Falls in the Elderly

Falls in the Elderly

People 60 years and above are referred to as Elders or Senior citizens. They are about 700,000 in the world today. This number is expected to increase to 2 billion in the year 2050.  Of this number 67% will live in the developing countries. There will be more elders than children by then. Unfortunately the bulk in the developed world are illiterates who will not be able to read as such are not privy to information available on the dangers in falls.

Falls in the Elderly

A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders (eg, stroke, seizure) or overwhelming environmental hazards (eg, being struck by a moving object) are not considered falls.

Annually, 30 to 40% of elderly people older than 65years fall. Falls are the leading cause of accidental death and the 7th leading cause of death in people above 65.

Falls threaten the independence of elderly people and cause a cascade of individual and socioeconomic consequences. However, physicians are often unaware of falls in patients who do not present with an injury because a routine history and physical examination typically do not include a specific evaluation for falls. Many elderly people are reluctant to report a fall because they attribute falling to the aging process or because they fear being subsequently restricted in their activities or institutionalized.

Etiology

The best predictor of falling is a previous fall. However, falls in elderly people rarely have a single cause or risk factor. A fall is usually caused by a complex interaction among the following:

• Intrinsic factors (age-related decline in function, disorders, and adverse drug effects)
• Extrinsic factors (environmental hazards)
• Situational factors (related to the activity being done, eg, rushing to the bathroom)

Intrinsic factors

Age-related changes can impair systems involved in maintaining balance and stability (eg, while standing, walking, or sitting). Visual acuity, contrast sensitivity, depth perception, and dark adaptation decline. Changes in muscle activation patterns and ability to generate sufficient muscle power and velocity may impair the ability to maintain or recover balance in response to perturbations (eg, stepping onto an uneven surface, being bumped). In fact, muscle weakness of any type is a major predictor of falls.

Chronic and acute disorders are major risk factors for falls. The risk of falls increases with the number of drugs taken. Psychoactive drugs are the drugs most commonly reported as increasing the risk of falls and fall-related injuries.

Extrinsic factors

Environmental factors can increase the risk of falls independently or, more importantly, by interacting with intrinsic factors. Risk is highest when the environment requires greater postural control and mobility (eg, when walking on a slippery surface) and when the environment is unfamiliar (eg, when relocated to a new home).

Situational factors

Certain activities or decisions may increase the risk of falls and fall-related injuries. Examples are walking while talking or being distracted by multitasking and then failing to notice an environmental hazard (eg, a curb or step), rushing to the bathroom (especially at night when not fully awake or when lighting may be inadequate), and rushing to answer the telephone.

Complications

Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death, particularly in elderly people who are frail and have preexisting disease comorbidities (eg, osteoporosis) and deficits in activities of daily living (eg, incontinence). Longer-term complications can include decreased physical function, fear of falling, and institutionalization.

Over 50% of falls among elderly people result in an injury. Although most injuries are not serious (eg, contusions, abrasions), fall-related injuries account for about 5% of hospitalizations in patients ≥ 65. About 5% of falls result in fractures of the humerus, wrist, or pelvis. About 2% of falls result in a hip fracture. Other serious injuries (eg, head and internal injuries, lacerations) occur in about 10% of falls. Some fall-related injuries are fatal. About 5% of elderly people with hip fractures die while hospitalized.

About half of elderly people who fall cannot get up without help. Remaining on the floor for more than 2 hours after a fall increases risk of dehydration, pressure ulcers, rhabdomyolysis, hypothermia, and pneumonia.

Function and quality of life may deteriorate drastically after a fall; at least 50% of elderly people who were ambulatory before fracturing a hip do not recover their previous level of mobility. After falling, elderly people may fear falling again, so mobility is sometimes reduced because confidence is lost. Some people may even avoid certain activities (eg, shopping, cleaning) because of this fear. Decreased activity can increase joint stiffness and weakness, further reducing mobility.

Common Causes of Fall in the Elderly*

Accident, environmental hazard, fall from bed

Gait disturbance, balance disorders or weakness, pain related to arthritis

Vertigo Visual disorder

Medications or alcohol

Acute illness

Confusion and cognitive impairment

Central nervous system disorder, syncope, drop attacks, epilepsy adapted from :Laurenze R Rubenstein 2013 and American Academy of family health