Falls in older adults are a significant cause of
morbidity
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
and
mortality and are a major class of
preventable injuries. Falling is one of the most common accidents that cause a loss in the quality of life for older adults, and is usually precipitated by a loss of balance and weakness in the legs. The cause of
falling
Falling or fallin' may refer to:
*Falling (physics), movement due to gravity
*Falling (accident)
*Falling (execution)
*Falling (sensation)
People
* Christine Falling (born 1963), American serial killer who murdered six children
Books
* ''Fall ...
in
old age is often multifactorial and may require a multidisciplinary approach both to treat any injuries sustained and to prevent future falls.
Falls include dropping from a standing position or from exposed positions such as those on
ladder
A ladder is a vertical or inclined set of rungs or steps used for climbing or descending. There are two types: rigid ladders that are self-supporting or that may be leaned against a vertical surface such as a wall, and rollable ladders, such ...
s 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.
A review of
clinical trial
Clinical trials are prospective biomedical or behavioral research studies on human participants designed to answer specific questions about biomedical or behavioral interventions, including new treatments (such as novel vaccines, drugs, diet ...
evidence by the
European Food Safety Authority
The European Food Safety Authority (EFSA) is the agency of the European Union (EU) that provides independent scientific advice and communicates on existing and emerging risks associated with the food chain. EFSA was established in February 2002, ...
led to a recommendation that people over age 60 years should
supplement the diet with
vitamin D
Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group are vitamin D3 (c ...
to reduce the risk of falling and bone fractures.
Falls are an important aspect of
geriatric medicine
Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of older adults. The term ''geriatrics'' originates from the Greek γέρων ''geron'' meaning "old man", and ιατρός ''iatros' ...
.
Definition
Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall. Falls are of concern within medical treatment facilities. Fall prevention is usually a priority in healthcare settings.
A 2006 review of literature identified the need for standardization of falls
taxonomy
Taxonomy is the practice and science of categorization or classification.
A taxonomy (or taxonomical classification) is a scheme of classification, especially a hierarchical classification, in which things are organized into groups or types. ...
due to the variation within research. The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem.
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."
The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews.
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
Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displa ...
and
dislocations
In materials science, a dislocation or Taylor's dislocation is a linear crystallographic defect or irregularity within a crystal structure that contains an abrupt change in the arrangement of atoms. The movement of dislocations allow atoms to sl ...
. 5% of fallers end up having a fracture as a result of their fall, and 1% fracture their
neck of femur
The femoral neck (femur neck or neck of the femur) is a flattened pyramidal process of bone, connecting the femoral head with the femoral shaft, and forming with the latter a wide angle opening medialward.
Structure
The neck is flattened from ...
.
**
Disuse atrophy and muscle wasting from reduced physical activity during recovery periods
*Due to bed rest
**
Pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severi ...
**
Pressure sores
**
Dehydration
In physiology, dehydration is a lack of total body water, with an accompanying disruption of metabolic processes. It occurs when free water loss exceeds free water intake, usually due to exercise, disease, or high environmental temperature. Mil ...
**
Hypothermia
Hypothermia is defined as a body core temperature below in humans. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe ...
*A fear of falling
[Department of Health, ''National service framework for older people; Standard 6 – Falls'', Crown Copyright, 24 May 2001]
accessed:19/5/2008
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 include 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
Fall prevention includes any action taken to help reduce the number of accidental falls suffered by susceptible individuals, such as the elderly (idiopathic) and people with neurological (Parkinson's, Multiple sclerosis, stroke survivors, Guilla ...
.
Intrinsic factors
*Balance and gait
**As a result of
stroke disease,
Parkinsonism
Parkinsonism is a clinical syndrome characterized by tremor, bradykinesia (slowed movements), rigidity, and postural instability. These are the four motor symptoms found in Parkinson's disease (PD), after which it is named, dementia with Lewy b ...
,
arthritic changes,
neuropathy,
neuromuscular disease
A neuromuscular disease is any disease affecting the peripheral nervous system (PNS), the neuromuscular junction, or skeletal muscle, all of which are components of the motor unit. Damage to any of these structures can cause muscle atrophy and wea ...
or
vestibular disease
The vestibular system, in vertebrates, is a sensory system that creates the sense of balance and spatial orientation for the purpose of coordinating movement with balance. Together with the cochlea, a part of the auditory system, it constitutes ...
.
*Visual motor reaction time problems
**An extended
reaction time
Mental chronometry is the scientific study of processing speed or reaction time on cognitive tasks to infer the content, duration, and temporal sequencing of mental operations. Reaction time (RT; sometimes referred to as "response time") is meas ...
will delay responses and compensations to standing or walking imbalances, thus increasing the likelihood of falls.
*Medications
**
Polypharmacy
Polypharmacy (polypragmasia) is the simultaneous use of multiple medicines by a patient for their conditions. Most commonly it is defined as regularly taking five or more medicines but definitions vary in where they draw the line for the minimum ...
is common in older people
**
Sedatives
A sedative or tranquilliser is a substance that induces sedation by reducing irritability or excitement. They are CNS depressants and interact with brain activity causing its deceleration. Various kinds of sedatives can be distinguished, but t ...
significantly increase the risk of falling
**
Cardiovascular
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
medications can contribute towards falls
*Visual impairment
**Visual impairments,
glaucoma
Glaucoma is a group of eye diseases that result in damage to the optic nerve (or retina) and cause vision loss. The most common type is open-angle (wide angle, chronic simple) glaucoma, in which the drainage angle for fluid within the eye rem ...
,
macular degeneration
Macular degeneration, also known as age-related macular degeneration (AMD or ARMD), is a medical condition which may result in blurred or no vision in the center of the visual field. Early on there are often no symptoms. Over time, however, som ...
and
retinopathy
Retinopathy is any damage to the retina of the eyes, which may cause vision impairment. Retinopathy often refers to retinal vascular disease, or damage to the retina caused by abnormal blood flow. Age-related macular degeneration is technically inc ...
increase the risk of falling and of hip fractures.
**
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
Dementia is a disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease. The symptoms involve progressive impairments in memory, thinking, and behavior, which negatively affe ...
increases the likelihood of falls
*Cardiovascular causes
**
Orthostatic hypotension
Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down. Primary orthostatic hypertension is also often referred to as neurogenic orthostatic hyp ...
**
Postprandial hypotension
**
Carotid sinus syndrome
In human anatomy, the carotid sinus is a dilated area at the base of the internal carotid artery just superior to the bifurcation of the internal carotid and external carotid at the level of the superior border of thyroid cartilage. The carotid ...
**
Neurocardiogenic syncope– the commonest cause of syncope in A&E patients
**
Cardiac arrhythmias
**Structural heart disease, such as
valvular heart disease
Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left side of heart and the pulmonic and tricuspid valves on the right side of heart). These ...
Extrinsic factors
![Passenger compartment Class 440](https://upload.wikimedia.org/wikipedia/commons/4/47/Passenger_compartment_Class_440.jpg)
*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 bulb
An incandescent light bulb, incandescent lamp or incandescent light globe is an electric light with a wire filament heated until it glows. The filament is enclosed in a glass bulb with a vacuum or inert gas to protect the filament from oxid ...
s preferred
r LEDs?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
handrail
A handrail is a rail that is designed to be grasped by the hand so as to provide safety or support. In Britain, handrails are referred to as banisters. Handrails are usually used to provide support for body or to hold clothings in a bathroom o ...
s, 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
Friction is the force resisting the relative motion of solid surfaces, fluid layers, and material elements sliding against each other. There are several types of friction:
*Dry friction is a force that opposes the relative lateral motion of ...
, causing poor
traction and individual instability. All surfaces should have a high
friction coefficient
Friction is the force resisting the relative motion of solid surfaces, fluid layers, and material elements sliding against each other. There are several types of friction:
*Dry friction is a force that opposes the relative lateral motion of t ...
with shoe soles.
*Clothing/footwear poorly fitted,
shoes
A shoe is an item of footwear intended to protect and comfort the human foot. They are often worn with a sock. Shoes are also used as an item of decoration and fashion. The design of shoes has varied enormously through time and from culture t ...
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 stick
A walking stick or walking cane is a device used primarily to aid walking, provide postural stability or support, or assist in maintaining a good posture. Some designs also serve as a fashion accessory, or are used for self-defense.
Walking st ...
s or walking frames, such as
Zimmer frame
A walker (North American English) or walking frame (British English) is a device that gives support to maintain balance or stability while walking, most commonly due to age-related mobility disability, including frailty. Another common equival ...
s so as to improve user stability.
Grab bar
Grab bars are safety devices designed to enable a person to maintain balance, lessen fatigue while standing, hold some of their weight while maneuvering, or have something to grab onto in case of a slip or fall. A caregiver may use a grab bar to a ...
s and
hanging strap
In urban public transport, provision is made for standing passengers, often called straphangers or standees, to rationalize operation and to provide extra capacity during rush hour.
Occurrence
On crowded rapid transit urban lines, while most t ...
s should be supplied plentifully, especially in critical areas where users may be vulnerable.
Diagnosis
When assessing a person who has fallen an eyewitness account of the incident is helpful. The person who fell may have had some loss of consciousness and may not be able to give an accurate description of the fall. In practice, these eyewitness accounts are often unavailable. 30% of cognitively intact older people are unable to remember a documented fall three months later.
Important points of inquiry:
*Visual motor
reaction time
Mental chronometry is the scientific study of processing speed or reaction time on cognitive tasks to infer the content, duration, and temporal sequencing of mental operations. Reaction time (RT; sometimes referred to as "response time") is meas ...
*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
The relationship between the person at risk of falling and their environment is important for determining the risk falls and taking measures to prevent falls. An assessment with an occupational therapist may be helpful to determine an appropriate rehabilitation plan to prevent falls by taking into consideration both the person and their living environment.
A large body of evidence shows that efforts to include exercise decrease the risk of falls,
and yet the fear of falling can lead to a decrease in participation in physical exercise.
Possible interventions to prevent falls include:
Environmental adaptations
Improvements to the person's environment such as their home or workplace may help to reduce the risk of falling.
*A review of the current living conditions
*Adding safety devices, such as grab handles, high friction floors, as well as low power lighting at night to the person's home or work environment
*Identify and remove potential hazards
Behavioural interventions
*Regular exercise - lower limb strengthening exercise to increase muscle strength. Other forms of exercise, such as those involving gait, balance, co-ordination and functional tasks, may also help improve balance in older adults.
*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.
*Monitoring of medications and ongoing medical problems - For example, people with
polymyalgia rheumatica
Polymyalgia rheumatica (PMR) is a syndrome experienced as pain or stiffness, usually in the neck, shoulders, upper arms, and Hip (anatomy), hips, but which may occur all over the body. The pain can be sudden or can occur gradually over a period. ...
often take long-term steroids, leading to
osteoporosis. Research in the UK has also suggested that these people would benefit from a falls assessment when first diagnosed, and regular treatment reviews.
*Improvements to footwear and utilization of orthotic devices if required.
*
Supplementation with
vitamin D
Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group are vitamin D3 (c ...
is not recommended in those without vitamin D deficiency for fall prevention in older adults.
Interventions to minimize the consequences of falls
*
Hip protectors may decrease risk of hip fractures slightly, although they may slightly increase the risk of a pelvic fracture in older adults living in nursing care facilities. Little or no effect reported on other fractures or falls.
*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.
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. Older people who have experienced at least one fall in the last 6 months, or who believe that they may fall in the coming months, should be evaluated with the aim of reducing their risk of recurrent falls.
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 report falls should be asked about their circumstances and frequency to assess risks from gait and balance which may be compromised. A fall risk assessment is done by a clinician to include history, physical exam, functional capability, and environment.
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% experience multiple falls annually. The risk is greater in people older than 80 years, in which the annual incidence of falls can reach 50%.
History
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."
Economics
The health care impact and costs of falls in older adults are significantly rising all over the world. The cost of falls is 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 the 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.
Research
Furthermore, a 2012 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.
References
External links
Morse Fall AssessmentAn assessment tool to determine and quantify persons as low, mid, and high risk for falls.
– Centers for Disease Control and Prevention
{{DEFAULTSORT:Falls In Older Adults
Geriatrics
Older adults
Old age refers to ages nearing or surpassing the life expectancy of human beings, and is thus the end of the human life cycle. Terms and euphemisms for people at this age include old people, the elderly (worldwide usage), OAPs (British usage ...
Causes of death
Injuries