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Falls in the Elderly

by Laurence Z. Rubenstein, MD, MPH

A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders (eg, stroke, seizure) or overwhelming environmental hazards (eg, being struck by a moving object) are not considered falls.

Annually, 30 to 40% of elderly people living in the community fall; 50% of nursing home residents fall. In the US, falls are the leading cause of accidental death and the 7th leading cause of death in people 65; 75% of deaths caused by falls occur in the 13% of the population who are 65. In 2000, direct medical costs for fall injuries totaled $20 billion. By 2020, the costs are projected to reach $44 billion.

Falls threaten the independence of elderly people and cause a cascade of individual and socioeconomic consequences. However, physicians are often unaware of falls in patients who do not present with an injury because a routine history and physical examination typically do not include a specific evaluation for falls. Many elderly people are reluctant to report a fall because they attribute falling to the aging process or because they fear being subsequently restricted in their activities or institutionalized.

Etiology

The best predictor of falling is a previous fall. However, falls in elderly people rarely have a single cause or risk factor. A fall is usually caused by a complex interaction among the following:

  • Intrinsic factors (age-related decline in function, disorders, and adverse drug effects)

  • Extrinsic factors (environmental hazards)

  • Situational factors (related to the activity being done, eg, rushing to the bathroom)

Intrinsic factors

Age-related changes can impair systems involved in maintaining balance and stability (eg, while standing, walking, or sitting). Visual acuity, contrast sensitivity, depth perception, and dark adaptation decline. Changes in muscle activation patterns and ability to generate sufficient muscle power and velocity may impair the ability to maintain or recover balance in response to perturbations (eg, stepping onto an uneven surface, being bumped). In fact, muscle weakness of any type is a major predictor of falls.

Chronic and acute disorders ( Some Disorders That Contribute to Risk of Falls) and use of drugs ( Some Drugs That Contribute to Risk of Falls) are major risk factors for falls. The risk of falls increases with the number of drugs taken. Psychoactive drugs are the drugs most commonly reported as increasing the risk of falls and fall-related injuries.

Extrinsic factors

Environmental factors can increase the risk of falls independently or, more importantly, by interacting with intrinsic factors. Risk is highest when the environment requires greater postural control and mobility (eg, when walking on a slippery surface) and when the environment is unfamiliar (eg, when relocated to a new home).

Situational factors

Certain activities or decisions may increase the risk of falls and fall-related injuries. Examples are walking while talking or being distracted by multitasking and then failing to notice an environmental hazard (eg, a curb or step), rushing to the bathroom (especially at night when not fully awake or when lighting may be inadequate), and rushing to answer the telephone.

Complications

Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death, particularly in elderly people who are frail and have preexisting disease comorbidities (eg, osteoporosis) and deficits in activities of daily living (eg, incontinence). Longer-term complications can include decreased physical function, fear of falling, and institutionalization; falls reportedly contribute to > 40% of nursing home admissions.

Over 50% of falls among elderly people result in an injury. Although most injuries are not serious (eg, contusions, abrasions), fall-related injuries account for about 5% of hospitalizations in patients 65. About 5% of falls result in fractures of the humerus, wrist, or pelvis. About 2% of falls result in a hip fracture. Other serious injuries (eg, head and internal injuries, lacerations) occur in about 10% of falls. Some fall-related injuries are fatal. About 5% of elderly people with hip fractures die while hospitalized; overall mortality in the 12 mo after a hip fracture ranges from 18 to 33%.

About half of elderly people who fall cannot get up without help. Remaining on the floor for > 2 h after a fall increases risk of dehydration, pressure ulcers, rhabdomyolysis, hypothermia, and pneumonia.

Function and quality of life may deteriorate drastically after a fall; at least 50% of elderly people who were ambulatory before fracturing a hip do not recover their previous level of mobility. After falling, elderly people may fear falling again, so mobility is sometimes reduced because confidence is lost. Some people may even avoid certain activities (eg, shopping, cleaning) because of this fear. Decreased activity can increase joint stiffness and weakness, further reducing mobility.

Some Disorders That Contribute to Risk of Falls

Functional Impairment

Disorder

BP regulation

Anemia

Arrhythmias

Cardioinhibitory carotid sinus hypersensitivity

COPD

Dehydration

Infections (eg, pneumonia, sepsis)

Metabolic disorders (eg, diabetes, thyroid disorders, hypoglycemia, hyperosmolar states)

Neurocardiogenic inhibition after micturition

Postural hypotension

Postprandial hypotension

Valvular heart disorders

Central processing

Delirium

Dementia

Stroke

Gait

Arthritis

Foot deformities

Muscle weakness

Postural and neuromotor function

Cerebellar degeneration

Myelopathy (eg, due to cervical or lumbar spondylosis)

Parkinson disease

Peripheral neuropathy

Stroke

Vertebrobasilar insufficiency

Proprioception

Peripheral neuropathy (eg, due to diabetes mellitus)

Vitamin B 12 deficiency

Otolaryngologic function

Acute labyrinthitis

Benign paroxysmal positional vertigo

Hearing loss

Meniere disease

Vision

Cataract

Glaucoma

Macular degeneration (age-related)

Some Drugs That Contribute to Risk of Falls

Drugs

Mechanism

Aminoglycosides

Direct vestibular damage

Analgesics (especially opioids)

Reduced alertness or slow central processing

Antiarrhythmics

Impaired cerebral perfusion

Anticholinergics

Confusion/delirium

Antihypertensives (especially vasodilators)

Impaired cerebral perfusion

Antipsychotics

Extrapyramidal syndromes, other antiadrenergic effects

Diuretics (especially when patients are dehydrated)

Impaired cerebral perfusion

Loop diuretics (high-dose)

Direct vestibular damage

Psychoactive drugs (especially antidepressants, antipsychotics, and benzodiazepines)

Reduced alertness or slow central processing

Evaluation

  • Clinical evaluation

  • Performance testing

  • Sometimes laboratory testing

After treatment of acute injuries, assessment aims to identify risk factors and appropriate interventions, thus decreasing the risk of future falls and fall-related injuries.

Some falls are promptly recognized because of an obvious fall-related injury or concern about a possible injury. However, because elderly people often do not report falls, they should be asked about falls or mobility problems at least once per year.

Patients who report a single fall should be evaluated for a balance or gait problem using the basic Get-Up-and-Go Test. For the test, patients are observed as they rise from a standard armchair, walk 3 m (about 10 ft) in a straight line, turn, walk back to the chair, and sit back down. Observation may detect lower-extremity weakness, imbalance while standing or sitting, or an unsteady gait. Sometimes the test is timed. A time of > 12 sec indicates a significantly increased risk of falls.

Patients who require a more complete assessment of risk factors for falls include

  • Those who have difficulty during the Get-Up-and-Go Test

  • Those who report multiple falls during screening

  • Those who are being evaluated after a recent fall (after acute injuries are identified and treated)

History and physical examination

When a more complete assessment of risk factors is needed, the focus is on identifying intrinsic, extrinsic, and situational factors that can be reduced by interventions targeted at them.

Patients are asked open-ended questions about the most recent fall or falls, followed by more specific questions about when and where a fall occurred and what they were doing. Witnesses are asked the same questions. Patients should be asked whether they had premonitory or associated symptoms (eg, palpitations, shortness of breath, chest pain, vertigo, light-headedness) and whether consciousness was lost. Patients should also be asked whether any obvious extrinsic or situational factors may have been involved. The history should include questions about past and present medical problems, use of prescription and OTC drugs, and use of alcohol. Because eliminating all risk of future falls may be impossible, patients should be asked whether they were able to get back up without help after falling and whether any injuries occurred; the goal is reducing the risk of complications due to future falls.

The physical examination should be comprehensive enough to exclude obvious intrinsic causes of falls. If the fall occurred recently, temperature should be measured to determine whether fever was a factor. Heart rate and rhythm should be assessed to identify obvious bradycardia, resting tachycardia, or irregular rhythms. BP should be measured with patients supine and after patients stand for 1 and 3 min to rule out orthostatic hypotension. Auscultation can detect many types of valvular heart disorders. Visual acuity should be evaluated with patients wearing their usual corrective lenses if needed. Abnormalities in visual acuity should trigger a more detailed visual examination by an optometrist or ophthalmologist. The neck, spine, and extremities (especially the legs and feet) should be evaluated for weakness, deformities, pain, and limitation in range of motion.

A neurologic examination should be done (see Evaluation of the Neurologic Patient : Neurologic Examination); it includes testing muscle strength and tone, sensation (including proprioception), coordination (including cerebellar function), stationary balance, and gait. Basic postural control and the proprioceptive and vestibular systems are evaluated using the Romberg test (in which patients stand with feet together and eyes both open and closed). Tests to establish high-level balance function include the one-legged stance and tandem gait. If patients can stand on one leg for 10 sec with their eyes open and have an accurate 3-m (10-ft) tandem gait, any intrinsic postural control deficit is likely to be minimal. Physicians should evaluate positional vestibular function (eg, with the Dix-Hallpike maneuver—see Nystagmus) and mental status (see Mental status).

Performance tests

The Performance-Oriented Assessment of Mobility or the Timed Up-and-Go test can identify problems with balance and stability during walking and other movements that may indicate increased risk of falls. These tests are especially helpful if the patient had difficulty doing the basic Get-Up-and-Go test.

Laboratory tests

There is no standard diagnostic evaluation. Testing should be based on the history and examination and helps rule out various causes: a CBC for anemia or leukocytosis, blood glucose measurement for hypoglycemia or hyperglycemia, and electrolyte measurement for dehydration. Tests such as ECG, ambulatory cardiac monitoring, and echocardiography are recommended only when a cardiac cause is suspected. Carotid massage under controlled conditions (IV access and cardiac monitoring) has been proposed to determine carotid hypersensitivity and ultimately who might respond to pacemaker treatment. Spinal x-rays and cranial CT or MRI are indicated only when the history and physical examination detect new neurologic abnormalities.

Prevention

The focus is on preventing or reducing the number of future falls and fall-related injuries and complications while maintaining as much of the patient’s function and independence as possible. For more information, see the Cochrane review abstract interventions for preventing falls in older people living in the community , the American Geriatrics Society guideline for the prevention of falls in older persons , and the British Medical Journal interventions for the prevention of falls in older adults .

Patients who report a single fall and who do not have problems with balance or gait on the Get-Up-and-Go Test or a similar test should be given general information about reducing risk of falls. It should include how to use drugs safely and reduce environmental hazards ( Home Assessment Checklist for Hazards That Increase Risk of Falling).

Home Assessment Checklist for Hazards That Increase Risk of Falling

Location

Hazard

Correction

Rationale

General household

Lighting

Too dim

Provide ample lighting in all areas

Improves visual acuity and contrast sensitivity

Too direct, creating glare

Reduce glare with evenly distributed light, indirect lighting, or translucent shades

Improves visual acuity and contrast sensitivity

Inaccessible light switches

Provide night-lights or touch-activated lights

Install switches that are immediately accessible when entering a room or motion sensors that activate lights

Reduces risk of tripping over or bumping into unseen obstacles in a dark room

Carpets, rugs, linoleum

Torn

Repair or replace torn carpet

Reduces risk of tripping and slipping, especially for people who have difficulty stepping

Slippery

Provide rugs with nonskid backs

Reduces risk of slipping

Curled edges

Tack or tape down rugs or linoleum to prevent curling

Replace rugs or linoleum

Reduces risk of tripping

Chairs, tables, other furnishings

Unstable

Provide furniture stable enough to support the weight of a person leaning on table edges or chair arms and backs

Do not use chairs that have wheels or that swivel

Repair legs that are loose

Increases support for people with impaired balance and helps with transferring

Chairs without armrests

Provide chairs with armrests that extend forward enough to provide leverage when getting up or sitting down

Helps people with proximal muscle weakness and helps with transferring

Obstructed pathways

Arrange furnishings so that pathways are not obstructed

Remove clutter from hallways

Reduces risk of tripping over or bumping into obstacles, making movement in the home easier and safer, especially for people with impaired peripheral vision

Wires and cords

Exposed in pathways

Tack cords above the floor or run beneath floor coverings

Reduces risk of tripping

Kitchen

Cabinets, shelves

Too high

Keep frequently used items at waist level

Install shelves and cupboards at an accessible height

Reduces risk of falls due to frequent reaching or climbing on ladders or chairs

Floors

Wet or waxed

Place a rubber mat on the floor in the sink area

Wear rubber-soled shoes in the kitchen

Use nonslip wax

Reduces risk of slipping, especially for people with a gait disorder

Bathroom

Bathtub or shower

Slippery tub or shower floor

Install skid-resistant strips or rubber mat

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

Reduces risk of sliding on a wet tub or shower floor

Need to use the side of the bathtub for support or transfer

Install grab bars in shower

Install a portable grab bar on the side of the tub

Take grab bar on trips

Helps with transferring

Towel racks, sink tops

Unstable for use as support while transferring from the toilet, tub, or shower

Fasten grab rails to wall studs

Helps with transferring

Toilet seat

Too low

Use elevated toilet seat

Helps with transferring to and from the toilet

Doors

Locks

Remove locks from bathroom doors or use locks that can be opened from both sides of the door

Enables other people to enter if a person falls

Stairways

Height

Height of steps too high

Correct step height to < 15 cm

Reduces risk of tripping, especially for people who have difficulty stepping

Handrails

Missing

Install and anchor rails well on both sides of the stairway

Use cylindrical rails placed 2.5–5 cm from the wall

Provides support and enables people to grasp the rail with either hand

Too short and end of rail unclear

Extend beyond the top and bottom step and turn ends inward

Signals that the top or bottom step has been reached

Configuration

Too steep or too long

Install landings on stairways

Provides a rest stop, especially for people with heart or pulmonary disorders

Condition

Slippery

Place nonskid treads securely on all steps

Prevents slipping

Lighting

Inadequate

Install adequate lighting at both the top and bottom of stairway

Provide night-lights or bright-colored adhesive strips to clearly mark steps

Outlines location of steps, especially for people with impaired vision or perception

Exercise

Patients who have fallen more than once or who have problems during initial balance and gait testing should be referred to physical therapy or an exercise program. Physical therapy and exercise programs can be done in the home if patients have limited mobility. Physical therapists customize exercise programs to improve balance and gait and to correct specific problems contributing to fall risk. More general exercise programs in health care or community settings can also improve balance and gait. For example, tai chi may be effective and can be done alone or in groups. The most effective exercise programs to reduce fall risk are those that are tailored to the patient’s deficit, are provided by a trained professional, have a sufficient balance challenge component, and are provided over the long term (eg, 4 mo). Many senior citizen centers, YMCAs, or other health clubs offer free or low-cost group exercise classes tailored to senior citizens, and these classes can help with accessibility and adherence.

Assistive devices

Some patients benefit from use of an assistive device (eg, cane, walker). Canes may be adequate for patients with minimal unilateral muscle or joint impairment, but walkers, especially wheeled walkers, are more appropriate for patients with increased risk of falls attributable to bilateral leg weakness or impaired coordination (wheeled walkers can be dangerous for patients who cannot control them properly). Physical therapists can help fit or size the devices and teach patients how to use them (see Therapeutic and Assistive Devices).

Medical management

Drugs that can increase the risk of falls should be stopped, or the dosage should be adjusted to the lowest effective dose. Patients should be evaluated for osteoporosis and, if osteoporosis is diagnosed, treated to reduce risk of fractures from any future falls. If any other specific disorder is identified as a risk factor, targeted interventions are required. For example, drugs and physical therapy may reduce risk for patients with Parkinson disease. Vitamin D, particularly taken with Ca, can reduce fall risk, especially in patients with reduced blood vitamin D levels. Pain management, physical therapy, and sometimes joint replacement surgery may reduce risk for patients with arthritis. A change to appropriate lenses (single lenses rather than bifocals or trifocals) or surgery, particularly for removal of cataracts, may help patients with visual impairment.

Environmental management

Correcting environmental hazards in the home may reduce the risk of falls ( Home Assessment Checklist for Hazards That Increase Risk of Falling). Patients should also be advised on how to reduce risk due to situational factors. For example, footwear should have flat heels, some ankle support, and firm, nonskid midsoles. Many patients with chronic limited mobility (eg, caused by severe arthritis or paresis) benefit from combined medical, rehabilitative, and environmental strategies. Wheelchair adaptations (eg, removable foot plates to reduce tripping during transfers, antitip bars to prevent backward tipping), removable belts, and wedge seating may prevent falls in patients with poor sitting balance or severe weakness when they are sitting or transferring.

Restraints may lead to more falls and other complications and should generally not be used. Surveillance by a caregiver is more effective and safer. Motion detectors may be used, but a caregiver must be present to respond promptly to the triggered alarm.

Hip protectors (padding sewn into special undergarments) have been shown to reduce hip fractures in high-risk patients, but many patients are reluctant to wear protectors indefinitely. Compliant flooring (eg, firm rubber) can help dissipate the impact force, but a floor that is too compliant (eg, soft foam) may destabilize patients.

Patients should also be taught what to do if they fall and cannot get up. Useful techniques include turning from the supine position to the prone position, getting on all fours, crawling to a strong support surface, and pulling up. Having frequent contact with family members or friends, a phone that can be reached from the floor, a remote alarm, or a wearable emergency response system device can decrease the likelihood of lying on the floor for a long time after a fall.

Key Points

  • Each year, 30 to 40% of elderly people living in the community and 50% of nursing home residents fall.

  • Falls contribute to > 40% of nursing home admissions and are the 7th leading cause of death in people 65.

  • Causes are multifactorial and include age- and illness-related decline in function, environmental hazards, and adverse drug effects.

  • Assess the patient for predisposing factors and assess the home for hazards.

  • To the extent possible, treat causative disorders, change or stop causative drugs, and correct environmental hazards.

  • Patients who have fallen more than once or who have problems during balance and gait testing may benefit from physical therapy or an exercise program.

  • Teach techniques for getting off the floor and consider use of a wearable emergency response device.

Resources In This Article

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