterson moves interventions to the cognitive-behavioral level, specially focusing on fear of falling. She describes a group program on which we collaborated to reduce fear of falling and to increase social and physical activity levels. In another paper, Peterson and colleagues Jonathan Howland and Jes Lauritzen describe a more recent approach to preventing fall-related hip fractures--the use of hip protectors. While several studies support the efficacy of these protective garment pads in reducing fall-related injuries, unfortunately studies also suggest that user acceptance is low. Finally, two specific programs are highlighted. The National Fire Protection Association in partnership with the Centers for Disease Control created a program called Remembering When that focuses on two leading causes of unintentional injury in the home for older adults. The paper by Sharon Gamache describes the program and the variety of ways in which it has been implemented. A grassroots injury prevention coalition is described by a trauma nurse and a firefighter and emergency medical technician. Lorrie Willett and Barry Sullivan from northeastern Massachusetts describe their experiences as "first responders" to calls from older people who have fallen. These experiences led to identification of an under-reported problem with falls in their community and a call to action. This issue concludes with a list of resources for assessment and intervention approaches. From Generations Winter 2002 issue, 26(4): 5-6. © 2002 American Society on Aging
|
