Approximately 60 percent of falls in the older population occur in an institutional setting (acute care, skilled nursing and assisted living facilities). Falls most often occur at night due to attempts to get to the bathroom; and during the day due to tripping or orthostatic hypotension.
Falls and related injuries and complications account for 12 percent of deaths in the older population; two-thirds of those who fall will fall again within six months.
With the occurrence of and the high probability of falls in the elderly population, teaching fall recovery skills is extremely important. Unfortunately, fall recovery is often left to the last minute prior to patient discharge or not addressed at all.
Often, both therapists and patients have concerns about practicing and learning this skill for fear of an inability on the patient’s part to rise from the floor.
However, learning fall recovery skills is an important part of a balance program for the elderly population regardless of setting.
There are numerous risk factors related to falls in the elderly. Risk factors include:
General changes with age: Shifts in center of gravity, increased flexion at the hips and knees, a stiffer and shuffling gait, decreased proprioception, decreased righting reflexes, increased response time and decreased ability to adjust to new environments.
Pathologies: Central nervous system disorders, dizziness or vertigo, multiple chronic diseases, orthostatic hypotension and syncope.
Medications: Those taking non-narcotic or narcotic analgesics, non-steroidal anti-inflammatory drugs, cardiovascular medications, diuretics, ACE inhibitors, beta and calcium channel blockers, sedative-hypnotics, antidepressants and antipsychotics.
Environment: Throw rugs, torn carpeting, slippery or obstructed floors, glossy floors, absence of railings and grab bars in hall/bath, high beds, inappropriately placed furniture in rooms/hall, poorly fitted shoes, lighting (either too dim or too bright), presence of tubes/catheters and restraints.
Recovery Methods
Fall recovery training can occur through both sequential methods and through backward-chaining.
Sequential Teaching. This method of teaching requires the patient to begin on the floor lying in a supine position. A floor mat may be used during the initial stages.
If a patient has difficulty lying down on the floor, initial training can begin on a mat table. A nearby chair may also be used for support. Once lying supine, the sequence of steps is:
- The patient rolls onto left (or right) side;
- Push up into side sitting supported on an extended left arm;
- The right hand is placed next to the left extended arm and the patient pushes up on both hands, turning the trunk until kneeling on all fours;
- Push up to a high kneeling position (on both knees) using the chair for support if necessary;
- Bring the left leg through to place foot on the floor (half-kneeling);
- Assume standing position independently or by pushing up with both hands on the chair to stand.
Backward-Chaining Method. This method of teaching requires the patient to begin in a sitting or standing position. Each step must be completed with ease before the next step is attempted or added.
Step 1: The patient sits in a chair or mat/low plinth and turns slightly to one side, sliding one knee over the edge until it is resting and bearing weight on a support (e.g., cushion, foam wedge). The patient then pushes back up onto the chair. This step can begin in standing while holding on to a chair or other support. The patient lowers to a support then returns to standing.
Step 2: The patient follows the same procedure as in Step 1, assuming a half kneeling position with a support cushion or wedge, and then returns to the starting position.
Step 3: The patient follows the sequence of Step 1 and 2, progressing from half kneeling to high kneeling (both knees on the floor). Then, the patient pushes back up to standing or sitting.
Step 4: Complete steps 1 through 3 followed by placing both hands on the floor to assume a prone kneeling position and then return to standing or sitting.
A cushion, pillow or foam wedge can be used as an intermediate training stage for placement of hands. When patients have mastered the first three steps, they do not need to repeat them with each attempt to master subsequent stages.
Step 5: Lower the body from prone kneeling to side sitting/half sitting, then progress back through the chain until standing or sitting.
Step 6: Complete step 5, then lower the body to a side-lying position. Progress back through the chain until standing or sitting.
Step 7: Roll from side-lying to supine and progress back through the chain until standing or sitting.
Choosing a method of teaching for the patient will be dependent on factors such as balance, strength, range of motion, cognition level and the patient’s personal comfort level. An appropriate assessment of these factors prior to initiating fall recovery training is necessary.
Resource
Reese, A.C. (1996). Preparing older people to cope after a fall. Physiotherapy, 82(4), 227-235.
