Falls in Older Adults

Most falls occur when several factors interact. Factors include

• Physical conditions that impair mobility or balance

• Use of certain medications

• Hazards in the environment

• Potentially hazardous situations

For example, people with Parkinson disease and impaired vision (physical conditions that impair mobility or balance) 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 medications 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 conditions that increase the risk of falling include impairments in the following:

• Balance or walking

• Vision

• Sensation, particularly in the feet

• Muscle strength

• Cognition

• Blood pressure or heartbeat

For example, loss of muscle strength may prevent older adults from maintaining or recovering balance when they step on an uneven surface or are bumped. With aging, people become less able to judge where objects are in relation to each other and may need brighter light to see well. Cognitive impairment may prevent older adults from remembering to take safety measures when walking—for example, to hold onto the railing when going up and down stairs. Low blood pressure or a slow heartbeat can cause dizziness fainting, or loss of consciousness. The reason is that heart problems can reduce the amount of blood reaching the brain.

Use of certain medications can also increase the risk of falling. These medications include those that affect attention (such as opioid analgesics, antianxiety medications, and some antidepressants) or lower blood pressure (such as antihypertensives, diuretics, and some heart medications).

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

• Unfamiliar 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 walking while talking on a cordless phone can make walking more hazardous.

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 or vertigo

• Light-headedness

• 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)

• 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 many people, falls seem to be an important factor in their decision to move to a nursing home or an assisted-living facility. For all these reasons, falls can greatly reduce quality of life.

Some falls can be serious and 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.

• A doctor's evaluation

• Sometimes laboratory tests

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. People who have fallen may be reluctant to tell their doctor because they think falling is just part of getting older, especially if they have not been injured. 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. They may 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.

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 dizziness, vertigo, and palpitations) 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 medications 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.

• 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 assessment 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) 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.

• Treatment of injuries from falls

• Treatment of any disorders that could lead to falls

• Physical therapy

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 medications are stopped, the dose is reduced, or another medication 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.

Older adults 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 may help some older adults who have a type of vertigo called benign paroxysmal positional vertigo (BPPV). The Epley maneuver 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 medications being taken: People can ask a doctor or another health care practitioner to review all prescription and nonprescription medications being taken to see if any of the medications could increase the risk of falling. If such medications are being used, doctors may be able to lower the dose or people may be able to stop taking the medication.

• 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 adults need a physical therapist to train them to walk, particularly if they need to use an assistive device such as a walker or cane (see figure Just the Right Height). 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.

Just the Right Height

For people who are recovering from a leg injury or surgery, using a cane that is the correct height is important. A cane that is too long or too short can cause low back pain, poor posture, and instability. The cane should be held on the side opposite of an injured leg.

Hazards in the environment can sometimes be removed or corrected (see table Checklist for Preventing Falls in the Home).

• 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. Nightlights can be helpful.

• 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, hallways, and stairways can be stored out of the way of walking.

• Flooring (including rugs and linoleum) with tears or curled edges should be repaired, tacked down, or replaced.

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

• Furniture should be stable enough to support the weight of a person leaning on table edges or chair arms and back.

• 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.

• The shower can be equipped with skid-resistant strips, a rubber mat, or a seat.

• 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 or carry a mobile phone in their pocket 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 osteoporosisnursing or residential care facilities may consider wearing a hip protector, an undergarment with a plastic and foam pad placed over the hip. Hip protectors may prevent hip fractures if worn regularly by people in care facilities, but they have not been shown to be as effective for people living independently at home.

Knowing what to do if a fall occurs can help older adults 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 adults 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.

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

1. Centers for Disease Control and Prevention: This web site provides statistics about falls in older adults and links to discussions about ways to prevent falls,

2. National Council on Aging (NCOA): This web site provides links to articles that discuss statistics about falls in older adults, ways to prevent them, and myths about falling.

3. National Safety Council: Fall-prevention measures to keep older adults independent