Falls in older adults

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Falls in older adults
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Specialty Emergency medicine, gerontology
Accidental deaths in the United States
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2020

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2004
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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]

Contents

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.

Definition

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]

Signs and symptoms

Causes

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]

Intrinsic factors

Extrinsic factors

Hanging straps with triangular handles in a modern Japanese commuter train Tokyu 5050 series EMU 001.JPG
Hanging straps with triangular handles in a modern Japanese commuter train
Grab rails on a longer-distance commuter train catering for mainly seated passengers Passenger compartment Class 440.jpg
Grab rails on a longer-distance commuter train catering for mainly seated passengers
A staircase with metal handrails BMF Gelander.jpg
A staircase with metal handrails

Diagnosis

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]

Prevention

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:

Environmental adaptations

Improvements to the person's environment such as their home or workplace may help to reduce the risk of falling. [14]

Behavioural interventions

Interventions to minimize the consequences of falls

Hospital

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]

Screening

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]

Epidemiology

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]

History

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]

Economics

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]

Research

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]

Related Research Articles

<span class="mw-page-title-main">Osteoporosis</span> Skeletal disorder

Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone sterility, 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.

<span class="mw-page-title-main">Urinary tract infection</span> Infection that affects part of the urinary tract

A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney infection (pyelonephritis). Symptoms from a lower urinary tract infection include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection include fever and flank pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody. In the very old and the very young, symptoms may be vague or non-specific.

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is the general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, and behavior. Aside from memory impairment and a disruption in thought patterns, the most common symptoms 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, caregivers, and on 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 what is caused by normal aging.

<span class="mw-page-title-main">Asthma</span> Long-term inflammatory disease of the airways of the lungs

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.

<span class="mw-page-title-main">Pneumonia</span> Inflammation of the alveoli of the lungs

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.

<span class="mw-page-title-main">Type 2 diabetes</span> Type of diabetes mellitus with high blood sugar and insulin resistance

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, strokes, 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.

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<span class="mw-page-title-main">Cardiovascular disease</span> Class of diseases that involve the heart or blood vessels

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<span class="mw-page-title-main">Upper respiratory tract infection</span> Medical condition

An upper respiratory tract infection (URTI) is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, larynx or trachea. This commonly includes nasal obstruction, sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold. Most infections are viral in nature, and in other instances, the cause is bacterial. URTIs can also be fungal or helminthic in origin, but these are less common.

<span class="mw-page-title-main">Pressure ulcer</span> Skin ulcer (bed sore)

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.

<span class="mw-page-title-main">Polypharmacy</span> Use of five or more medications daily

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.

<span class="mw-page-title-main">Hip fracture</span> Broken bone in hip joint region

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.

<span class="mw-page-title-main">Sarcopenia</span> Muscle loss due to ageing or immobility

Sarcopenia is a type of muscle loss that occurs with aging and/or immobility. It is characterized by the degenerative loss of skeletal muscle mass, quality, and strength. The rate of muscle loss is dependent on exercise level, co-morbidities, nutrition and other factors. The muscle loss is related to changes in muscle synthesis signalling pathways. It is distinct from cachexia, in which muscle is degraded through cytokine-mediated degradation, although the two conditions may co-exist. Sarcopenia is considered a component of frailty syndrome. Sarcopenia can lead to reduced quality of life, falls, fracture, and disability.

<span class="mw-page-title-main">Respiratory tract infection</span> Infectious disease affecting nose, throat and lungs

Respiratory tract infections (RTIs) are infectious diseases involving the 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.

<span class="mw-page-title-main">Fall prevention</span> Interventions to prevent injury in domestic settings

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.

<span class="mw-page-title-main">Hip protector</span>

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.

<span class="mw-page-title-main">Frailty syndrome</span> Weakness in elderly person

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.

<span class="mw-page-title-main">Falling (accident)</span> Cause of injury or death

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.

<span class="mw-page-title-main">Geriatric trauma</span> Medical condition

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%.

References

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  2. ↑ Bao 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
  3. 1 2 Sarofim M (2012). "Predicting falls in the elderly: do dual-task tests offer any added value? A systematic review". Australian Medical Student Journal. 3 (2): 13–19.
  4. ↑ Chang, Huan J. (2010-01-20). "Falls and older adults". JAMA. 303 (3): 288. doi: 10.1001/jama.303.3.288 . ISSN   0098-7484. PMID   20085959.
  5. ↑ "Scientific Opinion on the substantiation of a health claim related to vitamin D and risk of falling pursuant to Article 14 of Regulation (EC) No 1924/2006". EFSA Journal. 9 (9) 2382. 2011. doi: 10.2903/j.efsa.2011.2382 .
  6. ↑ Hughes, R. G.; Currie, L. (2008). "Fall and Injury Prevention – Patient Safety and Quality – NCBI Bookshelf". Ncbi.nlm.nih.gov. PMID   21328754 . Retrieved 2015-12-15.
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  13. 1 2 3 Department of Health, National service framework for older people; Standard 6 – Falls, Crown Copyright, 24 May 2001, accessed:19/5/2008
  14. 1 2 3 4 E, Jian-Yu; Li, Tianjing; McInally, Lianne; Thomson, Katie; Shahani, Uma; Gray, Lyle; Howe, Tracey E.; Skelton, Dawn A. (2020-09-03). "Environmental and behavioural interventions for reducing physical activity limitation and preventing falls in older people with visual impairment". The Cochrane Database of Systematic Reviews. 2020 (9): CD009233. doi:10.1002/14651858.CD009233.pub3. ISSN   1469-493X. PMC   8095028 . PMID   32885841.
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  16. ↑ Tricco, AC; Thomas, SM; Veroniki, AA; Hamid, JS; Cogo, E; Strifler, L; Khan, PA; Robson, R; Sibley, KM; MacDonald, H; Riva, JJ; Thavorn, K; Wilson, C; Holroyd-Leduc, J; Kerr, GD; Feldman, F; Majumdar, SR; Jaglal, SB; Hui, W; Straus, SE (7 November 2017). "Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis". JAMA. 318 (17): 1687–1699. doi:10.1001/jama.2017.15006. PMC   5818787 . PMID   29114830.
  17. 1 2 Grossman, David C.; Curry, Susan J.; Owens, Douglas K.; Barry, Michael J.; Caughey, Aaron B.; Davidson, Karina W.; Doubeni, Chyke A.; Epling, John W.; Kemper, Alex R.; Krist, Alex H.; Kubik, Martha; Landefeld, Seth; Mangione, Carol M.; Pignone, Michael; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien-Wen (24 April 2018). "Interventions to Prevent Falls in Community-Dwelling Older Adults". JAMA. 319 (16): 1696–1704. doi: 10.1001/jama.2018.3097 . PMID   29710141.
  18. ↑ Ishigaki, Erika Y.; Ramos, Lidiane G.; Carvalho, Elisa S.; Lunardi, Adriana C. (2016-11-08). "Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review". Brazilian Journal of Physical Therapy. 18 (2): 111–118. doi:10.1590/S1413-35552012005000148. ISSN   1809-9246. PMC   4183251 . PMID   24760166.
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  21. ↑ "Polymyalgia rheumatica: treatment reviews are needed". NIHR Evidence. 2022-06-21. doi:10.3310/nihrevidence_51304. S2CID   251774691 . Retrieved 2022-08-05.
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  23. ↑ Tricco, Andrea C.; Thomas, Sonia M.; Veroniki, Areti Angeliki; Hamid, Jemila S.; Cogo, Elise; Strifler, Lisa; Khan, Paul A.; Robson, Reid; Sibley, Kathryn M.; MacDonald, Heather; Riva, John J. (2017-11-07). "Comparisons of Interventions for Preventing Falls in Older Adults". JAMA. 318 (17): 1687–1699. doi:10.1001/jama.2017.15006. ISSN   0098-7484. PMC   5818787 . PMID   29114830.
  24. ↑ Santesso, Nancy; Carrasco-Labra, Alonso; Brignardello-Petersen, Romina (2014-03-31). "Hip protectors for preventing hip fractures in older people". The Cochrane Database of Systematic Reviews. 3 (3): CD001255. doi:10.1002/14651858.CD001255.pub5. ISSN   1469-493X. PMC   10754476 . PMID   24687239. S2CID   27652715.
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  27. ↑ Rodríguez-Molinero, Alejandro (2017). "A two-question tool to assess the risk of repeated falls in the elderly". PLOS ONE. 10 (12(5)): e0176703. Bibcode:2017PLoSO..1276703R. doi: 10.1371/journal.pone.0176703 . PMC   5425174 . PMID   28489888.
  28. ↑ "Clinical Practice Guideline: Prevention of Falls in Older Persons". The American Geriatrics Society. 2016.
  29. ↑ Tinetti (1988). "Risk Factors for Falls among Elderly Persons Living in the Community". N Engl J Med. 319 (26): 1701–7. doi:10.1056/NEJM198812293192604. PMID   3205267.
  30. ↑ Nevitt (1989). "Risk factors for recurrent nonsyncopal falls. A prospective study". JAMA. 261 (18): 2663–68. doi:10.1001/jama.1989.03420180087036. PMID   2709546.
  31. ↑ Rodríguez-Molinero (2015). "Falls in the Spanish elderly population: Incidence, consequences and risk factors". Rev Esp Geriatr Gerontol. 50 (6): 274–80. doi:10.1016/j.regg.2015.05.005. PMID   26168776.
  32. ↑ Rapp (2014). "Fall incidence in Germany: results of two population-based studies, and comparison of retrospective and prospective falls data collection methods". BMC Geriatr. 14: 105. doi: 10.1186/1471-2318-14-105 . PMC   4179843 . PMID   25241278.
  33. ↑ Shumway-Cook (2009). "Falls in the Medicare population: incidence, associated factors, and impact on health care". Phys Ther. 89 (4): 324–32. doi:10.2522/ptj.20070107. PMC   2664994 . PMID   19228831.
  34. ↑ Tinetti ME, Speechley M, Ginter SF (Dec 1988). "Risk factors for falls among elderly persons living in the community". N Engl J Med. 319 (26): 1701–7. doi:10.1056/NEJM198812293192604. PMID   3205267.
  35. ↑ "Costs of Falls Among Older Adults". Centers for Disease Control and Prevention, Home and Recreational Safety, U.S. Department of Health & Human Services, Bethesda, MD. 2016. Retrieved 2 December 2016.
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