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falls in the elderly

Definition of a fall: A sudden, uncontrolled, unintentional, non-purposeful downward movement hitting the floor or an object such as a chair (VA 96). Etiology: 1) intrinsic factors a) syncope# - orthostatic hypotension as etiology of syncope & falls in demented elderly [77] - atrial fibrillation with rapid ventricular response [92] b) neurologic disorders - comorbidities in the elderly - cognitive impairment, Alzheimer's disease [15] - stroke [15] - Parkinson's disease - depression [64,91] - gait & balance disorders* [15] - vestibular dysfunction - proprioceptive dysfunction - cerebellar dysfunction [119] - neuropathies, peripheral neuropathy - vitamin B12 deficiency - pyridoxine toxicity - GALOP syndrome - chronic idiopathic ataxic neuropathy - lumbar spinal stenosis - drop attack c) musculoskeletal disorders - underlying pathology - deconditioning - arthritis, osteoarthritis - paralysis - muscular weakness - sarcopenia, frailty - joint pain - foot problems d) sensory impairment - visual disturbance - multifocal eye glasses [20] - cataracts, glaucoma, age-related macular degeneration [131] - poor contrast sensitivity is associated with increased risk of falls - near or distance visual acuity is not [139] - hearing impairment - olfactory dysfunction may be mediated in part by cerebellar effects [119] - chronic pain may perturb other sensory modalities [21] e) cardiovascular disorders [50] - postural hypotension [14] - diminished baroreceptor sensitivity - diminished arterial compliance, wide pulse pressure - 40% of community-dwelling elderly with unexplained fall have prior diagnosis of orthostatic hypotension [64] - elderly with either immediate (< 3 minutes) or delayed (> 3 minutes) orthostatic hypotension at risk of falls (RR= 1.7) - risk slightly higher with delayed orthostatic hypotension [132] - postprandial hypotension [3] - higher systolic BP variability associated with falls in nursing home residents [148] - cardiac arrhythmia, including ventricular tachycarida, atrial fibrillation [92] - carotid sinus syndrome - acute myocardial infarction [121] - subclinical cardiovascular disease doubles risk [88] - most common cause of recurrent unexplained falls [137] f) acute medical illness g) medications - psychotropic drugs top the list [122] - antipsychotics (any or all) - perazine, melperone, loxapine, cariprazine, chlorprothixene, thioridazine, pimavanserin, risperidone, olanzapine, quetiapine [116] - risperidone (produces parkinsonism) [5,116] - sedative/hypnotics - benzodiazepines (trazodone no better) [84] - clobazam, prazepam, oxazepam, nitrazepam, lormetazepam, flurazepam, estazolam [116] - barbiturates - anxiolytics - meprobamate, zopiclone [116] - medication use to treat insomnia [98] - zolpidem - eszopiclone may be safer in elderly [65]; not safer (GRS11) [3] - antidepressants - tricyclic antidepressants [5,87] - amitriptyline, doxepin, imipramine, maprotiline, nortriptyline, trimipramine [116] - selective serotonin reuptake inhibitors (SSRI) [5] - citalopram, escitalopram, paroxetine, sertraline [116] - SSRI associated with decreased risk of fall-related injuries [144] - selective serotonin-norepinephrine reuptake inhibitors (SSRI) - duloxetine, venlafaxine [116] - SNRI associated with decreased risk of fall-related injuries [144] - bupropion associated with decreased risk of fall-related injuries [144] - monoamine oxidase inhibitors [32] - moclobemide [116] - atypical antidepressants - mirtazapine [116] - mirtazapine associated with decreased risk of fall-related injuries [144] - trazodone associated with decreased risk of fall-related injuries [144] - anticonvulsants [32] - secobarbital, cannabidiol, clorazepate, perampanel, eslicarbazepine, primidone, divalproex, oxcarbazepine, lorazepam, phenytoin, clonazepam, carbamazepine [116] - gabapentin & pregabalin [87] - diuretics* - class 1a antiarrhythmic agents - antihypertensive agents [72] - higher dose of antihypertensive medication is independently associated with falls in the elderly [71] - no association with antihypertensives [100] - perindopril, nitrendipine, reserpine, nimodipine, nicardipine, randolapril [116] - aliskiren/HCTZ, amlodipine/valsartan, valsartan/HCTZ [116] - in older adults with unplanned hospitalizations, frailty or polypharmacy, starting antihypertensive treatment is linked to acute kidney injury & risk of falls [125] - similar rates of injurious falls & cardiovascular events after initiating any first-line antihypertensive in elderly with limited life expectancy [135] - Alzheimer agents & other CNS-active drugs - sodium oxybate, dalfampridine, ergoloid mesylate, rivastigmine, donepezil, galantamine, memantine, valbenazine, teriflunomide, modafinil, glatiramer, lanreotide, melatonin, dextroamphetamine/amphetamine [116] - in patients with cognitive impairment, cholinesterase inhibitors reduce risk of falls [129] - anti-Parkinson agent - piribedil, procyclidine, benserazide, tolcapone, rasagiline, carbidopa, levodopa, entacapone, opicapone, istradefylline, biperiden, rotigotine, cabergoline, pramipexole, trihexyphenidyl,ropinirole - carbidopa/levodopa, carbidopa/levodopa/entacapone [116] - systemic glucocorticoids - hypoglycemic agents, insulin & oral hypoglycemics [104 - narcotics (opiates) [104] - especially during the 1st 4 weeks of treatment [134] - anticholinergic agents (parasympatholytics) [113] - 4 or more medications h) antipsychotics, anti-Parkinson agents, opioids, anticonvulsants, antidepressants, sedative/hypnotics, anxiolytics, muscle relaxants, NSAIDs & antirheumatic agents consistently increase risk of falls in the elderly [123] i) risk of falls higher in 14 days prior to administration of antipsychotics &/or cholinesterase inhibitors (RR=6.2) than after administration (RR=1.2-1.3) [106] j) risky behaviors - hurrying or running, especially when carrying heavy load - hurrying may be due to urge incontinence [59] - high-risk activities, particularly standing on unsteady object k) fear of falling is a risk factor for falls in the elderly [23] l) history of falls in the past year is the most predictive risk factor [3,99] 2) Extrinsic factors a) environmental obstacles b) slippery surfaces c) ill-fitting clothes & footwear [137] - walking barefoot or in socks/stockings [126] d) poor lighting e) inappropriate furniture 3) risk of a fall at home is greatest in the 2 weeks immediately following hospitalization [3] 4) mechanisms of falls in long-term care facility [35] - incorrect weight shifting associated with 41% of falls [35] - tripping or stumbling associated with 21% of falls - bumping associated with 11% of falls - slipping associated with 3% of falls - 24% of falls occur while walking forward - 13% of falls occur while standing - 12% of falls occur while sitting down [35] 5) modifiable risk factors - cognition, physical function, psychological wellbeing, health status predicted subsequent falls [103] 6) non-modifiable risk factors - age > 85 years - male, white * balance problems top the list in the absence of other significant factors # establish syncope vs non-syncope in initial assessment * Ref 5 states diuretics NOT associated with falls * review of predictive models [143] Epidemiology: 1) 1/3 of community-living individuals > 75 years of age fall at least once in a year; 1/2 of these have multiple falls 2) 10% of falls in the elderly cause major injuries including factures & intracranial hemorrhage [99] - falls are the leading cause of death from traumatic brain injury in seniors [99] - 5% of falls in the elderly result in a fracture; 1% in hip fracture 3) account for 40% of admission to nursing homes 4) women more likely than men to sustain injury after fall - in males, better mobility not as protective of falls compared with females [103] - poorer executive function, with decreased judgement or slowed decision-making during mobility in males vs females suggested [103] 5) risk of in home falls is greatest in 2 week period after hospitalization 6) deaths from falls increased in elderly >= 65 years of age in the U.S. - from 47 to 62 per 100,000 people between 2007 & 2016 [83] - death varied widely across states, from 24 per 100,000 in Alabama to 143 per 100,000 in Wisconsin [83] - deaths more common in elderly > 85 years of age, whites & men [83] - fall-related mortality doubled among adults >= 75 years in U.S. from 2000-2016, from 61 to 116 per 100,000 men, & from 46 to 106 per 100,000 women [86] - between 1999 & 2020, from 10,097 in 1999 to 36,508 in 2020 [118] - deaths in men higher than women 38 per 100,000 in 1999 to 82 in 2020, vs 24 in 1999 to 60 in women [118] 7) injurious falls occur early on medical/surgical units [90] - peak incidence between day 1 & 4 - 47% of injurious falls occur by day 3 of admission - Injurious falls associated with mental state change 24 hours prior to the fall more likely to have a bed alarm &/or physical restraint as fall prevention interventions [90] 8) most falls occur in the bathroom > bedroom > kitchen > living room [99] 9) < 1/2 of elderly who fall tell their clinician [99,137] 10) high prevalence of elderly using medications that increase risk of falls with little evidence of reduction in use of these medications after fall-related injury [112] History: - ask about previous falls - circumstances of previous falls - history of falls in the past year is the most predictive risk factor [3,99] - ask about risk factor for falls - fear of falling suggests balance disorder &/or mobility disorder [3,56] Laboratory: 1) serum chemistries a) serum vitamin B12 b) Chem 7 panel - serum glucose, serum Na+, serum K+, serum creatinine, BUN c) serum Ca+2 (with Chem 7 = basic metabolic panel) 2) complete blood count (CBC) 3) thyroid function tests [32] - serum TSH, thyroxine (total) in serum, free T4 4) serum 25-hydroxyvitamin D [32] 5) therapeutic drug test if indicated - anticonvulsants, antiarrhythmics, tricyclic antidepressants, aspirin [32] Special laboratory: 1) performance-based balance & gait testing* a) have the patient rise from a chair, walk down a hall, turn, walk back & sit again b) Tinetti balance & gait evaluation [16] c) get-up & go test d) one leg balance [7] e) quadriceps strength [3] f) short steps, slow walking speed, difficulty turning, wide base of support & possible steppage gait to increase proprioceptive input suggest peripheral neuropathy [3] g) diminished gait speed & step length & difficulty with initiation of movement, changing direction, moving around or over objects, & dual-task performance suggest cognitive impairment [3] h) antalgic gait suggests arthritis [3] i) forward flexed posture, lower extremity weakness, knee buckling, & leg pain relieved by sitting suggests spinal stenosis [3] 2) Morse fall risk assessment scale 3) electrocardiogram & echocardiogram if syncope 4) Holter if syncope: event-recorder is better * top priority in the absence of other significant factors Radiology: - X-ray* of injuries - bone mineral density: men >= 70 years, women >= 65 years - CT neuroimaging* a) head injury b) new focal neurologic sign - magnetic resonance imaging of spine for suspected a) cervical spondylosis b) lumbar spinal stenosis * CT of subdural hematoma [115] * X-ray of subtrochanteric fracture of femur (hip fracture) [115] * X-ray of femoral neck fracture (hip fracture) [115] * X-ray of humeral neck fracture [115] Complications: - persistent fear of falling is associated with social, psychological, & physical risk factors for disability [56] - bone fratures - long-bone fractures, especially hip fracture - pelvic fracture - falling on outstretched hand - distal radius fracture - scaphoid fracture - humeral neck fracture - sedentary frail elderly at higher risk [145] - intracranial injury: - subdural hematoma - intracerebral hematoma - death: - strongest predictors of in-hospital mortality after fall - Glasgow Coma Scale score <15 - age >=70 [25] - hypertension is the greatest intrinsic risk factor for a fatal fall although in most cases contributing factors are unknown [136]* - home is the most common place for a fatal fall (61%) - bedrooms, bathrooms & stairs are the most common sites of in-home fatal fall - head trauma is the most common injury in a fatal fall - the median survival after a fatal fall is 2 days with 24% of deaths occurring within 24 hours, range 0-25 hours to > 1 year [136] - timely discovery after a fall increases survival time - male seniors who engage in hazardous activities or tasks with high levels of difficulty in the workplace are at risk of fatal fall - male or rural senior adults are more likely to experience delays in receiving timely care or no care at all resulting in significant survival vs female or urban counterparts [136]* - injurious falls in the elderly may be a harbinger of dementia (RR=1.1-1.2) [146] * data from study of adults >= 60 years in Southwest China [136] * also see in hospital falls Management: === General === 1) review the circumstances of current & past falls (first step) [3] - if patient is on anticoagulation & head trauma cannot be ruled out, transfer patient to the emergency room - non-licensed caregivers cannot perform neurochecks 2) multifactorial risk assessment, a multidisciplinary approach [120,137] a) physician b) physical therapist - physical therapy in long term care facilities has resulted in improved physical performance & improvement in ADL but has not reduced falls [3] c) occupational therapist d) podiatrist [29] e) home assessment nurse f) paramedics - protocol for transport to emergency department vs followup with primary care provider within 18 hours, including consult with primary care providers as needed reduces unnecessary emergency department visits without sacrifice of appropriate care [81] g) physical & occupational therapy services provided by a home health agency - Medicare Part A skilled home health care - access to short-term nursing & rehabilitation services for up to 60 days - eligibility requires a health care provider certify a need for skilled nursing or rehabilitation & meets Medicare homebound criteria h) multifactorial intervention addressing balance*, gait, strength, vision, medication & environmental factors [128] i) very low-certainty evidence precludes determining whether population-based multicomponent or nutrition medication interventions are effective at reducing falls & fall-related injuries in the elderly [133] j) multifactorial & exercise interventions are associated with reduced risk of falls across multiple clinical trials [141] 3) risk factor reduction reduces incidence of falls by 46% [7,16,18] a) primary prevention: (community living elderly) - routine in-depth work-up not cost effective - simple approaches recommended [33] - consistent hearing aid use by elderly with hearing impairment is associated with lower risk of falls [127] - use of monofocal lenses when ambulating by elderly with visual impairment - a falls clinic may reduce risk of falls [46] b) fall risk assessment should incorporate intrinsic & extrinsic factors [3] c) see in-hospital falls prevention 4) discontinue offending medications if possible [14,16] a) medications most readily modifiable risk factor [18] b) psychotropic agents top the list of implicated drugs [26] - antidepressants (including SSRI) increase risk of falls & continued use should be evaluated periodically, especially after a fall [3] - benzodiazepines, sedative/hypnotics & opiates c) zolpidem associated with 6-fold increased risk of falls & 2-fold risk of hip fracture in elderly inpatients [36] d) low-dose aspirin does not decrease risk of falls, but increases risk of serious falls [114] e) STOPPFALL is a tool for optimizing medication review for fall prevention [142] 5) home safety evaluation (occupational therapy) [34,58,62] a) elimination of environmental hazards - hazzards found in 2/3 of homes [18] - most likely to reduce falls immediately after hospital discharge [3,138] b) remove electrical cords & loose items from floor c) carpet edges fixed to the floor - use shallow-pile carpet d) slip-resistant indoor & outdoor surfaces & steps - non-skid wax on floor e) grab bars in bathroom (toilet & shower), secure bathmats f) properly fitting shoes g) improved lighting (indoor & outdoor), eliminate glare, night lights h) lower bed [104] i) simple home improvements are cost-effective [58] j) education & counseling about environmental hazzards have only a modest benefit [40] 6) Cochrane review 2023 reviews interventions for fall prevention in 4 categories - reduction of home fall hazzards - assistive technology - education - home modifications [117] === treatment of underlying disorders === - manage foot disorders & recomment appropriate footwear [104] - postural hypotension - discontinue offending antihypertensive agents - compression stockings [104] - liberalize salt intake [104] - optimize hydration - fludrocortisone or midodrine as indicated - correction of vision & hearing problems [16] - cataract surgery in the 1st eye reduces risk of falls [54] - exercise combined with vision assessment & treatment (RR, 0.17) compared with exercise & balance training (RR=0.51) [80] - avoid bifocal lenses while walking [104] - adequate nutrition & hydration - improving calcium & protein intakes by with dairy foods reduces risk of falls & fractures in residents in assisted living [107] - treat vitamin D deficiency - USPSTF & AGS recommends against vitamin D supplementation to prevent falls in community-dwelling adults >= 65 years [3,79,82] - American Geriatric Society formerly recommended vitamin D supplementation for elderly at high risk of falls [3,69] - vitamin D not useful in elderly with normal serum 25-hydroxyvitamin D - vitamin D supplements do not reduce risk for falls in older adults [3,48,60] - vitamin D3 2000 IU daily does not reduce risk of falls in community-dwelling elderly [95] - vitamin D3 100,000 IU monthly does not reduce risk of falls in community-dwelling elderly [93], - vitamin D supplementation may reduce falls in care facilities [3,45] - vitamin D3 supplementation at doses of 1000-4000 IU/day does not prevent falls compared with doses of 200 IU/day in elderly with elevated fall risk & low serum 25-OH vitamin D levels [97] - high-dose vitamin D3 (60,000 IU monthly) actually increases fall risk [63] - vitamin D doses between 1000 and 4000 IU/day might increase the risk of first time falls with fractures [102] - vitamin D 800-1000 IU/day may reduce risk of falls by increasing muscle strength [8,12,19,22,41] - vitamin D 800-1000 IU/day reduces falls in the elderly - lower or higher doses do not [140] - number to treat: 15 to prevent one fall [8] - hazzard ratio: 0.74 [12] - vitamin D prevents [43,68] does not prevent [48,60] falls in the elderly - treat urge incontinence - decreased vibration & temperature sensation does not warrant neurology consult [3] - bigeminy & other benign arrhythmias does not warrant cardiology consult [3] - do not discontinue or avoid starting anticoagulation in patients with atrial fibrillation & infrequent falls [18] - embolic stroke risk of atrial fibrillation > risk or intracerebral hemorrhage from fall [18] === individualize care plan === - fall-prevention programs are labor-intensive [5,6] - fall-prevention programs can have unintended consequences among some patient populations [28] - training nursing home staff can reduce falls up to 90 days after training, but not after 180 days [108] - falls are especially difficult to prevent in - patients with dementia [4] - no specific interventions beneficial in patients with dementia beyond treating reversible risk factors [18] - hospitalized or institutionalized elderly [13] - warning posters placed over patient beds may be of benefit [24] - see in-hospital falls prevention - see prevention of falls === exercise &/or physical therapy === - indications: all elderly at risk [34,42] history of falls [3] - exercise consistently beneficial across multiple clinical trials [141] - exercise alone or as part of a multicomponent intervention is effective [79,80,82] - walking exercise alone has NOT been shown to reduce risk of falls [3] - exercise does not reduce risk of falls, but does reduce risk of injurious falls (6 vs 13 per 100 person-years) [60] - stand-alone exercise programs that emphasize multiple exercise categories are effective in reducing fall risk in community-dwelling elderly [55] - exercise, such as walking & balance training (RR=0.51) [80,82] - balance* & gait training contributes more to fall reduction than does strength training [3] {see FICSIT trial} - muscle strengthening - combined strength & balance training may be better [5] - multicomponent intervention consisting of strength & balance exercises reduces falls, injurious falls, & fear of falling over 24 months (RR=0.6-0.7) [105] - integrated cognitive-behavioral therapy & exercise may alleviate fear of falling [111] - multi-component group exercise intervention consisting of strength, endurance & balance training appears to be the best strategy to reduce risk of falls [3,37] - Tai Chi 3 times/week, which combines both strengthening & balance, reduces fall risk among community-living elderly [3,37] - exercises that challenge balance, use a higher dose of exercise, & do not include a walking program are the most effective [39] - balance training* a component of successful fall reduction programs [42] - balance training 3 time/week can prevent fall-related injuries [3,61] - digitally delivered balance training may reduce risk of falls [101] - exercise/physical therapy scheduled toileting, cognitive behavioral therapy & vitamin D supplementation [3] - data is mixed on vitamin D [3] - training on a treadmill outfitted with a virtual reality screen that displayed the position of the patient's feet & a program of simulated obstacles & distractors reduces risk of falls relative to treadmill alone [76] - long-term exercise is associated with a reduction in fall injury, & probably fractures in older adults [85] - exercise has little or no lasting effect on falls after cessation [130] - home exercises 3x/week + 30 minutes walking twice weekly in elderly >= 70 years who have fallen in the prior year reduces fall risk from 2.1 to 1.4 per person-year [86] - community exercise programs helpful [3] - multifactorial & exercise-based interventions failed to prevent falls in elderly > 70 years of age [96] === assistive technology === - assistive devices - indicated in patients with gait disorder - not indicated if gait is normal - patients with Parkinson's disease often have a tendency to fall backwards & do best with front wheel walkers or rollators [3,89] - most elderly who have alarms do not use them [17] 13) clinical training, geriatric expertise, & access to diagnostic equipment identified as essential in reducing potentially avoidable fall-related transfers to the emergency department [109] === prognosis & followup === 1) prognosis: - inability to get up & longer down times portend poor outcomes [17] - frailty index more accurate than injury severity score in predicting outcome [99] 2) Follow-up: a) monthly for 3 months, then quarterly to assess risk factors b) keep diary of falls; falls are under-reported * balance training is a component of successful fall reduction programs === Veterans Administration guidelines, Falls management: === - LOW RISK - Educate the patient/family on the following Fall Prevention: - Activity level and orders - Making sure that wheelchair and commode brakes are locked - Wear non-skid slippers - How to maximize safety (i.e., eliminate spills, clutter, etc) - Medication time/dose, side effects, and precautions - Call for assistance with activities out of bed, as appropriate - Maximize environmental safety as listed: - Lock all moveable equipment - Maintain occupied bed in low position - Maintain adequate and appropriate lighting - HIGH RISK - Educate the patient/family on fall prevention as listed above - Maximize environmental safety as listed above - Increase the frequency of rounds - Anticipate ADL needs - Assistance with activities out of bed - Hip Protectors, consider for patients with: - history of falling - low bone density or osteoporosis - over the age of 80 - normal or underweight, - history of prior hip fracture - data not very supportive of benefit for hip protectors === American Geriatrics Society guidelines, Falls management: === - multifactorial assessment of fall risk including: - examination of feet & footwear - a functional assessment - an environmental assessment that includes home safety - assessing the patient's perceived functional ability & fear of falling - minimize medications, particularly antipsychotics & other psychoactive drugs - assess & treat postural hypotension - vitamin D 800 IU per day for all older adults at increased risk for falling - in community-dwelling elderly, a multifactorial intervention that includes exercise that focuses on balance, gait, & strength training, such as tai chi or physical therapy (all) [3] - identify & treat cataracts, i.e. cataract surgery, ASAP - screening all patients aged 65+ annually for falls* - use of the Timed Up and Go as a gait assessment, rather than relying on gait speed* - clinical judgment on whether or not to check an ECG for those at risk for falling* * differs from World Falls Guidelines === GRS8 proposes an algorithm-based approach === , - if patient has fallen once, observe gait & balance only [3] (regardless of circumstance of fall) - if normal, no further evaluation is needed - if gait or balance is abnormal or patient has fallen more than once - visual acuity testing - assess for orthostatic hypotension - evaluation of quadriceps strength, gait & balance - examination of feet & footwear - medication review - home safety evaluation [3]

Related

environmental assessment for fall risk get up & go test (timed up & go, TUG) hip fracture Morse fall risk assessment scale prevention of falls prevention of fractures retropulsion (tendency to fall backward) risk factors for falls Tinetti gait & balance evaluation

Specific

in-hospital falls

General

accidental fall geriatric disorder; disease of old age; geriatric syndrome

References

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