Most Older Adults Who Experience a Fall Are Likely to Fall Again
Am Fam Physician. 2000 Apr one;61(seven):2159-2168.
See related patient information handout on the causes of falls and tips for prevention, written past the author of this commodity.
Article Sections
- Abstract
- Epidemiology of Falls in the Elderly
- Evaluation of the Elderly Patient Who Falls
- Prevention of Falls
- References
Falls are the leading cause of injury-related visits to emergency departments in the The states and the primary etiology of accidental deaths in persons over the age of 65 years. The mortality charge per unit for falls increases dramatically with age in both sexes and in all racial and ethnic groups, with falls accounting for lxx pct of accidental deaths in persons 75 years of age and older. Falls can be markers of poor health and declining part, and they are often associated with significant morbidity. More than than xc percent of hip fractures occur as a result of falls, with nigh of these fractures occurring in persons over 70 years of historic period. Ane third of customs-dwelling elderly persons and 60 per centum of nursing abode residents fall each year. Take chances factors for falls in the elderly include increasing age, medication use, cognitive impairment and sensory deficits. Outpatient evaluation of a patient who has fallen includes a focused history with an accent on medications, a directed physical test and simple tests of postural command and overall concrete function. Treatment is directed at the underlying crusade of the fall and can return the patient to baseline function.
Elderly patients who accept fallen should undergo a thorough evaluation. Determining and treating the underlying cause of a fall tin can return patients to baseline function and reduce the gamble of recurrent falls. These measures can have a substantial affect on the morbidity and mortality of falls. The resultant gains in quality of life for patients and their caregivers are significant.
Epidemiology of Falls in the Elderly
- Abstruse
- Epidemiology of Falls in the Elderly
- Evaluation of the Elderly Patient Who Falls
- Prevention of Falls
- References
From 1992 through 1995, 147 meg injury-related visits were fabricated to emergency departments in the Usa.ane Falls were the leading crusade of external injury, bookkeeping for 24 percent of these visits.1 Emergency department visits related to falls are more common in children less than five years of historic period and adults 65 years of age and older. Compared with children, elderly persons who fall are 10 times more likely to be hospitalized and eight times more than likely to die as the result of a fall.2
Trauma is the fifth leading crusade of death in persons more than 65 years of historic period,3 and falls are responsible for 70 pct of accidental deaths in persons 75 years of age and older. The elderly, who represent 12 pct of the population, account for 75 per centum of deaths from falls.4 The number of falls increases progressively with age in both sexes and all racial and ethnic groups.v The injury charge per unit for falls is highest among persons 85 years of age and older (e.g., 171 deaths per 100,000 white men in this age group).6
Annually, 1,800 falls direct result in death.7 Approximately ix,500 deaths in older Americans are associated with falls each year.eight
Elderly persons who survive a fall experience significant morbidity. Infirmary stays are almost twice as long in elderly patients who are hospitalized later a autumn than in elderly patients who are admitted for another reason.ix Compared with elderly persons who do not fall, those who fall experience greater functional reject in activities of daily living (ADLs) and in physical and social activities,ten and they are at greater risk for subsequent institutionalization.11
Falls and concomitant instability can be markers of poor health and declining function.12 In older patients, a fall may be a non-specific presenting sign of many acute illnesses, such as pneumonia, urinary tract infection or myocardial infarction, or information technology may be the sign of astute exacerbation of a chronic disease.thirteen Nearly ane 3rd (range: 15 to 44.9 percent) of community-domicile elderly persons and upward to sixty percent of nursing home residents fall each twelvemonth; one half of these "fallers" accept multiple episodes.14 Major injuries, including head trauma, soft tissue injuries, fractures and dislocations, occur in 5 to 15 percent of falls in any given twelvemonth.15 Fractures account for 75 per centum of serious injuries, with hip fractures occurring in 1 to 2 percent of falls.15
In 1996, more than than 250,000 older Americans suffered fractured hips, at a cost in excess of $10 billion. More than xc percent of hip fractures are associated with falls, and near of these fractures occur in persons more than than 70 years of age.8 Hip fracture is the leading fall-related injury that results in hospitalization, with these hospital stays being significantly prolonged and costly.sixteen It is projected that more than 340,000 hip fractures will occur in the yr 2000, and this incidence is expected to double by the middle of the 21st century.17
One fourth of elderly persons who sustain a hip fracture die within six months of the injury. More than 50 percent of older patients who survive hip fractures are discharged to a nursing abode, and nearly ane half of these patients are however in a nursing dwelling house one yr later.18 Hip fracture survivors experience a ten to 15 percent subtract in life expectancy and a meaningful refuse in overall quality of life.
Most falls do non finish in death or result in meaning physical injury. However, the psychologic impact of a fall or near fall often results in a fear of falling and increasing self-restriction of activities. The fear of future falls and subsequent institutionalization often leads to dependence and increasing immobility, followed by functional deficits and a greater adventure of falling.
Evaluation of the Elderly Patient Who Falls
- Abstract
- Epidemiology of Falls in the Elderly
- Evaluation of the Elderly Patient Who Falls
- Prevention of Falls
- References
SCREENING
Elderly patients with known risk factors for falling should be questioned about falls on a periodic basis. Specific inquiry is necessary considering of the fears many elderly persons harbor about existence institutionalized. Thus, these patients are unlikely to requite falling as a chief complaint.
A single fall is not always a sign of a major problem and an increased chance for subsequent falls. The fall may only be an isolated event. However, recurrent falls, defined as more than two falls in a six-month period, should be evaluated for treatable causes. An immediate evaluation is required for falls that produce injuries or are associated with a new acute illness, loss of consciousness, fever or abnormal claret pressure level.
HISTORY
A thorough history is essential to determine the mechanism of falling, specific hazard factors for falls, impairments that contribute to falls and the advisable diagnostic work-up. Many patients attribute a fall to "simply tripping," only the family medico must determine if the autumn occurred considering of an environmental obstacle or another precipitating factor.
The dr. should inquire near the activity the patient was engaged in just before and at the time of the fall, especially if the activity involved a positional alter. The location of the autumn should be ascertained. It is besides important to know whether anyone witnessed the fall and whether the patient sustained any injuries. The patient and, if applicable, witnesses or caregivers should be asked in particular most previous falls and whether the falls were the same or dissimilar in character. The md as well needs to decide who is available to assist the patient.
The mnemonic Catastrophe is helpful for recalling the principal items in a functional research (Table 1).19
TABLE one
CATASTROPHE: A Mnemonic for Obtaining a Functional History After a Fall or Near Autumn in an Elderly Patient
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RISK Factor Cess
The hazard of sustaining an injury from a fall depends on the individual patient's susceptibility and environmental hazards. The frequency of falling is related to the accumulated consequence of multiple disorders superimposed on age-related changes. The literature recognizes a myriad of gamble factors for falls (Table 2).20,21 The likelihood of falling increases with the number of risk factors.22
Tabular array ii
Risk Factors for Falls
| Demographic factors |
| Older age (especially ≥ 75 years) |
| White race |
| Housebound status |
| Living solitary |
| Historical factors |
| Utilise of pikestaff or walker |
| Previous falls |
| Astute affliction |
| Chronic weather condition, especially neuromuscular disorders |
| Medications, especially the use of 4 or more prescription drugs (see Table four) |
| Physical deficits |
| Cognitive impairment |
| Reduced vision, including age-related changes (i.e., decline in visual acuity, decline in accommodative capacity, glare intolerance, contradistinct depth perception, presbyopia [about vision], decreased night vision, reject in peripheral vision) |
| Difficulty rise from a chair |
| Foot issues |
| Neurologic changes, including historic period-related changes (i.east., postural instability; slowed reaction time; diminished sensory sensation for light touch, vibration and temperature; pass up of key integration of visual, vestibular and proprioceptive senses) |
| Decreased hearing, including historic period-related changes (i.e., presbycusis [increment in pure tone threshold, predominantly high frequency], impaired speech bigotry, excessive cerumen accumulation) |
| Others |
| Environmental hazards (see Figure 2) |
| Risky behaviors |
The gamble factors responsible for a fall can be intrinsic (i.e., age-related physiologic changes, diseases and medications) or extrinsic (i.e., ecology hazards). It is essential to remember that a single autumn may have multiple causes, and repeated falls may each take a different etiology. Thus, information technology is critical to evaluate each occurrence separately.
Intrinsic Factors. Normal concrete and mental changes related to aging (only not associated with disease) decrease functional reserve. As a consequence, elderly patients become more susceptible to falls when they are confronted with any challenge.
Some age-related changes are not necessarily "normal," but they are modifiable. When possible, these conditions should exist treated.
Virtually whatever acute or chronic illness can cause or contribute to falls. The nigh common etiologies of falls are listed in Table iii.23
TABLE 3
Common Causes of Falls in the Elderly*
| Blow, environmental hazard, fall from bed |
| Gait disturbance, balance disorders or weakness, hurting related to arthritis |
| Vertigo |
| Medications or booze |
| Acute disease |
| Confusion and cerebral damage |
| Postural hypotension |
| Visual disorder |
| Central nervous system disorder, syncope, drib attacks, epilepsy |
A critical element of the targeted history is a review of medications, including prescription, over-the-counter, herbal and illicit drugs. Cherry-red flags are polypharmacy (4 or more than prescription medications),24 the initiation of a new drug therapy in the previous two weeks25 and the use of whatsoever drug listed in Table four.
TABLE 4
Drugs That May Increase the Risk of Falling
| Sedative-hypnotic and anxiolytic drugs (especially long-acting benzodiazepines) |
| Tricyclic antidepressants |
| Major tranquilizers (phenothiazines and butyrophenones) |
| Antihypertensive drugs |
| Cardiac medications |
| Corticosteroids |
| Nonsteroidal anti-inflammatory drugs |
| Anticholinergic drugs |
| Hypoglycemic agents |
| Whatever medication that is likely to touch on residual |
Tricyclic antidepressants and other heterocyclic antidepressants have long been associated with an increased risk for falls. The selective serotonin reuptake inhibitor (SSRI) antidepressants are largely costless of the side effects of tricyclic antidepressants and take been presumed to be safer for utilise in persons at loftier risk for falling. Still, a contempo big written report of almost 2,500 nursing domicile residents constitute little difference in the rate of falls between patients receiving tricyclic anti-depressants and those receiving SSRIs.26 Thus, the doc needs to maintain a high index of suspicion when reviewing the medications taken past a patient who falls.
Extrinsic Factors. In a fall, more active persons are probable to be exposed to high-intensity forces at impact, whereas the chance of injury in less active persons depends more on their susceptibility (i.e., the presence of frail bones or ineffective protective responses).27 Fragile elderly persons tend to autumn and injure themselves in the abode during the course of routine activities. Vigorous older persons are more likely to participate in dynamic activities and to fall and be injured while challenged past environmental hazards such as stairs or unfamiliar areas away from home.28
A variety of extrinsic factors, such as poor lighting, unsafe stairways and irregular floor surfaces, are involved in falls among the elderly. Many of these factors tin can exist modified.
Figure 1 shows how intrinsic and extrinsic factors can combine to change the likelihood of falling in the elderly patient.29
The Changing Approach to Falls in the Elderly
FIGURE 1.
Factors that contribute to the take chances of falls in the elderly population.
Adapted with permission from Steinweg KK. The irresolute approach to falls in the elderly. Am Fam Physician 1997;56:1815–22,1823.
Concrete Test
A mnemonic (I HATE FALLING) tin be used to remind the md of key concrete findings in patients who fall or nearly fall (Table 5).nineteen This mnemonic focuses the physician's attention on common problems that are likely to reply to treatment. Most falls have multiple causes. Just rarely are all of the causes fully reversible. Yet, a fractional positive touch on on one or a few causes ofttimes makes a major difference in quality of life for the patients and caregivers.
TABLE 5
I HATE FALLING: A Mnemonic for Central Physical Findings in the Elderly Patient Who Falls or Nearly Falls
| I | Inflammation of joints (or articulation deformity) |
| H | Hypotension (orthostatic blood pressure changes) |
| A | Auditory and visual abnormalities |
| T | Tremor (Parkinson'southward illness or other causes of tremor) |
| Due east | Equilibrium (balance) problem |
| F | Pes issues |
| A | Arrhythmia, heart block or valvular disease |
| L | Leg-length discrepancy |
| 50 | Lack of conditioning (generalized weakness) |
| I | Illness |
| Northward | Nutrition (poor; weight loss) |
| One thousand | Gait disturbance |
A home visit is invaluable for assessing modifiable risk factors and determining appropriate interventions. A home safety checklist can guide the visit and ensure a thorough evaluation (Figure 2).23 It is particularly important to assess caregiver and housing arrangements, environmental hazards, alcohol use and compliance with medications.17
Abode Prophylactic Checklist
FIGURE 2.
Checklist for evaluating safety during the home visit.
Adjusted with permission from Rubenstein LZ. Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Convalescent geriatric care. St. Louis: Mosby, 1993:296–304.
An algorithm for the evaluation of falls is presented in Effigy 3 .
Evaluation of Falls
FIGURE 3.
Suggested algorithm for the evaluation of falls in the elderly.
Balance and Gait Testing. Postural control is a complex task that involves residual, ambulation capability, endurance, range of motion, sensation and force. Several uncomplicated tests have exhibited a stiff correlation with a history of falling. These functional balance measures are quantifiable and correlate well with the ability of older adults to ambulate safely in their environment. The tests tin also be used to measure changes in mobility after interventions have been applied.
I-leg balance is tested by having the patient stand unassisted on one leg for five seconds. The patient chooses which leg to stand on (based on personal comfort), flexes the opposite knee to allow the foot to clear the floor and then balances on 1 leg for as long as possible. The physician uses a watch to time the patient'due south 1-leg residuum.30 This test predicts injurious falls but not all falls.
The timed "Up & Go" test evaluates gait and balance (Tabular array 6).31 The patient gets up out of a standard armchair (seat meridian of approximately 46 cm [18.iv in.]), walks a distance of 3 m (10 ft.), turns, walks dorsum to the chair and sits down again. The patient wears regular footwear and, if applicable, uses any customary walking assist (e.chiliad., cane or walker). No physical assistance is given. The doctor uses a stopwatch or a wristwatch with a second hand to time this action. A score of thirty seconds or greater indicates that the patient has impaired mobility and requires assistance (i.e., has a high take chances of falling). This test has been shown to exist as valid every bit sophisticated gait testing.
Tabular array 6
Timed "Up & Go" Test
| Job | Go up out of a standard armchair (seat height of approximately 46 cm [18.4 in.]), walk a altitude of 3 one thousand (10 ft.), plough, walk back to the chair and sit down again. | |
| Requirements | Ambulate with or without assistive device and follow a three-stride command. | |
| Trials | One practise trial and so three actual trials. The times from the three actual trials are averaged. | |
| Time | 1 to 2 minutes | |
| Equipment | Armchair, stopwatch (or wristwatch with a 2nd hand) and a measured path | |
| Predictive results | Seconds | Rating |
| < 10 | Freely mobile | |
| < 20 | Mostly contained | |
| 20 to 29 | Variable mobility | |
| > xxx | Impaired mobility | |
A simpler culling is the "Get-Upwards and Get" test.32 In this examination, the patient is seated in an armless chair placed 3 m (ten ft.) from a wall. The patient stands, walks toward the wall (using a walking help if i is typically employed), turns without touching the wall, returns to the chair, turns and sits downwardly. This action does not demand to exist timed. Instead, the physician observes the patient and makes note of any balance or gait problems.
In watching patients perform the "Up & Get" test or the "Go-Up and Go" test, the physician should consider the following questions: How safe does this activity appear for this patient? Are at that place any tip-offs to remediable causes of impaired mobility?
Overall physical part should also be assessed. This is accomplished by evaluating the patient's ADLs and instrumental activities of daily living (IADLs). An alternative is the Concrete Performance Examination (PPT).33 This performance-based test includes vii usual daily activities. The patient is asked to write a sentence, lift a volume, put on and take off a jacket, selection upwardly a penny, turn 360 degrees and walk almost 15 m (l ft.). The medico evaluates the performance of these activities to make up one's mind whether the patient is at increased chance for recurrent falls. If a trouble is detected, the physician should establish measures to prevent falls, such equally reducing medications (when possible), improving environmental prophylactic and encouraging exercise that improves balance.
Prevention of Falls
- Abstract
- Epidemiology of Falls in the Elderly
- Evaluation of the Elderly Patient Who Falls
- Prevention of Falls
- References
When the cause of a autumn is not determined or a patient remains at high run a risk for falls, referral to a falls prevention program may be warranted. Recent studies have shown that such programs tin can reduce the rate of falls in the elderly. In i study,34 the interactive group had a relative hazard of falling of 0.39 compared with the control group. Interventions included the modification of environmental hazards and the evaluation and treatment of claret pressure, vision problems and mental status changes, including depression. Interventions that may be successful in reducing falls are listed in Table 7.22
Tabular array 7
Interventions to Reduce the Risk of Falls in the Elderly
| Risk factors | Interventions |
|---|---|
| Postural hypotension: a drop in systolic blood pressure of ≥ 20 mm Hg or to < 90 mm Hg on continuing | Behavioral recommendations, such every bit ankle pumps or hand clenching and elevation of the head of the bed |
| Decrease in the dosage of a medication that may contribute to hypotension; if necessary, discontinuation of the drug or substitution of another medication | |
| Pressure stockings | |
| If indicated, fludrocortisone (Florinef), in a dosage of 0.one mg two or three times daily, to increment blood pressure | |
| If indicated, midodrine (ProAmatine), in a dosage of ii.5 to v mg iii times daily, to increase vascular tone and claret pressure | |
| Employ of a benzodiazepine or other allaying-hypnotic drug | Education well-nigh appropriate utilise of allaying-hypnotic drugs |
| Nonpharmacologic treatment of sleep bug, such every bit slumber brake | |
| Tapering and discontinuation of medications | |
| Utilise of four or more prescription medications | Review of medications |
| Environmental hazards for falling or tripping | Home safety assessment with advisable changes, such every bit removal of hazards, selection of safer furniture (right elevation, more than stability) and installation of structures such equally grab confined in bathrooms or handrails on stairs |
| Any impairment in gait | Gait training |
| Employ of an advisable assistive device | |
| Residuum or strengthening exercises if indicated | |
| Any damage in remainder or transfer skills | Balance exercises and preparation in transfer skills if indicated |
| Environmental alterations, such as installation of catch bars or raised toilet seats | |
| Harm in leg or arm muscle forcefulness or range of motion (hip, ankle, knee, shoulder, hand or elbow) | Exercises with resistive bands and putty resistance training ii or three times a week, with resistance increased when the patient is able to consummate 10 repetitions through the total range of motion |
An outpatient assessment using the tools outlined in this commodity tin allow the master care doc to identify risk factors quickly and accurately, and to assess the patient who has fallen or nearly fallen. Critical steps in reducing the risk of falls in the elderly are listed in Table viii.28
Tabular array viii
Critical Steps in Reducing the Risk of Falls in the Elderly
| Eliminate ecology hazards. |
| Improve home supports. |
| Provide opportunities for socialization and encouragement. |
| Alter medication. |
| Provide balance grooming. |
| Modify restraints. |
| Involve the family. |
| Provide follow-upwardly. |
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REFERENCES
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Members of various family unit exercise departments develop articles for "Trouble-Oriented Diagnosis." This article is one in a serial coordinated by the Department of Family Medicine at the Uniformed Services University of the Wellness Sciences, Bethesda, Md. Invitee editors of the series are Francis G. O'Connor, LTC, MC, USA, and Jeannette E. South-Paul, COL, MC, USA.
Copyright © 2000 by the American University of Family unit Physicians.
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