Falls in the elderly

Identifying risk factors is crucial in preventing falls, say Dr Leena Menon and Dr Govind Menon.

The most important consequence of falls is osteoporotic fracture (Photograph: SPL)
The most important consequence of falls is osteoporotic fracture (Photograph: SPL)

Falls in the elderly are a growing problem due to the ageing population and it is a challenge for clinicians to manage these patients due to their multiple comorbidities.

It has been difficult to get accurate data on the incidence and prevalence of falls because of the use of varied definitions.

A practical definition was suggested in 1988, which is now used in most studies. This defined a fall as 'an event which results in a person coming to rest unintentionally on the ground or lower level, not as a result of a major intrinsic event, such as stroke, or overwhelming hazard'.1

WHO ICD-9 states that a fall is 'an unexpected event where a person falls to the ground from an upper level or the same level'.

Epidemiology
The majority of falls are not reported. This leads to difficulties in estimating the exact prevalence and incidence of falls in the older population. Epidemiological studies have demonstrated that 28-35 per cent of over-65s will sustain a fall over a one-year period.2 This increases to about 50 per cent in the over-75s as they accrue more comorbidities.3

The problem is compounded by the increasing number of elderly people in the UK. In the past 25 years there has been an increase in the number of people aged over 65 years, to 1.7 million. The fastest growing population has been the over-80s age group, from 660,000 in 1984 to 1.4 million in 2009.

It is predicted that this number will reach 3.5 million by 2034, which will be about 5% of the total population.

Consequences of falls
The most important consequence of falls is osteoporotic fracture, especially of the hip and wrist. Wrist fractures are more common than hip fractures between age 65 and 75, whereas hip fractures are more common in the over-75s.

This is probably due to the older person's slowed reflexes and loss of ability to protect the hip by breaking the fall with the wrist.3

Other consequences include non-fatal injury, fear and loss of function and independence.4

Without doubt this has cost implications on social care and independent living. A hip fracture will cost about £5,000-£20,000 to treat, which will include rehabilitation and social care costs. The UK spends at least £1.7 billion annually on treatment related to falls.5

Risk factors and screening
Identifying risk factors is crucial in preventing falls in the elderly population. Causes have been classified into five major categories: 6

  • Environmental, such as loose carpets, baths without rails, poor lighting, unsafe stairs and ill-fitting shoes.
  • Medication, such as antidepressants, sedatives or hypnotics.
  • Medical conditions associated with ageing, including weakness or arthritis, poor vision and cognitive impairment.
  • Nutritional factors, such as calcium and vitamin D deficiency.
  • Lack of exercise.

Recent guidelines from the American Geriatric Society and British Geriatric Society recommend that any older person coming into contact with a healthcare provider should be screened for falls:7

  • Have they presented with an acute fall?
  • Have they had two or more falls in the past 12 months?
  • Do they have difficulty with walking or balance?

If an older person answers positive to any of the questions or they report a single fall in the past 12 months, they need to be evaluated for gait and balance.

Frequently used tests include the 'get up and go' test. The patient should be observed standing from a chair without the use of their arms and asked to walk three metres, turn around and return to sit down again.8 Any difficulty with this should be noted to trigger a formal multidisciplinary assessment.

There are other risk assessment tools to identify individuals at high risk of falls in a hospital setting. A multifactorial risk assessment (see box below) should be performed by a clinician with appropriate skills and training.

Multifactorial fall risk assessment

History

  • History of falls: detailed description of the circumstances of the fall, frequency, symptoms at the time of the fall, injuries, other consequences, recall of events by witness.
  • Medication review: all prescribed and OTC medications.
  • History of relevant risk factors: acute or chronic medical problems (osteoporosis, urinary incontinence, cardiovascular disease).

Physical examination

  • Assess gait, balance, mobility and lower extremity joint function.
  • Neurological function: cognition, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function.
  • Muscle strength.
  • Cardiovascular: heart rate, rhythm, pulse, BP.
  • Visual acuity.
  • Examination of feet and footwear.

Functional assessment

  • Activities of daily living including use of mobility aids.
  • Individual's perceived functional ability and fear related to falling.

Environmental assessment

  • Including home safety.

Prevention
Prevention should be targeted at high-risk groups. It requires an accurate assessment with targeted multidisciplinary and multifactorial interventions. A significant risk reduction may be achieved in selected populations.

  • Dr Leena Menon is a GP partner, Caerphilly; Dr Govind Menon is a consultant in elderly care medicine, Cardiff

References

1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319: 1701-7.

2. Masud T, Morris RO. Epidemiology of falls. Age Ageing 2001; 30 Suppl 4: 3-7.

3. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006; 35 Suppl 2: ii37-ii41.

4. Berg WP, Alessio HM, Mills EM et al. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing 1997; 26: 261-8.

5. McKay C, Anderson KE. How to manage falls in community dwelling older adults: a review of the evidence. Postgrad Med J 2010; 86: 299-306.

6. Nuffield Institute for Health, University of Leeds and NHS Centre for Reviews and Dissemination. Preventing falls and subsequent injury in older people. Effective Health Care 1996; 2(4): 1-16.

7. Panel on Prevention of Falls in Older People. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older people. J Am Geriatr Soc 2011; 59: 148-57. www.americangeriatrics.org/files/documents/health_care_pros/ JAGS.Falls.Guidelines.pdf

8. Podsiadlo D, Richardson S. The timed 'Up & Go': a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39: 142-8.

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