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Falls of the Elderly

Essentials

  • Falls are common among the elderly They usually occur indoors, at home when doing daily chores.
  • The consequences of falls may be severe.
  • The reasons for falling must be found out. To prevent further falls, a plan should be written including measures to reduce risk factors and physical exercises.
  • Think also about the prevention and treatment of osteoporosis Osteoporosis.

Epidemiology

  • One in three adults aged ≥ 65 years and one in two adults aged ≥ 80 years or living in institutionalized care fall at least once a year. One in seven elderly people falls several times per year.
  • Almost one in two of the falls results in some type of injury. Every tenth fall leads to a serious injury, e.g. a hip fracture.
  • In many cases, falling also causes impaired functional ability, fear of falling and depression.

Risk groups

Risk factors for falls

  • The risk factors are divided into external and internal factors. In addition, risk factors associated with activity can be distinguished. Most falls are due to several factors that are simultaneously present.
  • A history of falls is a strong predictor of recurring falls.
  • The significance of internal factors increases with age.

Internal

  • Advanced age
  • Impaired muscle strength in lower limbs
  • Impaired balance
  • Medication increasing the risk of falls (polypharmacy, psychotropic drugs, opioids, potent anticholinergic drugs, blood pressure lowering drugs and drugs causing orthostatism)
  • Alcohol
  • Impaired vision or hearing
  • Any acute condition/disease
  • Chronic diseases (memory disorders, depression, Parkinson's disease, degenerative diseases of lower limbs, sequel of paralysis, diabetes)
  • Vertigo/dizziness
  • Urinary incontinence
  • Undernutrition

Associated with activity

  • Reaching out
  • Acting in a hurry
  • Getting up
  • Walking in socks/stockings

External

  • Slippery surfaces, , thresholds, edges of carpets, stairs
  • Poor lighting
  • Poor shoes, unsuitable assistive devices

Examining a patient who has fallen

History

  • The history suggests the possible cause of the fall. The patient, caregivers and eye witnesses should be interviewed.
  • Any injuries, reasons for falling and risk factors
  • In what situation did the patient fall?
    • Getting out of bed, walking, reaching out, hurrying
    • Time of day, place
    • External factors
    • Did the patient get up again without help and how soon (lying for a long time will cause complications)?
  • Other symptoms associated with the fall
    • Dizziness, loss of bladder control, chest pain (hypotensive collapse caused by nitroglycerin?), arrhythmia, unconsciousness before or after the fall, convulsions
  • Recent changes in the state of health, medication, eating or drinking

Physical examination

  • General status
    • Walking ability (walking into the office), need for aids
    • Nutritional state
    • Frailty (gerastenia) and its degree
    • Mood, cognition
  • Cardiovascular system
    • Blood pressure in the sitting position and 30 s and 3 min after standing up Brief Orthostatic Test
    • Auscultation of the heart (heart rate, murmurs, arrhythmia)
  • Senses
    • Near and far vision (ophthalmological examination within the past 12 months is enough; otherwise E chart, reading text)
    • Hearing (speech from 1 m)
  • Neurological examinations
    • Unilateral symptoms, sensation in lower limbs
    • Balance (walking, standing on one foot for more than 5 s, Romberg)
    • Muscle strength (getting up from a chair, hand grip strength when squeezing the examiner's hands)
    • Stiffness, slowness (Parkinson's disease, some memory disorders)
  • Examination of joints in lower limbs (osteoarthritis)
  • The risk of falling can be assessed with tools such as FROP-COM http://www.nari.net.au/frop-com and FRAT http://www.physio-pedia.com/Falls_Risk_Assessment_Tool_(FRAT). Find out also about local tools.

Multiprofessional assessment of risk of falling

  • If the cause of falling in an elderly person living at home remains unclear, they have several risk factors for falling or have sustained severe injury, more detailed investigations and measures should be planned multiprofessionally at a “falls clinic”. A multiprofessional team should include at least a geriatrician or a physician with expertise in the treatment of the elderly, a nurse and a physiotherapist.
  • The assessment should include investigating the causes of falling and planning measures to prevent further falls together with the elderly person and their family.
    • Written plan
    • The effects of the measures and rehabilitation should be followed up individually in 3-6 months.
  • Treatment of osteoporosis

Assessment methods

Laboratory examinations

  • The following tests should be done if falling is suspected to have been caused by a disease or if the elderly person was lying on the floor for a long time after falling.
  • Basic blood count with platelet count, potassium, sodium, CRP, creatinine (GFR Gfr Calculator), plasma glucose, ionized calcium, 25-OH vitamin D, chemical urinalysis
  • ECG (consider also Holter)

Imaging

Management Reducing Falls in Acute Hospitals

  • Prevention of falls by reducing risk factors is the best treatment. See table T1.
    • Experts such as an ophthalmologist, physiotherapist, therapeutic dietitian or memory nurse can be involved in the treatment.
  • The risk of falls should be assessed at least annually in association with the follow-up of other diseases.

Falls of the elderly-reducing the risk factors

Risk factorInterventions
Impaired sense of balanceBalance exercises in a group or individually according to a programme made by a physiotherapist
Other physical exercise
Removing or replacing medicines affecting balance
Assessment of aids and appliances, checking home safety Home Fall-Hazard Reduction for Preventing Falls in Older People
Reduced muscle strength, physical inactivityMuscle strength exercises in a group or individually according to a programme drawn up by a physiotherapist
Walking
Dietary assessment and guidance Assessment of Nutritional Status in the Elderly
Assessment of aids and appliances, checking home safety
Medication associated with risk of fallsReduction of polypharmacy, checking the doses and duration of treatment with any required medication Managing the Medication of Elderly People
  • Any single strongly anticholinergic drug or combinations of several mild anticholinergics
  • Tricyclic and SSRI antidepressants
  • Drugs causing orthostatism
  • Benzodiazepines, opioids, antipsychotic agents
AlcoholMini intervention Brief Interventions for Risky Use of Alcohol
Comprehensive geriatric assessment
Group therapy, peer support
Vision, hearingChecking the eyeglasses, correcting any refractive error, management of cataracts, low vision aids
Improving lighting, checking home safety
Hearing aid, other assistive devices for hearing
Undernutrition Assessment of Nutritional Status in the ElderlyRecognizing and treating conditions making patients susceptible to undernutrition
Assessment by a therapeutic dietitian
Fear of fallingGuided balance and physical exercises
Acute diseasesDetection and treatment
Chronic diseasesDepression Depression in the Elderly
Memory disorders Treatment of a Patient with Memory Disease
Parkinson's disease Parkinson's Disease
Musculoskeletal disorders
Orthostatic hypotension Hypertension in Elderly PatientsChecking the medication, fludrocortisone 0.1 mg ½ tablet once daily, up to 1 tablet twice daily, as necessary
Sufficient fluid intake
Rest after meals
Raising the head end of the bed
Slow rising to upright position
Compression stockings
Dizziness Vertigo
Foot problemsAssessment by a chiropodist, management of calluses and corns
Appropriate shoes
Degeneration of the cervical spinePersonal belongings and other items at a height easy to reach
Physiotherapy, pain management
Risk factors at homeAssessment on home visit, alterations as necessary Home Fall-Hazard Reduction for Preventing Falls in Older People

Bone treatment

Improving the home safety

  • Assessment should be done and recommendations given by the caregiver, a home nurse or a physiotherapist according to the elderly patient's needs Home Fall-Hazard Reduction for Preventing Falls in Older People.
    • Lighting: adequate general lighting, a light in the staircase and a night light in the bedroom and the toilet
    • Clear access (in the apartment, on the staircase, in the yard, removal of snow and ice in the wintertime)
    • Handrails on stairs
    • Ensure carpets are well fitted with low edges, use anti-slip underlay or backing for carpets, and, as necessary, remove raised thresholds and carpets.
    • Toilet and bathroom: handles, non-slip floor and bathtub / shower cubicle floor, and, as necessary, a raised toilet seat. The lock on the door of the toilet should also open from the outside.
    • Steady and high enough chairs and bed, support rails
    • Kitchen: Items should be accessible without having to reach
    • Appropriate shoes worn at home (low, non-slip heal)
  • If the safety of the patient seems to be insufficient, consider arranging for follow-up (by a home nurse and/or home aid) and obtaining a safety telephone in case of further falls, particularly if the elderly person cannot get up from the floor independently.

Community planning

  • Sufficient sanding of the streets in wintertime
  • Benches along the streets and in the shops
  • Low-floor vehicles in public transportation
  • Safe street crossing

    References

    • Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 2022;51(9): [PubMed]
    • Xu Q, Ou X, Li J. The risk of falls among the aging population: A systematic review and meta-analysis. Front Public Health 2022;10():902599 [PubMed]
    • Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing 2021;50(4):1189-1199 [PubMed]
    • Seppala LJ, van de Glind EMM, Daams JG, et al. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others. J Am Med Dir Assoc 2018;19(4):372.e1-372.e8 [PubMed]
    • Hohtari-Kivimäki U, Salminen M, Vahlberg T, et al. Orthostatic Hypotension is a Risk Factor for Falls Among Older Adults: 3-Year Follow-Up. J Am Med Dir Assoc 2021;22(11):2325-2330 [PubMed]
    • Hohtari-Kivimäki U, Salminen M, Vahlberg T, et al. Predicting Value of Nine-Item Berg Balance Scale Among the Aged: A 3-Year Prospective Follow-Up Study. Exp Aging Res 2016;42(2):151-60 [PubMed]
    • Dautzenberg L, Beglinger S, Tsokani S, et al. Interventions for preventing falls and fall-related fractures in community-dwelling older adults: A systematic review and network meta-analysis. J Am Geriatr Soc 2021;69(10):2973-2984 [PubMed]
    • Rikkonen T, Sund R, Koivumaa-Honkanen H, et al. Effectiveness of exercise on fall prevention in community-dwelling older adults: a 2-year randomized controlled study of 914 women. Age Ageing 2023;52(4): [PubMed]
    • Chiu CY, Ng MY, Lam SC, et al. Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis. Clin Rehabil 2023;37(3):294-311 [PubMed]