Falls in the elderly

1. Epidemiology and aetiology

Falls are a major health concern for older people. One third of the population aged 65 years and over has a fall each year. This rises to 50 per cent of those aged 85 years and above. Of those who fall, 50 per cent have multiple falls.

There are no clinically useful ethnic variations in falls rates, but fracture risk is higher in those prone to osteoporosis, particularly Caucasian women. The incidence of falls is higher for the first three months following relocation to a new environment.

Falls are a leading cause of injury-related hospitalisation in those aged 65 and over. The NHS spends about £1.7 billion per year on costs related to falls.

About a third of older people develop a fear of falling after a fall, which puts them at a higher risk of further falls, reduced activities of daily living and increased institutionalisation.

It is important to realise that, although age is a risk factor, falls are not inevitable. Patient risk identification and prevention strategies can prevent a large proportion of falls.

Risk factors
Falls can be classified in various ways: injurious versus non-injurious and explained versus unexplained. Risks are intrinsic, pertaining to the physical or cognitive state of the patient, or extrinsic - environmental hazards.

Classification
The key task is to distinguish a fall from standing height from syncope. The term accidental fall can be misleading as many patients with postural instability are not aware of this unless distracted or displaced, for example by an uneven paving stone.

Risk factors for falling

  • Age.
  • Female sex.
  • History of falls.
  • Reduced ability to perform activities of daily living.
  • Impaired balance, mobility or gait.
  • Poor vision.
  • Reduced peripheral sensation.
  • Medical conditions (Parkinson's disease, stroke, arthritis).
  • Cognitive impairment.
  • Four or more medications/psychoactive drugs.
  • Urge incontinence.

2. Making a diagnosis

History
Patients often omit to mention falls. Therefore, inquiries about falls, risk factors and fear of falling should be made of all older people, at least yearly.

After a fall, a history should be taken of previous falls and their context, and symptoms and behaviour preceding each event.

Dizziness is a particularly difficult symptom to pin down. It might mean unsteadiness, vertigo, orthostatic hypotension, confusion or a combination of these.

Difficulty or dependency in everyday personal or domestic care should also be considered. Tools have been developed to structure the necessary inquiries, for example the elderly fall screening test.

Examination
A full clinical examination, focusing particularly on cardiovascular, neurological and joint problems, should also include assessments of cognition - abbreviated mental test score - and visual acuity - coarsely tested by reading small print.

An orthostatic drop of systolic blood pressure of more than 20mmHg or of diastolic pressure of more than 10mmHg is significant, particularly when symptomatic. Testing this requires the patient to lie down for 10 minutes, then blood pressure is measured while standing for one, two and three minutes.

Gait and balance can be assessed by observing the 'timed up and go' test: the patient rises from a dining-room-type chair, walks 3m - with their usual assistance device - turns and returns to sit down. If this takes 15 seconds or more, or looks unsteady, then a diagnostic assessment and mobility treatment plan is needed. This might require referral to a geriatrician or physiotherapist, and an assessment of home hazards and ergonomic challenges.

Risk factors for osteoporosis should also be sought, including low BMI - 19 or less - or height loss of more than two inches.

Investigations
After a fall many older patients and all frail patients should have an FBC, renal, liver and bone profiles, and perhaps measurement of 25-OH-vitamin D levels, as most patients attending a falls clinic are deficient.

Other investigations should be determined individually. Significant abnormal findings on echocardiogram or 24-hour cardiac monitoring are unlikely if the cardiac examination and resting ECG are normal.

Syncope usually requires specialist assessment including carotid sinus massage and tilt table testing. A similar approach is needed for patients with recurrent unexplained falls. Brain imaging is unlikely to help in the absence of focal neurological signs.

3. Managing the condition

The mainstays of management are strength and balance training, home hazard assessment and safety interventions and optimising medication and vision. Medication review requires particular scrutiny of 'culprit medications', which are those with cardiovascular or CNS effects.

Other medical treatments are aimed at the underlying condition, for example cardiac pacing for heart block, and ongoing review of progressive conditions such as Parkinson's disease. Orthostatic hypotension may improve with increased fluid intake (two litres daily), in repeated small amounts, head-up tilt of the bed and elastic stockings. For a few, fludrocortisone may be necessary.

Strength and balance training has good evidence for falls reduction, but exercises must be progressive in intensity and maintained.

Correcting impaired visual acuity is helpful. There is class-one evidence that cataract extraction can reduce falls (by up to 34 per cent) and fractures. Bifocal lenses are implicated in some falls, particularly on stairs or slopes, and may need to be avoided.

Although vitamin D deficiency impairs muscle strength and balance, recent trials have not confirmed earlier evidence that vitamin D plus calcium reduces falls and fractures in frail older people. Despite this, most geriatricians still prescribe it.

NICE advises that women aged 75 years and over who have sustained a fragility fracture, including vertebral body collapse, should be offered secondary osteoporosis prevention, initially with calcium, vitamin D and a bisphosphonate.

Although hip protectors can reduce fall impact and fractures in some individuals, their widespread use in the community has not proved effective, partly due to low adherence rates.

26 June is National Falls Awareness Day. For more information, visit www.helptheaged.org.uk/fallsday

Contributed by Dr Belinda McCall and Dr Indu Koshi, specialist registrars in geriatric and general medicine, Guy's and St Thomas' NHS Foundation Trust, London.

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