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MarittaSalonoja

Falls of the Elderly

Essentials

  • Falling is common among the elderly, and its cause must be found out.
  • Falling can be prevented by reducing the risk factors and by exercises.
  • When an elderly person comes to an appointment, ask about falls during the previous 12 months.
  • Reduce already in advance both the person-related (internal) and the environment-related (external) risk factors for falling.
  • Consider also the prevention and treatment of osteoporosis.

Epidemiology

  • 30-40% of persons aged ≥ 65 years and every second of persons aged ≥ 80 years or of those living in institutionalized care fall at least once a year. One in seven elderly persons falls several times per year.
  • Almost every second of the fallers incurs some type of injury. Every tenth fall leads to a serious injury, e.g. a hip fracture.

Risk groups

  • Oldest of the elderly
  • Elderly persons with
    • a history of falling
    • a memory disorder
    • weakened thigh muscles and impaired balance
    • mobility impairments or persons who otherwise move about only a little
    • difficulties in the activities of daily living

Risk factors for falls

Internal

  • Poor thigh muscle strength and/or impaired balance
  • Medications, alcohol
    • Polypharmacy increases the risk
    • Specific risk medications include benzodiazepines and their derivatives.
    • Other risk medications include other centrally acting drugs (pain medication and psychotropic medication) as well as blood pressure lowering drugs.
    • Alcohol use has increased in the elderly age groups. About one third of patients admitted for the treatment of a hip fracture have alcohol in their blood.
  • Any acute condition/disease may impair the general status and lead to a fall
  • Chronic diseases and symptoms
    • Vertigo/dizziness
      • A common symptom in the advanced years of life, associated with balance difficulties and decreasing functional ability; doubles the risk of falling.
      • Multifactorial aetiology
    • Memory diseases and other neurological diseases, depression, osteoarthrosis, orthostatic hypotension, urinary incontinence
    • Impaired vision or hearing
    • Malnutrition, frailty (gerastenia)
  • Fear of falling

External

  • Slippery surface, poor lighting, rough surface, obstacles, need to reaching for objects, stairs
  • Poor shoes, unsuitable assistive devices

Examining the falling patient

History

  • First, investigate the cause of the fall and assess fall risk.
  • History suggests the possible cause of the fall. The patient, caregivers, eye witnesses should be interviewed. Often there are several causes and risk factors in the background.
    • In what situation did the patient fall?
      • Getting out of bed, while walking, in the toilet, reaching out, at rest or during exertion
      • Time of the day
    • 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
    • Did the patient get up without help, how soon, and what was the state of consciousness?
    • Recent changes in the state of health; review the patient's medication, eating and drinking

Physical examination

Laboratory examinations

  • Examine as needed: basic blood count with platelet count, plasma potassium, sodium, CRP, creatinine (GFR Gfr Calculator), blood glucose, calcium (ionized), serum 25(OH)D, chemical urinalysis, ECG (consider also Holter).

Radiological examinations

  • Chest x-ray and head CT scan when needed

Management

  • Prevention of falls is the best treatment: identify risk factors and risk groups.
  • Treat acute illnesses and check management of chronic diseases.
  • Check the medications, including over the counter drugs. Remove the unnecessary ones.
    • Medications for dizziness are not beneficial in preventing falls, unless orthostatism is detected.
  • Draw up a care plan to manage the causes and risk factors of falling.
  • Assessment of risk factors together with individual interventions, as well as regular exercise, play a role in the prevention of falls.
    • Checking/planning the use of assistive devices and grab rails
    • External hip protectors can prevent 60% of hip fractures in high-risk persons Hip Protectors for Preventing Hip Fractures in Older People.
    • Regular physical exercise prevents falling Physical Activity and Prevention of Falls in Elderly, increases muscle strength and improves balance.
    • Balance, strength of the thigh muscles, gait and blood pressure should be followed up when a drug affecting the central nervous system or the blood pressure is started in an elderly patient who has risk factors for falling.
  • Prevent osteoporosis.
  • Treat osteoporosis.

Reducing the risk factors Reducing Falls in Acute Hospitals

  • See table T1.

Falls of the elderly-reducing the risk factors

Risk factorIntervention
Impaired visionChecking the eyeglasses, correcting the refractive error, management of cataracts, improving lighting
Impaired hearingHearing aid, other assistive devices
Impaired sense of balanceRemoving medicines affecting balance, balance exercises, walking.
Weakened muscle strengthMuscle strength exercises, walking
MedicationElimination of polypharmacy, if possible. Avoiding any single strongly anticholinergic drug or combinations of several mild anticholinergics, avoiding tricyclic and SSRI antidepressants and drugs causing orthostatism. Avoiding benzodiazepines, opioids, antipsychotic agents, reducing doses, checking the duration of treatment
MalnutritionRecognizing depression, memory disorders and malignant diseases. Examining and treating other conditions leading to malnutrition.
DepressionRecognizing depression
Nonpharmacological treatment and medicines if needed (no tricyclic antidepressants)
Memory diseasesRemoving unnecessary medicines, avoiding anticholinergic drugs and benzodiazepines, optimal treatment of chronic diseases, improving home safety, exercises
Foot problemsManagement of callus and hallux valgus, appropriate shoes
Parkinson's diseaseChecking the medication, treating orthostatism, physical activity and walking exercises, rehabilitation
Orthostatic hypotension
Checking medicines, sufficient intake of fluids, rest after dining, raising the head end of the bed, slow rising to upright position
Possible medication: fludrocortisone (0.1 mg ½ × 1, up to 1 × 2)
Degeneration of the cervical spinePersonal belongings at an easy reach, physiotherapy
Musculoskeletal disordersTreating underlying diseases; walking aids, non-slip spikes on soles and on the cane, improved home safety

Improving the home safety

  • A home visit is often needed: the patient and the caregiver should check with a doctor, physiotherapist or home nurse what arrangements are needed at home.
    • Lighting: adequate general lighting, a light in the staircase and a night light in the bedroom and the toilet.
    • Clear access: in the apartment, in the staircase, in the yard, removal of snow and ice in the wintertime
    • Handrails in stairs
    • Low-edged carpets, anti-sliding friction material underneath, removal of doorsteps and carpets when needed
    • Toilet and bathroom: handles, non-slip floor and bathtub bottom and a raised toilet seat. A lock on the door of the toilet should also open from the outside.
    • Steady and high enough chairs and bed.
    • Kitchen: Items should be accessible without having to reach.
    • Appropriate shoes (low, non-slip heal)
  • If the safety of the patient (and the caregiver) seems to be insufficient, consider arranging for a home nurse or home aid to follow up the patient and obtaining a safety telephone in case of further falls.

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