Report on Seniors’ falls in Canada

Report on Seniors’ falls in Canada
Report on
Seniors’ falls
in Canada
Report on
Seniors’ falls
in Canada
Division of Aging and Seniors
Public Health Agency of Canada
Postal Locator: 1908A1
Ottawa, Ontario
K1A 1B4
Tel.: (613) 952-7606
Fax: (613) 957-9938
E-mail: [email protected]
Web site: www.phac-aspc.gc.ca/seniors-aines
This publication is available in alternative formats upon request. The Public Health Agency of
Canada is not responsible for errors or any consequences arising from the use of the information published in this report.
© Minister of Public Works and Government Services Canada, 2005
Cat. No.: HP25-1/20005E
ISBN: 0-662-41415-2
Également disponible en français sous le titre : Rapport sur les chutes des aînés au Canada
Table of contents
Dedication and acknowledgements........................................................................ 4
Foreword .................................................................................................................... 5
Statistics on seniors’ falls ......................................................................................... 6
1. Introduction ........................................................................................................ 7
1.1 How this report is organized...................................................... 7
1.2 Seniors’ falls – definitions .......................................................... 8
1.3 Action on seniors’ falls............................................................... 8
2. The scope of the problem ................................................................................... 10
2.1 What seniors report about falls and related injuries .............. 10
2.2 What hospitalization data tell us about seniors’ falls.............. 15
2.3 What hospitalization data tell us about falls
in residential care...................................................................... 21
2.4 What mortality data tell us about deaths due to falls............. 25
3. Risk factors for falls and fall-related injuries in seniors ................................. 30
3.1 Biological and medical risk factors .......................................... 31
3.2 Behavioural risk factors............................................................ 32
3.3 Environmental risk factors ....................................................... 35
3.4 Socio-economic risk factors ..................................................... 36
4. Evidence-based best practices for the prevention of falls ............................... 37
4.1 Existing practice guidelines ...................................................... 37
4.2 Best practices for fall prevention ............................................. 38
4.3 Selecting appropriate approaches according to setting .......... 45
4.4 Recovery from a fall .................................................................. 46
4.5 Factors influencing client compliance in fall prevention ....... 47
5. Supporting fall prevention strategies................................................................ 50
6. The way forward.................................................................................................. 52
References................................................................................................................. 54
List of tables and figures......................................................................................... 61
Appendix A – Risk factors for falls and fall-related injuries ................................. 62
Appendix B – List of the Public Health Agency of Canada’s resources
on seniors’ falls ................................................................................ 63
Report on Seniors’ falls in Canada
3
Dedication
The Division of Aging and Seniors dedicates this document to the memory of
Margery Boyce (1932-1997), who devoted over two decades to the field of aging
and seniors. She was a passionate advocate for all aspects of seniors’ safety, and the
inspiration for much of Health Canada’s, and now the Public Health Agency of
Canada’s leadership in the area of seniors’ falls prevention. Her deep concern for
seniors is perpetuated in the work of the Division through its continued federal
leadership on health issues related to aging and seniors.
Acknowledgements
The creation of this document has truly been a collective effort by many who
share a commitment to seniors’ falls prevention. The Public Health Agency of
Canada wishes to thank all those who contributed their time and effort to the
development, review and production of this document.
Special thanks to Jennette Toews, Policy Analyst, Division of Aging and Seniors,
for her leadership and commitment to the research and analysis that led to the
creation of this document.
4
Report on Seniors’ falls in Canada
Foreword
Most of us have heard of a senior who has fallen, been injured and suffered devastating
effects: disability, chronic pain, loss of independence and a lesser quality of life. Such falls not
only alter the course of aging, they also have serious repercussions on the lives of family and
friends, and on Canada’s public health resources.
Recognizing that falls are one of the most costly and complex injury issues facing seniors, the
Public Health Agency of Canada (PHAC) has prepared this Report on seniors’ falls in Canada
to support and promote research, policies and programs to prevent seniors’ falls. It is the first
report to present comprehensive data on fall injuries and deaths, as well as evidence on risk
factors and best practices for prevention, solely for Canadians age 65 years and over.
The development of this report was inspired by the unprecedented momentum and interest
in seniors’ falls prevention over the past decade in Canada and around the world. Health
Canada and the Public Health Agency of Canada are proud of the work that has been carried
out in the area of injury prevention and, in particular, of fall prevention among seniors.
The Report on seniors’ falls in Canada provides information to support continued research
and action to prevent falls and injuries among seniors in Canada. As surveillance, research
and program initiatives expand, our collective understanding of risk factors and the prevention of falls will increase. This improved understanding holds promise for the development of
effective new interventions and policies to reduce the human suffering and financial costs of
falls and fall-related injuries among Canadian seniors.
David Butler-Jones, MD
MHSc, CCFP, FRCPC, FACPM
Chief Public Health Officer
Public Health Agency of Canada
Report on Seniors’ falls in Canada
5
Statistics on seniors’ falls
■
Falls are the second leading cause, after motor vehicle
collisions, of injury-related hospitalizations for all ages,
accounting for 29% of injury admissions.1
■
Almost 62% of injury-related hospitalizations for
seniors are the result of falls.2
■
The fall-related injury rate is nine times greater
among seniors than among those less than 65 years
of age.3
■
Almost half of seniors who fall experience a minor
injury, and 5% to 25% sustain a serious injury
such as a fracture or a sprain.4
■
Falls cause more than 90% of all hip
fractures in seniors and 20% die within
a year of the fracture.5
■
Families are often unable to provide
care, and 40% of all nursing home
admissions occur as a result of falls
by older people.6
■
Even without an injury, a fall can cause
a loss in confidence and a curtailment of
activities, which can lead to a decline in
health and function and contribute to
future falls with more serious
outcomes.7
■
A 20% reduction in falls would
translate to an estimated 7,500 fewer
hospitalizations and 1,800 fewer permanently disabled seniors. The overall
national savings could amount to
$138 million annually.8
■
The magnitude of the problem of falls
among older adults is reflected in the
300% increase in publications on the
issue between 1985 and 2005.9
6
Report on Seniors’ falls in Canada
1
Introduction
This report was designed to support the
efforts of all those who work on research,
programs and policies to reduce seniors’
falls and fall-related injuries. It presents a
comprehensive analysis of national data –
for Canadians age 65 and over – on fall
injuries and deaths, as well as evidence on
risk factors and best practices for the prevention of injuries to seniors living in both
community and institutional settings.
The report provides new national information through analysis of the following data:
■ epidemiological evidence on falls highlighting seniors’ self-reported data from
the Canadian Community Health
Survey;
■ hospitalization data from the Canadian
Institute for Health Information
Discharge Abstract Database; and
■ mortality data from Statistics Canada’s
Canadian Vital Statistics.
Four Technical reports are available online
(www.phac-aspc.gc.ca/seniors-aines/pubs/
seniors_falls/technical/index.htm) describing in detail the data requests, analyses and
interpretation of the data used on:
■
■
■
■
injury resulting from falls among
Canadians age 65 and over;
hospitalizations due to falls among
Canadians age 65 and over;
hospitalizations due to falls among
Canadians age 65 and over living in
residential care facilities; and
deaths due to falls among Canadians
age 65 and over.
1.1 How this report is organized
Chapter 1, Introduction, presents the document’s objectives, definitions, the main data
sources used and the work of the Canadian
government in the area of seniors’ falls
prevention.
It also examines:
■ information on multifaceted risks for
falls among seniors;
■ evidence-based best practices for the
prevention of falls and injury from falls;
and
■ issues surrounding the development
and sustainability of fall prevention
initiatives.
Chapter 2, The scope of the problem,
provides the first comprehensive overview
of data on fall-related injuries and deaths
among Canadians age 65 and over. Sections
present data on self-reported falls, fallrelated hospitalization data for all seniors
and for seniors living in residential care
facilities, and vital statistics data on fallrelated mortality.
In addition, appendices provide a comprehensive list of risk factors for falls and
fall-related injuries, and a list of the Public
Health Agency of Canada’s fall prevention
publications (including the online Inventory
of fall prevention initiatives in Canada – 2005).
Chapter 3, Risk factors for falls and fallrelated injuries in seniors, presents the
latest evidence concerning fall risks from
widely adopted guidelines and reviews other
more recent studies on the prevention of
falls. The information is organized under
Report on Seniors’ falls in Canada
7
biological, behavioural, environmental and
socio-economic risk factors.
Chapter 4, Evidence-based best practices
for the prevention of falls, summarizes the
evidence for a broad range of best practices
for the prevention of falls and fall-related
injuries, plus some recent findings on
addressing fear of falling, selecting the
best approaches for specific settings, and
recovery from a fall.
Chapter 5, Supporting fall prevention
strategies, presents new information about
factors affecting the sustainability of fall
prevention programs.
Chapter 6, The way forward, addresses the
potential of provincial and territorial data,
including those on hospitalizations and
deaths due to falls, to support local and
regional fall prevention initiatives that
respond to the unique circumstances in
each jurisdiction.
1.2 Seniors’ falls – definitions
All statistics and information reported in
this document refer to Canadians age 65
and over unless otherwise stated. Words or
expressions such as ‘senior’, ‘older adult’,
‘older person’ – all refer to this age group.
A fall is often defined as a sudden and unintentional change in position resulting in an
individual landing at a lower level such as
on an object, the floor, or the ground, with
or without injury. Different data sets define
falls in various ways. These are described
under each section.
8
Report on Seniors’ falls in Canada
1.3 Action on seniors’ falls
Throughout Canada, stakeholders are taking
action to reduce falls and fall-related injuries
among seniors. Several provinces and territories have identified falls among seniors as
a serious public health issue and are developing interventions and strategies for fall
prevention. In some cases, strategies are an
element of broader approaches that address
injury prevention, healthy living or chronic
disease across all ages. Professional health
associations, universities and research institutes are developing new evidence on seniors’ falls and this knowledge development
is supported by fall prevention activities of
professional and voluntary organizations
that have a focus on either injury prevention
or seniors’ issues.
The Canadian Medical Association “urges
federal, provincial and territorial governments to develop and support initiatives
to reduce the risk of older persons from
falling and sustaining fractures and other
serious medical complications.”
Source: Resolutions concerning impact of falls on
the health of older persons, Canadian
Medical Association, 135th AGM,
Saint John, NB, 2002.
The Public Health Agency of Canada
(PHAC) is leading continued federal action
on seniors’ falls as an important part of its
mandate in preventing disease and injury
and promoting good health. PHAC has
developed a unique capability as a result
of more than a decade of dedicated Health
Canada investments in seniors’ falls prevention. Within PHAC, research, surveillance
and epidemiological activities support the
development of evidence to reduce falls.
The Division of Aging and Seniors, originally
in Health Canada and now part of PHAC,
has been the focal point for seniors’ falls
prevention activity within the federal government. The launch of The safe living guide:
A guide to home safety for seniors in 1996 was
the first of several fall prevention publications developed by the Division. (See
Appendix B for a complete list of the
Division’s publications on seniors’ falls prevention). The Division has also supported
collaborative jurisdictional action between
the federal government and the provinces
and territories through the Federal/
Provincial/Territorial Ministers Responsible
for Seniors. In 1999, the F/P/T Ministers
Responsible for Seniors commissioned an
inventory of prevention programs, An inventory of Canadian programs for the prevention
of falls among seniors living in the community,
and a systematic review of the effectiveness
of fall prevention programs for communitydwelling seniors. The findings of these studies formed the basis of A best practices guide
for the prevention of falls among seniors living
in the community, published in 2001.
The growing interest in seniors’ falls prevention led to the first national meeting of
stakeholders from across Canada in July
2000, to determine national priorities and
directions on seniors’ falls. The subsequent
launch of a partnership between Health
Canada and Veterans Affairs Canada
enhanced the momentum on fall prevention
both regionally and nationally.
This partnership, the Health Canada/
Veterans Affairs Canada Falls Prevention
Initiative, sought to advance understanding
and knowledge of effective seniors’ falls
prevention interventions and to enhance
community capacity to deliver fall prevention programs using a population health
approach. The Initiative provided timelimited funding to community-based fall
prevention projects that addressed environmental hazards, personal health practices,
high risk populations and assistive device
use. Throughout its four-year mandate, it
supported knowledge development on the
risk factors for falls, capacity building to
address falls, and contributed further evidence on program models best able to
reach seniors living in the community.
Across Canada, there are ever growing numbers of fall prevention interventions taking
place within community, acute care, and
long-term care settings. Key to targeting
resources for the prevention of falls and
related injuries is enhanced knowledge on
the scope and nature of seniors’ falls and the
evidence for best practices for prevention. It
is hoped that the overview of seniors’ falls
data and the review of the evidence contained in this report will contribute to
the ongoing development of seniors’ falls
prevention strategies of the future.
Report on Seniors’ falls in Canada
9
2
The scope of
the problem
A comprehensive overview of the nature
and scope of seniors’ injuries in Canada was
derived from the study and analysis of:
■ epidemiological evidence on falls highlighting seniors’ self-reported data from
the Canadian Community Health Survey
(CCHS);
■ hospitalization data from the Canadian
Institute for Health Information
Discharge Abstract Database (DAD) for
all seniors, then more specifically for
seniors in residential care; and
■ mortality data from Statistics Canada’s
Canadian Vital Statistics.
It is important to note that every data
source has its own definition of a fall based
on the nature of the data, for example, selfreports vs. hospital records. Consequently,
care should be taken in comparing falls
data from different sources. It is also critical to recognize the distinct limitations of
any data source, including the inherent
potential for data errors and the impact
on hospitalization and mortality data of
changes in the International Classification
of Diseases (more details are provided on
pages 15-16, and in the Technical reports, at:
www.phac-aspc.gc.ca/seniors-aines/pubs/
seniors_falls/technical/index.htm).
2.1 What seniors report about
falls and related injuries
This section provides national estimates
based on the Canadian Community Health
Survey (CCHS) data from seniors age
65 and over who indicated that they had
suffered a fall-related injury in the previous
10
Report on Seniors’ falls in Canada
year, serious enough to limit their normal
activities. Included are estimates of cases
and rates of injurious falls, types of injury,
types of activity, and where treatment
was obtained.
The Canadian Community
Health Survey
CCHS is a component of the Population
Health Survey Program of Statistics
Canada. Cycle 2.1 of the Survey provides
estimates of health determinants, health
status and health system utilization for
the health regions across the country. The
CCHS targets individuals age 12 or older
who are living in private dwellings. The
CCHS uses face-to-face interviews with
respondents randomly selected from
households in selected sample areas
based on the area frame designed for the
Canadian Labour Force Survey. People
living on Indian reserves or Crown lands,
residents of institutions, full-time members of the Canadian Armed Forces, and
residents of certain remote regions are
excluded. The CCHS produces estimates
representing approximately 98% of the
Canadian population age 12 and older.
Definition and data
In the CCHS data, a fall is ‘defined’ by the
respondents when they indicate first, that
they suffered an injury in the previous year
serious enough to limit their normal activities, and second, that the injury was the
result of a fall.
This section:
■ provides estimates for the Canadian
population based on self-reports from
a sample of individuals;
■ includes data for those age 65 and over
for 2002/03 (cycle 2.1 of the CCHS);
■ presents data for the age groups 65-69,
70-74, 75-79, and 80 and over; and
■ analyzes data collected over a 12-month
period beginning in September 2002.
The estimates provided come from a sample
of respondents randomly selected from
households in selected sample areas. It
should be noted that such estimates are
prone to error. The Technical report – Injury
(www.phac-aspc.gc.ca/seniors-aines/pubs/
seniors_falls/technical/index.htm) provides
details about the sampling method, sampling and non-response error, the specific
survey questions used for the falls analysis,
and an interpretation of the findings. Also,
there is a well documented tendency for
persons self-reporting falls to understate
actual incidence. Further, the CCHS provides
information about only the most serious
injury resulting from a fall in the prior year,
thus losing information, important in this
context, from those who experienced more
than one fall or from those who fell but
were not injured.
Findings
Table 1 data have been extrapolated from
the sample (CCHS, cycle 2.1) to the total
population age 65 and over. It shows that
the sample of approximately 29,000 respondents for 2002/03, represents a population
of approximately 3.8 million Canadians age
65 and over. In the sample age 65 and over,
56% were female. The median age for the
sample age 65 and over was 72 years. Sixty
percent of the sample age 65 and over was
married, while 34% was widowed, separated
or divorced.
The CCHS data indicates that, compared to
the population of seniors as a whole, those
who reported experiencing an injurious fall
were more likely to be female (68% vs. 56%),
more likely to be in the 80+ age group (28%
vs. 21%), more likely to be widowed, separated or divorced (46% vs. 34%), more likely
to have post-secondary graduation (34% vs.
32%), and more likely to have a household
income of less than $15,000 (14% vs. 10%).
The finding that those experiencing an injurious fall were more likely to be women and
more likely to be age 80 and over is well
supported by the literature on falls among
seniors.10 What is not well known is the significant association between marital status
and fall injury risk. The CCHS data suggests
that those without a spouse, who may be
living alone, may be at greater risk for a fall
with injury. It was surprising, and contrary
to the literature,11 to find that more years of
education were associated with a higher risk
of sustaining a fall-related injury.
Figure 1 presents estimated cases of injurious falls based on self-reports from the
CCHS sample, broken down by gender
and age group. Adding the total cases for
each age group, there are almost 180,000
injurious falls annually in the Canadian
population age 65 and over.
Figure 2 shows rates of injurious falls for
men and women by age group. The rate of
injurious falls increased with age from a low
of 35 per 1000 population age 65-69 to a
high of 76 per 1000 population age 80 and
over. Female rates exceed male rates in all
age groups. These differences are statistically
significant except for age 75-79. Overall,
Report on Seniors’ falls in Canada
11
Table 1 DISTRIBUTION OF CCHS (CYCLE 2.1) SAMPLE FOR AGE 65 AND OVER, 2002/03
Total CCHS sample
Population Percent
With a fall causing injury
95%
confidence
intervals
Population Percent
95%
confidence
intervals
Gender
Male 1,658,918
Female 2,124,857
N 3,783,775
43.8
56.2
42.8
55.3
44.9
57.1
56,912
123,441
180,353
31.6
68.4
30.8
67.3
32.3*
69.5*
65-69 1,154,063
70-74 1,027,278
75-79 804,061
80+ 798,373
30.5
27.1
21.3
21.1
29.5
26.3
20.4
20.3
31.5
28.0
22.1
21.9
40,274
44,568
44,977
50,534
22.3
24.7
24.9
28.0
21.6
23.9
23.9
26.9
23.1*
25.5*
25.9
29.1*
60.0
1.6
59.0
1.4
60.9
1.9
86,352
1,269
47.9
0.7
47.1
0.6
48.6*
0.8
33.9
4.2
32.8
3.9
35.0
4.6
82,803
9,413
45.9
5.2
44.4
4.8
47.4*
5.7*
45.2
44.5
46.0
72,419
40.2
39.5
40.8*
15.6
4.4
14.8
4.0
16.4
4.8
31,539
10,846
17.5
6.0
16.6
5.5
18.4*
6.5*
31.5
30.4
32.5
61,620
34.2
33.0
35.3*
10.4
26.8
21.0
12.6
6.5
22.8
9.9
25.8
20.1
11.9
6.0
21.6
11.0
27.7
21.8
13.3
6.9
23.9
26,037
45,483
37,258
22,560
14,165
34,851
180,353
14.4
25.2
20.7
12.5
7.9
19.3
13.7
24.4
19.8
11.8
7.3
18.3
15.2*
26.1
21.5
13.2
8.5*
20.3*
Age
Marital status
Married 2,268,605
62,219
Common-law
Widowed/Separated/
Divorced 1,283,672
Single 160,348
Education
Less than secondary
school graduation 1,711,479
Secondary school
graduation 589,166
Some post-secondary 166,470
Post-secondary
graduation 1,190,164
Household income
Less than $15,000 394,564
$15,000 to $29,999 1,012,461
$30,000 to $49,999 793,169
$50,000 to $79,999 478,270
$80,000 or more 244,189
Not stated 861,122
N 3,783,775
*significant at p<0.05 level
12
Report on Seniors’ falls in Canada
survey respondents reported a fall-related
injury in the past year, serious enough to
limit normal activities, at a national average
rate of 47.7 per 1000 population age 65
and over.
among women. However, the increases
found in the rate of falls by age and gender
is of concern. The finding that the rates for
women are statistically significantly higher
than those for men among all but one age
group may be related to lower income,
greater social isolation and higher rates
of chronic disease among women.
It is not surprising that the number of falls
increased with age with the greatest increases
Figure 1 ESTIMATED CASES OF INJURIES RESULTING FROM A FALL, BY AGE GROUP AND GENDER,
AGE 65+, CANADA, 2002/03
Total
Estimated cases
60,000
50,000
Female
20,000
39,000
30,000
29,000
26,000
30,000
50,000
45,000
45,000
40,000
40,000
Male
16,000
15,000
15,000
11,000
10,000
0
70-74
65-69
75-79
80+
Age group
Source: Canadian Community Health Survey, Cycle 2.1.
Figure 2 ESTIMATED RATES OF INJURIES RESULTING FROM A FALL, BY AGE GROUP AND GENDER,
AGE 65+, CANADA, 2002/03
Rate of falls per 1,000
100
Total
Female
Male
88
77
80
66
61
60
40
46
76
56
50
46
35
28
22
20
0
65-69
70-74
75-79
80+
Age group
Source: Canadian Community Health Survey, Cycle 2.1.
Report on Seniors’ falls in Canada
13
Figure 3 presents the distribution of the types of injuries
reported by seniors who experienced an injury as a result
of a fall. Over one third (37%) of the injuries sustained
were to the hip, thigh, knee,
lower leg, ankle, or foot, followed by the wrist or hand
(17%) and the back (14%).
Figure 4 shows that the majority
of respondents (44%) reported
slipping, tripping, or stumbling. Over one quarter (26%)
Multiple sites
reported falling while going
3%
Eyes / head / neck
up or down stairs. Response
6%
categories were combined in
Shoulder / upper / arm
the data set due to small num12%
bers and consequently, no
Elbow / lower arm further detail is available. It
4%
is most likely that the 20%
who reported “skating/skiing/
snowboarding/slipping/tripping
Wrist / hand
stumbling” on ice/snow had
17%
predominantly slipped, tripped,
or stumbled on ice/snow.
Figure 3 SELF-REPORTED FALLS RESULTING IN INJURY,
BY TYPE OF INJURY, AGE 65+, CANADA, 2002/03
Chest / abdomen / pelvis
7%
Upper or lower back /
upper or lower spine
14%
Hip / thigh,
knee / lower leg /
ankle / foot
37%
Source: Canadian Community Health Survey, Cycle 2.1.
Figure 4 SELF-REPORTED FALLS RESULTING IN INJURY,
BY TYPE OF ACTIVITY, AGE 65+, CANADA, 2002/03
Other
10%
Going up or down stairs
26%
Slip, trip,
stumble
on any surface
44%
Skating / skiing /
snowboarding, slip /
trip / stumble on ice / snow
20%
Source: Canadian Community Health Survey, Cycle 2.1.
14
Report on Seniors’ falls in Canada
The findings depicted in Figure
4 are similarly reflected in the
National Trauma Registry,12
where 23% of severe injuries
due to a fall among those age
65 and over were due to a fall
on or from stairs or steps.
Figure 5 indicates that, for
the 72% who sought medical
treatment within 48 hours,
the majority (65%) were treated in a hospital emergency
department. Many were treated
in a doctor’s office (20%) or a
hospital day clinic (9%). Of
those treated in the emergency
department, 38% reported that
they were admitted to hospital
for at least one night as a result
of the injury.
Figure 5 SELF-REPORTED FALLS RESULTING IN
INJURY, BY TYPE OF TREATMENT
RECEIVED WITHIN 48 HOURS, AGE 65+,
CANADA, 2002/03
Clinic
9%
Work / school / home
2%
Telephone / other
4%
Doctor’s
office
20%
Emergency
65%
Source: Canadian Community Health Survey, Cycle 2.1.
Summary
The 2002/03 CCHS sample for those age
65 and over was approximately 29,000
respondents, representing a population of
about 3.8 million Canadians age 65 and
over. Compared to the population of seniors
as a whole, those who reported experiencing
an injurious fall were more likely to be
female; in the 80+ age group; widowed,
separated or divorced; have post-secondary
graduation; and a household income of less
than $15,000. Based on the self-reports, the
rate of injurious falls increased with age and
the rates for women exceeded the rates for
men in all age groups. Over one third of the
injuries sustained were to the hip, thigh,
knee, lower leg or ankle. Most respondents
reported slipping, tripping, or stumbling
and over a quarter reported falling while
going up or down stairs. Almost three
quarters (72%) received medical treatment
from a health professional within 48 hours
of the injury.
2.2 What hospitalization data
tell us about seniors’ falls
The analyses provided in this section are
based on the Discharge Abstract Database
(DAD) at the Canadian Institute for Health
Information (CIHI). They include fall-related
hospitalization cases and rates, length of hospital stay, injury type, place of occurrence of
fall, and differences by age group and gender
for seniors age 65 and over, for the years
1998/99 through 2002/03.
The Discharge Abstract Database
(DAD)
The DAD of the Canadian Institute for
Health Information was originally
developed in 1963 to collect data on
hospital discharges in Ontario. Over
time, the mandate of the DAD has
expanded in scope, as determined by
each provincial and territorial ministry
of Health. The DAD includes hospital
in-patient data, as recorded in their
discharge records, from all acute care
hospitals across Canada, with the exception of rural hospitals in Manitoba and
all hospitals in Quebec.
Definitions and data
Revisions to codes in the International
Classification of Diseases (changes from
ICD 9 to ICD 10) greatly affected the coding
of data in hospitals around the world and
especially affected data on fall injuries.
Therefore, care must be taken in comparisons of data based on the two different
Report on Seniors’ falls in Canada
15
classifications. The ICD 10 classification
for hospitalization data is being gradually
implemented during the 2001-2006 period.
The Injury pyramid below provides a graphic illustration of the possible sources of falls
data, and shows that data currently available
provides an incomplete picture.
ICD 9 and ICD 10
The ICD 9 and ICD 10 provide for classification of a wide variety of falls including:
■ fall on same level from slipping, tripping and stumbling;
■ fall on same level due to collision with,
or pushing by, another person;
■ fall on and from stairs and steps;
■ fall on and from ladder or scaffolding;
■ fall from, out of or through building
or structure;
■ other fall from one level or another;
and
■ other/unspecified fall.
This section uses the DAD data pertaining
to acute care hospitalizations for falls
among persons 65 years and over in
Canada. Fall-related hospitalizations for a
specific population are a good estimate of
all falls resulting in serious injury for that
population. However, this data source does
not capture information on injurious falls
of lesser severity, which may be treated at
hospital emergency departments or physicians’ offices, or falls for which medical
treatment was not sought (see discussion
on Figure 5, on p. 14).
16
Report on Seniors’ falls in Canada
Source: Prevention of falls and injuries among the
elderly: A special report from the Office
of the Provincial Health Officer,
B.C. Ministry of Health Planning, 2004.
Data for this section:
■ include fall-related hospital discharges
from acute care facilities for those age
65 and over during fiscal years 1998/99
through 2002/03 (hospital discharges
include cases who have left hospital alive
or have died in hospital after admission);
■ reflect the number of hospital discharges
rather than the number of injured
seniors;
■ present information by age groups of
65-74, 75-84 and 85 and over;
■ identify causes of injury by the documented “External Cause of Injury” code
unless otherwise specified;
■ exclude cases with unknown age; and
■ show 95% confidence intervals where
appropriate.
The online Technical report – Hospitalizations
(www.phac-aspc.gc.ca/seniors-aines/pubs/
seniors_falls/technical/index.htm) provides
detailed information on the data source, the
analyses conducted and interpretations of
the findings.
Findings
Figure 6 shows that, on an age-specific
basis, the fall-related hospitalization rates
for the 65-74 and 75-84 age groups were
stable at about 6 and 16 per 1000 population respectively during 1998/99 to 2002/03.
The 85 and over age group was also stable
during this period at 43 per 1000 population. The anticipated growth among the 85
and over age group in Canada from 430,000
in 2001 to 1.6 million by 2041,13 together
with the fact that people are living longer
with chronic conditions, may suggest that
the rate of fall-related hospitalizations for
this age group could increase.
Figure 7 shows fall-related hospitalization
rates by gender and age groups for Canadians
age 65 and over for the year 2002/03. Men
and women both had increasing rates of
hospitalization with age. Women age 65-74
had rates of about 6 per 1000 population
increasing to 46 per 1000 in the 85 and over
age group. Men had a similar rate to women
in the 65-74 age group (4 per 1000) but
increased to only 32 per 1000 in the 85 and
over age group. For all those age 65 and
over, women had a rate of hospitalization of
about 16 per 1000 and men of 9 per 1000.
The findings that rates of fall-related hospitalizations were higher for women than for
men and that these differences increased
with advancing age are consistent with
other studies that show a strong correlation
between female gender, older age and the
risk of injurious falls.14 Conditions known
to be associated with aging, such as the
effects of a stroke, dementia and diabetes,
Figure 6 FALL-RELATED HOSPITAL CASES AND RATES, AGE 65+, CANADA, 1998/99 TO 2002/03
25,000
15,000
10,000
5,000
0
1998/99
1999/00
2000/01
2001/02
2002/03
65-74 cases
75-84 cases
85+ cases
65-74 rate/1000
75-84 rate/1000
85+ rate/1000
Confidence intervals are 95% confidence intervals.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
Report on Seniors’ falls in Canada
17
Rate per 1,000
Number of cases
20,000
50
45
40
35
30
25
20
15
10
5
0
are all known to increase the risk of falling
and being injured.15 Women are known to
be at higher risk for fall injuries due to their
higher rates of osteoporosis, which makes
them more likely to sustain a serious fracture from a fall.16
Figure 7 FALL-RELATED HOSPITALIZATION RATES, BY GENDER AND AGE GROUP, AGE 65+,
CANADA, 2002/03
50
Rate per 1,000 population 65+
45
Male
Female
40
35
30
25
20
15
10
5
0
75-84
85+
Age group
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
65-74
Days per separation
Figure 8 FALL-RELATED HOSPITALIZATIONS, AVERAGE LENGTH OF STAY PER CASE,
BY AGE GROUP, CANADA, 1998/99 TO 2002/03
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
65-74
75-84
1998/99
85+
1999/00
2000/01
2001/02
2002/03
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
18
Report on Seniors’ falls in Canada
Figure 8 illustrates that, generally, the older
the person, the longer their length of hospital stay for a fall-related injury. It also shows
that the average length of stay for all age
groups was relatively stable from 1998/99
to 2002/03. Over the five years, on average,
those age 65-74 had hospital stays of 11 days
after a fall, those age 75-84 had stays of
13 days, and those age 85 and over had stays
of nearly 14 days. Nationally, the average
number of total hospitalization days for
fall-related injuries among seniors was
273 per 1000 population age 65 and over.
Figure 9 shows that the average length of
hospital stay for a fall injury was consistently longer (by about 40%) than the average
length of stay for all causes of hospitalization for seniors age 65 and over. The average
length of stay for both falls and all causes
showed little change from 1998/99 through
2002/03.
Figure 10 shows that, over the five years,
nearly 85,000 Canadians age 65 and over
had injuries to their femur, pelvis, hip or
thigh, accounting for 56% of all fall-related
injuries among seniors treated in hospital.
Injuries to an upper limb, a lower limb, or
the spine accounted for 24% of fall-related
hospitalizations.
The majority of injuries to major joints, the
femur or pelvis are likely associated with hip
fractures, which other studies have shown
contribute to up to 40% of all fall-related
hospitalizations for this age group.17
Figure 11 shows the place of occurrence of
falls that led to a hospitalization, nationally,
among those age 65 and over for the period
1998/99 through 2002/03. Nearly half (47%)
of these falls occurred in or around the
home. Falls in residential institutions
accounted for 21% of hospitalizations
due to falls among those age 65 and over.
Figure 9 AVERAGE LENGTH OF STAY PER CASE, ALL CAUSES AND FALL-RELATED
HOSPITALIZATIONS, AGE 65+, CANADA, 1998/99 TO 2002/03
14
All Causes
Falls
Days per separation
12
10
8
6
4
2
0
1998/99
1999/00
2000/01
2001/02
2002/03
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
Report on Seniors’ falls in Canada
19
Figure 10 NUMBER AND PERCENT OF FALL-RELATED HOSPITAL CASES, BY INJURY TYPE,
AGE 65+, CANADA, 1998/99 TO 2002/03
40%
Major joint and femur
14%
Femur or pelvis
12%
Upper limb
10%
Other injuries
7%
Lower limb
5%
Spine
Thoracoabdominal
4%
Intracranial
4%
2%
Hip and thigh
2%
Open Wound
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Number of cases
Injury type as classified in Major Clinical Category 25: Significant Trauma.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
Figure 11 FALL-RELATED HOSPITAL CASES, BY PLACE
OF OCCURRENCE OF FALL, AGE 65+,
CANADA, 1998/99 TO 2002/03
Residential
institution
21%
Street 2%
Farm 0%
Recreational
1%
Home
47%
Public
building
4%
Other
25%
Industrial 0%
Source: Acute separations from 1998/99 to 2002/03,
Canadian Institute for Health Information Discharge Abstract Database.
20
Report on Seniors’ falls in Canada
Although the home is the more frequently reported place of occurrence
of falls, it is important to note that
approximately only 7.4% of those
age 65 and over live in residential
care settings18 and are therefore
contributing a far larger proportion
of hospital admissions compared
to seniors from other settings.
However, this is to be expected
given that seniors living in residential care settings are older and have
more chronic health conditions
that put them at much greater risk
for falls than those living in the
community.
Summary
Fall-related hospitalization data for
all seniors were analyzed for the
years 1998/99 through 2002/03.
Seniors’ fall-related hospitalizations
for all age groups remained stable over the
five years. The rates for women were consistently higher than for men and these differences increased with advancing age. The
average length of hospital stay for all age
groups was relatively stable and generally,
the older the person, the longer the length
of stay. Nearly 85,000 Canadians age 65 and
over had injuries to their femur, pelvis, hip
or thigh, accounting for the majority of all
fall-related injuries among seniors treated in
hospital. Almost half of the falls occurred in
or around the home.
2.3 What hospitalization data tell
us about falls in residential care
The information in this section is based on
data from the CIHI Discharge Abstract
Database (DAD) pertaining to acute care
hospitalizations for falls among adults age
65 and older, living in residential care facilities in Canada. (For more details about the
DAD, see page 15).
The analyses provided in this section
include fall-related hospitalization cases and
rates, length of hospital stay, place of occurrence of fall, and differences by age group
and gender for the years 1998/99 through
2002/03.
Definitions and data
The definitions and data cautions stated
in the previous section also apply to this
section, which uses the same data source,
further narrowed by selecting for residential care.
This section:
■ includes hospitalization data for persons
for whom “place of occurrence” of the
fall was designated as “Residential
Institution,” and the place they were
■
■
■
“transferred from” to hospital was
“Chronic Care Facility,” “Nursing Home”
or “Home for the Aged”;
does not include residents of care facilities under age 65;
does not include falls while outside the
residential care facility (this could be
a source of underreporting for this
population); and
does not include a calculation of any
rates, due to a scarcity of information on
total populations living in residential
care facilities for the years 1998/99
through 2002/03.
Fall-related injuries among those age 65
and older in residential care appear to be
far more frequent than among those who
are not in residential care.19 Seniors in
residential care account for approximately
7% of the 65+ population, but account for
15% of all fall-related hospitalizations for
that age group.
Approximately 50% of all long-term care
residents fall each year, and of these, 40%
fall twice or more each year.20 Approximately
10% of these falls result in serious injury,
including up to 5% in bone fractures.21 For
women living in a residential care facility,
the risk of sustaining a hip fracture is 10.5
times higher than for women of the same
age living in the community; less than 15%
of facility residents who sustain a hip fracture regain pre-injury ambulation status.22
In 2001, the Canadian population age
65 and over was approximately 3.9 million
people and of these, it is estimated that
7.4% or approximately 287,500 were living
in residential institutions. They represented
9.2% of senior women and 4.9% of senior
men. This is a decline since 1981, when
10.5% of senior women and 6.7% of senior
Report on Seniors’ falls in Canada
21
men lived in these facilities. Living in residential institutions is most common for
the oldest seniors, those age 85 and over.
However, for this age group, the proportion
of men in these facilities dropped from 29%
in 1981 to 23% in 2001, and the proportion
of women dropped from 41% in 1981 to
35% in 2001. Although the rates for seniors
living in residential institutions are declining, this trend is offset by the aging of
our population, which results in steadily
increasing numbers of seniors.23
Adults living in residential institutions
now tend to have more complex health
challenges, such as advanced dementia,
multiple chronic health conditions and
limited mobility. These characteristics put
this population at greater risk of falling
and sustaining a fall-related injury. The
online Technical report – Hospitalizations…in
residential care facilities (www.phac-aspc.gc.ca/
seniors-aines/pubs/seniors_falls/ technical/
index.htm) provides detailed information
on the analysis conducted and an interpretation of the findings.
Findings
Figure 12 shows that fall-related hospitalization cases for seniors not in residential care
ranged between 40,000 and 43,000 per year
through the period. Fall-related hospitalizations for seniors in residential care ranged
from about 6,000 to 9,000 per year. Seniors
age 65 and over who live in residential care
facilities and who fall represent about 12%
to 15% of all fall-related hospitalizations
among those age 65 and over across the
country from 1998/99 through 2002/03.
Over the 1998/99 to 2002/03 period, the
number of fall-related hospital cases for
those age 65 and over living in residential
care increased from about 6,000 to 7,000
with the greatest number seen in 2000/01
at about 9,000 cases.
Number of cases
Figure 12 FALL-RELATED HOSPITAL CASES FOR RESIDENTIAL CARE* VS.
NON-RESIDENTIAL CARE, AGE 65+, CANADA, 1998/99 TO 2002/03
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
Non-residential Care
1998/99
Residential Care
1999/00
2000/01
2001/02
2002/03
*Residential care homes include chronic care facilities, nursing homes, homes for the aged.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
22
Report on Seniors’ falls in Canada
Figure 13 shows that, from 1998/99 through
2002/03, there were over 40,000 fall-related
hospitalizations among Canadians age 65
and over living in residential care. This
is the equivalent of approximately 8,000
hospitalizations due to falls per year.
Figure 13 FALL-RELATED HOSPITAL CASES FOR RESIDENTIAL CARE,* BY AGE GROUP,
CANADA, 1998/99 TO 2002/03
5,000
65-74
75-84
85+
4,500
Number of cases
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
1998/99
1999/00
2000/01
2001/02
2002/03
*Residential care homes include chronic care facilities, nursing homes, homes for the aged.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
Figure 14 FALL-RELATED HOSPITALIZATIONS, AVERAGE LENGTH OF STAY PER CASE FOR
RESIDENTIAL CARE* VS. NON-RESIDENTIAL CARE, 1998/99 TO 2002/03
18
RCH
Other
16
Days per separation
14
12
10
8
6
4
2
0
1998/99
1999/00
2000/01
2001/02
2002/03
*Residential care homes include chronic care facilities, nursing homes, homes for the aged.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
Report on Seniors’ falls in Canada
23
The number of hospitalizations increased
with age in all years shown. The number
of cases among those age 65-74 increased
to over 1000 per year in 2000/01 with a
decrease in the final two years. The number
of cases among those age 75-84 increased
to about 3,500 per year in 2000/01 with a
decrease in the final two years. For those
age 85 and older, there was an increase in
hospitalizations due to falls to 4,500 in
2000/01 followed by a decrease over the
next two years.
Figure 14 shows that in 1998/99, the average
length of stay for fall-related hospitalizations for those age 65 and over living in
a residential care facility was about 19%
longer than the average length of stay for
those not living in residential care. This
gap narrowed over the five years and, by
2002/03, those not living in residential care
had longer stays on average compared to
those living in residential care. The average
length of stay for falls for non-residential
care patients has shown little change from
1998/99 through 2002/03.
Figure 15 illustrates that the older the person is, the shorter the stay in hospital. On
average, those 65-74 years of age stay in
hospital 15-20 days after a fall, while those
75-84 stay 13-15 days and those age 85 and
over stay 12-14 days. The average length
of stay in all age groups declined over the
five-year period. This contrasts with the
non-residential population that shows an
unchanging average length of stay over
the period.
Figure 16 shows that, over the five-year
period, nearly 17,000 Canadians age 65 and
over living in a residential care facility were
hospitalized for fall-related injuries to a
major joint, femur, pelvis, hip or thigh,
these accounting for more than 75% of all
fall-related injuries among those of this
Figure 15 FALL-RELATED HOSPITALIZATIONS, AVERAGE LENGTH OF STAY PER CASE FOR SENIORS
IN RESIDENTIAL CARE,* BY AGE GROUP, AGE 65+, CANADA, 1998/99 TO 2002/03
25
65-74
75-84
85+
Days per separation
20
15
10
5
0
1998/99
1999/00
2000/01
2001/02
2002/03
*Residential care homes include chronic care facilities, nursing homes, homes for the aged.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
24
Report on Seniors’ falls in Canada
group who were treated in hospital. Injuries
to the upper limbs, lower limbs or spine
accounted for 11% of fall-related hospitalizations for this age group. As mentioned
previously, the majority of the injuries to a
major joint, femur or pelvis are likely associated with hip fractures, which are shown in
other studies to contribute up to 40% of all
fall-related hospitalizations for this age
group.24 Most injuries are to the lower limbs.
Summary
From 1998/99 through 2002/03, about
40,000 Canadians age 65 and over living in
residential care were hospitalized for a fallrelated injury. Although over the five years,
the average length of hospital stay for those
living in residential care was longer than the
length of stay for those not living in residential care, the gap narrowed over the five
years and, by 2002/03, those not living in
residential care had longer stays on average
compared to those living in residential care.
Contrary to the data for fall-related hospitalizations for all seniors age 65 and over,
if a senior lived in residential care, the older
the person was, the shorter the hospital stay
and the average length of stay declined over
the five-year period. The population not living in residential care showed an unchanging
average length of stay over the period.
2.4 What mortality data tell us
about deaths due to falls
The analyses provided in this section present data from Canadian Vital Statistics on
all direct deaths due to falls among those
age 65 and over and include differences by
place of injury, gender, and age groups, as
well as trends over time.
Figure 16 NUMBER AND PERCENT OF HOSPITAL CASES ASSOCIATED WITH FALLS IN
RESIDENTIAL CARE BY INJURY TYPE, CANADA, 1998/99 TO 2002/03
Major joint and femur
57%
Femur or pelvis
19%
Upper limb
6%
Other injuries
6%
Lower limb
3%
Spine
2%
Thoracoabdominal
2%
Intracranial
2%
Hip and thigh
2%
Open Wound
1%
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Number of cases
Injury type as classified in Major Clinical Category 25: Significant Trauma.
Source: Acute separations from 1998/99 to 2002/03, Canadian Institute for Health Information Discharge Abstract Database.
Report on Seniors’ falls in Canada
25
Canadian Vital Statistics,
Death Database
The information in this section is based
on data from Statistics Canada’s
Canadian Vital Statistics, Death Database
for 1997/99 through 2000/02.
Definitions and data
Data were requested for Canadians age
65 and over for deaths due to unintentional
falls. Sample data runs resulted in Statistics
Canada limiting the data to six years in
two periods, 1997-1999 and 2000-2002.
Conversion from ICD 9 to ICD 10
coding affects analysis of data
on fall-related deaths
‘Accidental falls’ is a ‘cause of death’ category that was dramatically affected by the
implementation of the ICD 10. Changes
in the coding structure from ICD 9 to
ICD 10 occurred in the year 2000.
Included under the ICD 9 group of codes
for accidental falls is a code for “fracture,
cause unspecified.” This external cause
of death is not included in the ICD 10
category of codes for falls but rather
is included as a code under another category, “exposure to unspecified factor.”
Consequently, for this analysis, the ICD 9
code for “fracture, cause unspecified” was
not included as it could not be included
from the ICD 10 codes.
This section:
■ includes data on direct deaths, equivalent
to the ‘underlying cause of death’ as indicated on the medical certificate of death;
26
Report on Seniors’ falls in Canada
■
■
■
■
excludes indirect deaths, where a fall may
have eventually led to death but was not
the underlying cause of death;
presents data for age groups of 65-69,
70-74, 75-79, 80-84 and 85 years and over;
excludes deaths of non-residents of
Canada, deaths of residents of Canada
with unknown province or territory of
residence, and deaths for which age of
deceased was unknown; and
shows 95% confidence intervals
where appropriate.
The online Technical report – Deaths
(www.phac-aspc.gc.ca/seniors-aines/pubs/
seniors_falls/technical/index.htm) provides
detailed information on the specific data
request made to Statistics Canada, data limitations, the specific codes used to identify
falls, the analyses conducted and an interpretation of the findings.
Indirect deaths
An indirect death from a fall occurs when
the fall itself is not deadly, but the injuries
that are sustained undermine the individual’s health so much that other diseases
and illnesses prove fatal. Pneumonia and
infections are often the direct cause of
death where a fall is the indirect cause.
Adapted from: Prevention of falls and injuries among
the elderly: A special report from the
Office of the Provincial Health Officer.
B.C. Ministry of Health Planning, 2004.
Findings
Figure 17 shows that, for the six years examined, more than 7,000 Canadians age 65 and
over died as a direct result of a fall. This number increased from 3,209 in the 1997-1999
period to 4,110 in the 2000-2002 period. It
Figure 17
4500
DEATHS AND MORTALITY RATE* DUE TO FALLS,
AGE 65+, CANADA, 1997-2002
12
Deaths
Rate
4000
10
3500
Deaths
2500
6
2000
4
1500
1000
Rate per 10,000*
8
3000
2
500
0
0
1997-1999
2000-2002
*Age standardized to the 1991 Canadian population.
Source: Statistics Canada, Deaths Database.
also shows rates of deaths. On an age-standardized
basis, there was a statistically significant increase in
the rate of deaths due to falls from 8.1 per 10,000
population in the 1997-1999 period to 9.4 per 10,000
population in the 2000-2002 period.
The increasing number of fallrelated deaths among those age
65 and over reflects the growing
proportion of this age group in
Canada. There was also a statistically significant increase in the rate
of fall-related deaths. While the
interpretation of the data is complicated by the possible impact of
the conversion from ICD 9 to ICD
10 coding, nonetheless, the increase
in the number and rate of deaths
due to falls among seniors may be
due in part to an increase in health
conditions associated with increasing age. These conditions can
contribute to an increased risk of
sustaining a severe injury and a
decrease in the ability to recover
from an injury.
Figure 18 shows the number of
deaths by age group for the two
three-year periods. For both periods, the number of deaths increased
with age, rising from fewer than
Figure 18 DEATHS DUE TO FALLS, BY AGE GROUP, AGE 65+, CANADA, 1997-2002
2,500
2,000
Deaths
2098
Deaths 1997-99
Deaths 2000-02
1593
1,500
1,000
500
0
806
215 265
65-69
297 356
70-74
Source: Statistics Canada,Deaths Database.
445
585
75-79
659
80-84
85 +
Age group
Report on Seniors’ falls in Canada
27
300 in the 65-69 age group, to more than
2,000 in the 85 and over age group for the
second period.
Deaths due to falls among men increased
from 1,412 in the 1997-1999 period to
1,886 in the subsequent period. The agestandardized rate for men increased from
6.9 to 7.9 deaths per 10,000 population over
the six-year period. However, this increase
was not statistically significant (p>0.05).
Figure 19 indicates that the rate of deaths
due to falls increased with age from fewer
than 10 deaths per 10,000 population in
the youngest age group, to over 50 deaths
per 10,000 in the oldest age group. A significant difference in the rates from the first
period to the second was seen for all of the
age groups.
Location and type of fall
Additional analyses were carried out on data
concerning location and type of fall. Where
the location of the falls resulting in death
was known, over 53% occurred in a private
home environment, 18% in residential care
facilities, and 29% in other locations such as
public buildings, on the street, in a commercial or service area, in a recreation or sport
area and on a farm.
Figure 20 shows deaths due to falls by gender for Canadians age 65 and over. Deaths
due to falls among women rose from
approximately 1,797 in the 1997-1999 period to 2,224 in the subsequent period. This
translates into an age-standardized rate of
9.9 deaths per 10,000 in the first period
and 12.4 deaths per 10,000 in 2000-2002.
This increase was statistically significant
(p<0.05).
Although the majority of fall-related deaths
of seniors occurred in the home environment, it is important to consider the
amount of time that persons at greatest risk
Figure 19 MORTALITY RATE DUE TO FALLS BY AGE GROUP, AGE 65+, CANADA, 1997-2002
60
Mortality Rate 1997-1999
50
Rate per 10,000
Mortality Rate 2000-2002
40
30
20
10
0
65-69
70-74
Source: Statistics Canada, Deaths Database.
28
Report on Seniors’ falls in Canada
75-79
Age group
80-84
85 +
of falling spend inside compared to outside
their homes. Twenty-nine percent of falls
causing death occurred outside the home,
even though much less time may be spent
outside the home by those age 65 and over.
For fall-related injuries resulting in death
for seniors, falls within the home occurred
most often from one level to another (78%),
rather than on the same level (22%). This is
consistent with findings in the CIHI study
of severe injuries, showing that the majority
of these occurred on stairs and steps.25
By comparison, where a fall occurred outside the home (but not including residential
care facilities), 66% were the result of a fall
from one level to another and 34% were
due to falls on the same level. Significantly
more falls from one level to another
occurred in the home environment than
outside the home.
Figure 20
5000
4500
Summary
Mortality data from Statistics Canada were
analyzed for all direct deaths due to falls
among those age 65 and over, for the years
1997 to 2002. The analyses include differences by place of injury, gender, and age
group. In the period, more than 7,000
Canadians age 65 and over died as a direct
result of a fall. On an age-standardized
basis, there was a statistically significant
increase in the rate of deaths due to falls
from 1997-1999 to 2000-2002 and the rate
of deaths due to falls increased with age in
both time periods. The rate of deaths due
to falls was higher for women than for men.
Where the location of the fall was known,
the majority of falls resulting in deaths
among Canadians age 65 and over occurred
in the person’s home.
DEATHS AND MORTALITY RATE* DUE TO FALLS, BY GENDER, AGE 65+,
CANADA, 1997-2002
Male Deaths
Female Deaths
Male Rate
Female Rate
14
12
3500
10
3000
8
2500
2000
6
1500
4
1000
2
500
0
Rate per 10,000*
Deaths
4000
1997-1999
*Age standardized to the 1991 Canadian population.
2000-2002
0
Source: Statistics Canada, Deaths Database.
Report on Seniors’ falls in Canada
29
3
Risk factors for falls
and fall-related injuries in seniors
The previous chapter presented the epidemiology of fall-related injuries among
seniors in Canada. This chapter examines
current knowledge about fall risks. The information presented here was summarized from
several well-known guidelines and systematic
reviews of the literature on risk factors and
best practices for the prevention of falls and
fall-related injuries among seniors.
Review of current knowledge
The following sources were used:
■ A best practices guide for the prevention
of falls among seniors living in the community, Federal/Provincial/Territorial
Ministers Responsible for Seniors
(2001);26
■ the Rand Report (2002) more recently
cited as Interventions for the prevention
of falls in older adults: Systematic review
and meta-analysis of randomized clinical
trials, (2004);27
■ the Cochrane Review: Interventions for
preventing falls in elderly people (2001);28
the Cochrane Review: Population-based
interventions for the prevention of fallrelated injuries in older people (2005);29
■ the American Geriatrics Society’s
Guideline for the prevention of falls
in older persons, (2001);30 and
■ additional findings, highlighting
Canadian studies published after
the reviews.
The review conducted for the Best practices
guide of the F/P/T Ministers Responsible
for Seniors screened 674 studies, ultimately
reviewing 34 that evaluated fall prevention
interventions designed to reduce falls or
30
Report on Seniors’ falls in Canada
fall-related injuries among communitydwelling seniors.
The Rand Report screened 774 articles,
rejecting all but 34, which contributed data
to the meta-analysis. The Rand Corporation
also funded a report summarizing published
research on causal factors for falls, collating
data from 16 studies.
The American Geriatrics Society (AGS)
Guideline is one of the most adopted guidelines, prepared in collaboration with the
British Geriatrics Society and the American
Academy of Orthopaedic Surgeons. This
guideline outlines recommended practice
and establishes the strength of the recommendations based on the evidence in the
research literature.
The Cochrane Review (2001) focused on
randomized control trials and included
40 studies involving interventions with
seniors in community, facility and acute
care settings that measured falls or fallrelated injuries as an outcome. The 2005
Cochrane Review reviewed five studies that
reported changes in medically treated fallrelated injuries among older people following the implementation of a controlled
population-based intervention.
Risk factors – complex and interactive
Falls result from a complex interaction of
risk factors. As the number of risk factors
increases, the higher the risk of falling and
of being injured. For example, one study
showed that only 27% of people living in
the community, with no risk factor or only
one, had a fall. The figure rose to 78% for
those with four or more risk factors.31
Over the past 20 years or so, researchers
have assessed risk factors and grouped them
in various ways to facilitate comparisons in
research studies. Typically, risk factors have
been grouped into two main categories –
intrinsic factors that lie within the individual and include both demographic and
health factors, and extrinsic factors that lie
within either the physical or socio-economic
environment. However, a more recent model
for categorizing risk factors better captures
the interrelationships between behaviours
and other risk factors. The four categories of
risk factors in this model are biological and
medical, behavioural, environmental, and
socio-economic. (See Appendix A for a list
of the risk factors in all of these categories).
3.1 Biological and medical
risk factors
Biological and medical risk factors fall along
a continuum from effects of healthy aging
to pathological conditions. Normal aging
inevitably brings physical, cognitive and
affective changes which may contribute to
the risk of falls, including sensory, musculoskeletal, neurological, and metabolic
changes. Gender is also a key factor as
women fall more often than men and sustain
more injuries when they fall. Advanced age is
associated with higher rates of falls. Seniors
over 80 years of age are the most likely to fall
and be injured. However, it is not age per se
that increases the risk of falls – it is the comorbidity of aging related to changes.
■ Muscle weakness and reduced physical
fitness, particularly to the lower body,
are one of the most common intrinsic
risk factors for falling. A panel of the
American Geriatrics Society, British
Geriatrics Society and American
Academy of Orthopaedic Surgeons32
found it to be the most important risk
factor, increasing risk of a fall by four
to five times. A loss of muscle strength,
balance, flexibility and coordination can
contribute to difficulty accomplishing
activities of daily living. Related balance
and gait disorders also have been shown
to be closely linked to falls, creating a
three-fold increase in the risk of falling.
A recent Canadian study of veterans and
their caregivers confirmed these findings.33
■
Impaired control of balance and gait is
a factor leading to instability and falls.34
In particular, age-related changes in the
neural, sensory and musculoskeletal
systems can lead to impaired ability to
maintain upright stance or react to a
sudden loss of balance (e.g., a slip, trip
or push).35 Balancing reactions that
involve rapidly taking a step or reaching
to grasp an object for support play a
critical role in preventing falls, but the
ability to execute these reactions effectively can be impaired even in relatively
young and healthy seniors.36 Neurologic
disorders such as Parkinson’s disease or
hemiparesis due to stroke can exacerbate
these difficulties.37
■
Vision changes can contribute to falls.
Those with visual deficits such as reduced
acuity or contrast sensitivity, declined
accommodation to light and darkness,
or altered depth perception are two and
a half times more likely to have a fall.38
Visual deficits such as myopia, ulcerative
scars, corneal pathology, cataracts or
complications from cataract surgery
and glare intolerance are also thought
to increase the risk of falling. People
may also experience problems with new
Report on Seniors’ falls in Canada
31
periods of immobility often associated
with an acute illness are known to contribute to reduced bone density and
muscle mass.
glasses, particularly multi-focal lenses
that distort depth perception.39
■
Chronic illness has been associated with
an increased risk of falling. Arthritis is a
major contributor (osteoarthritis being
the most common form), increasing the
risk of a fall by 2.4 times.40 Senior
women experience more arthritis than
men (58% vs. 42%, CCHS 2003). Other
chronic illnesses such as stroke and
Parkinson’s disease increase the risk of
falls. Hypotension (low blood pressure)
affects 15% of all seniors and has been
associated with as many as 20% of all
falls.41 Osteoporosis, characterized by
low bone mass and the deterioration of
bone tissue, does not affect the risk of
falling per se, but does increase the risk
of fractures from a fall, particularly
those of the hip, spine and wrist. Other
chronic conditions frequently implicated
in falls include urinary incontinence and
cardiovascular conditions including
arrhythmias.
■
Physical disability can increase the risk
of falls. Physical disabilities linked to
aging include gait disorders, diminished
touch and sensation in limbs and feet,
hearing loss, poor balance, dizziness,
postural hypotension, sore feet and other
feet problems, and injuries from a previous fall. 42
■
Acute illness may be responsible for
between 10% to 20% of falls.43 One
example is acute infection. A Canadian
study found that anti-infective medications were highly associated with fallrelated hospital admissions, strongly
suggesting that people with acute infectious disease are at a high risk for falls
and injuries as a result of weakness,
fatigue or dizziness.44 Even the short
32
Report on Seniors’ falls in Canada
■
Cognitive impairment, such as confusion due to dementia and delirium, can
also increase the risk of a fall. The Rand
researchers reported an increased risk
of 1.8 times for persons with cognitive
impairment.45 The Canadian study of
veterans and caregivers also found that
worsening memory was associated with
more frequent falling.46
■
Depression has been reported by many
researchers as having a relationship to
falls, but such studies are often retrospective and the depression could well result
from the fall, rather than be a causal or
risk factor.47
3.2 Behavioural risk factors
■ A history of previous falls is one of the
best predictors of a future fall. Any previous fall increases the risk for another fall
threefold.48 A previous fall may reduce
mobility in older people, resulting in loss
of strength, balance and reflexes. Feelings
of fear and helplessness may also ensue,
further adding to restrictions on activity
and participation and reduced quality
of life.49
■
Risk-taking behaviour as a factor
associated with falls has not been studied
scientifically. The risk associated with
participation in activities is influenced by
individual, behavioural and situational
factors. For example, an older adult’s
vision and strength, awareness of the
environment, and protective behaviours,
such as using a handrail, influence the
risk of falls.50 Risk behaviours may
include climbing, reaching, or bending
while performing activities of daily living.51 Reviews of cases presenting in the
emergency department have shown that
many falls result from seniors climbing
ladders, standing on unsteady chairs, and
even participating in vigorous sports
such as skiing or tennis. Many seniors
report that their fall occurred when they
were rushing, not paying attention or
not using mobility devices prescribed
for them such as a cane or walker.52
■
■
Certain medications and multiple prescriptions are a significant factor in
many falls. Older people tend to take
more drugs than younger people and,
with age, they develop altered mechanisms for digesting and metabolizing
drugs. Both the half-life and the active
levels of a given dose increase with age,
making the cumulative effects of medication use unpredictable. Medications can
affect one’s risk of falling in several ways.
They can affect alertness, judgment, and
coordination. Certain drugs increase postural hypotension – a significant drop in
blood pressure with a change in position
(lie to sit or stand) – resulting in dizziness. Drugs can also alter the balance
mechanism and the ability to recognize
and adapt to obstacles. Finally, drugs may
impair mobility by causing increased
stiffness or weakness.53
Polypharmacy, defined as taking five or
more prescribed medications, is shown
to be a significant factor in many falls.54
The variety of prescription medications
is increasing and they are used in greater
numbers and in new combinations. Drugherb interactions may also be implicated
in falls as supplements, herbs and vitamins can react with each other or with
prescription medications.55 The effects of
various drug combinations are not yet
clearly understood, especially the possible
risks for falls in elderly individuals.
■
Benzodiazepines, such as alprazolam
(Xanax) and diazepam (Valium), are
often prescribed to treat sleep problems
and anxiety. Even the use of short-acting
benzodiazepines has a greater association
with falls and hip fractures.56
Everyday choices count
Behavioural risk factors are as simple as
the choice of footwear, or attempts to
prune a tree or reach an object on a high
shelf. These risks can also include lifestyle
factors such as alcohol use, poor diet and
lack of exercise, or the use of high-risk
medication or multiple medications that
predispose some seniors to falling. It can
be difficult for seniors, who may feel no
different than they felt in younger years, to
realize that the seemingly ordinary choices
they make and the actions they take may
greatly increase their chance of falling.
Source: Prevention of falls and injuries among
the elderly: A special report from the Office
of the Provincial Health Officer.
B.C. Ministry of Health Planning, 2004.
■
Patients taking psychotropic medications, such as paroxetine (Paxil) and
sertraline (Zoloft) prescribed for depression, appear to have about a two-fold
increased risk of falls and fractures,
compared with individuals not taking
these drugs. Some studies have also
found that use of nonsteroidal antiinflammatory drugs is associated with
falling. However, current evidence suggests that diuretics, in general, do not
cause falls and that thiazide diuretics
Report on Seniors’ falls in Canada
33
may help prevent fractures by slowing
the development of osteoporosis.57
■
The risks associated with anticoagulant
therapy, especially the risk of fallsrelated injury, are greater in the elderly.
A fall may result in head trauma but go
undiagnosed because patients are confused, do not remember falling, or fail
to report the fall. This is especially risky
in patients on anticoagulant therapy
since a fall with head trauma may result
in bleeding in the brain. Blunt head
trauma may cause behavioural and neurologic abnormalities and may be a sign
of bleeding in the brain or brain cavity.58
■
Excessive alcohol has been shown to
be a factor in increased rates of falling.
Consumption of 14 or more drinks per
week is associated with an increased risk
of falls in older adults.59 Cross-sectional
studies may fail to identify this risk of
heavier drinking, perhaps because older
adults at risk for falls decrease their
alcohol use over time or because heavier
drinkers at risk for falls tend not to enroll
in studies. Alcohol may also interact with
certain drugs to increase the risk of falls
by producing changes in awareness,
balance and gait. Alcohol used in moderation has not been associated with
increased fall rates.60
■
Footwear, clothing and handbags can
contribute to falls, although clear research
evidence is lacking. Footwear that fits
poorly, has worn soles, is not laced or
buckled when worn, or is of an unusual
heel height for the individual, can contribute to falls. As people age, their height
and posture change and long dressing
gowns or trousers, which may have fit
well at one time, can cause tripping
hazards resulting in a fall and related
34
Report on Seniors’ falls in Canada
injury.61 Many older people report falling
or sustaining a fall-related injury, as a
result of carrying an object such as a
handbag, laundry basket or grocery bag.62
Suspected mechanisms relate to altered
balance, altered recovery mechanisms
upon a trip or stumble, and altered
means of protection as the senior lands
on the ground or floor.63 Holding an
object, for example, has been shown to
impede ability to recover balance as it
prevents one from rapidly grasping a
handrail or other object for support.64
■
Inactivity and inadequate diet may
be important factors in both falls and
related injuries. Again, while clear
research evidence is lacking, people who
are hospitalized 19 days or more have
been shown to have an increased risk of
a fall.65 Undoubtedly, inactivity will result
in reduced muscle mass, decreased bone
density and poor balance. Dietary relationships to falls are less clear. However,
adequate protein, essential vitamins and
water are believed to be essential for
optimum health. If deficiencies do exist,
it is reasonable to expect that weakness,
poor fall recovery and increased injury
will ensue. Bone health is affected by
intakes of vitamin D and calcium and
deficiencies in these two nutrients have
been associated with increased risk of
fracture from a fall.
■
Fear of falling has been identified relatively recently as a risk factor in the fall
prevention literature. Fear of falling is
widespread and has been reported as the
most common fear of older adults.66 It is
an important aspect to consider, particularly for those who develop fear after
having fallen.67 Fear of falling is reported
by a significant number of older
or poorly-fitted handrails, and inadequate or excessive lighting. A recent
Canadian study examined stairs which
seniors said they found difficult to use.
Unsafe features identified most frequently
were: no contrast markings for stair
edges, non-uniform risers, stair dimensions that differ from the recommended
seven-inch maximum height or rise and
eleven-inch minimum run (toe to heel
allowance), open risers and lack of
handrails.75 Handrails that are securely
mounted at an appropriate height and
shaped correctly allow a functional grip
to be established.76 Stair surfaces and
floors that are slippery, excessively patterned, glare-producing or uneven also
have been implicated in falls.77
persons.68 Specific fears vary but often
include fear of falling again, being hurt
or hospitalized, not being able to get up
after a fall, social embarrassment, loss
of independence, and having to move
from home.69
Fear can positively motivate some seniors
to take precautions against falls and can
lead to gait adaptations that increase
stability.70 For others, fear can lead to
a decline in overall quality of life and
increase the risk of falls through a reduction in the activities needed to maintain
self-esteem, confidence, strength and balance.71 In addition, fear can lead to maladaptive changes in balance control (e.g.,
“stiffening”) that may increase the risk of
falling.72 People who are fearful of falling
also tend to lack confidence in their
ability to prevent or manage falls, which
increases the risk of falling again.73
■
Factors in and around the home that
contribute to falls include: loose or
uneven rugs; absence of night lights;
an absence of accessible light switches
at room entrances; hazardous shower
stalls; baths or toilets; lack of grab bars
or handrails; appliance cords or other
obstacles in walking routes; items stored
in high cupboards; and low furniture
such as beds or chairs. Outside the home
hazards can be found in such features as
garden paths and walks that are cracked
or slippery from rain, snow or moss.
Entrance stairs and poor night lighting
can also pose risks. Even pets can be a
tripping hazard.78
■
Factors in the public environment can
also trigger falls. A Canadian study
found that 65% of falls among seniors
occurred outdoors while walking on a
familiar route.79 Poor building design
and inadequate maintenance of buildings
can also contribute to falls. Most problematic are cracked or uneven sidewalks,
Fear, as it affects client compliance with
fall prevention strategies, is discussed in
Chapter 4, Section 5 of this report.
3.3 Environmental risk factors
Between 25% and 75% of falls in older people involve an environmental component.74
While individual levels of risk have not
been established for many of these factors,
researchers and clinicians have recognized
a number of hazards in the home and public environment that contribute to falls and
related injuries. These factors interact with
other risk factors, such as poor vision or
balance, to compound fall-related risk
for seniors.
■
Stairs can be problematic – hazardous
characteristics include uneven or excessively high or narrow steps, slippery
surfaces, unmarked edges, discontinuous
Report on Seniors’ falls in Canada
35
unmarked obstacles, slippery surfaces,
poor lighting and lengthy distances to
sitting areas and public restrooms.
■
■
Fall hazards in long-term care settings
and hospitals also have been identified.
Factors include chair and bed heights,
floor surfaces, lighting and lack of rest
areas. Many falls occur as people arise
from bed. Apart from the dizziness
sometimes associated with rising too
quickly, the physical structure of the bed
itself may be a factor. For example, when
bed rails are in the lowered position and
a person is moving to a standing position, space is lacking under the bed for
proper footing and balance. It is logical
to conclude that this may be a factor
explaining why so many institutional
falls occur in and around the bed.
Assistive devices can promote independence and mobility and may prevent
falls if properly used and safely maintained. However, cane tips can become
worn, making them unsafe. Walkers with
wheels or wheelchairs may lack a functioning locking mechanism posing a
hazard. Moreover, the use of canes and
walkers can interfere with the ability to
maintain balance in certain situations,
and the demands of using these devices
can be excessive for older adults.80
Having an assistive device does not
necessarily guarantee its use. Many older
people see such aids as symbols of their
old age and advanced frailty, and they
may be reluctant to use them because
of this stigma.81
36
Report on Seniors’ falls in Canada
3.4 Socio-economic risk factors
■ Income, education, housing and social
connectedness are recognized social
determinants of health but a limited
body of research exists on the relationship between falls and these determinants. A recent Canadian study of
veterans found that financial strain was
an independent predictor of both falls
and injurious falls, particularly among
the caregivers of veterans.82
Lower socio-economic status
increases risk
The study of social determinants of health
has repeatedly shown that one’s income,
education, housing and social connectedness all bear a strong relationship to one’s
health, level of disability and longevity.
People with low income, low education,
inadequate housing, lack of support networks or lack of access to appropriate
health or social services are all at a greater
risk for the chronic health conditions that
are, in turn, risk factors for falls. The role
that social and economic factors play in
contributing to falls is poorly understood.
However, contributing factors may include
poor literacy – resulting in an inability to
benefit from printed resources on strategies for preventing falls – or muscle weakness or ill health due to lack of funds for a
nutritional diet.
Source: Prevention of falls and injuries
among the elderly: A special report from the Office of
the Provincial Health Officer.
B.C. Ministry of Health Planning, 2004.
It has been suggested that, because a
relationship exists between income,
education and housing and certain
chronic health conditions, poor health
may be the link between these factors
and the increased risk of falling. For
example, the group most affected by low
income is women age 75 and over who
live alone. These women may not be able
to afford home modifications or assistive
devices, attend fitness programs or have
access to fall prevention information, all
of which would help reduce falls.
4
Summary
Literature and guidelines report that falls
result from a complex interaction of risk
factors and, as the number of risk factors
increases, the higher the risk of falling and of
being injured. Biological and medical, behavioural, environmental, and socio-economic
risk factors interact and compound. Normal
aging inevitably brings physical, cognitive
and affective changes which may contribute
to the risk of falls. Gender is also a key factor
as women fall more often than men and sustain more injuries when they fall. Advanced
age is associated with higher rates of falls
and fall injuries.
Evidence-based best practices
for the prevention of falls
Information provided in this chapter on
evidence-based best practices for the prevention of falls and fall-related injuries is
taken from the guidelines and systematic
reviews described in detail in Chapter 3.
Additional evidence, highlighting Canadian
interventions, is included here from studies
carried out after the reviews were published.
In 2003, the Canadian Public Health
Association called “on federal, provincial and
territorial governments to play a strong
coordinating role in integrating and harmonizing injury prevention to evidence-based
best practices.”
Source: CPHA 2003 resolutions and motions,
CPHA resolution No. 5, Injury prevention.
4.1 Existing practice guidelines
In Canada and internationally, professional
organizations and governments have established fall prevention guidelines based on
systematic reviews of research evidence on
best practices when working with seniors.
Guidelines prepared by professional organizations are generally considered prescriptive
for professional practice. Professional organizations in Canada are beginning to develop
practice guidelines on falls and seniors’ falls.
The Registered Nurses Association of
Ontario recently published their professional guideline, RNAO: Prevention of falls and
injuries in the older adult,83 including best
practices that address patient education and
post-fall prevention.
Report on Seniors’ falls in Canada
37
Internationally, one of the most widely
adopted guidelines is the Guideline for
the prevention of falls in older persons of
the American Geriatrics Society (AGS),
described in the previous chapter, prepared
in collaboration with the British Geriatrics
Society and the American Academy of
Orthopaedic Surgeons.
In the UK, the National Institute for Clinical
Excellence (NICE) has published Clinical
guideline 21: The assessment and prevention
of falls in older people 2004.84 The guideline
outlines good practice based on the best
available evidence of clinical and cost effectiveness. It encourages the participation of
older people in fall prevention programs
and supports fall prevention education for
professionals working with seniors known
to be at risk for falling.
Governments are developing comprehensive
guidelines and strategies for reducing falls.
The UK has established a National Health
Service Framework for Older People with an
entire section devoted to preventing falls.85
In Australia, the Department of Health and
Aging has developed a national fall prevention initiative for older people and the
Australian states of Queensland and New
South Wales have developed guidelines and
initiatives to reduce falls. The Queensland
government has produced comprehensive
setting-specific guidelines for public hospitals and state government residential aged
care facilities, incorporating community
integration.86 A 2004 Australian review of
research on preventing falls and fall injuries
in older people distinguishes between
approaches for community-based, hospitalbased and facility-based seniors.87
38
Report on Seniors’ falls in Canada
4.2 Best practices for
fall prevention
Brief risk assessment to screen for high risk
Since it is impractical to think that all older
people can be given a comprehensive fallrelated assessment and treatment plan, a
brief risk assessment is often the first step in
identifying who may benefit most from this
approach. The American Geriatrics Society’s
evidence-based guideline88 suggests that a
brief risk assessment would identify those
who should be referred for a comprehensive
fall evaluation. The three groups that such
an assessment should identify are: older
persons presenting for medical attention
with one or more falls; older persons who
report recurrent falls; and older persons
with abnormalities of gait and/or balance.
Such an assessment may vary for seniors
in different settings such as the community,
a hospital or a nursing home. Assessments
may be self-administered or used by first
responders including paramedics; primary
care personnel such as family physicians or
nurse practitioners; physiotherapists; occupational therapists; and paraprofessionals,
such as home support workers.
A Canadian study of veterans and caregivers
supported the inclusion of the following
factors in a brief risk assessment: lower limb
disability, lower extremity weakness, worse
memory than peers, one or more family
doctor visits in the past month, and taking
four or more medications. Physical inactivity
and serious foot problems are other factors
receiving some support for inclusion in a
brief risk assessment.89
Due to the multifactorial nature of falls, any
one test cannot identify individuals who are
at risk for falls.90
Evidence for a multifactorial,
population-based approach
Comprehensive clinical assessment
A comprehensive clinical risk assessment
usually consists of:
■ a review of falls history and circumstances; and
■ an assessment of gait, balance, mobility
and muscle weakness, osteoporosis risk,
perceived functional ability and fear of
falling, visual impairment and effects of
corrective eyewear, urinary incontinence,
home hazards, cardiovascular exam and
medication review.91
The AGS Guideline advises that the assessment should be performed by a clinician
with appropriate skills and experience. In
addition to the factors identified above, the
Guideline recommends including factors
related to acute and chronic health problems; lower extremity joint function; and
basic neurological function.
“Despite methodological limitations of
the evaluation studies reviewed, the consistency of reported reductions in fallrelated injuries across all programmes
support the preliminary claim that
the population-based approach to the
prevention of fall-related injury is effective and can form the basis of public
health practice.”
Source: Population-based interventions for the prevention of fall-related injuries in older persons (Review),
The Cochrane Collaboration, 2005.
Excellent models of multifactorial interventions have been developed in Canada and
elsewhere, although few have been tested
empirically.
■
Multifactorial interventions
The Rand Report, the Cochrane reviews
and the Federal/Provincial/Territorial best
practices guide all conclude that there is
compelling evidence to support the use of
multidisciplinary, multifactorial, health and
environmental approaches to fall prevention.
A comprehensive approach to fall prevention
among seniors typically includes a combination of assessment and interventions such as
exercise programs, behaviour change, medication review and modification, treatment
of contributing health conditions, assistive
and protective devices, environmental modifications, and education.
A study conducted in Edmonton has
shown promise in reducing falls using a
multifactorial, risk-abatement approach,
as well as a cognitive-behavioural and
environmental focus. The target population was relatively healthy and mobile,
community-dwelling older adults. The
older adults who had completed the
program made significant reductions in
eight out of nine risk factors addressed
in the program. Over a four-month
follow-up period, the proportion of
older adults who fell was lower in the
treatment group (17%) than in the control group (35%). In addition, a significantly lower proportion (20%) of
members of the treatment group, who
had reported a fall in the year before
the program, experienced a fall in the
follow-up period compared to similar
persons in the control group (35%).92
Report on Seniors’ falls in Canada
39
■
A study in which nurse practitioners
and a physical therapist were trained to
conduct comprehensive assessments and
three months of focused interventions
demonstrated significantly fewer ‘fallers’
and fewer total falls compared to the
control group.93
Exercise programs
Evidence is growing concerning the benefits
of exercise in reducing the risk of falls and
related injuries. Exercise can improve balance, mobility and reaction time. It can
increase bone mineral density in postmenopausal women and in people age
70 and over. The Rand Report concluded
that exercise interventions reduced the risk
of falls by 15% and the number of falls by
22%. The falls exercise programs typically
involved cardiovascular endurance, muscle
strength, flexibility and balance. The research
supports general activity such as walking
outside or mall walking indoors, cycling,
mild aerobic movements or other endurance
activities, and specific regimes geared toward
balance, strength or flexibility.94
Specific exercise regimes are associated with
reduced falls and/or injuries. Overall, the
Cochrane Review concluded that evidence
from three randomized control trials proved
that falls can be reduced through individually prescribed programs involving muscle
strengthening and balance retraining. Group
Tai Chi was also shown to be particularly
effective.95
Another review reported that 10 to 12 weeks
of gentle exercise that focused on balance,
strength and flexibility, produced a trend
toward reduced multiple falls among high
compliers. The review also reported on
the benefits of an 80-minute exercise program, follow-up visits, and telephone
40
Report on Seniors’ falls in Canada
encouragement. Participants reported fewer
falls than persons in a control group. A
combined strength and endurance training
program, three times a week for six months,
reduced the risk of falling by nearly half,
when compared with either strength or
endurance training alone.96
Studies of the benefits of walking show
mixed results. The Nurses’ Health Study
found walking to be preventive among
the 61,200 women studied.97 However, one
researcher has reported increased falls from
brisk walking among post-menopausal
women.98 Overall, Rand reviewers concluded
that the data clearly point to the benefits of
exercise in general, but they were not conclusive in recommending particular fall
prevention exercises.99
Clinical management of chronic
and acute illness
Chronic illnesses that are frequently implicated in falls risk include arthritis, Parkinson’s
disease, stroke, urinary incontinence, sudden reductions in blood pressure on rising,
and cardiovascular conditions including
arrhythmias. Unfortunately, the increased
risk of falls associated with chronic illnesses
may be compounded by additional risks
related to adverse reactions to medications
used to treat them. Similarly, the medications used to treat sleep disturbances and
acute illnesses may compound the fall risk.
Medication review and modification
Suggestions for improving medication management have been identified by a variety
of sources. An Australian guideline reported
that programs aimed at reducing the use of
sedatives and tranquillizers have resulted in
fewer hip fractures in nursing homes.100
They recommended the following:
■
■
■
■
■
use the lowest effective dosage of a
medication specific to the symptoms;
urge supervision and the use of walking
aids while such medications are being
taken;
decrease chronic use of medications;
limit multiple medication use; and
conduct regular reviews of all patients’
medications with a view to withdrawing
those that are not absolutely necessary.
The use of post-menopausal hormone
replacement therapy (HRT) is a controversial one. Some research has shown that
fractures of the wrist and hip may be
reduced with HRT and that bone loss may
be prevented for up to 15 years with as
much as a 50% reduction in fracture risk.
However, other risks associated with HRT
have yet to be resolved before informed
decisions can be made about its usefulness
in fracture prevention. Pending further
research, decisions on the use of HRT
should be made based on the risk profile
of individual seniors. Other bone enhancing
drugs are proving useful in reducing vertebral and hip fractures. These include biophosphonates (etidronate, alendronate,
pamidronate) and selective estrogen
receptor modulators (raloxifene).101
The B.C. Provincial Health Officer’s report
highlights the need for pharmacists to
communicate clearly with both clients and
physicians concerning the interplay of drugs
and falls. It also recommends that pharmacists promote the use of assistive devices such
as hip protectors and walking aids, apply
stickers to drugs known to increase the risk
of falls, and ensure that drug instructions
are in large typeface and are readily understood by the client.102 Non-pharmacological
approaches for patients can also be considered, including chiropractic and massage
therapy.
Vision referral and correction
While vision problems are a known risk for
falls, no research evidence yet exists to show
that treating visual problems can prevent
falls. However, many vision problems can be
corrected with a proper exam and corrective
lenses. Progressive lenses may give better
quality vision of surroundings; however, it
is not recommended that older patients be
switched from bifocal to progressive lenses
or vice versa.103
Opticians can warn older persons that it takes
time to adjust to new lenses – particularly
multi-focal lenses – and that during this
period they may be at high risk for a fall
or associated injury, particularly on stairs.
Simple suggestions include making sure the
environment is well-lit, avoiding neutral
colours, avoiding clutter and remembering
to remove reading glasses when moving
about.104 Some older people may refrain
from having regular eye exams and purchasing appropriate corrective lenses because of
the cost.
Assistive devices and other
protective equipment
Assistive and protective devices such as canes,
walkers, safety poles or bathroom grab bars
are often recommended to reduce the risk
of falling, although empirical research to
prove their effectiveness is lacking. While
there is no clear evidence that assistive
devices cause or prevent falls, their use
can play an important role in increasing
seniors’ confidence and mobility and
encouraging independence.105
Report on Seniors’ falls in Canada
41
A recent review of the literature highlighting
the demands and problems associated with
mobility aids suggests that there may be a
need for more cautious prescription of
mobility aids and improved training to use
the prescribed device safely.106 Safer mobility
aids are currently being developed, such as
novel handrail systems designed to promote
safe stair use among seniors, and new types
of footwear designed to improve balance by
facilitating pressure sensation from the sole
of the foot.107
In 2003, the Canadian Association of
Occupational Therapists called for
“Canadians [to] be informed of assistive
technology benefits in promoting independence and health, in order to facilitate their
use and social acceptance.”
Source: Position statement: Assistive
technology and occupational therapy, Canadian
Association of Occupational Therapists, 2003.
A national project of the Health Canada/
Veterans Affairs Canada Falls Prevention
Initiative held focus groups with older
adults, service providers and assistive device
stakeholders. They found that, for many
older persons, assistive devices, in particular
mobility aids, can be viewed as stigmatizing
and symbolic of aging and inevitable decline.
These perceptions can influence an individual’s decisions about whether or not to use
aids.108 Other researchers identified factors
affecting the use of adaptive equipment,
including age, gender, living environment,
and health condition. Their findings indicated that device use is greater for persons
with acute orthopaedic conditions and multiple impairments. The strongest predictor
of use is a client’s perceived need for the
device.109
42
Report on Seniors’ falls in Canada
Hip protectors are designed to reduce hip
fractures with falls. This protective underwear-type garment has a soft or hard shell
over the hip area. Researchers have reported
that these garments may be 80% to 95%
protective for hip fractures. A review commissioned by Health Canada and Veterans
Affairs Canada reported that five studies
showed reduced fractures among people
wearing hip protectors; however, only one
of these results was statistically significant.
The authors note that the non-significant
results may be due to different hip protectors being studied, small sample sizes and
poor compliance for wear.110 One study
reported that no one who was wearing hip
protectors at the time of a fall suffered a
hip fracture.111
Personal emergency call devices are designed
to enable prompt assistance to someone
who has fallen and needs help. While they
do not prevent people from falling, they can
reduce the seriousness of injury complications by ensuring prompt treatment and
reduced harm. Many residential care settings
have such call devices installed as alarm buttons near the floor. Alerting systems, which
alert care providers when an individual
becomes ambulatory, may reduce falls. An
ambulatory alarm secured to the thigh of
hospitalized seniors, was shown to reduce
falls by 45% in a general ward and 33% in
an orthopaedic ward in less than a year112
but these results have not been replicated
and may not be applicable to a communitydwelling population.
Nutrition and supplements
Limited but promising research evidence
exists for the benefits of altered nutrition
and supplements. One review has suggested
that increasing dietary calcium has the
greatest effect in improving bone mass
among persons with low bone density
and in those who have low calcium intake
(<400 mg/day)113. It is currently advised that
calcium supplements (1,500 mg/day) be
used with vitamin D (800 IU/day) or other
active agents. Institutionalized seniors may
benefit in particular, as they have been
shown to suffer vitamin D deficiency due
to lack of exposure to sunlight.114 A more
recent review from the United States combined data from five randomized clinical
trials and concluded that 37% of people
in control groups had a fall compared with
30% taking vitamin D.115
It is also reasonable to assume that underweight or malnourished persons would have
a greater risk of fracture due to limited adipose (fat) tissue to protect bones during a
fall, muscle weakness or poor reaction time.
Improving oral health and dentures may
enhance nutrition as well. These issues need
to be addressed population-wide as well as
on a case-by-case basis.
Environmental assessment and modification
In and around the home
Most falls occur in and around the home
and research indicates that home modifications may be effective in reducing the risk
of falls.116 An assessment of the home environment aims to enhance accessibility, safety, and performance of daily living activities.
The Public Health Agency of Canada’s Safe
living guide117 includes a validated home
safety checklist, which can be completed by
seniors themselves or together with volunteers or health care workers. Modifications
include removing clutter and securing electrical cords and loose carpets to prevent
tripping; installing grab bars and handrails;
improving lighting and keeping a working
flashlight nearby; and improving shower
and tub safety.
An important aspect of successful home
modifications is ensuring that the identified
hazards are actually corrected. Programs
that not only identified the hazards and the
needed modifications, but also carried out
the modifications, were more successful
than programs that left the modifications
up to the seniors.118 Studies which have
explored adherence to home modifications
recommended by an occupational therapist
indicate that factors such as the perceived
need for the modification and lower cognitive or functional status are related to
adherence. The older person’s involvement
in making the decision regarding the
options for modifications may also influence adherence.119
In 2003, the Canadian Public Health
Association passed a resolution to encourage
the development of changes to building
codes related to stair design and installation
of grab bars in bathtubs.
Source: CPHA 2003 resolutions and motions,
CPHA motion No. 2, Falls among seniors
as a priority public health issue.
Report on Seniors’ falls in Canada
43
Best practices for
environmental modifications
■
■
■
■
■
Include home modifications as part of
a fall reduction program.
Combine home modification programs
with strategies such as education and
counselling about reducing risks (especially other risks that interact with
environmental factors to increase the
chance of falls).
Offer some form of financial or manual
assistance in home modification programs because it provides real help to
seniors and improves the success rate.
Use the skills and training of occupational therapists for conducting home
assessments, as they are able to evaluate both the senior’s environment and
his or her ability to function in that
environment.
Target people who are ready to change.
Readiness is often a function of having
had a recent fall or an increased
understanding of fall risks.
Adapted from: A best practices guide for the prevention
of falls among seniors living in the community,
Federal/Provincial/Territorial Ministers Responsible
for Seniors, 2001.
In public spaces
There are many factors contributing to falls
in public spaces and it is difficult to determine the impact of a specific intervention.
However, a project in British Columbia
called STEPS (Study to Promote
Environmental Safety) produced an interesting model for reducing public fall hazards.
This project pulled together government
officials, seniors, city maintenance workers,
and building owners to examine and reduce
44
Report on Seniors’ falls in Canada
fall hazards in the community. A telephone
hotline enabled people to report falls and
hazards, leading to a repair or spray-painting
of the hazard until the repair could be
done.120 Public awareness campaigns can
also educate the community about fall
hazards – municipal workers, seniors,
caregivers, letter carriers, and others are
well situated to observe and report on fall
hazards in need of repair.
Building codes and standards can play an
important role in the prevention of falls.
The Canadian Hospital Injury Reporting
and Prevention Program (CHIRPP) reports
that stairs, floors and steps are implicated
in seniors’ falls more often than any other
household areas or items.121
The Canadian Standards Association has
undertaken several initiatives to improve
safety and security for seniors. A key initiative has been the development of B659-01:
Design for Aging, a guideline that outlines
principles for the development of products,
services and environments for an aging
society.122
Education
It is generally agreed that as a stand-alone
intervention, education does not produce
a measurable decline in falls or injuries.
However, educational efforts with individuals, family caregivers, professionals and
entire communities are recommended as
an adjunct to other interventions. Effective
education may take many forms including
pamphlets or other printed materials, public
talks or discussion groups and use of the
media. More intense education can take
place with individual counselling. A form of
skills education is being studied in Canada
to determine whether people can learn to
fall more safely. A researcher has found that
during a sideways fall, individuals can learn
to avoid impact to the hip by changing the
position of their body before they land on
the floor, thereby lowering their risk of a
hip fracture.123
Educating care providers is another approach
to fall prevention. An innovative educational
program equipped community health workers to do first level assessments of older
community-based clients receiving home
care services. Following a one-day training
session, the workers implemented a risk
screen and intervention tool with selective
clients. The total number of reported falls
dropped by 44% and the study is now being
replicated as a randomized control trial to
establish the relationship between a decline
in falls and the benefits of the program
more clearly.124
Addressing fear of falling
Existing education programs are tailored
to prevent falls; however, a need also exists
for post-fall interventions to prevent subsequent falls and to address fear of falling.125
Many fall prevention programs target fear
and self-efficacy but there is limited evidence of their effectiveness in reducing
fear. One study reported a modest shortterm effect in improving self-efficacy and
increasing level of activity using a cognitivebehavioural intervention. No effect remained
after six months.126 An intervention involving participation in Tai Chi classes resulted
in a reduction in fear of falling and risk of
falling. Use of hip protectors did not appear
to reduce fear of falling, but was associated
with improved self-efficacy.127
A recent study concluded that an intervention to reduce fear of falling through group
sessions was most effective for participants
who were less physically impaired, had
greater concern about falling and had
greater self-efficacy in making changes.128
There is evidence to suggest that interventions for people being treated for fall-related
injuries should try to lessen fear arousal.
Also, increased social support is needed as
a means to lessening fear.129 A multi-faceted
intervention strategy showed significant
improvements in the capacity of communitydwelling seniors to address fall risks.130
Programs seem to be more effective when
they target remediable individual and environmental risk factors for falls, and when
they are integrated into a range of services
including prevention and management,
acute care, rehabilitation, home care, and
long-term support.
4.3 Selecting appropriate
approaches according to setting
Community-based settings
Many of the fall prevention approaches
described above are appropriate to
community-based settings. Among seniors
in the community, interventions need to be
tailored to an individual’s level of frailty –
approaches suited to healthy, active seniors
will be different from those for seniors who
are more frail. In 2004, Health Canada conducted a survey to determine seniors’ attitudes to falls and concluded that younger,
healthy seniors tend to focus on healthy
eating and exercise, and do not tend to
think of this as preventing falls. Those who
are frail and more vulnerable tend to focus
on maintaining independence, and while
they are at a higher risk for falls, they have a
tendency to deny their risk. However, given
the right information by the right professional, many will change their environments
and behaviour to minimize their risk. Frail
Report on Seniors’ falls in Canada
45
seniors who depend on others for their care,
along with their professional and family
caregivers, are often very concerned about
falling and can benefit from education and
interventions.
Institutionalized seniors
A number of researchers have studied fall
prevention approaches in long-term care
facilities. Two promising examples are
as follows:
■ A randomized control trial in nursing
homes combined individualized assessment with interventions. Interventions
were in the areas of environmental and
personal safety (i.e., improvement in
room lighting, flooring, footwear, etc.),
wheelchair use and maintenance (i.e.,
assessment by an occupational therapist),
psychotropic drug prescriptions (i.e.,
assessment and recommendations for
change), transfer and ambulation (i.e.,
evaluation and recommendations for
change), and facility-wide interventions
(e.g., educational programs for staff).
The ‘intervention’ facilities had 19%
fewer recurrent falls compared with the
‘control’ facilities, and a 31% reduction
in the rate of injurious falls.131
■
A project funded by PHAC’s Population
Health Fund developed a falls surveillance tool for long-term care facilities,
based on a review of the literature on fall
prevention for residents in such facilities.
This project developed several collaborative protocols for recording, implementing and monitoring effective prevention
strategies for falls and fall-related
injuries.132
Hospitalized seniors
Many prevention practices are in place to
protect hospitalized seniors from falls
46
Report on Seniors’ falls in Canada
including educational activities for nursing
and support staff, patient orientation activities, reviews of prior falls, and modifications
to the environment. Environmental modifications include reducing ward or room
obstacles, adding extra lighting and grab
bars in bathrooms, and lowering bedrails
and bed height. Other approaches address
transfer and mobility issues with scheduled
ambulatory and physical therapy activities
and attention to footwear (e.g., non-skid
socks). In addition, hospitals have incorporated strategies to assist cognitively impaired
patients by: educating family members to
deal with confused patients; minimizing
sedating medications; and moving confused
patients closer to nursing staff.133
A recent systematic review reported a pooled
effect of a 25% reduction in the fall rate in
the studies that examined prospective interventions compared to fall risk in historical
controls. Minimizing bed rest is a practical
intervention that has implications for the
prevention of a number of serious hospitalacquired complications.134
4.4 Recovery from a fall
This section summarizes the evidence presented in systematic reviews, guidelines and
other studies concerning best practices for
recovery from a fall and post-fall prevention
of another fall.
Although there is information on the management of specific injuries, most notably
hip fractures, the concept of fall recovery is
not well recognized. Comprehensive fall
injury management needs to go beyond care
for the injury sustained to include assessment and reduction of the risk of future
falls (i.e., medication review, exercise, and
education) and the maintenance of a
healthy lifestyle, not prescribed by the fear
of falling and being injured again.
Clearly, depression may be triggered by a
fall-related injury and may affect recovery
from such injuries.
Fall recovery goes beyond healing the
physical injury
Across Canada, services for seniors who
have fallen vary, especially in relation to preventing future falls. The greatest variability
appears to be in home care, home supports
and physical therapy services. A step to consider is the addition of evidence-based fall
prevention guidelines for the professionals
who see patients presenting with a complaint of falls or with a fall-related injury.
These professionals can include physicians,
nurses, health workers in community and
long-term care, physical and occupational
therapists, etc.
“Fall outcomes are not limited to physical
trauma but include social withdrawal,
psychological trauma and increased
dependence.”
Source: Fall injuries among Saskatchewan seniors,
Saskatchewan Health, 2002.
A number of factors play a role in a senior’s
recovery from a fall. Two studies have
reported that almost half of those who fell
required help getting up and that 10% of
falls resulted in a wait of over one hour for
help to arrive.135 Compared with those who
were able to get up, those who could not
were more likely to suffer lasting decline in
activities of daily living. A key recommendation from the studies reviewed is that older
adults presenting for medical care with a fall
injury should be assessed for risk of falling
and that remediable risk factors should be
addressed.136
One worrisome complication for older
adults after hip fracture surgery is delirium,
which occurs in 35% to 65% of patients
and can adversely affect rehabilitation outcomes.137 Depression is another factor that
has implications for practice as it may affect
recovery from fall injuries. One study found
that depression prior to a fall-related injury
was not predictive of disability after the
injury. However, symptoms of depression
present two months after the injury were
linked to significantly higher rates of disability over the short and long term.138
4.5 Factors influencing client
compliance in fall prevention
A person’s need for autonomy, dignity and
independence, as well as the tendency to
minimize the seriousness of a fall or displace
blame may pose challenges to successful
implementation of fall prevention initiatives. One study interviewed older women
who had not followed through on recommendations to modify their environment
to reduce their risk of falling. The study
found that the women made decisions
about whether or not to implement changes
in their home based on their own perception of the level of risk, according to their
own experience and knowledge, rather than
on those of the person recommending the
changes. The women tended to modify their
behaviour rather than change their environment, opting to accept a level of environmental risk.139
Varying attitudes have been observed in
people who have fallen. One study found
four patterns of response: overall lack of
Report on Seniors’ falls in Canada
47
Seniors may overestimate
their level of fitness
An Ontario survey supported by the
Health Canada/Veterans Affairs Canada
Falls Prevention Initiative found that
many seniors overestimated their level of
fitness and underestimated their loss of
visual acuity. Such seniors may not recognize subtle deteriorations in their
strength, coordination and balance that
may make them prone to falling. Since
they do not think they are at risk for
falling, they may not take precautions
and may be less likely to respond to fall
prevention campaigns.
Source: Awareness and attitudes toward
fall prevention: Final report on a survey on Ontario
seniors, Ontario Public Health Association, 2002.
concern; a perception of the fall as part
of the natural aging process; viewing the
incident as a learning opportunity; and
experiencing the event as dramatic and
life-changing.140 Those who had little or
no concern tended to place great value on
maintaining their independence and made
no changes to reduce their risk of falling in
the future. Those who saw falling as part of
the aging process or as a learning opportunity took actions to reduce risk. Those who
experienced the event as ‘dramatic’ were
more fearful of falling in the future and
perceived themselves as very vulnerable to
falling. The latter group made the most
changes to reduce their risk of falling but
had a reduced sense of personal mastery.
Thus, it is important for clinicians to determine a client’s interpretations of a fall event
as it may affect the senior’s readiness to
make changes.
48
Report on Seniors’ falls in Canada
Communicating to a client about falling and
related fear is important both in treating
fall-related medical conditions and in preventing future falls. Communications need
to take into account the tendencies of people to dissociate from the likelihood of a
future fall, displace blame for falls, and
maintain a sense of personal control and
independence. Also, understanding the
complexity of fear of falling is important for
effective communication. Communications
should emphasize ‘healthy fear’ that results
in risk reduction rather than ‘unhealthy fear’
that may lead to increased risk of falls.
A study of ten women living in a nursing
home explored the women’s experiences and
feelings after having fallen.141 The women
described feelings of helplessness, annoyance and frustration as a result of falling.
Most expressed a fear of falling in the future
and had opted to use assistive devices for
mobility. They were reluctant to participate
in organized physical activity programs, in
part because they had never been involved
in physical activities for pleasure at any stage
in their life, but also due to their fear of
falling again.
Clearly, falls are an emotionally loaded topic
for older people. A study examining perceptions of falls found that the language used
by older people to describe their falls avoided connotations of personal vulnerability.142
Similarly, there is a tendency for people to
dissociate themselves from the likelihood
of falling and to consider others at greater
risk.143 Many individuals are strongly
motivated to underplay their personal
susceptibility.144
This tendency to avoid being perceived as
vulnerable may relate to the need for personal control or autonomy. For seniors who
have experienced a fall, there may be residual fear about possible loss of freedom. One
researcher found that, although older nursing home residents were falling regularly,
many were baffled as to why they were
included in a group of ‘frequent fallers’ as
they did not see themselves as persons who
repeatedly fell. The residents described the
falls as having been caused by an external
factor. The authors conclude that the defense
mechanism of displaced blame allowed frequent fallers to continue to view themselves
as intact.145 Interventions should take into
account the tendencies of frequent fallers
toward denial, as well as their need to preserve personal esteem and independence. It
is important to respect the rights of seniors
to live at risk.
Summary
There is compelling evidence for the effectiveness of combining comprehensive falls
assessments with multidisciplinary and multifactorial interventions that address health
and environmental factors to prevent falls
among seniors.
Some interventions focus on the combination of factors that put a senior at risk while
others address broader population-based
efforts, such as education and reducing public
hazards. These approaches are complementary and can be adapted to the community
or the institutional environment. A comprehensive approach typically includes exercise
programs, behavioural changes, review and
possible modification of medications, treatment of health conditions contributing to
risk, safety and protective aids, environmental
modifications and the education of seniors
and caregivers. With seniors who have experienced a fall injury, recovery, fear of falling
and attitude need to be addressed to prevent
further falls. Interventions need to support
seniors’ personal esteem and independence.
Report on Seniors’ falls in Canada
49
5
Supporting fall
prevention strategies
Developing effective fall prevention programs requires an understanding of the
incidence and nature of falls among seniors
and of the factors associated with falls.146
Also key to effective programming is
community support to maximize program
acceptance and sustainability. Programs
often build on elements already in place in
the community and rely on networks that
extend beyond their communities, such as
advocates and stakeholders from provincial
and national organizations and universities.
Programs are most successful when agencies
integrate fall prevention projects into their
broader organizational structure and goals,
so that fall prevention initiatives can, in
turn, support the broader missions of the
organizations.
individuals and the unique characteristics of
their living situation. Different approaches
are needed for vigorous seniors as well as for
frail seniors and for those living in the community as well as for those in institutions.
Specialized approaches may be required
when dealing with specific populations.
Recognizing client diversity, such as First
Nations groups or ethnocultural groups,
is important, as these may benefit from
specialized approaches to planning for fall
prevention. The success of any strategy is
dependent on the effective leadership and
active involvement of key stakeholders who
have the ability to build on the existing
strengths and capacities within each setting.
The Health Canada/Veterans Affairs Canada
Falls Prevention Initiative commissioned
a report to examine the factors that contribute to successful fall prevention programs. The study found that programs that
build on existing support can create a climate conducive to the success of a fall prevention initiative and that the impetus and
support for fall prevention programming
can come from a range of sources. The common element that supports an initiative is
the development of a shared understanding
that falls are a significant health risk and
that doing something about injurious falls
is possible.147
“Identify, develop and support Best Practice
Champions and include people who have
expertise in order to support, mentor and
train others within organizations to ensure
knowledge transfer.”
Selecting the appropriate prevention strategies is best done through a collaborative
process that reflects the risk profiles of
50
Report on Seniors’ falls in Canada
Source: Nursing best practice guideline: Prevention of
falls and fall injuries in the older adult,
Registered Nurses Association of Ontario, 2005.
The Health Canada/Veterans Affairs Canada
Falls Prevention Initiative funded a number
of fall prevention projects and found that
the projects that were sustained at the end
of the Initiative were those with strong community partnerships, strong leadership, and
additional financial support.148
Sustainability was most likely if fall prevention projects:
■ addressed sustainability in the initial
planning stages of projects;
■ had key champions to show leadership;
■ involved a wide range of stakeholders,
including local officials, service groups,
universities, provincial and national
organizations, and particularly seniors;
■ focused on specific project components
rather than entire programs (e.g.,
resources, partnerships and volunteer
networks);
■ supported outcomes such as increased
community interest and awareness;
■ had communities with previous capacity
for and experience in delivering fall
prevention initiatives;
■ secured funding for a project
coordinator;
■ had ‘train the trainer’ initiatives;
■ secured funding from multiple partners;
and
■ integrated falls projects into the broader
goals of the organization.
Summary
Strategies for fall prevention should reflect
current literature, with consideration for its
practical application and the local resources.
Programs to prevent falls and injuries tend to
focus on raising awareness, changing behaviours to reduce risk factors, and environmental and policy changes. For these programs to
be successful over the long term, it is key to
understand that sustainability is an ongoing,
active process requiring periodic adaptation
to conditions and circumstances.149
Projects identified challenges for sustainability as follows:
■ developing collaborative relationships
across jurisdictions;
■ identifying sources of sustainable
funding;
■ defining the most critical components
of a multi-component program;
■ identifying optimal recruitment strategies to attract and retain at-risk seniors;
■ adapting programs to address diversity;
■ maintaining volunteers and advisory
group members; and
■ preparing systematic evaluation plans.
Report on Seniors’ falls in Canada
51
6
The way forward
Until now, a national overview was not available concerning fall-related hospitalizations,
fall-related deaths and self-reported fall injuries for seniors in Canada. Report on seniors’
falls in Canada provides a clearer picture of the situation and profiles compelling evidence
for the effectiveness of combining comprehensive fall assessments with multidisciplinary
and multifactorial interventions that address health and environmental factors to prevent
falls among seniors.
While the national data presented in this report are important to demonstrate the nature
and severity of falls among seniors, provincial, regional and local surveillance are also
valuable sources of falls and fall-related injury data.
It is vital that the wealth of data and evidence at all levels continue to be studied, shared,
and built upon to provide a truly comprehensive picture of seniors’ falls across Canada.
Those working within the jurisdictions are best situated to access their own data sources
and to understand their strengths and limitations: regional variations in falls data need to
be interpreted carefully as there are differences in the range of biological, behavioural,
environmental, social and economic fall risk factors within regions. Variability also exists
among jurisdictions in the types of infrastructures, policies and resources available to
address seniors’ falls.
As surveillance, research and program initiatives expand, collective understanding of risk
factors and prevention of falls will increase. By sharing key evidence on seniors’ falls and
prevention strategies, the Public Health Agency of Canada and other stakeholders can
contribute to the development of effective new interventions and policies, and to the
reduction of trauma, disability and premature death from falls among Canada’s seniors.
52
Report on Seniors’ falls in Canada
Report on Seniors’ falls in Canada
53
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149
Davis, N. “Elderly women’s narratives of falling,
fear of falling, the role of physical activity and
their impact on autonomy and quality of life.” MA
Dissertation. University of Ottawa, April 2001.
Martin, M. “The construction of the risks of
falling in older people: Lay and professional
perspectives final report.” Scottish health feedback.
Edinburgh: 1999.
Braun, B. “Knowledge and perception of fallrelated risk factors and fall reduction techniques
among community-dwelling elderly individuals.”
Physical therapy, Vol. 78, 1998, pp. 1262-76.
Ballinger, C. and S. Payne. “The construction of
the risk of falling among and by older people.”
Ageing and society, Vol. 22, 2002, pp. 305-24.
Wright, B. et al. “Frequent fallers: Leading groups
to identify psychological factors.” Journal of gerontological nursing, Vol. 16, No. 4, 1990, pp. 15-19.
Saskatchewan Health. “Fall injuries among
Saskatchewan seniors.” 2002.
Scott., V. et al. Environmental scan: Seniors and
veterans falls prevention initiatives in British
Columbia. 2005.
Health Canada/Veterans Affairs Canada Falls
Prevention Initiative. Sustainability of communitybased falls prevention programs. Community
Health Research Unit, University of Ottawa, 2004.
Ibid.
List of tables and figures
Table 1
Distribution of CCHS (Cycle 2.1)
sample for age 65 and over,
2002/03
Figure 1 Estimated cases of injuries resulting from a fall, by age group and
gender, age 65+, Canada, 2002/03
Figure 2 Estimated rates of injuries resulting from a fall, by age group and
gender, age 65+, Canada, 2002/03
Figure 3 Self-reported falls resulting in
injury, by type of injury, age 65+,
Canada, 2002/03
Figure 4 Self-reported falls resulting
in injury, by type of activity,
age 65+, Canada, 2002/03
Figure 5 Self-reported falls resulting in
injury, by type of treatment
received within 48 hours,
age 65+, Canada, 2002/03
Figure 6 Fall-related hospital cases and
rates, age 65+, Canada, 1998/99
to 2002/03
Figure 7 Fall-related hospitalization
rates, by gender and age group,
age 65+, Canada, 2002/03
Figure 8 Fall-related hospitalizations, average length of stay per case, by age
group, Canada, 1998/99 to
2002/03
Figure 9 Average length of stay per case, all
causes and fall-related hospitalizations, age 65+, Canada,
1998/99 to 2002/03
Figure 11 Fall-related hospital cases, by
place of occurrence of fall, age
65+, Canada, 1998/99 to 2002/03
Figure 12 Fall-related hospital cases for
residential care vs. non-residential
care, age 65+, Canada, 1998/99
to 2002/03
Figure 13 Fall-related hospital cases for
residential care, by age group,
Canada, 1998/99 to 2002/03
Figure 14 Fall-related hospitalizations,
average length of stay per case for
residential care vs. non-residential
care, 1998/99 to 2002/03
Figure 15 Fall-related hospitalizations,
average length of stay per case for
seniors in residential care, by age
group, age 65+, Canada, 1998/99
to 2002/03
Figure 16 Number and percent of hospital
cases associated with falls in
residential care by injury type,
Canada, 1998/99 to 2002/03
Figure 17 Deaths and mortality rate due to
falls, age 65+, Canada, 1997-2002
Figure 18 Deaths due to falls, by age group,
age 65+, Canada, 1997-2002
Figure 19 Mortality rate due to falls by
age group, age 65+, Canada,
1997-2002
Figure 20 Deaths and mortality rate due to
falls, by gender, age 65+, Canada,
1997-2002
Figure 10 Number and percent of fallrelated hospital cases, by injury
type, age 65+, Canada, 1998/99
to 2002/03
Report on Seniors’ falls in Canada
61
Appendix A Risk factors for falls and
fall-related injuries
Biological / Medical
■ Advanced age
■ Female gender
■ Chronic illness/disability:
-Stroke
-Parkinson’s disease
-Heart disease
-Incontinence/frequency
-Depression
■ Acute illness
■ Cognitive impairment
■ Gait disorders
■ Poor balance
■ Postural sway
■ Muscle weakness
■ Poor vision
■ Impaired touch and/or proprioception
Environmental
■ Poor building design and/or
maintenance
■ Inadequate building codes
■ Poor stair design
■ Lack of:
-Handrails
-Curb ramps
-Rest areas
-Grab bars
■ Poor lighting or sharp contrasts
■ Slippery or uneven surfaces
■ Obstacles and tripping hazards
■ Assistive devices
Behavioural
■ Multiple medications
■ Use of:
-Tranquillizers
-Antidepressants
-Antihypertensives
■ Excessive alcohol
■ Risk-taking behaviour
■ Lack of exercise
■ Previous fall/recurrent falls
■ Fear of falling
■ Inappropriate footwear
■ Lack, inappropriate use or improper use
of mobility aids
■ Poor nutrition or hydration
Social / Economic
■ Low income
■ Lack of education
■ Illiteracy/language barriers
■ Poor living conditions
■ Unsafe housing
■ Poor social environment
■ Living alone
■ Lack of support networks and social
interaction
Adapted by V. Scott (2005) from: Federal/Provincial/Territorial inventory of Canadian programs for the prevention of
falls among seniors living in the community, 2001.
62
Report on Seniors’ falls in Canada
Appendix B List of the Public Health Agency
of Canada’s resources on seniors’ falls
These publications are available on the Division of Aging and Seniors Web site at:
www.phac-aspc.gc.ca/seniors-aines
12 steps to stair safety
This one-page checklist reminds seniors
of the common hazards in stairways,
and the proper ways to set up and use
their stairs.
A best practices guide for the prevention of
falls among seniors living in the community
The Guide is based primarily on a systematic review of the studies evaluating
the effectiveness of fall prevention strategies for community-dwelling seniors and
then, based on these studies, determining
effective interventions and strategies.
An inventory of Canadian programs for the
prevention of falls among seniors living in
the community
This is a national inventory of Canadian
programs designed to reduce falls or
fall-related injuries among communitydwelling seniors.
Bruno and Alice
This light-hearted, humourous and
entertaining publication offers seniors
easy-to-read and important information
on injury prevention in the home.
Falls prevention initiative – Health Canada/
Veterans Affairs Canada: Summaries of
funded projects 2000-2004
The booklet describes 40 projects funded
under the Falls Prevention Initiative, that
help identify and promote effective falls
prevention strategies for veterans and
seniors.
Go for it! A guide to choosing and using
assistive devices
The guide is aimed at helping users in
finding the best solution regarding the
choice of communication aids, cognition
aids, personal mobility aids, housekeeping aids, adaptations to the home and
other premises and recreation aids.
Help yourself to assistive devices!
This leaflet provides a wealth of information on available assistive devices to
facilitate the activities of daily living.
Inventory of fall prevention initiatives in
Canada – 2005 (available online only)
This inventory is a revised listing of falls
prevention programs/projects available
for seniors living in the community.
Promising pathways: A handbook of
best practices
This handbook provides information on
the most effective strategies and interventions for reducing falls and preventing injuries among seniors who live in
the community. It also offers tools and
resources for planning and implementing
fall prevention programs.
Stay safe!
The poster illustration is of a senior’s
living room and contains 14 dangers
that can cause seniors to fall or injure
themselves.
Report on Seniors’ falls in Canada
63
The safe living guide: A guide to home
safety for seniors
This guide presents ideas on how to
prevent injuries in and around the home.
It provides information in the form of
check lists, fact sheets and tips, as well
as a resource section.
You can prevent falls!
This pamphlet focuses on how seniors
can prevent falls by making the needed
adjustments to their homes and lifestyles,
by eating well, staying fit, and using
devices that will facilitate their daily lives
while keeping them safe.
64
Report on Seniors’ falls in Canada
Additional Web resources
Canadian Health Network
CHN is a national, bilingual Internetbased health information service funded
by PHAC.
www.canadian-health-network.ca
Health Portal
Offers resources on seniors’ health issues
and concerns including safety and injury
prevention.
www.healthportal.gc.ca
Seniors Canada Online
Offers easy electronic access to seniorrelated services.
www.seniors.gc.ca
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