Falls in older adults are a significant cause of morbidity and mortality and are a major class of preventable injuries. Falling is one of the most common accidents that cause a loss of function, independence, and quality of life for older adults, and is usually precipitated by multiple risk factors.Eibling, D. (2018). Balance disorders in older adults.Clinics in GeriatricMedicine,4(2), 175–181. doi:10.1016/j.cger.2018.01.002Bao X., Qiu Q.-X., Shao Y.-J., Quiben M., Liu H. Effect of Sitting Ba-Duan-Jin Exercises on Balance and Quality of Life among Older Adults: A Preliminary Study. Rehabil. Nurs.. 2020;45(5):271-278. doi:10.1097/rnj.0000000000000219 The cause of falling in old age is often multi-factorial, and a multidisciplinary approach may be needed both to prevent and to treat any injuries sustained.
The definition of a "fall" tends to vary depending on who is reporting the fall and to whom, though it is generally accepted that falling includes dropping from a high position to a low one, often quickly. However a fall does not necessarily mean falling to the ground: the individual could fall back into a chair or bed, and they may be assisted by another person to help slow down the fall and perhaps avoid injury. The severity of injury is generally related to the height of the fall and the individual's health, for example whether there is osteoporosis. The type of surface onto which the person falls is also important as harder surfaces can cause more severe injury.
Sometimes falls can be prevented by ensuring that interior surfaces are dry and free of clutter, carpets are tacked down, paths are well lit, hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated, and shoes have low heels or rubber soles. External surfaces are harder to control but ideally, to reduce falls, it can be helpful to walk on surfaces that are not wet or icy, are well lit, and are flat; and to have hands and arms free to help regain balance or protect from a fall.
A review of clinical trial evidence by the European Food Safety Authority led to a recommendation that people over the age of 60 years should supplement their diet with vitamin D to reduce the risk of falling and bone fractures. Falls are an important aspect of geriatric medicine. In 2018, the United States Preventive Service Task Force actually recommended against vitamin D supplementation to help prevent falls, citing lack of association or conflicting results between the supplement and reduced falls in older adults. Rather, older adults should be screened for osteoporosis; and if diagnosed the need to slow or stop bone loss is paramount. This can be accomplished through proper nutrition, lifestyle changes, exercises, fall prevention strategies and some medications.
Definition Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall. Falls are of concern within medical treatment facilities. Fall prevention is usually a priority in healthcare settings.
A 2006 review of literature identified the need for standardization of falls taxonomy due to the variation within research. The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem. ProFane recommended that a fall be defined as "an unexpected event in which the participants come to rest on the ground, floor, or lower level." The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews.
Signs of the risk of falling A fear of falling or post fall psychological trauma. Anyone, but especially older adults may limit or refuse to move frequently or exercise for fear of recurrent falls and injury.Department of Health, National service framework for older people; Standard 6 – Falls, Crown Copyright, 24 May 2001, accessed:19/5/2008 History of falls History or presence of bruises or fractures Due to bed rest, perhaps from an acute or chronic illness: Pneumonia Pressure sores Dehydration Hypothermia Physical de-condition, weakness, or frailty "Risk factors for falls in order of evidence strength include a history of falls, impairment in balance, reduced muscle strength, visual problems, polypharmacy (defined as taking over four medications) or psychoactive drugs, gait difficulty, depression, orthostasis or dizziness, functional limits, age over 80 years, female sex, incontinence, cognitive difficulties, arthritis, diabetes, and pain"
Symptoms or results of a fall
Trauma Mild injuries. Small bruises or scratches. Moderate to severe injuries. Deep bruises (hematomas), any bone fracture, but commonly hip fractures, or head trauma. Soft tissue injuries. Bilateral orbital haematomas (two black eyes) suggests that the person was probably not conscious as they fell as they did not manage to protect their face before they hit the ground. Fractures and dislocations. 95% of hip fracture in older adults resulted from a fall. Disuse atrophy and muscle wasting from reduced physical activity during recovery periods, perhaps due to recovery of a moderate or severe injury from a fall or any other illness or injury.
Causes Falls are often caused by a number of factors such as intrinsic vs extrinsic or modifiable vs non-modifiable. The older adult who may fall could have 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 may be grouped into intrinsic factors, such as existence of a specific ailment or disease. External or extrinsic factors include the environment and the way in which it may encourage or deter accidental falls. Such factors as lighting and illumination, personal aid equipment and floor traction are all important in fall prevention.
Modifiable risk factors can include items such as gait, strength, and balance deficits, medication used, home hazards, orthostatic hypotension, vision and hearing problems, foot issues or inappropriate footwear and the presence of comorbidities. This is the basis the US Center for Disease Control (CDC) STEADI (STEADI-Stopping Elderly Accidents, Deaths and Injuries) fall prevention initiative. Evidence supports the need for early identification or screening for fall risk, assessment of fall risk factors for the appropriate referral to evidence-based interventions that are patient-specific
Intrinsic factors Balance and gait Organ and physiologic changes occur with age, such as muscle strength, the nervous system (which impacts balance, gait, vision and hearing) As a result of stroke disease, Parkinsonism, arthritic changes, neuropathy, neuromuscular disease or vestibular disease. Visual motor reaction time problems An extended reaction time will delay responses and compensations to standing or walking imbalances, thus increasing the likelihood of falls. Medications Polypharmacy is common in older people (the take of 4 or more medications; high risk medications related to fall risk should also be avoided) There is a list of high-risk medication related to falls in older adults that is derived from the Beer's list; general categories include antihypertensives, antihistamines, benzodiazepines, sedatives, antihyperglycemics and anticonvulsants Visual impairment Visual impairments, glaucoma, macular degeneration and retinopathy increase the risk of falling and of hip fractures. Bifocals and trifocals can increase the risk of falling as the lower portion of corrective lenses are optimized for distances approximately , thus precluding clear vision of one's feet/floor, approximately below one's eyes. 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
Extrinsic factors
These factors are often associated with the built environment (structure, features or buildings) in which people live and work, or community outdoors spaces naturally occurring. Poor lighting due to low luminance of existing lights or lamps, so preventing hazard identification and avoidance. Eyesight deteriorates with age, and extra lighting will be needed where seniors move frequently. The luminance provided by the bulbs used should be higher than normally accepted. Stairs with inadequate handrails, or too steep, encouraging trips and falls. Handrails should approach two inches in diameter as reduced hand strength and coordination are preferred over thinner options. Any grab bars are also of more benefit at larger diameters. The steps should be spaced widely with low risers, and surfaces should be slip-resistant. Softer surfaces can help limit impact injuries by cushioning loads. Doorways with adequate headroom so that the user's head does not hit the lintel. Doorways of low headroom (less than about ) are common in old houses and cottages for example. Rugs/floor surfaces with low friction, causing poor traction and individual instability. All surfaces should have a high friction coefficient with shoe soles and limited clutter. Polished marble floors would be the poorest choice for bathroom or kitchen floors, where various water spills will exacerbate loss of friction. Clothing/footwear poorly fitted, shoes of low friction against floor. Rubber soles with ribs normally have a high friction coefficient or very smooth soles should be avoided as too much traction and too little can both present a fall hazard. Familiar footwear with medium levels of traction is preferred. Clothing should fit the user well, without trailing parts (hems falling below the heel and loose shoelaces) which could snag with obstacles. Lack of equipment/aids such as walking sticks or walking frames, such as Zimmer frames so as to improve user stability. Grab bars and hanging straps should be supplied plentifully, especially in critical areas where users may be vulnerable. The lower part of bifocals and trifocal spectacles provide good focus for reading but usually impair vision of items and obstacles five feet away, in the path of a walker. "Walking glasses" providing a sharp focus to the area immediately in front of a walker is recommended.
Screening and diagnosis There are multiple ways to screen older adults for their risk of falls. Commonly used are subjective questions asking older adults to report their falls or fear of falling. The subjective nature of screening questions, whether they are evidence-based or not, does not always provide an accurate risk screening. Though it can provide a place to start a conversation between older adult and health care provider or older adults and family members/caregivers.
The American Geriatrics Society and the British Geriatrics Society recommend that all older adults should be screened for "falls in the past year". Fall history is the strongest risk factor associated with subsequent falls. Older people who have experienced at least one fall in the last 6 months, or who believe that they may fall in the coming months, should be evaluated with the aim of reducing their risk of recurrent falls. Special attention should be aimed at persons who are living alone, when other fall risk factors are noted.
Many health institutions in the USA have developed screening questionnaires. Enquiry includes difficulty with walking and balance, medication use to help with sleep/mood, loss of sensation in feet, vision problems, fear of falling, and use of assistive devices for walking.
Older adults who report falls should be asked about their circumstances and frequency to assess risks from gait and balance which may be compromised. A clinician performs a fall risk assessment, to include history, physical exam, functional capability, and environment.