Why do older people fall? Contrary to popular assumption, poor reflexes or tripping may not be to blame, according to groundbreaking research from Simon Fraser University, released in 2012.
The study, published in The Lancet, is the first to use digital video data from closed-circuit cameras installed in long-term care facilities. The cameras were installed in various common areas like living rooms and hallways of two different nursing homes in British Columbia, with permission from the residents and staff. The aim of the research, according to principal author Stephen Robinovitch, was to determine exactly what precipitated each fall, rather than relying on a questionnaire or so-called self-report after the fact, as previous studies have done.
A total of 227 falls among 130 residents were captured on video, and analyzed by Robinovitch’s team at the university’s Injury Prevention and Mobility Laboratory.
“This is the first study to collect objective evidence of the cause and circumstances of falls,” Robinovitch says. “Previous data was collected anecdotally and depended on a person’s memory of what caused them to fall—or witnesses' memories, if there were any. We wanted to get video that would act like the black box in an airplane to determine what led to the crash.”
Dangers of falling: Falls in older people can be catastrophic, statistics reveal. In fact, falls are the number one cause of injury and injury-related deaths in people over the age of 65. In Canada, about 27,000 older people suffer a hip fracture (broken hip) each year, incurring a medical treatment cost of more than $1B; in the US, there are 300,000 hip fractures annually. A quarter of patients with hip fractures will die within a year, and half will suffer a major decline in independence, such as being forced to move from a home in the community to long-term care.
What really causes falls: While dizziness, medication side effects, and certain health conditions like arrhythmias can contribute to falls, most falls in the past were attributed to simple “slips and trips,” according to Robinovitch. The causes were determined by questioning the seniors themselves, or from laboratory reenactments of slipping, using much younger subjects. But these external causes, like tripping over uneven surfaces or catching a foot on a chair leg or walker, only triggered about 20% of the falls in the Simon Fraser study.
Much more common were falls caused by what the researchers call “incorrect transfer or shifting of bodyweight,” which accounted for 41% of tumbles. These involved a body movement that caused the center of gravity to change improperly while walking or standing, and because it seemed intentional—or at least self-induced—the researchers describe the action as “internal” in origin. Many of these misjudgements or over-corrections occurred while transferring from a walker to a chair, or vice versa.
Only a very small proportion (3%) of falls were caused by slipping. While forward walking was one of the activities most commonly preceding a fall, so were sitting down and standing quietly.
Reaction time and bracing for a fall: Though many people think an older person simply can’t react quickly enough to break a fall—or may not know they’re falling until it’s too late to prevent it—researchers discovered that was not typically the case.
“A full 75% of the falls involved hand impact,” Robinovitch says, “but it had no effect. In a way, this is good news: people have the reaction time, and the recognition that they’re falling, so the arms reach out. The problem is that action doesn’t break their falls, which may be related to a lack of muscle strength in their upper body.”
Clues for prevention of falls: Having precise information about which circumstances and actions lead to falls can help caregivers learn how to prevent them, according to Robinovitch. For example, the video can be used to show health-care providers, like physiotherapists and occupational therapists, scenarios that cause problems for older adults with balance or mobility issues, helping to answer the question, "why is my patient falling?" And since so many falls occurred as a person was leaving a walker to sit in a chair, or standing from a chair to use a walker, he suggests such assistive devices be modified to make those transitions easier.
Other research has also called for a redesign of conventional walkers, along with better education on how to use them safely. A 2009 review of admissions to emergency departments revealed that more than 47,000 older people are treated each year in the U.S. for falls associated with walkers and canes. Lead researcher, and epidemiologist with the U.S. Centers for Disease Control and Prevention, Judy A. Stevens writes that 87% of those accidents involved walkers—with women having a higher injury rate in all age categories. The study, published in the Journal of the American Geriatrics Society, also found that 60% of fall injuries happen at home, and only 16% in nursing homes.
Stephen Robinovitch suggests his data could also be used to update building codes in future long-term care facilities, to include things like softer flooring materials. His team is investigating whether using a thick sublayer under hospital-grade vinyl works to protect residents from more serious injuries when falls do happen.
“At least we finally have some solid, objective data about what causes falls, and how they might be prevented.”
Falls and Fractures. US National Institutes of Health National Institute on Aging Public Information Sheet. Accessed October 17, 2012.
Judy A. Stevens, Karen Thomas, Leesia Teh, Arlene I. Greenspan. "Unintentional Fall Injuries Associated with Walkers and Canes in Older Adults Treated in U.S. Emergency Departments." Journal of the American Geriatrics Society Volume 57, Issue 8, pages 1464–1469, August 2009.
Stephen N Robinovitch, Fabio Feldman, Yijian Yang, Rebecca Schonnop, Pet Ming Lueng, Thiago Sarraf, Joanie Sims-Gould, and Marie Loughin. “Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study.” The Lancet, Early Online Publication, 17 October 2012. doi:10.1016/S0140-6736(12)61263