Falls in older adults

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Every year, many older people suffer from falls. These falls in older adults are a significant cause of morbidity and mortality, and can have a serious effect on the person who falls. Falls can be caused by many things, and often the cause is multi-factorial, and require a multi-disciplinary approach to treat any injuries sustained during the fall, and to prevent any future falls.[1] Falls include dropping from a standing position, or from exposed positions such as those on ladders or stepladders. The severity of injury is generally closely related to the height of the fall, the greater the height, then the greater the personal damage. The state of the ground surface onto which the victim falls is also important, harder surfaces causing more severe injury.

Definition[edit]

The unintentionally dropping onto the ground or lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard.”[2] Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall.[3] Such falls are clearly of accidental origin, which might include a large number of causes, such as slips, trips and over-balancing.

Falls are one of the giants of geriatric medicine.

Incidence[edit]

Every year, the following proportion of people suffer from a fall[citation needed]:

>65 years >75 years Institutional Care Recurrent Fallers Healthy Elderly
28–35% 32–45% >50% 60–70% 15%

Falls are the most common report given by patients over the age of 65 to emergency departments.[citation needed]

Causes of falls[edit]

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 includes 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.[4]

Intrinsic factors[edit]

  • Balance and Gait
As a result of stroke disease, Parkinsonism, arthritic changes, neuropathy, neuromuscular disease or vestibular disease.
  • Visual and Motor Reaction Time Problems
An extended reaction time will delay responses and compensations to standing or walking imbalances, thus increasing the likelihood of falls.

Extrinsic factors[edit]

Hanging straps with triangular handles in a modern Japanese commuter train
Grab rails on a longer-distance commuter train catering for mainly seated passengers
A staircase with metal handrails
Front-wheeled walker.
  • 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 bulbs preferred.
  • Stairs with inadequate handrails, 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.
  • Clothing/footwear poorly fitted, shoes 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

Consequences of falls[4][edit]

  • 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 and dislocations. 5% of fallers end up having a fracture as a result of their fall, and 1% fracture their neck of femur[citation needed].
    • Disuse atrophy and muscle wasting from reduced physical activity during recovery periods
  • "Long Lies"
  • Psychological
    • A fear of falling

Presentation and assessment[edit]

When assessing a patient who has fallen, it is important to try to get an eye-witness account of the incident. As the faller may have had some loss of consciousness, they may not give an accurate description of the fall. However, in practice, these eye-witness accounts are often unavailable. It is also important to remember than 30% of cognitively intact older people are unable to remember a documented fall three months later.[citation needed] Important points of inquiry:

  • Visual motor reaction time
  • Frequency of falls
  • Effectiveness of "parachute" corrective response of moving hand and arm to "break" the fall
  • Eye witness 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

Investigations[edit]

It is good practice to exclude anaemia, renal failure, and electrolyte imbalance, and to perform an ECG and a chest x-ray. Other tests should be tailored to the cause of the fall.

Interventions[edit]

Main article: Fall prevention

A large body of evidence shows that a multi-disciplinary approach to assessment and treatment results in the best outcome.[5][6][7]

Possible interventions include:

  • Provision of safety devices such as grab handles,

high friction floors and footwear, as well as high power lighting

  • Hip protectors
  • Regular exercise
  • Treatment for osteoporosis
  • Review – monitoring of medications and ongoing medical problems
  • Tackling environmental issues

Research[edit]

A fall occurs when a person's centre of mass goes outside of the base of support. A majority of research on postural instability has focused on the anterior/posterior directions due to the structure of the legs and the frequency of falls in those directions. Maki, Holliday, & Topper (1994) has stated that sway in the medial/lateral directions can be just as important, “Results show strong evidence linking deficits in postural balance related to the control of the m–l stability with an increased risk of falling”.[8] The mechanisms of postural instability are not fully understood, but research has suggested that disorders affecting sensory input and efferent motor signals are the primary causes.

Furthermore, a recent 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.[1]

References[edit]

  1. ^ a b Sarofim, M. (2012). "Predicting falls in the elderly: do dual-task tests offer any added value? A systematic review". AMSJ; 3(2): 13–19.
  2. ^ .comTinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701–7. [PubMed: 3205267]
  3. ^ http://www.ncbi.nlm.nih.gov/books/NBK2653/
  4. ^ a b Department of Health, National service framework for older people; Standard 6 – Falls, Crown Copyright, 24 May 2001, [1] accessed:19/5/2008
  5. ^ Tinetti, ME; Baker DI; Garrett PA; Gottschalk M; Koch ML; Horwitz RI (March 1993). "Yale FICSIT: risk factor abatement strategy for fall prevention". J Am Geriatr Soc 41 (3): 315–20. PMID 8440856. 
  6. ^ Tinetti, ME; Baker DI; McAvay G; Claus EB; Garrett P; Gottschalk M; Koch ML; Trainor K; Horwitz RI. (September 1994). "A multifactorial intervention to reduce the risk of falling among elderly people living in the community". N Engl J Med. 331 (13): 821–7. doi:10.1056/NEJM199409293311301. PMID 8078528. Retrieved 2008-05-19. 
  7. ^ Close, J; Ellis M; Hooper R; Glucksman E; Jackson S; Swift C. (January 1999). "Prevention of falls in the elderly trial (PROFET): a randomised controlled trial". Lancet 353 (9147): 93–7. doi:10.1016/S0140-6736(98)06119-4. PMID 10023893. 
  8. ^ Maki, B. E., Holliday, P. J., & Topper, A.K. (1994). A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population, Journal of Gerontology, 49(2), M72-M84.

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