15
Falls in Older Persons Risk Factors and Prevention

Falls are a marker of frailty, immobility, and acute and chronic health impairment in older persons. Falls in turn diminish function by causing injury, activity limitations, fear of falling, and loss of mobility. Most injuries in the elderly are the result of falls; fractures of the hip, forearm, humerus, and pelvis usually result from the combined effect of falls and osteoporosis.

Prevention of falls must span the spectrum of ages and health states within the older population and address the diversity of causes of falls without unnecessarily compromising quality of life and independence. Intrinsic risk factors for falls have been found in controlled studies, which allow the identification of those at risk and suggest potential preventive interventions. Elderly individuals with multiple health impairments are at greatest risk, but many healthy older persons also fall each year. Current understanding of the etiology of postural instability and falling is limited, and there is little information about the effectiveness of interventions to prevent falls.

A fall is an unintentional event that results in the person coming to rest on the ground or another lower level.56 Falls can be described in terms of three phases. The first phase is an initiating event that displaces the body's center of mass beyond its base of support. Initiating events involve extrinsic factors such as environmental hazards; intrinsic factors such as unstable joints, muscle weakness, and unreliable postural reflexes; and physical activities in progress at



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The Second Fifty Years: Promoting Health and Preventing Disability 15 Falls in Older Persons Risk Factors and Prevention Falls are a marker of frailty, immobility, and acute and chronic health impairment in older persons. Falls in turn diminish function by causing injury, activity limitations, fear of falling, and loss of mobility. Most injuries in the elderly are the result of falls; fractures of the hip, forearm, humerus, and pelvis usually result from the combined effect of falls and osteoporosis. Prevention of falls must span the spectrum of ages and health states within the older population and address the diversity of causes of falls without unnecessarily compromising quality of life and independence. Intrinsic risk factors for falls have been found in controlled studies, which allow the identification of those at risk and suggest potential preventive interventions. Elderly individuals with multiple health impairments are at greatest risk, but many healthy older persons also fall each year. Current understanding of the etiology of postural instability and falling is limited, and there is little information about the effectiveness of interventions to prevent falls. A fall is an unintentional event that results in the person coming to rest on the ground or another lower level.56 Falls can be described in terms of three phases. The first phase is an initiating event that displaces the body's center of mass beyond its base of support. Initiating events involve extrinsic factors such as environmental hazards; intrinsic factors such as unstable joints, muscle weakness, and unreliable postural reflexes; and physical activities in progress at

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The Second Fifty Years: Promoting Health and Preventing Disability the time of the fall. The second phase of a fall involves a failure of the systems for maintaining upright posture to detect and correct this displacement in time to avoid a fall. This failure is generally due to factors intrinsic to the individual, such as loss of sensory function, impaired central processing, and muscle weakness. The third phase is an impact of the body on environmental surfaces, usually the floor or ground, which results in the transmission of forces to body tissue and organs. The potential for injury is a function of the magnitude and direction of the forces and the susceptibility of tissues and organs to damage. A fourth phase, although not part of a fall, concerns the medical, psychological, and health care sequelae of the fall and attendant injuries. These sequelae effect the degree of damage and disability resulting from the fall. Approaches to preventing falls and their consequences should focus on factors related to each of these phases. Falls with certain initiating characteristics (e.g., loss of consciousness, stroke, overwhelming external force from a motor vehicle accident, or violence) are often excluded from the definition of falls in older persons.56 The causes of these falls are different from the typical fall associated with neuromuscular and sensory impairment in an older person and are therefore a distinct topic. The committee concurs in this exclusion; consequently, such falls will not be covered in this chapter. THE HEALTH BURDEN OF FALLS AND FALL-RELATED INJURIES IN OLDER PERSONS Mortality In 1986, there were 8,313 deaths from falls reported in the United States for persons aged 65 and older, making falls the leading cause of death from injury in the elderly.94 This number, derived from death certificates, may underestimate the number of deaths in which falls are a contributing factor.27,49 The rate of fall-related deaths rises rapidly with age for whites aged 70 and older; it rises less dramatically for nonwhites 75 and older (Figure 15-1). By age 85, approximately two-thirds of all reported injury-related deaths are due to falls.6 Older men are more likely than older women to die from a fall; the highest mortality rate occurs in white men aged 85 and over (171 per 100,000), followed by white women aged 85 and over (127 per 100,000). The rate of mortality from falls has declined in recent decades77 (Figure 15-2), which may reflect increased survival of hip fracture patients92 and improved trauma care.95 Some studies suggest

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The Second Fifty Years: Promoting Health and Preventing Disability FIGURE 15-1 Death rates from falls per 100,000 persons by age, sex, and race: United States 1986. Source: National Center for Health Statistics annual mortality data tapes reporting external underlying cause of death. that falls in the frail elderly, especially falls with a ''long lie" (a long waiting time on the ground after a fall before help arrives), are associated with increased mortality independent of injury severity;36,112 this finding, however, is still uncertain.16 Fall-related Injuries In general, fractures are the most common serious injury resulting from falls in older persons. Specifically, fractures of the hip, wrist, humerus, and pelvis in this age group result from the combined effects of falls, osteoporosis, and other factors that increase susceptibility to injury.21,65 Each year in the United States there are approximately

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The Second Fifty Years: Promoting Health and Preventing Disability 220,000 each of hip and wrist fractures in persons over the age of 6573 (see Chapter 6). Although precise estimates are not available, there are several times as many fractures of other bones in persons aged 65 and older as there are hip and wrist fractures.29,33,81 The proportions of some frequently occurring fractures (e.g., those of the rib, hand, foot, and ankle) that result from falls versus other types of trauma are also uncertain. The epidemiology of fracture is reviewed in greater detail in Chapter 6. Other serious injuries resulting from falls include hematoma, joint dislocation, severe laceration, sprain, and other disabling soft tissue injury. There are few data on fall-related injuries other than fracture in the U.S. population. In a regional study in northeastern Ohio, the rate of emergency room treatment of fall-related injuries in persons aged 75 and older approached 80 per 1,000 per year in women and 60 per 1,000 per year in men.29 Another recent study in Dade County, Florida, found an exponential increase with age in the rate of fall injuries that received hospital and emergency room treatment among persons aged 65 and older. These rates were higher in women than men at all ages.95 Among those over age 75, fall injury rates in women exceeded 100 per 1,000 per year; in men they exceeded 80 per FIGURE 15-2 Death rates from falls per 100,000 persons by age, sex, and year: United States. Source: National Center for Health Statistics annual mortality data tapes reporting external underlying cause of death.

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The Second Fifty Years: Promoting Health and Preventing Disability 1,000 per year. About 40 percent of treated fall injuries were fractures. Most falls, however, do not cause sufficient injury to receive medical attention. Only 3 to 5 percent of falls in elderly persons who reside in the community and in nursing homes result in fractures, with fewer than 1 percent of falls causing hip fractures.36,75,93,103 Only about 5 to 10 percent of falls cause other serious injuries requiring medical care.36,102 Between 30 and 50 percent of falls result in a variety of minor soft tissue injuries that do not receive medical attention; the remainder cause no injury or only trivial damage.36,75,82 Frequency of Falls The few large community surveys of falls in this country and elsewhere have been retrospective, asking respondents about falls in the past year. This focus probably results in significant underreporting and misclassification.22,75 Nevertheless, these studies find that about one-quarter of persons aged 65 to 74 and a third or more of those aged 75 and older report a fall in the previous year,17,84,92 figures that are roughly consistent with 12-month recall data from the National Health Interview Survey (Figure 15-3). About half of those elderly persons (of all ages) who report falling in the previous year fall two or FIGURE 15-3 Percentage of older individuals reporting falls in the previous 12 months by age and sex: United States. Source: National Health Interview Survey's 1984 Supplement on Aging.

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The Second Fifty Years: Promoting Health and Preventing Disability more times, a finding consistent with recent prospective studies.75,103 The rate of falls is even higher in health care institutions, with an annual average incidence of about 1,600 per 1,000 nursing home patients.93 Disability Estimates from the National Health Interview Survey indicate that, among persons aged 65 and older in 1986, there were 5.8 million acute injuries of all types associated with 58.9 million days of restricted activity and 18.8 million bed days.74 Falls probably account for a large part of this total injury burden. About one-quarter of falls in the community result in an activity limitation owing to injury or fear of falling.75,103 Disabilities resulting from hip, wrist, and other fractures in the elderly are substantial (see Chapter 6), but there are few data on disability-associated fall injuries other than fracture. One study found that about half of those persons aged 65 and older living at home who are hospitalized for a fall injury are not discharged to their home;95 this group also includes one-third of those with injuries other than a hip fracture. The psychological and functional consequences of falls can be severe whether or not an injury occurs, but such consequences have received insufficient attention and study. Postural instability or a fall can lead to fear of falling and anxiety about normal activities on the part of the older person at risk, as well as among family members and care givers. The result may be a reduction in activity, decreased mobility, and increased dependence, often self-imposed but sometimes originating from others (e.g., family members, care givers). Fear of falling, or "postfall syndrome," may contribute to nursing home admissions109 and loss of independence.56 Costs Meaningful estimates of the medical and other economic costs of falls in the elderly are not possible. Fall-related fractures, however, constitute the major portion of the costs of osteoporosis, which have recently been estimated at $7 to 10 billion annually.81 For example, about 90 percent of the estimated $5.2 billion in direct medical costs for osteoporosis in 1986 were attributable to hospital and nursing home care; 66 percent of hospitalizations and 82 percent of nursing home care admissions for osteoporosis involve fractures in which a fall is usually the source of trauma in an elderly person.83 Studies are needed of the costs of fall injuries other than fractures, of fall

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The Second Fifty Years: Promoting Health and Preventing Disability injuries treated on an outpatient basis, of nursing home admissions triggered by fear of falling, and of activity limitations and disability owing to falls. DETERMINANTS OF FALLS: RISK FACTORS AND CAUSES Current prospects for the prevention of falls are uncertain, although several intrinsic and pharmacologic factors that are associated with an increased risk of falls have been identified. Many falls in the elderly are probably multifactorial, resulting from the convergence of several intrinsic, pharmacologic, environmental, behavioral, and activity-related factors. However, knowledge regarding the etiologic mechanisms of these risk factors and how they combine to produce falls remains limited. Perhaps even more limited is an understanding of situational and environmental factors that precipitate a fall in persons with predisposing characteristics. Situational and environmental factors may be among the most important determinants of risk in healthy older persons. Finally, a better understanding is needed of factors that affect the risk of injury and other adverse outcomes of a fall. Intrinsic Risk Factors Falls are a recognized marker of frailty and mobility impairment in the elderly. The presence and severity of functional disability is a useful indicator of the risk of falling in individuals and populations (Table 15-1). Data from the National Health Interview Survey's 1984 Supplement on Aging indicate that persons aged 75 to 84 who require help with activities of daily living are 14 times more likely, and those with limitations in walking, transfer, and balance activities are 10 times more likely, to report having two or more falls in the previous 12 months compared with persons with no limitations.43 The association of falls with frailty and functional disabilities in the elderly is also evident in the high rates of falls reported in nursing homes.93 The design of effective preventive measures, however, requires knowledge of treatable impairments and conditions that contribute to functional disability, frailty, and falls in older populations. Normal gait and postural stability depend on the proper functioning of sensory, neuromuscular, and musculoskeletal systems. Limb proprioceptive and tactile input, visual input, and vestibular input are critical for maintaining the body's center of gravity within

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The Second Fifty Years: Promoting Health and Preventing Disability TABLE 15-1 Selected Intrinsic Risk Factors for Falls Type of Risk Factor Measure (Studies) Strength of Evidencea Demographic Age > 80 Men (7,15,75,103); Female (9,75,103) Strong Inconsistent General health and functioning ADL, IADL, mobility impairment (17,31,62,75,90,103,105,111); Reduced physical activity/exercise (15,75,103); Past history of falls (15,55,75,103, 105,112) Strong; Weak; Strong Medical conditions Arthritis (9,14,32,75,90,103,105); Stroke (15,62,75,84); Parkinson's disease (15,32,75); Dementia (13,14,32,68); Incontinence (55,62,75,90,103,105); Postural hypotension (15,17,75,90,103,105) Moderate; Moderate; Strong; Strong; Strong; Inconsistent Musculosketal and neuromuscular Reduced knee, hip, or ankle strength (14,15,75,90,104,105,110,112); Reduced grip strength (9,15,75,110); Hip or knee pain/arthritis; Foot problems (9,31,75,82,103); Impaired knee/plantar reflexes; (31,75,90); Slowed reaction time (1,31,75) Strong; Strong; Moderate; Inconsistent; Weak; Weak Sensory Impaired visual acuity (11,15,17,75, 82,90,103,105); Reduced depth perception (75); Visual perceptual error (15,89,106); Impaired lower extremity sensory function (11,14,75,90,97,103,105) Strong; Weak; Weak; Inconsistent Other neurologic signs Frontal cortex/release (90,105); Cerebellar, pyramidal, extrapyramidal (75,90) Weak; Weak Gait, balance, physical performance Gait "abnormalities" (37,75,90,103, 105,112); Reduced walking speed (15,37,52,75); Postural sway (11,15,75,89); Impaired dynamic balance (75,89,90,103,105, 112,113); Impaired tandem gait, one leg balance (14,75, 103); Difficulty arising from chair (15,75, 103,104) Strong; Strong; Moderate; Strong; Moderate; Strong Cognitive, psychological Reduced mental status test score (13,15,17,55,69,75,84,90,103,105, 112); Depression (17,32,69,75,103,105) Strong; Strong

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The Second Fifty Years: Promoting Health and Preventing Disability Type of Risk Factor Measure (Studies) Strength of Evidencea Medication use Sedatives, hypnotics, anxiolytics (9,15,17,32,55,62,75,84,86,90, 97,103,105,111,112); Antidepressants (9,17,62,75,86); Cardiovascular (9,15,17,32,75,84, 90,103,105); NSAIDS* (15,32); Number of medications (9,14,15,32, 90,105) Strong; Moderate; Inconsistent; Weak; Strong Note: ADL = Activities of Daily Living; IADL = Instrumental Activities of Daily Living. Numbers in parentheses indicate references. a Strong = association in multiple studies; at least two of which are prospective; moderate = association in multiple studies, only one of which is prospective—some studies are negative; Weak = association in only a few studies, none of which are prospective—some studies are negative; Inconsistent = generally conflicting and inconsistent findings in multiple studies. * NSAIDS = National Health Interview Survey Supplement on Aging, 1984. its base of support, and these sensory pathways may be compromised by age and disease.114 In addition, age-related disturbances in the organization and central neurological integration of sensory and motor functions may impair the speed, effectiveness, and reliability of postural reflexes, leading to falls.99,115 Age-related slowing of postural reflexes may increase the muscular force required for an effective response to postural disturbances,99 but the strength of skeletal muscles involved in postural control and walking declines with increasing age.12,35,117 Weak muscles and unstable or painful joints may also initiate postural disturbances during voluntary movement. Several studies have found that impaired vision, lower extremity sensory impairment, reduced lower extremity strength, and reduced grip strength are associated with the risk of falls (see Table 15-1). Arthritis in lower extremity joints and foot disorders contribute to gait and balance problems and are also associated with falls in several studies (Table 15-1). Other sensory problems that may contribute to falls, including cervical mechanoreceptor116 and vestibular disorders,72 and the role of impaired central processing in postural instability and falls,53 need more investigation. A few studies have assessed the association of falls with slowed reaction time, impaired reflexes, and other neurologic signs, with inconclusive results (Table 15-1).

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The Second Fifty Years: Promoting Health and Preventing Disability Performance-based measures of gait, balance, and neuromuscular function are strong predictors of falls (Table 15-1), probably because they reflect the combined effect of sensory, neurological, and musculoskeletal impairments on postural stability during the activities in which falls commonly occur.38,103 Impaired cognitive function and depression are associated with an increased risk of falls in several studies. Whether the association of cognitive impairment and falls reflects neurological and psychomotor causes of falls, or behavioral factors related to mental and psychological states, is uncertain.70 It is suspected that psychotropic, diuretic, antihypertensive, and antiparkinsonian medications, especially when inappropriately dosed, may contribute to falls in the elderly by decreasing alertness, depressing psychomotor function, or causing fatigue, dizziness, and postural hypotension.60 Evidence is strongest for an association of falls with the use of hypnotic-anxiolytic drugs, particularly benzodiazepines85 (Table 15-1). The role of diuretic and antihypertensive medications in increasing the risk of postural hypotension and falls needs further investigation.85 Several studies have found an association of falls with the number of medications being taken. Research is needed to determine possible synergistic effects among drugs that might increase postural instability.10 Several common chronic medical conditions, including arthritis, dementia of the Alzheimer's type, stroke, cataracts, and urinary incontinence, as well as such uncommon conditions as Parkinson's disease, are associated with falls in one or more studies (Table 15-1). Although most studies have not found an association of falls with chronic cardiovascular conditions, including postural hypotension, their role as risk factors remains uncertain. Falls may also be a nonspecific manifestation of a variety of chronic and acute conditions.102 In sum, many impairments, disabilities, and conditions repeatedly have been found to be associated with the risk of falls in the elderly. This risk appears to increase with the number of risk factors a person has,76,103 so that those persons most likely to fall can be identified. Additional research is needed, however, including controlled trials, to determine which treatable risk factors are causal. Situational and Extrinsic Risk Factors The risk of falls in apparently healthy older persons is substantial,76,103 suggesting that behavioral, psychosocial, activity-related, and environmental factors are important in the etiology of falls and

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The Second Fifty Years: Promoting Health and Preventing Disability may combine with intrinsic risk factors to increase risk. For example, minor environmental hazards that are easily negotiated by a healthy individual can become major obstacles to mobility and safety for a person with gait or balance impairments. More generally, the physical demands of certain activities or tasks may exceed the competence of the individual, resulting in a fall.47 Although potentially an important area of inquiry, current understanding of this type of fall risk factor is quite limited. In healthy, active older persons, situational and extrinsic factors may be the predominant determinants of risk. Compared with frail and impaired elderly persons, falls among the individuals in this group are thought more often to involve overt environmental hazards, risk-taking activities like climbing ladders, hurrying, or running; in addition, they are more often likely to occur away from home.56 Exposure to fall risks is spread over a wide range of physical environments and activities. In contrast, falls in health-impaired older persons are thought to occur during routine ambulation and transfer maneuvers, usually without an overt environmental hazard, and to occur at home. Among the functionally impaired elderly, fall risks are focused on activities required for basic mobility within a familiar environment. If these contrasting patterns of fall risk are valid, then preventive efforts may need to be tailored to the health level of the population.54 In addition, the two contrasting patterns of risk define a continuum along which many people move with advancing age and declining function. Behavioral, cognitive, and psychological factors that influence how an individual perceives and adapts to the dynamic and changing fit between his or her capabilities and environmental and task demands are a potentially important focus for fall prevention.47,50,106 Additional research in this area is needed to guide the design of behavior-oriented prevention efforts. Individual adaptations to increasing fall risks range from avoidance of specific high-risk activities and removal of environmental hazards, to enhancement of personal and environmental resources to maintain desired activities, to general curtailment of mobility and activities. Modification of activities and behaviors aimed at reducing risk is often appropriate; however, a delicate balance must always be struck between reduction in risk and maintenance of quality of life and independence. Although drastic reductions in activity may decrease falls in the short-term by reducing exposure, over the long-term, reduced self-confidence and physical deconditioning may only increase risk.

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The Second Fifty Years: Promoting Health and Preventing Disability set of factors, with intrinsic, environmental, and situational factors combining to cause most falls in both healthy and impaired persons. For example, slowed postural reflexes may increase the risk of falls owing to slips and trips in otherwise healthy persons, and it is possible that postural reflexes can be improved by training and exercise. The goal of prevention should be not only to reduce falls but to reduce injury and other sequelae of falls. The risk of injury from a fall is the product of a sequence of risks, including the probability of falling, the effectiveness of protective responses, protection by local shock absorbers, including environmental surfaces, and the strength and resiliency of tissue and organs.64 Thus, preventive efforts should address each of the phases in the injury sequence.18 Approaches to decreasing susceptibility to fall injuries are currently limited to therapy to prevent bone loss (see Chapter 6). Environmental surfaces that cushion the impact of a fall, as well as learned protective responses, should also be explored. Finally, improved approaches to treatment and rehabilitation of injuries in the elderly should be emphasized.18 RECOMMENDATIONS Research Randomized trials of fall prevention interventions are a high priority. Agencies of the National Institutes of Health are currently sponsoring a program of such research, and consideration should be given to increasing funding to support a greater number of trials. Interventions that should be given a high priority for randomized trials include the following: focused exercise and strength training regimes; physical therapy, rehabilitation, and training for specific balance and gait impairments; comprehensive medical diagnosis and treatment focused on neuromuscular, musculoskeletal, and sensory impairments thought to cause falls; adherence to conservative guidelines for use of hypnotic-anxiolytic drugs; improved vision care and updated lens prescriptions; modification of environmental risks in the home; behavioral/educational interventions focusing on risk awareness and risk-taking behaviors; and multiple risk factor interventions.

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The Second Fifty Years: Promoting Health and Preventing Disability Intervention trials should provide information on the effectiveness of distinct treatment components, either by focusing on a single component or, when multifactor interventions are used, through a "crossed" or "matrix" design. Where appropriate, investigators should also provide data on the costs and benefits of the program. Trials should be undertaken in both community-dwelling and institutionalized populations. Support should be provided for observational studies of falls that will expand the knowledge base for future intervention designs by increasing understanding of the etiologic mechanisms of falls and of interactions among risk factors. High priority should be given to the following: better understanding of situational risk factors (behavioral, psychosocial, activity-related, and environmental variables) and how these interact with gait, balance, and other impairments in causing falls; better understanding of the pathophysiology of postural control abnormalities in the elderly to identify new leads for therapy; studies of the effect of psychosocial factors on adaptation and on the coping strategies of older persons adjusting to physical impairments, postural instability, and falls; greater understanding of the effects of injury on the psychological function and quality of life of older persons; studies of where falls occur in the home and of the location and prevalence of various home hazards; studies of the risk attributable to specific home hazards, especially in relation to the person's time at risk to these exposures and their functional disabilities; in cognitively impaired and demented patients, an increased understanding of the respective roles of neurological and behavioral factors in causing falls; studies of diuretic and antihypertensive therapy and falls that examine specific drug types, underlying cardiovascular conditions, and new versus established use, and that have the power to detect moderate increases in risk; studies of the distribution and determinants of risk factors for falls in populations, especially neuromuscular, sensory, gait, and balance impairments; and monitoring of new drugs and postmarketing surveillance in elderly patients for side effects that cause postural instability and falls.

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The Second Fifty Years: Promoting Health and Preventing Disability Support should be provided for studies that address methodological issues in research on falls, including the following: use of intermediate outcome variables, such as balance and strength measures, to estimate the effectiveness of interventions in preventing falls and injuries; reliable methods of self-report ascertainment and description of falls in community-dwelling populations; development of reliable falls surveillance mechanisms for institutionalized and cognitively impaired populations, including accelerometers and other technological approaches; methods for quantifying exposure to fall risk, especially environmental and activity-related risk factors, which are important in assessing the efficacy of interventions that increase exposure by increasing physical activity and mobility; and methods for describing and classifying the full range of fall injuries and other adverse sequelae, including fear of falling and activity limitations. The recommendation made in the National Research Council/Institute of Medicine report Injury in America for the use of E-codes (from the World Health Organization's International Classification of Diseases , "External Causes of Injury") in medical records, including hospital discharge records, should be implemented. This practice would allow better tracking of national health objectives, the performance of analytic studies, and evaluation of the effectiveness of proposed preventive measures. Indeed, implementation of this objective would benefit a broad range of injury research and prevention activities. Studies of the biomechanical and other determinants of fall injuries, particularly the understanding of impact responses and tolerances, should be emphasized as a potential means of preventing fall injuries through the environmental control of mechanical energy. Increased research in this area might lead to the design of energy-absorbing surfaces or unobtrusive protective clothing for high-risk older persons. Support should be provided for studies of the economic costs of fall-related injuries other than fractures, of outpatient treatment of fall injuries, and of nursing home admissions related to falls. Education and Services Support should be allocated for community-based demonstration projects in injury prevention in general and in prevention of

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The Second Fifty Years: Promoting Health and Preventing Disability falls in particular, stressing education, reduction of environmental risks, and changes in risk-taking behavior. As part of these projects, methods for coordinating existing public- and private-sector organizations and mobilizing new community injury control resources (e.g., retired firemen, building trades workers) should be developed and evaluated. State-of-the-art fall prevention techniques should be integrated into existing national/local injury control programs. Public education aimed at both the older population and society at large should provide information on risk factors for falls and injuries, ways to modify risks, and sources of assistance in risk reduction. These activities should make aggressive use of several media, including television, radio, and the health care delivery system. Treatment and rehabilitation programs addressing the psychological ("post-fall syndrome") and disability outcomes of falls should be developed and tested. The general topic of injury prevention for the older person should be a required part of the core curriculum of training and continuing education of health professionals. Curriculum areas should include the significance of injury (and falls in particular) as a public health problem, risk factors for injury, and presumptive and demonstrated injury control strategies. Professional training in architecture, city planning, product design, and human factors engineering should include information on the range of capabilities and limitations of the older population so that these factors can be incorporated into designs, standards, and plans. Agencies that set and enforce architectural, building, and safety standards affecting the environments of older persons should take into account the range of capabilities in the elderly population. Applied multidisciplinary studies that address the intersection of standards for the built environment, human factors, and aging should be supported. Adequate reimbursement for injury prevention efforts should be sought, including reimbursement for clinical evaluation and interventions to decrease the risk of falling. Other Areas In addition to implementation of the recommendations for prevention of osteoporosis outlined in Chapter 6, the recommendations of the surgeon general's 1988 Workshop on Health Promotion and Aging regarding injury control, medications, and physical activity

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The Second Fifty Years: Promoting Health and Preventing Disability should also be implemented, with particular emphasis on the following: research and evaluation of promising approaches to improving the understanding and effective use of medications in the elderly, including medication profiles and diaries, color-coding, special packaging, large print, pictographs, and messages adapted to social, cultural, and educational differences; education of patients, family members, and health care providers in proper use, monitoring of side effects, and management of multiple medications for the older individual; continued research on the full spectrum of physiological, functional, and psychosocial effects of exercise regimes and regular physical activity, including strength, endurance, bone mass, agility, coordination, flexibility, and well-being; and research to determine the appropriate type, intensity, frequency, and duration of exercise necessary to achieve the potential benefits in health and functional capacity across a wide age span and range of health status and abilities. REFERENCES 1. Adelsberg, S., Pitman, M., and Alexander, H. Lower extremity fractures: Relationship to reaction time and coordination time . Archives of Physical Medicine and Rehabilitation 1970; 70:737-739. 2. American Institute of Architects Foundation. Design for Aging: An Architect's Guide. Washington, D.C.: American Institute of Architects Press, 1986. 3. Aniansson, A., Ljungberg, P., Rundgren, A., and Wettereqvist, H. Effect of a training programme for pensioners on condition and muscular strength. Archives of Gerontology and Geriatrics 1984; 3:229-241. 4. Aniansson, A., and Gustafsson, E. Physical training in elderly men with special reference to quadriceps muscle strength and morphology. Clinical Physiology 1981; 1:87-98. 5. Ascione, F. J., and Shrimp, L. A. The effectiveness of four education strategies in the elderly. Drug Intelligence and Clinical Pharmacy 1984; 18:126-131. 6. Baker, S., O'Neill, B., and Karpf, R. S. The Injury Fact Book. Cambridge, Mass.: Lexington Books, 1984. 7. Beers, M., Avorn, J., Soumerai, S. B., Everitt, D. E., Sherman, D. S., and Salem, S. Psychoactive medication use in intermediate-care facility residents. Journal of the American Medical Association 1988; 260:3016-3020. 8. Black, F. O., Wall, C. III, Rockette, H. E., Jr., and Kitch, R. Normal subject postural sway during the Romberg test. American Journal of Otolaryngology 1982; 3:309-318. 9. Blake, A. J., Morgan, K., Bendall, M. J., Dallosso, H., Ebrahim, S. B. J., Arie, T. H. D., Fentem, P. H., and Bassey, E. J. Falls by elderly people at home: Prevalence and associated factors. Age and Ageing 1988; 17:365-372.

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