Risk factors

Risk of falls

These are many and varied with often more than one risk factor in the individual affected. It is essential to consider these when looking at preventative measures. Identification particularly of modifiable risk factors is important in this context.

Risk factors for falls include:^[2][3]

• High age
• Female gender
• Low weight
• Previous falls
• Dependency in activities of daily living
• Orthostatic hypotension
• Medication (especially psychotropic)
• Polypharmacy
• Alcohol abuse
• Diabetes mellitus^[4]
• Confusion and cognitive impairment
• Disturbed vision
• Disturbed balance or co-ordination
• Gait disorders
• Inappropriate footwear
• Environmental factors

Risk of injury

It is also instructive to examine the risk factors for fracture of the proximal femur. In so doing this reveals risk factors not just for falls but for falls resulting in injury. Again an individual may have several risk factors. These include:

• Weak bones. With increasing age, conditions which predispose to weakness and fracture occur - for example:
  • Osteoporosis
  • Osteomalacia^[5]
  • Paget's disease of bone
  • Metastases (to bone)
• Predisposition to falls. This includes the risk factors listed above as examples from research literature. Dementia is a particular risk factor for falls. In those with dementia, impaired visuospatial ability is often associated with increased risk of falling.^[6]
• Poor self-protection. This is common in the elderly. Examples include:
  • Lack of protective subcutaneous fat
  • Neurological problems (prevents reflex breaking or cushioning of the the fall)
  • Falls associated with loss of consciousness (for example, syncope)
  • Motor and sensory problems
  • Multiple contributory factors (for example slow, stiff joints, drugs and environmental factors is a common combination of factors)

The scope for prevention

The scope for prevention can be appreciated by considering some of the common conditions and risk factors predisposing to falls in the elderly. From this the wide range of preventative measures and treatment possibilities can be appreciated. Accurate assessment and diagnosis is clearly essential to prevent falls.

Environmental factors

Falls caused by accidents related to the patient's environment can often be prevented. The National Institute for Health and Clinical Excellence (NICE) recommends that all people at risk of falls should be offered a home assessment and interventions to modify environmental hazards.^[7] For example:

• Loose rugs or mats (especially on a slippery floor)
• Electric leads (trailing across the floor)
• Wet surfaces (especially bathroom)

Measures such as the installation of handles and rails can reduce the risk of falls.The community team may work in association with the local council to install these without charge to the patient.

Power and balance^[7]

Rising from a chair and walking around the room requires muscular power, proprioception and balance. Inactivity, perhaps associated with joint pain, as in osteoarthritis, results in weakness of muscles, loss of joint position sense and loss of balance. Hence:

• Patients should be encouraged to keep active and to exercise as much as possible. This strengthens muscles and maintains joint position sense and balance. This can sometimes effectively be organised as a group intervention.^[8][9]
• Elderly people who have had a fall particularly may lose confidence and become less active.
• Activity must be encouraged - for example, after retirement.
• Activity may have to be modified to suit the individual's needs and fitness.
• A wide variety of activities (from dancing to Tai Chi) can be undertaken often with the secondary gain of social contact.
• Activities which develop power and balance are particularly helpful.
• Establishing a network of local exercise-related activities and organisations may be helpful. Meetings and activities can be promoted with, for example, advertisements in the practice.

Neurological problems^[7]

There may be neurological disease causing motor and sensory impairment and increased risk of falls. For example:

• Even minor strokes can cause significant weakness.
• Parkinson's disease impairs mobility (abnormal posture, freezing of gait, frontal impairment, poor leaning balance and leg weakness are independent risk factors). ^[10]
• Neuropathy may occur with, for example, diabetes.
• Proximal myopathy (from, for example, thyrotoxicosis, Cushing's syndrome and use of steroids) may impair mobility, particularly rising from sitting.
• Conditions that impair co-ordination will impair mobility and predispose to falls.
• Cognitive impairment may impair co-ordination. This may not be immediately apparent but the patient may have early and concealed dementia predisposing to falls. The recognition of dementia can be difficult, but cognitive screening tests such as the 6 Item Cognitive Impairment Test can help.

Where possible the underlying disease should be treated. A multidisciplinary approach with input from physiotherapy, occupational therapy and perhaps social care, is often required.

Alcohol^[11][12]

• Alcohol may cause a number of problems which predispose to falls.
• Even modest social alcohol consumption may compound or exacerbate other risk factors for falls.
• Falls represent a major cause of morbidity and mortality in problem drinkers of all ages.
• The recognition of alcohol abuse is often difficult:
  • Relatives may express concern.
  • Alcoholics are often very adept at concealing the problem.
  • The problem may occur after a fall has led to admission to hospital and subsequent behavioural problems are not recognised as delirium tremens.
• Intoxication causes acute instability.
• Chronic alcoholism may cause complications predisposing to falls:
  • Polyneuropathy
  • Wernicke's encephalopathy
  • Korsakoff's syndrome
• A blood test may confirm, for example:
  • Macrocytosis
  • Abnormal liver function tests (raised gamma GT)
• Treatment of alcoholism or problem drinking in the elderly can be very difficult.

Loss of consciousness

Loss of consciousness (LOC) is often followed by a fall. It may result from a variety of causes - for example:

• Syncope (including micturition syncope)
• Dizziness (a vague term that needs exploration)
• Arrhythmias (cardiac output may be compromised):
  • Bradycardia
  • Tachyarrhythmia (broad complex tachycardia, narrow complex tachycardia)
  • Atrial fibrillation (rarely causes LOC)
  • Paroxysmal supraventricular tachycardia (rarely causes LOC)
  • ECG may give some indication (but ambulatory ECG may be required)
  • Insertion of a pacemaker may be necessary
  • Ablation therapy for arrhythmias may be beneficial (results are sometimes disappointing)
• Convulsions (including true epilepsy and other causes like alcohol withdrawal)

Drop attacks

Falls are called drop attacks when the cause is unknown, the event unexpected and there is no loss of consciousness. The account of a witness is most helpful. Causes may include:

• Cardiovascular disease (as for those causes associated with loss of consciousness but in a less severe form)
• Carotid sinus hypersensitivity (tends to cause drop attacks rather than syncope)
• Transient ischaemic attacks (there may be weakness or confusion for a few seconds or several minutes with no residual neurological signs)
• Orthostatic hypotension (fall of at least 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure on moving from a supine to an upright position) may result from:
  • Dehydration
  • Treatment of hypertension
  • Autonomic neuropathy
  • Reduced adaptability of the ageing circulation

Visual disturbance

NICE has found no firm evidence that treatment of visual disturbance as a single intervention reduces falls but agrees it is good practice to treat impaired vision where found.^[7] Gradual loss of vision has many causes. Causes include:

• Cataracts
• Macular degeneration
• Central retinal artery occlusion
• Central retinal vein occlusion
• Visual field defects

Referral to an optician can be useful in diagnosis and management.

Medication^[7]

Drugs can contribute to falls in many ways. Medication needs to be reviewed regularly, taking into account risk and benefit. Examples of the ways in which drugs can increase the risk of falls include:

• Sedative medication, including hypnotics (may impair co-ordination and cause falls).^[13] There is a particular risk of falls in agitated patients with cognitive impairment.
• Confusion particularly from psychotropic medication may increase the risk of falls.
• Polypharmacy is common in elderly patients. The scope for interactions and other effects likely to cause falls is increased.
• Orthostatic hypotension caused by:
  • Diuretics (can cause dehydration and may cause urgency and falls)
  • Vasodilators (including calcium-channel blockers and nitrates)
  • Alpha adrenergic blockers
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Alpha-blockers
  • Phenothiazines
  • Tricyclic antidepressants
  • Levodopa
  • Bromocriptine
  • Betablockers
  • Insulin^[14]

Putting prevention into practice^[7]

The aetiology of falls is usually multifactorial. The most effective prevention of falls is likely to involve a multidisciplinary, holistic and patient specific approach. Measures should take into account the person's medical conditions, social circumstances and psychological factors. The approaches may involve:

• Primary prevention. This means taking measures to prevent falls in people who have not fallen. Examples include:
  • Increasing exercise and physical activity
  • Reviewing medication
  • Changing adverse environmental factors
  • Improving management of any medical conditions
• Secondary prevention. This means taking measures to prevent further falls in those who have had a previous fall/falls (with or without injury). Examples are likely to be similar to those for primary prevention but will be more focused in the light of information about the fall/falls. Those who have already had a fall are at much higher risk of further falls. Secondary prevention is likely to target resources more effectively.

Assessment of someone who falls^[7][15]

This should apply to all patients who fall including those in the community who fall without sustaining serious injury.This should incorporate a good history of exactly what happened (If possible get collaboration from a witness). For example:

• Was it tripping over something or a loss of balance?
• Was there loss of consciousness?
• Is there a history of any previous falls?
• As always in the elderly, note drug history.
• What is the history of alcohol consumption?
• Past medical history is important in assessing risk of falls and injury.
• Home assessment can be very instructive in diagnosis, risk assessment and falls prevention. It can identify environmental factors.
• Examination can be tailored to the history but will usefully include:
  • Cardiovascular assessment
  • Selective neurological assessment
  • Functional assessment (of for example gait and transferring)
  • MMSE score
  • Vision testing

A literature search reveals a somewhat confusing picture in the identification of useful assessment tools. Clinical history of a fall and biological rather than chronological age are better predictors of future falls than objective assessment of function.^[16]

NICE recommends the following as being pragmatic tests which can be used in any situation and without the use of special equipment:^[15]

• Timed Up & Go Test: request that the patient rise from a chair without the support of their arms, walk 3 metres, turn round and sit down again. A walking aid can be used if required. Completion of the test without unsteadiness or difficulty suggests a low risk of falling.
  
  
• Turn 180° Test: request that the patient stand up and step around until they are facing the opposite direction. If more than four steps are required to do this, further assessment is indicated.

Who should be involved in prevention?^[7]

Many primary care trusts now have a multidisciplinary falls team who can assess and treat those at risk but members of the primary care team should also contribute to the falls prevention strategy. Informal carers and local communities can also play a part.^[17] Anyone who has been admitted to hospital as a result of a fall or who has been identified as being at-risk should be assessed.

What measures are effective?^[7]

NICE has identified four interventions with evidence-based effectiveness:

• Strength and balance training
• Home hazard intervention and follow-up
• Medication review
• Cardiac pacing where indicated

Methods deemed ineffective or with an equivocal evidence base include:

• Brisk walking (may be hazardous in postmenopausal women)
• Low-intensity exercise combined with continence training
• Cognitive and behavioural interventions
• Referral for visual disturbance (but should not be discouraged on grounds of good practice)
• Vitamin D (may help to improve bone strength but there is no evidence that it reduces fall frequency)
• Hip protectors (equivocal results in trials)