Falls in the elderly

Background

Definition

• Event which results in a person coming to rest inadvertently on the ground or floor or other lower level

Etiology

• Falls are caused by a combination of intrinsic and extrinsic risk factors combined with a precipitating factor

Intrinsic Risk Factors

• Gait & balance impairment
• Peripheral neuropathy
• Vestibular dysfunction
• Muscle weakness
• Vision impairment
• Advanced age
• Impaired ADLs
• Orthostasis
• Dementia
• Drugs

Extrinsic Risk Factors

• Environmental hazards
• Poor footwear
• Restraints

Precipitating Causes

• Trips and slips
• Drop attack
• Syncope
• Dizziness
• Acute medical illness

Clinical Presentation

• Assess circumstances, causes, consequences, and comorbidities
• History
  • What happened before? Were there any preceding symptoms or prodrome?
  • What happened? How long were they down? How did they get up?
    • Loss of consciousness due to syncope or seizures
  • What happened after? Was there any traume, fracture, anxiety?
• Risk of falls
  • History of prior falls or gait instability
  • Age-related changes: sensory input, central processing, motor output
  • Comorbidities
    • Dementia
    • Atrial fibrillation, heart failure, COPD, diabetes
    • Cataracts, glaucoma
    • BPPV, Parkinson disease, stroke
  • Situational
    • Drugs: SSRIs, benzodiazepines, antihypertensives
      • Highest risk are benzodiazepines, alcohol, and antidepressants
      • Having 4+ prescribed medications
    • Environment: carpet, slippery floors
  • Orthostatic vitals: supine BP/HR, then BP/HR at 1 and 3 minutes
  • Neurological exam, including proprioception
• Functional history

Physical Examination

• Vitals, including orthostatics
• Cognitive testing, with MMSE
• Vision and hearing screen
• Cardiovascular: rule our aortic stenosis, arrhythmia, carotid bruits
• Gait assessment: timed up and go, 30-second chair stand, or 4-stage balance test
• Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)
• MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis

Prognosis

• After hip fracture, 2 year mortality is 30%

Management

Individuals Interventions

• Refer to [1] below
• Otago exercise program (incidence rate ratio 0.68, 0.56-0.79)
• Home assessment and modification (RR 0.79, 0.65-0.97)
• Hazard assessment and modification for fallers (2 trials, RR 0.56, 0.42-0.76)
• Withdrawal of psychotropic medication (RR 0.34, 0.16-0.74)
• Academic detailing and feedback to clinicians on medication modification (1 trial, RR 0.61, 0.41-0.91)
• Cardiac pacing in fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, RR 0.42, 0.23-0.75)
• Antislip shoe device for icy conditions (RR 0.42, 0.22-0.78)
• Expedited first cataract surgery, in women (1 trial, RR 0.60, 0.36-0.98)
• Tai Chi (RR 0.65, 0.51-0.82)
• Vitamin D (RR 0.72, 0.55-0.95) in long-term care

Multifactorial Intervention to Reduce Falls

• Refer to [2] below
• NNT of 8 to prevent 1 fall

Risk Factor	Assessor	Intervention
postural hypotension (SBP ≥20, or to <90 standing)	RN	ankle pumps, hand clenching, elevation of head of bed, change/adjust culprit medications if possible
use of benzos or other sedative/hypnotic drugs	RN	education about medcation use, nonpharmacologic treatment of sleep disorder, discontinuation of medications
≥4 prescription medications	RN	review of medications with primary physician
inability to transfer safely to bathtub or toilet	RN	training in transfer skills, environmental alterations (grab bars, raised toilet seats)
environmental hazards for falls	RN	removal of hazards, safer furniture, grab bars, handrails
any gait impairment	PT	gait training, assistive device
any transfer or balance impairment	PT	balance exercises, environmental alterations
impairment in limb strength or range of motion	PT	resistance and range of motion exercises

Further Reading

1. Gillespie LD, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146.
2. Tinetti ME, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331(13):821-7.