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Falls in older adults | |
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Front-wheeled walker | |
Specialty | Emergency medicine, gerontology |
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 in the quality of life for older adults, and is usually precipitated by a loss of balance and weakness in the legs. [1] [2] The cause of falling in old age is often multifactorial and may require a multidisciplinary approach both to treat any injuries sustained and to prevent future falls. [3] Falls include dropping from a standing position or from exposed positions such as those on ladders or stepladders. The severity of injury is generally related to the height of the fall. The state of the ground surface onto which the victim falls is also important, harder surfaces causing more severe injury. Falls can be prevented by ensuring that carpets are tacked down, that objects like electric cords are not in one's path, that hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated and that shoes have low heels or rubber soles. [4]
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 the diet with vitamin D to reduce the risk of falling and bone fractures. [5] Falls are an important aspect of geriatric medicine.
Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall. [6] Falls are of concern within medical treatment facilities. Fall prevention is usually a priority in healthcare settings. [7]
A 2006 review of literature identified the need for standardization of falls taxonomy due to the variation within research. [8] The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem. [9] 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." [9] The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews. [10] [11] [12]
Falls are often caused by a number of factors. The faller may live with many 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. [13]
When assessing a person who has fallen an eyewitness account of the incident is helpful. The person who fell may have had some loss of consciousness and may not be able to give an accurate description of the fall. In practice, these eyewitness accounts are often unavailable. 30% of cognitively intact older people are unable to remember a documented fall three months later.[ citation needed ] Important points of inquiry: [13]
The relationship between the person at risk of falling and their environment is important for determining the risk falls and taking measures to prevent falls. An assessment with an occupational therapist may be helpful to determine an appropriate rehabilitation plan to prevent falls by taking into consideration both the person and their living environment. [14] [15] A large body of evidence shows that efforts to include exercise decrease the risk of falls, [16] [17] and yet the fear of falling can lead to a decrease in participation in physical exercise. [14]
Possible interventions to prevent falls include:
Improvements to the person's environment such as their home or workplace may help to reduce the risk of falling. [14]
People who are hospitalized are at risk for falling. A randomized trial showed that use of a tool kit reduced falls in hospitals. Nurses complete a valid fall risk assessment scale. From that, a software package develops customized fall prevention interventions to address patients' specific determinants of fall risk. The kit also has bed posters with brief text and an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders. [25]
American Geriatrics society (AGS)/British Geriatrics Society (BGS) 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. [26] 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. [27]
Many health institutions in 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 fall risk assessment is done by a clinician to include history, physical exam, functional capability, and environment. [28]
The incidence of falls increases progressively with age. According to the existing scientific literature, approximately one-third of the elderly population experiences one or more falls each year, while 10% experience multiple falls annually. The risk is greater in people older than 80 years, in which the annual incidence of falls can reach 50%. [29] [30] [31] [32] [33]
Researchers have tried to create a consensual definition of a fall since the 1980s. Tinneti et al. defined a fall as "an event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard." [34]
The health care impact and costs of falls in older adults are significantly rising all over the world. The cost of falls is categorized into 2 aspects: direct cost and indirect cost.
Direct costs are what patients and insurance companies pay for treating fall-related injuries. This includes fees for the hospital and nursing home, doctors and other professional services, rehabilitation, community-based services, use of medical equipment, prescription drugs, changes made to home and insurance processing.
Indirect costs include the loss of productivity of family caregivers and long-term effects of fall-related injuries such as disability, dependence on others and reduced quality of life.
In the United States alone, the total cost of falling injuries for people 65 and older was $31 billion in 2015. The costs covered millions of hospital emergency room visits for non-fatal injuries and more than 800,000 hospitalizations. By 2030, the annual number of falling injuries is expected to be 74 million older adults. [35]
Furthermore, a 2012 systematic review has demonstrated that performing dual-task tests (for example, combining a walking task with a counting task) may help in predicting which people are at an increased risk of a fall. [3]
Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the vertebrae in the spine, the bones of the forearm, the wrist, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. After the broken bone heals, the person may have chronic pain and a decreased ability to carry out normal activities.
Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control. Aside from memory impairment and a disruption in thought patterns, the most common symptoms of dementia include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, their caregivers, and their social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than might be caused by the normal aging process.
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. These may occur a few times a day or a few times per week. Depending on the person, asthma symptoms may become worse at night or with exercise.
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity of the condition is variable.
Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.
Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, fatigue and unexplained weight loss. Symptoms may also include increased hunger, having a sensation of pins and needles, and sores (wounds) that do not heal. Often symptoms come on slowly. Long-term complications from high blood sugar include heart disease, stroke, diabetic retinopathy which can result in blindness, kidney failure, and poor blood flow in the limbs which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon.
Delirium is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days. As a syndrome, delirium presents with disturbances in attention, awareness, and higher-order cognition. People with delirium may experience other neuropsychiatric disturbances, including changes in psychomotor activity, disrupted sleep-wake cycle, emotional disturbances, disturbances of consciousness, or, altered state of consciousness, as well as perceptual disturbances, although these features are not required for diagnosis.
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone. It is believed to be the fourth leading cause of disability in the world, affecting 1 in 7 adults in the United States alone. The most common symptoms are joint pain and stiffness. Usually the symptoms progress slowly over years. Other symptoms may include joint swelling, decreased range of motion, and, when the back is affected, weakness or numbness of the arms and legs. The most commonly involved joints are the two near the ends of the fingers and the joint at the base of the thumbs, the knee and hip joints, and the joints of the neck and lower back. The symptoms can interfere with work and normal daily activities. Unlike some other types of arthritis, only the joints, not internal organs, are affected.
Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases, heart failure, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, arrhythmia, congenital heart disease, valvular heart disease, carditis, aortic aneurysms, peripheral artery disease, thromboembolic disease, and venous thrombosis.
Stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functioning properly.
Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction. The most common sites are the skin overlying the sacrum, coccyx, heels, and hips, though other sites can be affected, such as the elbows, knees, ankles, back of shoulders, or the back of the cranium.
Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions. The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time. Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older. In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population. In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects. Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.
A hip fracture is a break that occurs in the upper part of the femur, at the femoral neck or (rarely) the femoral head. Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Usually the person cannot walk.
Respiratory tract infections (RTIs) are infectious diseases involving the lower or upper respiratory tract. An infection of this type usually is further classified as an upper respiratory tract infection or a lower respiratory tract infection. Lower respiratory infections, such as pneumonia, tend to be far more severe than upper respiratory infections, such as the common cold.
Fall prevention includes any action taken to help reduce the number of accidental falls suffered by susceptible individuals, such as the elderly (idiopathic) and people with neurological or orthopedic indications.
A hip protector is a specialized form of pants or underwear containing pads along the outside of each hip/leg, designed to prevent hip fractures following a fall. Recent developments include the use of double-sided adhesive films that are breathable and more comfortable to wear than specialised pants. The adhesive films are safer because they can be worn in the bath or shower, or when toileting. Hip protectors are most commonly used in elderly individuals who have a high risk of falls and hip fractures.
Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. Frailty is a condition associated with ageing, and it has been recognized for centuries. It is a marker of a more widespread syndrome of frailty, with associated weakness, slowing, decreased energy, lower activity, and, when severe, unintended weight loss. As a frequent clinical syndrome in the elderly, various health risks are linked to health deterioration and frailty in older age, such as falls, disability, hospitalization, and mortality. Generally, frailty refers to older adults who lose independence. It also links to the experiences of losing dignity due to social and emotional isolation risk. Frailty has been identified as a risk factor for the development of dementia.
Falling is the action of a person or animal losing stability and ending up in a lower position, often on the ground. It is the second-leading cause of accidental death worldwide and a major cause of personal injury, especially for the elderly. Falls in older adults are a major class of preventable injuries. Construction workers, electricians, miners, and painters are occupations with high rates of fall injuries.
Geriatric trauma refers to a traumatic injury that occurs to an elderly person. People around the world are living longer than ever. In developed and underdeveloped countries, the pace of population aging is increasing. By 2050, the world's population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. While this trend presents opportunities for productivity and additional experiences, it also comes with its own set of challenges for health systems. More so than ever, elderly populations are presenting to the Emergency Department following traumatic injury. In addition, given advances in the management of chronic illnesses, more elderly adults are living active lifestyles and are at risk of traumatic injury. In the United States, this population accounts for 14% of all traumatic injuries, of which a majority are just mainly from falls.
Prevention of type 2 diabetes can be achieved with both lifestyle changes and use of medication. The American Diabetes Association categorizes people with prediabetes, who have glycemic levels higher than normal but do not meet criteria for diabetes, as a high-risk group. Without intervention, people with prediabetes progress to type 2 diabetes with a 5% to 10% rate. Diabetes prevention is achieved through weight loss and increased physical activity, which can reduce the risk of diabetes by 50% to 60%.