Falls in older adults

Falls in older adults are a significant cause of morbidity and mortality and are an important class of preventable injuries. The cause of falling in old age is often multifactorial, and may require a multidisciplinary approach both to treat any injuries sustained and to prevent future falls.^[1] Falls include dropping from a standing position, or from exposed positions such as those on ladders or stepladders. The severity of injury is generally related to the height of the fall. The state of the ground surface onto which the victim falls is also important, harder surfaces causing more severe injury. Falls can be prevented by ensuring that carpets are tacked down, that objects like electric cords are not in one's path, that hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated and that shoes have low heels or rubber soles.^[2]

A review of clinical trial evidence by the European Food Safety Authority led to a recommendation that people over age 60 years should supplement the diet with vitamin D to reduce the risk of falling and bone fractures.^[3] Falls are an important aspect of geriatric medicine.

Definition

Researchers have tried to create a consensual definition of a fall since the 1980s. Tinneti et al defined a fall as "an event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard.”^[4] Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall.^[5] Such falls are clearly of accidental origin, which might include a large number of causes, such as slips, trips and over-balancing.

A 2006 review of literature identified the need for standardization of falls taxonomy due to the variation within research.^[6] The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem.^[7] ProFane recommended that a fall be defined as "an unexpected event in which the participants come to rest on the ground, floor, or lower level."^[7] The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews.^[8][9][10]

Signs and symptoms

• Trauma
  • Soft tissue injuries. Bilateral orbital haematomas (two black eyes) suggests that the faller was probably not conscious as they fell, as they did not manage to protect their face as they hit the ground.
  • Fractures and dislocations. 5% of fallers end up having a fracture as a result of their fall, and 1% fracture their neck of femur.
  • Disuse atrophy and muscle wasting from reduced physical activity during recovery periods
• Due to bed rest
  • Pneumonia
  • Pressure sores
  • Dehydration
  • Hypothermia
• A fear of falling^[11]

Causes

Falls are often caused by a number of factors. The faller may live with many risk factors for falling and only have problems when another factor appears. As such, management is often tailored to treating the factor that caused the fall, rather than all of the risk factors a patient has for falling. Risk factors may be grouped into intrinsic factors, such as existence of a specific ailment or disease. External or extrinsic factors includes the environment and the way in which it may encourage or deter accidental falls. Such factors as lighting and illumination, personal aid equipment and floor traction are all important in fall prevention.^[11]

Intrinsic factors

• Balance and Gait

As a result of stroke disease, Parkinsonism, arthritic changes, neuropathy, neuromuscular disease or vestibular disease.

• Visual and Motor Reaction Time Problems

An extended reaction time will delay responses and compensations to standing or walking imbalances, thus increasing the likelihood of falls.

• Medications
  • Polypharmacy is common in older people
  • Sedatives significantly increase the risk of falling
  • Cardiovascular medications can contribute towards falls
• Visual impairment
  • Glaucoma, macular degeneration and retinopathy increase the risk of falling
  • Bifocals and trifocals can increase the risk of falling as the lower portion of corrective lenses are optimized for distances approximately 18inches, thus precluding clear vision of one's feet/floor, approximately 4.5 to 5.5 feet below one's eyes.
• Cognitive problems
  • Dementia increases the likelihood of falls
• Cardiovascular causes
  • Orthostatic hypotension
  • Postprandial hypotension
  • Carotid sinus syndrome
  • Neurocardiogenic syncope– the commonest cause of syncope in A&E patients
  • Cardiac arrhythmias
  • Structural heart disease, such as valvular heart disease

Extrinsic factors

Hanging straps with triangular handles in a modern Japanese commuter train

Grab rails on a longer-distance commuter train catering for mainly seated passengers

A staircase with metal handrails

Front-wheeled walker.

• Poor lighting due to low luminance of existing lights or lamps, so preventing hazard identification and avoidance. Eyesight deteriorates with age, and extra lighting will be needed where seniors move frequently. The power of the bulbs used should be higher than normally accepted, with incandescent bulbs preferred especially as they react much more quickly than other types of bulb when switched on. This is vital when entering a room where an obstacle can trip the user for example, especially if not seen in time to prevent the accident.
• Stairs with inadequate handrails, or too steep, encouraging trips and falls. The steps should be spaced widely with low risers, and surfaces should be slip-resistant. Softer surfaces can help limit impact injuries by cushioning loads.
• Doorways with adequate headroom so that the user's head does not hit the lintel. Doorways of low headroom (less than about 2 metres) are common in old houses and cottages for example.
• Rugs/floor surfaces with low friction, causing poor traction and individual instability. All surfaces should have a high friction coefficient with shoe soles.
• Clothing/footwear poorly fitted, shoes of low friction against floor. Rubber soles with ribs normally have a high friction coefficient, so are preferred for most purposes. Clothing should fit the user well, without trailing parts (hems falling below the heel and loose shoe strings) which could snag with obstacles
• Lack of equipment/aids such as walking sticks or walking frames, such as Zimmer frames so as to improve user stability. Grab bars and hanging straps should be supplied plentifully, especially in critical areas where users may be vulnerable.

Diagnosis

When assessing a person who has fallen, it is important to try to get an eyewitness account of the incident. As the faller may have had some loss of consciousness, they may not give an accurate description of the fall. However, in practice, these eyewitness accounts are often unavailable. It is also important to remember than 30% of cognitively intact older people are unable to remember a documented fall three months later. Important points of inquiry:^[11]

• Visual motor reaction time
• Frequency of falls
• Effectiveness of "parachute" corrective response of moving hand and arm to "break" the fall
• Eyewitness account
• Associated features
• Risk factors for falling
• legal and illegal drug interactions
• Sedative and alcohol consumption
• Assessment of proper, safe use of cane or walker assistive device

Prevention

A large body of evidence shows that a multi-disciplinary approach to assessment and treatment results in the best outcome.^[12][13][14]

Possible interventions include:

• Provision of safety devices such as grab handles, high friction floors and footwear, as well as low power lighting at night
• Regular exercise - lower limb strengthening exercise to increase muscle strength.^[15] Other forms of exercise, such as those involving gait, balance, co-ordination and functional tasks, may also help improve balance in older adults.^[16]

• A 2014 review concluded that exercise interventions may reduce fear of falling (FOF) in community-dwelling older adults immediately after the intervention, without evidence of long-term effects.^[17]
• Review– monitoring of medications and ongoing medical problems
• Supplementation with vitamin D, as determined by the European Food Safety Authority that vitamin D deficiency is associated with increased risk of falling and bone fractures in women and men over 60 years old; "in order to obtain the claimed effect, 800 I.U. (20 μg) of vitamin D from all sources should be consumed daily."^[3][18]
• Tackling environmental issues, including a review of current living conditions (action checklist)

Interventions to minimize the consequences of falls:

• Hip protectors - probably decrease chance of hip fractures slightly , although it may increase the small chance of a pelvic fracture in older adults living in nursing care facilities. Little or no effect reported on other fractures or falls^[19]
• Treatment for osteoporosis

Hospital

People who are hospitalized are at risk for falling. A randomized trial showed that use of a tool kit reduced falls in hospitals. Nurses complete a valid fall risk assessment scale. From that, a software package develops customized fall prevention interventions to address patients' specific determinants of fall risk. The kit also has bed posters with brief text and an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.^[20]

Screening

American Geriatrics society (AGS)/British Geriatrics Society (BGS) recommend that all older adults should be screened for "falls in the past year". Fall history is the strongest risk factor associated with subsequent falls.^[21]

Many health institutions in USA have developed screening questionnaires. Enquiry includes difficulty with walking and balance, medication use to help with sleep/mood, loss of sensation in feet, vision problems, fear of falling, and use of assistive devices for walking.

Older adults who reports falls should be asked about the circumstances and frequency. They should have an assessment of gait and balance. Older persons who present for medical attention because of a fall, or who report recurrent falls in the past, fail the gait & balance test, or report difficulties in walking & balance should have a multifactorial fall risk assessment. A multifactorial fall risk assessment is done by a clinician and includes focused history, physical exam, functional assessment and environment assessment.^[22]

Epidemiology

The incidence of falls increases progressively with age. According to the existing scientific literature, approximately one-third of the elderly population experiences one or more falls each year, while 10% suffer multiple falls. The risk is even greater in people older than 80 years, in which the annual incidence of falls can reach 50%.^{[23][24][25] [26] [27]}

Economics

The health care impact and costs of falls in older adults is significantly rising all over the world. The cost of falls are categorized into 2 aspects: direct cost and indirect cost.

Direct costs are what patients and insurance companies pay for treating fall-related injuries. This includes fees for hospital and nursing home, doctors and other professional services, rehabilitation, community-based services, use of medical equipment, prescription drugs, changes made to home and insurance processing.

Indirect costs include the loss of productivity of family caregivers and long-term effects of fall-related injuries such as disability, dependence on others and reduced quality of life.

In the United States alone, the total cost of falling injuries for people 65 and older was $31 billion in 2015. The costs covered millions of hospital emergency room visits for non-fatal injuries and more than 800,000 hospitalizations. By 2030, the annual number of falling injuries is expected to be 74 million older adults.^[28]

Research

A fall occurs when a person's centre of mass goes outside of the base of support. A majority of research on postural instability has focused on the anterior/posterior directions due to the structure of the legs and the frequency of falls in those directions. Maki, Holliday, & Topper (1994) has stated that sway in the medial/lateral directions can be just as important, “Results show strong evidence linking deficits in postural balance related to the control of the m–l stability with an increased risk of falling”.^[29] The mechanisms of postural instability are not fully understood, but research has suggested that disorders affecting sensory input and efferent motor signals are the primary causes.

Furthermore, a recent systematic review has demonstrated that performing dual-task tests (for example, combining a walking task with a counting task) may help in predicting which people are at an increased risk of a fall.^[1]

References

External links

• Morse Fall Assessment An assessment tool to determine and quantify persons as low, mid, and high risk for falls.
• Falls Among Older Adults: Brochures and Posters (in English, Spanish, and Chinese) US Centers for Disease Control and Prevention
• Falls Among Older Adults: An Overview US Centers for Disease Control and Prevention
• Costs of Falls Among Older Adults US Centers for Disease Control and Prevention
• Hip Fractures Among Older Adults US Centers for Disease Control and Prevention
• Falls in Nursing Homes US Centers for Disease Control and Prevention
• CDC Fall Prevention Activities US Centers for Disease Control and Prevention
• Preventing Falls: What Works―A CDC Compendium of Effective Community-based Interventions from Around the World US Centers for Disease Control and Prevention
• Preventing Falls: How to Develop Community-based Fall Prevention Programs for Older Adults US Centers for Disease Control and Prevention
• Public Health Grand Rounds: Help Older Adults Live Better, Longer: Prevent Falls and Traumatic Brain Injuries US Centers for Disease Control and Prevention
• CDC’s Division of Unintentional Injury– Podcasts US Centers for Disease Control and Prevention