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Falls in the Elderly

by Laurence Z. Rubenstein, MD, MPH

  • Most falls occur when people with a physical condition that impairs mobility or balance encounter an environmental hazard.

  • Although many people have no symptoms before a fall, some have dizziness or other symptoms.

  • After a fall, people may have broken bones or bruises.

  • Doctors often do tests to evaluate whether an underlying condition contributed to the fall.

  • Falls may be prevented by taking precautions around the home.

  • After injuries are treated, people work with physical therapists to help reduce the risk of subsequent falls.

Many older people fear falling. And they have good reason to do so. Falls are common among older people. About one third of older people who live at home fall at least once a year, and about half of people who live in a nursing home fall. In the United States, falls are the leading cause of accidental death and the 7th leading cause of death in people age 65 or over. Once a person has had a fall, they are more likely to fall again.

Falls often cause injuries. Some of the injuries, such as a broken hip, can be serious. Older people are more likely to break bones in falls because many older people have porous, fragile bones (osteoporosis—see Osteoporosis). Some injuries caused by a fall are fatal.

Fear of falling can lead to problems. People may worry about doing their usual activities and thus lose their self-confidence and even their independence. Older people can do many things to help overcome their fears and to reduce their risk of falling. Knowing what causes falls can help.

Did You Know...

  • Although many older people fall, falls are not a normal part of growing older.

Causes

Falls can be caused by physical conditions that impair mobility or balance, hazards in the environment, or potentially hazardous situations. Most falls occur when several causes interact. For example, people with Parkinson disease and impaired vision (physical conditions) may trip on an extension cord (an environmental hazard) while rushing to answer the telephone (a potentially hazardous situation).

A person's physical condition is affected by changes due to aging itself, physical fitness, disorders present, and drugs used. The physical condition probably has a greater effect on the risk of falling than do environmental hazards and hazardous situations. Not only does a poor or impaired physical condition increase the risk of falls, but it also affects how people respond to hazards and hazardous situations.

Physical impairments that increase the risk of falling include those involving

  • Balance or walking

  • Vision

  • Sensation, particularly in the feet

  • Muscle strength

  • Cognition

  • Blood pressure or heartbeat

Use of drugs that affect attention (for example, opioid analgesics, antianxiety drugs, and some antidepressant drugs) or lower blood pressure (for example, antihypertensive, heart, and diuretic drugs) can also increase the risk of falling.

Hazards in the environment are involved in many falls. Falls may occur when people do not notice a hazard or do not respond quickly enough after a hazard is noticed.

Environmental hazards that increase the risk of falling include

  • Inadequate lighting

  • Throw rugs

  • Slippery floors

  • Electrical or extension cords or objects that are in the way of walking

  • Uneven sidewalks and broken curbs

  • Unfamiliarity with surroundings

Most falls occur indoors. Some happen while people are standing still. But most occur while people are moving—getting in or out of bed or a chair, getting on or off a toilet seat, walking, or going up or down stairs. While moving, people may stumble or trip, or balance may be lost. Any movement can be hazardous. But if people are rushing or if their attention is divided, movement becomes even more hazardous. For example, rushing to the bathroom (especially at night when not fully awake or when lighting may be poor) or to answer the telephone or talking on a cordless phone can make walking more hazardous.

Symptoms

Often before falling, people have no symptoms. When an environmental hazard or a hazardous situation results in a fall, there is little or no warning. However, if a fall is partly or completely due to a person’s physical condition, symptoms may be noticed before falling. Symptoms may include dizziness, light-headedness, or irregular or rapid, pounding heartbeats (palpitations).

After a fall, injuries are common and tend to be more severe as people age. Over half of all falls result in at least a slight injury, such as a bruise, sprained ligament, or strained muscle. More serious injuries include broken bones, torn ligaments, deep cuts, and damage to organs such as a kidney or the liver. About 2% of falls result in a broken hip. Other bones (in the upper arm, wrist, and pelvis) are broken in about 5% of falls. Some falls result in loss of consciousness or a head injury.

Falls can cause even more problems if people cannot get up right away or summon help. Such a situation may be frightening and may make people feel helpless. Remaining on the floor, even for a few hours, can lead to problems such as dehydration, low body temperature (hypothermia), pneumonia, rhabdomyolysis (muscle breakdown that can lead to kidney damage or failure), and skin sores due to pressure (pressure sores—see Pressure Sores).

The effects of a fall may last a long time. About half of people who could walk before they fell and broke a hip cannot walk as well afterward, even after treatment and rehabilitation. People who have fallen may develop a fear of falling that robs them of their self-confidence. As a result, they may stay at home and give up activities, such as shopping, visiting friends, and cleaning. When people become less active, joints can become stiff and muscles can become weak. Stiff joints and weak muscles can further increase the risk of falling and make remaining active and independent more difficult. For all these reasons, falls can greatly reduce quality of life. For many people, falls seem to be an important factor in the decision to move to a nursing home or an assisted-living facility.

Rarely, falls result in death. Death may occur immediately—for example, when the head hits a hard surface and causes uncontrolled bleeding in or around the brain. Much more commonly, death occurs later, resulting from complications of serious injuries caused by the fall.

Diagnosis

People who have fallen may be reluctant to discuss the problem with anyone, including a doctor, especially if they have not been injured. But even people who have been seriously injured during a fall and have been treated in an emergency department may be reluctant to admit they have fallen. People may be reluctant because they think falling is just part of getting older. And they do not want others to think they are helpless and now must move from their home into a more supervised environment such as a nursing home. Nonetheless, it is vitally important for people to tell their doctor if they have fallen, even if the doctor has not asked, so that the doctor can uncover treatable reasons behind the fall.

To identify the cause of the fall, doctors ask about the circumstances of the fall, including any symptoms experienced just before the fall (such as chest pain, vertigo, and shortness of breath) and any activities that may have contributed to the fall. They ask any witnesses to the fall to describe what they saw. Doctors also ask about the use of prescription and nonprescription drugs or alcohol that may have contributed to the fall. Doctors ask people whether they lost consciousness and whether they were able to get up without help.

Doctors do a physical examination first to check for injuries and to obtain information about possible causes of the fall. Parts of the examination include the following:

  • Blood pressure measurement: If blood pressure decreases when people stand up, the fall may have been caused by orthostatic hypotension (see Dizziness or Light-Headedness When Standing Up).

  • Heart sounds: With a stethoscope, doctors listen to the heart for evidence of a very slow heart rate, abnormal rhythms, heart valve problems, and heart failure.

  • Muscle strength and range of motion assessment: Doctors assess the back and legs and check for problems in the feet.

  • Vision and nervous system assessment: Doctors check nervous system functions such as muscle strength, coordination, sense of position, and balance.

Doctors sometimes ask people to do some usual activities, such as sitting in a chair and then standing up and walking or stepping up on a step. Observing these activities may help doctors identify conditions that contributed to the fall.

If the fall resulted from an environmental hazard and no major injury occurred, no tests may be done. However, when people’s physical condition could have contributed to the fall, tests may be needed. For example, when the physical examination detects evidence of a heart problem, heart rate and rhythm may be recorded using electrocardiography (ECG). This test may take a few minutes and be done in the doctor’s office, or people may be asked to wear a portable ECG device (Holter monitor—see Figure: Holter Monitor: Continuous ECG Readings) for 1 or 2 days. Blood tests, such as a complete blood count and measurements of electrolyte levels, may be helpful in people who have been experiencing dizziness or light-headedness. If the nervous system appears to be malfunctioning, computed tomography (CT) or magnetic resonance imaging (MRI) of the head may be helpful.

Prevention

Older people can do many simple, practical things to help reduce the risk of falling.

  • Exercising regularly: Weight training or resistance training may help strengthen weak legs and thus may improve steadiness during walking. Tai Chi and balancing exercises such as standing on one leg can help improve balance. Exercise programs should be tailored to a person's needs. Many senior citizen centers, YMCAs, or other health clubs offer free or low-cost group exercise classes tailored to senior citizens.

  • Wearing appropriate shoes: Shoes that have firm, nonslip soles, some ankle support, and flat heels are best.

  • Standing up slowly after sitting or lying down and taking a moment before starting to move: This strategy can help prevent dizziness because it gives the body time to adjust to the change in position.

  • Learning a simple head maneuver: A simple head maneuver called the Epley maneuver (see Figure: The Epley Maneuver: A Simple Cure for a Common Cause of Vertigo) may help some older people who feel dizzy when they move. It involves turning the head in specific ways. Doctors usually do the maneuver the first time, but people can learn how to do it themselves if it needs to be repeated.

  • Reviewing drugs being taken: People can ask a doctor or another health care practitioner to review all prescription and nonprescription drugs being taken to see if any of the drugs could increase the risk of falling. If such drugs are being used, doctors may be able to lower the dose or people may be able to stop taking the drug.

  • Having vision checked regularly: Getting the correct glasses and wearing them can help prevent falls. Treatment of glaucoma or cataracts, which limit vision, can also help.

  • Consulting with a physical therapist about ways to reduce the risk of falling: Some older people need a physical therapist to train them to walk, particularly if they need to use an assistive device such as a walker or cane. Physical therapists can help fit or size people for other assisted devices (such as removable foot plates on wheelchairs) and teach them how to use them.

Hazards in the environment can sometimes be removed or corrected.

  • Lighting can be improved by increasing the number of lights or changing the types of lights.

  • Light switches can be positioned so that they are easily reached. Motion-sensitive lights or lights that turn on when they are touched can be used.

  • Adequate lighting for steps (inside and outside) and for outdoor areas used at night is particularly important. Steps should have nonskid treads and sturdy, secure handrails. Bright-colored adhesive strips can be applied to clearly mark steps.

  • Electrical or extension cords that are in the way of walking can be eliminated by adding more electrical outlets, or the cords may be tacked over doorways or beneath floor coverings.

  • Items that clutter floors and stairways can be stored out of the way of walking.

  • Grab bars can be installed next to toilets, tubs, and other places for people who need something to hold onto when they stand up. Grab bars must be installed correctly, so that they do not pull out of the wall.

  • Elevated toilet seats can help.

  • Loose throw rugs can be removed or taped or tacked down or nonskid backs can be used.

  • Nonslip mats should be used in the bathroom and kitchen.

  • Frequently used household items can be stored in cabinets, cupboards, or other spaces between waist and eye level, so that they can be reached without stretching or bending.

Learning how to safely handle potentially hazardous situations may be more important than removing an environmental hazard. Sometimes people need to pay more attention to potential hazards and think about ways to accomplish daily tasks more safely. For example, they can place cordless phones around the home so that they do not have to rush to answer phone calls.

Falls cannot always be prevented. So, people who are likely to fracture a hip, such as people who have osteoporosis, should maximize the strength of their bones by taking adequate calcium and vitamin D and taking additional prescription drugs to slow their bone loss. Some people may consider wearing a hip protector, an undergarment with a plastic and foam pad placed over the hip, which may prevent hip fractures if worn regularly.

Knowing what to do if a fall occurs can help older people be less afraid of falling. If they fall and cannot get up, they can turn onto their stomach, crawl to a piece of furniture (or other structure that can support their weight), and pull themselves up.

Older people should also have a good way to call for help. People who have fallen several times may keep a telephone in a place that can be reached from the floor. Another option is installing a personal emergency response system (a medical alert device) that signals someone to check in on them. Most of these systems include an alert button worn on a necklace. Pressing the button calls for help.

Checklist for Preventing Falls in the Home

All rooms

Reachable light switch

No electrical or extension cords in the way of walking

No throw rugs

Cordless phones

Sturdy furniture (no loose legs or wheels or swivels)

Clutter removed from hallways

Walkways cleared

Kitchen

Reachable cabinets (so that bending and stretching are unnecessary)

Nonslip mats

Bedroom

Reachable bedside light

Night-light

Tacked down or nonskid rugs or wall-to-wall carpet

Bathroom

Elevated toilet seat

Grab bars

Nonslip mats

Night-light

Skid-resistant strips or rubber mat in shower or bathtub

Use of shower shoes or a bath seat (a bath seat enables people with impaired balance to sit while showering)

Removal of locks or use of locks that can be opened from both sides of the door

Living room

Tacked down or nonskid rugs or wall-to-wall carpet

Armrests on chairs

Steps (inside and outside)

Good lighting

Sturdy railings

Nonslip treads

Height of step less than 15 centimeters (about 6 inches)

Treatment

The first priority is treatment of injuries, such as head injuries, fractures, sprained ligaments, and strained muscles. The next priority is to prevent subsequent falls by treating disorders that may have contributed to the fall. For example, in people who have a very slow heart rate accompanied by light-headedness, a pacemaker for the heart may be implanted. If possible, potentially harmful drugs are stopped, the dose is reduced, or another drug is substituted.

Physical and occupational therapists can help improve people’s walking and balance as well as their self-confidence after a fall. They can provide tips on how to avoid falling. Therapists can also encourage people to remain active. Physical therapy and supervised balance training and stretching can help reduce the risk of falling.

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