Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Prevention of Household and Recreational Injuries in the Elderly

Prepared by R. Wayne Elford, MD, CCFP, FCFP, Professor and Director of Research and Faculty Development, Department of Family Medicine, University of Calgary, Alberta

Overview
In the 1979 Canadian Task Force report, home and recreational injuries were acknowledged to constitute an important proportion of accidents. The report emphasized the particular risk for the elderly.< 1> At that time there was insufficient literature on the subject to justify a recommendation on scientific grounds. This lack of evidence persists for most areas of injury prevention among the elderly. New evidence has emerged, however, supporting multi-disciplinary post-fall assessment where this service is available. Accidental injury and death caused by motor vehicle accidents (46.5% of all deaths due to accidents) is covered in a separate chapter (Chapter 44).

Burden of Suffering
The seven leading causes of unintentional death in Canada are falls (21%), drowning (6.4%), burns, fire-related injuries (4.8%), suffocation (4.7%), poisonings (4.7%), bicycle and sports-related injuries (1.7%), and firearms (0.7%).<2> Injuries sustained in falls are a major cause of mortality and morbidity in the elderly population.<3> Table 1 summarizes the Canadian mortality and morbidity rates for various types of injury in the elderly. A brief description of the risk factors associated with each of the leading causes of unintentional injury in the elderly is provided.

Falls
In 1988 there were 2,100 deaths due to falls.<2> Falls resulting in serious injury or death were much more frequent among those aged 55 and over; 70% of fatal falls were among persons 75 years and over.<4> Ninety-five percent of injuries among the elderly living in long-term care facilities were due to falls.<5> One percent of falls by individuals aged 65 and over result in hip fracture. A descriptive study found fewer than 30% of 219 women aged 59 and over with hip fractures regained reported pre-fracture levels of physical function. Also, high post-surgery depression scores were associated with poorer recovery. A case-control study of 149 institutionalized and 68 non-institutionalized elderly persons (15% female and 87% male respectively), matched by age, sex and living location, found fallers were more physically and functionally impaired with hip weakness, poor balance and more medications predictive of falls in institutionalized patients (logistic regression p<0.05). Falls without fracture are among the most common causes of admission of the elderly to geriatric hospitals, residential homes and nursing homes, often due to family concerns about safety, restricted mobility and independence. Risk factors for falling include increased age, female sex, presence of more than one disease, dementia, depression, acute illness, decreased mobility, confinement to the home, postural gait instability, gait disturbance, sensory impairment, medications and possibly dietary deficiencies.<6>

Drowning
In 1987 there were 429 deaths due to drowning in Canada, including 135 boating accidents. Only 12% of drowning victims were over 65 years of age.<7>

Burns, Scalds and Fire-Related Deaths
There were 429 fire-related deaths in Canada in 1987 and 85% occurred in private dwellings.<4> Of the 402 accidental deaths among Canadians caused by fire and flames in 1988, about 21% involved persons over 65 years of age.<7> The number of fires and fire deaths (844 in 1978) has declined continually and has been attributed to better education, more widespread use of smoke detectors and fewer people smoking.<8>

Poisoning
Of the 424 fatal poisonings in Canada in 1987, 16% of the deaths were among seniors over 65 years of age.<4,7> Most were by drugs and medications (58%); 23% were by solid and liquid substances and 19% by gases and vapours. Among elderly adults, sedatives are the most commonly reported agents causing morbidity.

Suffocation
Almost two-thirds of the 415 Canadian deaths by suffocation in 1987 resulted from inhalation and/or ingestion of food; 13% were in adults over 65 years of age.<4,7>

Effectiveness of Prevention Maneuvers
During the past decade numerous descriptive studies concerning home and recreational accidents have been published. More important however, is the steady stream of experimental and quasi-experimental studies demonstrating that accidental injury and death are not random, unpredictable events, but are both predictable and preventable<9> and must be looked upon as a disease whose prevention must be approached scientifically. One model for organizing preventive measures against accidental injury and death is the Haddon Matrix,<10> named after a leading thinker in injury control. The Haddon Matrix for generating countermeasures provides a multifactorial model for developing approaches to injury prevention.<10> Three widely adopted approaches to interventions for accidental injury arising from this model are described in greater detail; namely, public health education, environmental legislation, and individual counselling.

Public Health Education
In general, modifying the environment appears to be more effective than trying to change human behaviour among the elderly.

Legislative/Environmental
Many studies have demonstrated a far greater impact on promoting home and recreational safety by influencing legislators, who in turn can modify the environment through building codes and safety legislation (Table 2).

Individual Counselling
The "Year 2000 Injury Control Objectives for Canada" recommend that individual counselling be targeted particularly towards high risk groups; namely, the socio-economically disadvantaged, the aboriginal people, situations where alcohol and/or substance abuse is suspected, and the elderly living alone.<16> Evidence concerning the effectiveness of legislative action and individual counselling for these activities will be presented sequentially for each major type of home and recreational injury.

Falls
Systematic identification and reduction of environmental hazards prevents injuries. As with other unintentional injuries, modifying the environment (stairs, especially those with undifferentiated edges, slippery floor, surface clutter, poor lighting, unexpected obstacles and ill-fitting footwear) can be far more effective than trying to change the behaviour of people living in that environment. Several checklists for home safety evaluation<17> and for studying the epidemiology and risk of falls have been published, but none has been evaluated in clinical practice. Exercise programs have demonstrated positive effects on the muscle strength, flexibility, and cardiovascular and respiratory systems of older people. Physiotherapy improved mobility and balance in one third to one half of 100 patients over age 65 who had recently fallen; less than one half of patients fell in the 4 months following treatment. Recreational walking appeared to reduce the risk of fracture in a cohort of elderly persons.

A Falls Clinic, coordinating the expertise of a geriatrician, neurologist, cardiologist and psychiatrist, combined with resources in audiology, ophthalmology and podiatry as well as home visits by an occupational therapist eliminated falls for 1 year in 77% of patients who had fallen previously.<6,18> Another randomized controlled trial of a post-fall assessment, including a detailed physical examination and environmental assessment by a nurse practitioner, laboratory tests, electrocardiogram and 24-hour Holter monitoring reduced hospitalizations by 26% (p<0.05) and hospital days by 52% (p<0.01) for 160 elderly ambulatory residential care facility patients but did not significantly decrease falls reported on nursing incident reports (9% lower) or deaths (17% lower) with 2 years of follow-up.<19> Recommendations for rehabilitation therapies were given to 60% of intervention subjects. Recommendations for environmental alterations were made for 45% and alterations in medication for 43%. The authors concluded that though falls may not be easily prevented, they indicate the presence of important treatable conditions and some of the disability and costs associated with falls may be obviated by a thorough assessment.

An 1989 review indicated there were no controlled studies demonstrating the effectiveness of detecting disease, changing medication, promoting exercise, initiating home nursing visits to assess environmental hazards, educating patients, counselling on medication use, physical therapy or balance and gait training on reducing falls.<17>

Burns
"Granny gown" burns among elderly women are still a common problem. Cooking-related flame burns can be reduced by encouraging the independent elderly not to wear loose fitting garments in the kitchen, not to keep condiments or spices over the stove and to use the rear rather than front burner while cooking.<20> The only evidence with respect to the effectiveness of counselling on burn prevention in the elderly was at the level of expert opinion – "The physician can help reduce the incidence and the severity of fire and burn injuries by reviewing precautions with his elderly patients and their families and by stressing basic first aid procedures and the need for immediate medical attention, since even small burns can become serious if not properly treated."<21>

Recommendations of Others
In 1989, the U.S. Preventive Services Task Force recommended that it may be clinically prudent to provide counselling on measures to reduce the risk of unintentional household or environmental injuries from falls, drowning, fires or burns, poisoning, and firearms.<22>

The following recommendations from the National Institute of Aging<17> to primary care physicians concerning older patients are based on expert opinion only:

  1. Assess for falls as a routine part of a physical history for those aged 65 years or older (as if falling is expected).
  2. Assess for underlying disease.
  3. Observe for sway or unsteady gait, using the equivalent of the "Get up and go test".
  4. Weigh the benefit of each drug against its potential for contributing to falls; use those less likely to impair balance and gait.
  5. Have a checklist of environmental hazards that a health educator or nurse can review with the patient. Assess home when appropriate.
  6. Encourage the use of handrails and adequate lighting on stairs and in bathrooms. Advise marking the edges of steps so that they are clearly recognizable.
Conclusions and Recommendations
There is good evidence for referring elderly patients to multidisciplinary post-fall assessment teams, where such a service is available (A Recommendation).<6,18> On the other hand, there is insufficient evidence to support including assessment and counselling of elderly patients for the risk of falling in the routine health examination of the elderly (C Recommendation). It may be included, however, on other grounds. There is fair evidence that safety aids reduce the incidence and severity of injuries in the elderly<19> (B Recommendation), however, there is insufficient evidence to support counselling elderly patients and their families about acquisition of safety features, such as stair railings, bath tub railings, nonflammable fabrics. Such counselling may be included in the periodic health examination on other grounds (C Recommendation).

Unanswered Questions (Research Agenda)
The Haddon Matrix for generating countermeasures provides a model for planning research. The "human" sector presents a major challenge for behavioural medicine (e.g., medication prescribing practices in the elderly). Much remains to be learned about lifestyle patterns and behaviour change strategies. It is in this last area that individual practitioners spend most their time and energy. The "timing" of health education messages, the effectiveness of different motivational techniques, the counselling skills required by health care providers, and the atmosphere most conducive to anticipatory care, all require further elucidation.

Evidence
This review deals with household and recreational injuries without considering occupational or aviation related injuries. These limitations were incorporated in the MEDLINE search strategy: accidents as a major mesh heading under the subheadings diagnosis, economics, epidemiology, law and jurisprudence, mortality, prevention and control, standards and trends; and not aviation, occupational or traffic accidents. References were identified for the years 1981 – November 1991. Other sources included Statistics Canada, Health and Welfare Canada, the Insurance Bureau of Canada the Poison Control Centre, supporting documents of other recommending bodies and references from identified literature.

This review was initiated in January 1991 and recommendations were finalized by the Task Force in June 1993.

Full Citation
Elford RW. Prevention of household and recreational injuries in the elderly. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 912-20.