Falls in older adults

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Falls in older adults
Classification and external resources
Specialty geriatrics
ICD-10 R29.6

Falls in older adults are a significant cause of morbidity and mortality and are an important class of preventable injuries. The cause of falling in old age is often multifactorial, and may require a multidisciplinary approach both to treat any injuries sustained and to prevent 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 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.[2]

A review of clinical trial evidence by the European Food Safety Authority led to a recommendation that people over age 60 years should supplement the diet with vitamin D to reduce the risk of falling and bone fractures.[3] Falls are an important aspect of geriatric medicine.

Definition[edit]

Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall.[4] Such falls are clearly of accidental origin, which might include a large number of causes, such as slips, trips and over-balancing.[citation needed]

A 2006 review of literature identified the need for standardization of falls taxonomy due to the variation within research.[5] The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem.[6] 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."[6] The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews.[7][8][9]

Signs and symptoms[edit]

Causes[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.[10]

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 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 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.
  • 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, causing poor traction and individual instability. All surfaces should have a high friction coefficient with shoe soles.
  • 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
  • Lack of equipment/aids such as walking sticks or walking frames, such as Zimmer frames so as to improve user stability. Grab bars and hanging straps should be supplied plentifully, especially in critical areas where users may be vulnerable.

Diagnosis[edit]

When assessing a person who has fallen, it is important to try to get an eyewitness 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 eyewitness 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:[10]

  • Visual motor reaction time
  • 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[edit]

A large body of evidence shows that a multi-disciplinary approach to assessment and treatment results in the best outcome.[11][12][13]

Possible interventions include:

  • Provision of safety devices such as grab handles, high friction floors and footwear, as well as low power lighting at night
  • Regular exercise - lower limb strengthening exercise to increase muscle strength.[14] Other forms of exercise, such as those involving gait, balance, co-ordination and functional tasks, may also help improve balance in older adults.[15]
  • 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.[16]
  • Review– monitoring of medications and ongoing medical problems
  • Supplementation with vitamin D, as determined by the European Food Safety Authority that vitamin D deficiency is associated with increased risk of falling and bone fractures in women and men over 60 years old; "in order to obtain the claimed effect, 800 I.U. (20 μg) of vitamin D from all sources should be consumed daily."[3][17]
  • Tackling environmental issues, including a review of current living conditions (action checklist)

Interventions to minimize the consequences of falls:

  • Hip protectors – probably decrease chance of hip fractures slightly, although it may increase the small chance of a pelvic fracture in older adults living in nursing care facilities. Little or no effect reported on other fractures or falls[18]
  • Treatment for osteoporosis

Hospital[edit]

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.[19]

Screening[edit]

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.[20] 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.[21]

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.[22]

Epidemiology[edit]

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%.[23][24][25][26][27]

History[edit]

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.”[28]

Economics[edit]

The health care impact and costs of falls in older adults is significantly rising all over the world. The cost of falls are 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 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.[29]

Research[edit]

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". Australian Medical Student Journal. 3 (2): 13–19. 
  2. ^ Chang, Huan J. (2010-01-20). "FAlls and older adults". JAMA. 303 (3): 288–288. doi:10.1001/jama.303.3.288. ISSN 0098-7484. 
  3. ^ a b Panel on Dietetic Products, Nutrition and Allergies (2011). "Scientific Opinion on the substantiation of a health claim related to vitamin D and risk of falling pursuant to Article 14 of Regulation (EC) No 1924/2006". EFSA Journal 2011;9(9):2382 [18 pp.]. Brussels, Belgium: European Food Safety Authority. doi:10.2903/j.efsa.2011.2382. 
  4. ^ "Fall and Injury Prevention – Patient Safety and Quality – NCBI Bookshelf". Ncbi.nlm.nih.gov. Retrieved 2015-12-15. 
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  7. ^ Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE (2012). "Interventions for preventing falls in older people living in the community". Cochrane Database of Systematic Reviews (9): CD007146. doi:10.1002/14651858.CD007146.pub3. PMID 22972103. 
  8. ^ Hopewell S, Adedire O, Copsey BJ, Sherrington C, Clemson LM, Close JC, Lamb SE (2016). "Multifactorial and multiple component interventions for preventing falls in older people living in the community (Protocol)". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD012221. 
  9. ^ Sherrington C, Tiedemann A, Fairhall NJ, Hopewell S, Michaleff ZA, Howard K, Clemson L, Lamb SE (2016). "Exercise for preventing falls in older people living in the community (Protocol)". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD012424. 
  10. ^ a b c Department of Health, National service framework for older people; Standard 6 – Falls, Crown Copyright, 24 May 2001, [1] accessed:19/5/2008
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  14. ^ Ishigaki, Erika Y.; Ramos, Lidiane G.; Carvalho, Elisa S.; Lunardi, Adriana C. (2016-11-08). "Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review". Brazilian Journal of Physical Therapy. 18 (2): 111–118. doi:10.1590/S1413-35552012005000148. ISSN 1809-9246. PMC 4183251Freely accessible. PMID 24760166. 
  15. ^ Howe, T. E.; Rochester, L; Neil, F; Skelton, D. A.; Ballinger, C (2011). "Exercise for improving balance in older people" (PDF). The Cochrane Database of Systematic Reviews (11): CD004963. doi:10.1002/14651858.CD004963.pub3. PMID 22071817. 
  16. ^ Kendrick D, Kumar A, Carpenter H, Zijlstra G, Skelton DA, Cook JR, Stevens Z, Belcher CM, Haworth D, Gawler SJ, Gage H, Masud T, Bowling A, Pearl M, Morris RW, Iliffe S, Delbaere K (2014). "Exercise for reducing fear of falling in older people living in the community". Cochrane Database of Systematic Reviews. Art. No.: CD009848 (11): CD009848. doi:10.1002/14651858.CD009848.pub2. PMID 25432016. 
  17. ^ Spiro, A; Buttriss, J. L. (2014). "Vitamin D: An overview of vitamin D status and intake in Europe". Nutrition Bulletin. 39 (4): 322–350. doi:10.1111/nbu.12108. PMC 4288313Freely accessible. PMID 25635171. 
  18. ^ Santesso, Nancy; Carrasco-Labra, Alonso; Brignardello-Petersen, Romina (2014-03-31). "Hip protectors for preventing hip fractures in older people". The Cochrane Database of Systematic Reviews. 3 (3): CD001255. doi:10.1002/14651858.CD001255.pub5. ISSN 1469-493X. PMID 24687239. 
  19. ^ Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F, Meltzer S, Tsurikova R, Zuyov L, Middleton B (2010-11-03). "Fall prevention in acute care hospitals: A randomized trial". JAMA. 304 (17): 1912–1918. doi:10.1001/jama.2010.1567. ISSN 0098-7484. PMC 3107709Freely accessible. PMID 21045097. 
  20. ^ DK, Kiely (1998). "Identifying nursing home residents at risk of falling". Journal of American Geriatrics Society. 46 (5): 551–555. PMID 9588366. 
  21. ^ Rodríguez-Molinero, Alejandro (2017). "A two-question tool to assess the risk of repeated falls in the elderly". PLoS One. 10 (12(5)): e0176703. Bibcode:2017PLoSO..1276703R. doi:10.1371/journal.pone.0176703. PMC 5425174Freely accessible. PMID 28489888. 
  22. ^ "Clinical Practice Guideline: Prevention of Falls in Older Persons". The American Geriatrics Society. 2016. 
  23. ^ Tinetti (1988). "Risk Factors for Falls among Elderly Persons Living in the Community". N Engl J Med. 319 (26): 1701–7. doi:10.1056/NEJM198812293192604. PMID 3205267. 
  24. ^ Nevitt (1989). "Risk factors for recurrent nonsyncopal falls. A prospective study". JAMA. 261 (18): 2663–68. doi:10.1001/jama.1989.03420180087036. PMID 2709546. 
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  26. ^ Rapp (2014). "Fall incidence in Germany: results of two population-based studies, and comparison of retrospective and prospective falls data collection methods". BMC Geriatr. 14: 105. doi:10.1186/1471-2318-14-105. PMC 4179843Freely accessible. PMID 25241278. 
  27. ^ Shumway-Cook (2009). "Falls in the Medicare population: incidence, associated factors, and impact on health care". Phys Ther. 89 (4): 324–32. doi:10.2522/ptj.20070107. PMC 2664994Freely accessible. PMID 19228831. 
  28. ^ Tinetti ME, Speechley M, Ginter SF (Dec 1988). "Risk factors for falls among elderly persons living in the community". N Engl J Med. 319 (26): 1701–7. doi:10.1056/NEJM198812293192604. PMID 3205267. 
  29. ^ "Costs of Falls Among Older Adults". Centers for Disease Control and Prevention, Home and Recreational Safety, U.S. Department of Health & Human Services, Bethesda, MD. 2016. Retrieved 2 December 2016. 

External links[edit]