Standing Behind Seniors

Injuries resulting from falls in old people – resulting in recurrent pain, functional impairment, disability, and even death – are a major public-health concern. Specialized geriatric health services need to be developed to provide preventive, curative and rehabilitative care to this vulnerable population…
Dr Suneela Garg/ Dr Samar Hossain/ Dr Divya Gupta

India as the second most populous country in the world has 76.6 million people at or over the age of 60, constituting above 7.7% of total population. The problems faced by this segment of the population are numerous owing to the social and cultural changes that are taking place within the country. The major area of concern is the health of the elderly with multiple medical and psychological problems.
Certain problems of the health or disease of the patients over 50 years of age warrant special consideration. Injuries in the elderly population have more alarming consequences (more difficult treatment, higher costs) than in the younger population. The majority of the injuries are caused by traffic accidents and falls, for which it is important to devise preventive strategies.

Epidemiological Data
A study by Dionyssiotis Y on the problem of falls among older people, found that more than 30% of people over the age of 65 years fall each year and in half of the cases falls are recurrent. About one in ten falls results in serious injuries such as hip fracture, subdural hematoma, other fractures or even traumatic brain injury.

It was found in a study conducted in the Eastern Mediterranean region that 30%–40% of adults older than 65 years residing in the community fall each year. The rates were higher in hospitalized patients and nursing home residents. In Qatar, the prevalence of falls among the elderly in 2008 was 34% (119 of 355 attendees); out of this figure, 47% of elderly individuals suffered a fall while 53% experienced recurrent falls. In the United States, national estimates of the incidence and direct medical costs associated with fall-related injuries in mature patients aged ≥65 in 2000, showed that 10,300 were fatal. Furthermore, an additional 2.6 million nonfatal fall-related injuries were reported. The estimated total cost of medical treatment for these injuries was $0.2 billion for fatal falls and $19 billion for nonfatal falls.

In a multi-centric community study evaluating health problems in the elderly (Year 2003), in ten states across India, covering a total population of 10,200 elderly with equal rural and urban distribution, the incidence of falls was found to be 14%.

Assessment of the morbidity profile and its determinants will help in the application of interventions, both medical and social, to improve the health status and thus the quality of life of the elderly in northern India. The distribution of history of fall among elderly people over 60 years old shows that, out of the total sample population, 103 (51.5%) subjects had fallen. Fracture was reported in 21.3%, and other injuries occurred in 79.6% of those who had fallen. Fractures among females (26.4%) were reported more frequently compared with males (16%) and fracture was seen more in urban subjects (29.4%) compared with rural subjects (13.4%).

Injuries resulting from falls in elderly people are a major public-health concern, representing one of the main causes of longstanding pain, functional impairment, disability, and death in this population. The problem is going to worsen, since the rates of such injuries seem to be rising in many areas, as is the number of elderly people in both the developed and developing world.

The most common mechanism of injury in the elderly population is due to fall. About 30%-50% of falls in the elderly result in minor injuries, including bruises, abrasions, and lacerations, but an estimated 10% of all falls in seniors cause major injuries, including intracranial injuries (ICIs) and fractures.

Falls are the most common cause of injuries among senior citizens and the top reason for a hospital admission for trauma. They constitute the second leading cause of unintentional deaths after road traffic accidents. Advanced age substantially increases the likelihood of hospitalization after a fall. Falls account for 87% of all fractures among people aged 65 years or older.

Risk Factors for falls-
The risk factors can be intrinsic or extrinsic.

The intrinsic risk factors include the following-
Recurrent falls
Increase in falls with an increase in the age
Females fall more often than males and are more likely to suffer from fractures when they fall
A solitary lifestyle
The use of benzodiazepines in the elderly population leads to an increase in the risk of hip fracture by 44%
Underlying medical conditions like vascular diseases, COPD, depression and arthritis
Others like cognitive disorders, attenuated vision, ulcers and deformed feet
The extrinsic risk factors include-

Poor lighting
Slippery floors
Uneven surfaces

Falls are potentially preventable and hence much interest is being shown in the evaluation of falls and identifying the risk factors, which help in falls prevention programmes. As the population ages, the problems related to falls and fractures are expected to grow and pose an even greater challenge to the healthcare systems. Meeting these challenges requires a clear understanding of the prevalence and nature of falls, innovative planning to develop prevention programmes, systems and structures which will support falls prevention initiatives, and substantial reforms and policies at the local and national levels.
A majority of falls are predictable and therefore preventable. Community-based falls registries and surveillance systems should be set up to better understand the prevalence, nature, and the trends of unintentional injuries at the population level in India.

Population based interventions or interventions aimed at specific groups at high risk of falling should be undertaken. Simple interventions can be planned to reduce a single risk factor or multifactorial interventions, environmental modifications, mobility aids and educational programs.There is a need for developing a comprehensive care of providing preventive, curative and rehabilitative services to the elderly.

India and other developing countries face the major challenges of prevention, pre-hospital care and rehabilitation in their rapidly changing environments to reduce the burden of fall-related injuries. There is a need for developing a comprehensive care of providing preventive, curative and rehabilitative services to the elderly. Unlike developed countries, India does not have well-structured health services for the elderly, leading to a relatively ad hoc system of healthcare delivery to this vulnerable population. Specialized geriatric health services have to be developed, to educate, develop and maintain healthy lifestyles and to provide comprehensive healthcare.

Protective factors for falls in older age are related to behavioural change and environmental modification. Behavioural change to healthy lifestyle is a key ingredient to encourage healthy ageing and avoid falls.

Non-smoking, moderate alcohol consumption, maintaining weight within normal range in mid to older age, playing an acceptable level
of sport protect older people from falling.

(The authors are Director Professor/Senior Resident Doctors, Department of Community Medicine, Maulana Azad Medical College, New Delhi)

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