Falls in older adults

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.

Definition

The medical definition of a fall is: "An event which results in a person coming to rest inadvertently at a lower level, other than as a consequence of a violent stroke, loss of consciousness, or a sudden onset of paralysis"Fact|date=May 2008.

A person can also come to rest inadvertently at a lower level due to a faint or syncope, a stroke, transient ischaemic attack or some other cause of sudden paralysis.

Falls are one of the giants of geriatric medicine.

Incidence

Every year, the following proportion of people suffer from a fallFact|date=May 2008:

Falls are the commonest presenting complaint to A&E in patients over the age of 65Fact|date=May 2008.

Causes of falls

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 grouped into intrinsic and extrinsic factors.

Intrinsic Factors

*Balance and Gait::As a result of stroke disease, Parkinsonism, arthritic changes, neuropathy, neuromuscular disease or vestibular disease.
*Medications
**Polypharmacy is common in older people
**Sedatives significantly increase the risk of falling
**Cardiovascular medications can contribute towards falls
*Visual imparement
**Glaucoma, macular degeneration and retinopathy increase the risk of fallingFact|date=May 2008
**Bifocals can increase the risk of fallingFact|date=May 2008
*Cognitive problems
**Dementia increases the likelihood of falls
*Cardiovascular causes
**Orthostatic hypotension
**Postprandial hypotension
**Carotid sinus syndrome
**Neurocardiogenic syncope - the commonest cause of syncope in A&E patients
**Cardiac arrhythmias
**Structural heart disease, such as valvular heart disease
*Urinary incontinence

Extrinsic Factors

*Poor lighting
*Stairs
*Rugs/floor surfaces
*Clothing/footwear
*Lack of equipment/aids

=Consequences of fallsDepartment of Health, "National service framework for older people; Standard 6 - Falls", Crown Copyright, 24 May 2001, [http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066] accessed:19/5/2008] =

*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 femurFact|date=May 2008.
*"Long Lies"
**Pneumonia
**Pressure sores
**Dehydration
**Hypothermia
*Psychological
**A fear of falling

Presentation and assessment

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 laterFact|date=May 2008.Important features to ask about include:
*The number of falls
*Eye witness account
*Associated features
*Risk factors for falling
*What drugs the faller is taking
*How much alcohol the faller drinks

Investigations

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

A large body of evidence shows that a multi-disciplinary approach to assessment and treatment results in the best outcome [ cite journal | last = Tinetti | first = ME | coauthors = Baker DI, Garrett PA, Gottschalk M, Koch ML, Horwitz RI | year = 1993 | month = March | title = Yale FICSIT: risk factor abatement strategy for fall prevention | journal = J Am Geriatr Soc | volume = 41 | issue = 3 | pages = 315-20 | pmid = 8440856] [ cite journal | last = Tinetti | first = ME | coauthors = Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, Koch ML, Trainor K, Horwitz RI.| year = 1994 | month = September | title = A multifactorial intervention to reduce the risk of falling among elderly people living in the community | journal = N Engl J Med. | volume = 331 | issue = 13 | pages = 821-7 | pmid = 8078528 | url = http://content.nejm.org/cgi/content/full/331/13/821 | accessdate = 2008-05-19] [ cite journal | last = Close | first = J | coauthors = Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. | year = 1999 | month = January | title = Prevention of falls in the elderly trial (PROFET): a randomised controlled trial | journal = Lancet | volume = 353 | issue = 9147 | pages = 93-7| pmid = 10023893] .

Possible interventions include:
*Hip protectors
*Regular exercise
*Treatment for osteoporosis
*Review - monitoring of medications and ongoing medical problems
*Tackling environmental issues

References