Happy New Year to all! This year marks the 30th anniversary of the advent of Advances in Skin & Wound Care. Watch for special articles in next month's edition to commemorate this publishing achievement. We look forward to another year of providing you with cutting-edge clinical and investigational content.
This month's continuing education article by Catherine Cheung, MD, FRCPC, on page 40 explores the nexus between the risk of unintentional falls in older adults and the consequent injuries to the musculoskeletal system and the skin.
Unintentional patient falls are a complex phenomenon that often present as an ill-fated sextet: a confluence of (1) advanced age, (2) a decline in neuromotoric function, (3) a loss of muscle mass and strength, (4) an inability to respond to perturbations of balance, (5) a high risk of unintentional falls, and (6) and a high potential for disruption of skin integrity (injury).
Comprehensive wound care predicates that in addition to our core competencies in wound management, we must have a complete knowledge of the causality, evaluation, and prevention of falls in older adults, as highlighted in the continuing education article.
From an epidemiologic standpoint, national annualized data estimates of unintentional falls were based on emergency department visits from July 1, 2000, to December 31, 2000.1 Therefore, estimates may be affected by seasonality. Falls occur in a bimodal distribution, therefore the falls risk peaks in children aged 10 to 14 years (638,873) and continues to rise in adolescents and young adults aged 15 to 24 years (1,103,864). However, the risk of falls stabilizes at middle age (656,056), and subsequently peaks again at 65 years or older (1,628,146).1 Falls from low heights are classified as those that occur from a standing height (<6 ft), walking downstairs, or from the bed. Falls in older adults typically are caused by a loss of the dynamic and static balance needed to maintain a safe upright position while sitting or ambulating. Owing to the clinical nature and the environment, it is often impossible to establish the causality of a bruise, hematoma, or skin tear coincident to a fall.
Intuitively, we have clinical evidence that the cause and effect of a traumatic fall can manifest in skin tears and exacerbate other preexisting wounds. In the continuing education feature, the author posits that the trauma of the fall and disruption of skin integrity may also put the patient at a recurrent risk of falls. The literature is lacking in research describing the relationship between traumatic falls and subsequent skin wounds; however, there may be an innate basis and validity for the assertion. In the current literature, authors characteristically couch the loss of mobility, falls, and fractures as a constellation of risk factors, which may be causal to developing a chronic wound. This is not meant as a criticism, just a finding in a clinical review. Continuing medical education in wound care focuses on chronic wounds that are incurred while the patient is sitting, recumbent, or supine during a prolonged surgery or hospitalization. Most falls, however, occur in the frail older adult while walking or attempting to walk.
A review of recent, peer-reviewed content using recognized online databases about the relationship of wounds to falls identified mostly expert opinion papers. Several review articles also were selected. Within each of the selected manuscripts, a search was conducted using keywords related to falls, wounds, and skin tears. This process revealed an unanticipated finding. In several of the articles that included "skin tears" in their titles, there was an average of only 1 or 2 references to falls. One example is: "For instance, an older person who is able to mobilize at home, but falls frequently, may be vulnerable to skin tears as a result."2 A similar article stated, "According to existing literature, intrinsic and extrinsic risk factors for skin tears may include falls, poor nutrition, impaired mobility, cognitive impairment, and dry, fragile skin."3 The most comprehensive use of the keyword "falls" as related to skin tears was found in a recent review on the subject.4
In summary, what I learned from this exercise is that while there are no levels of scientific evidence linking falls to skin tears, we must focus on falls risk management as a preventive measure. Falls are dangerous both physically and psychologically. Two resources I recommend on falls risk management are (1) the Centers for Disease Control and Prevention's STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Tool Kit5 and (2) this issue's continuing education article.
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