Prevention of Falls in the Elderly

See related article on Recurrent Falls.

Falls in the elderly are a problem for 2 main reasons:

• They are more likely to happen than falls in younger patients.
• They are more likely to result in serious injury. For example: Two common fractures as a result of falls in the elderly are:
  • Wrist fractures (including Colles fracture and dislocations of the wrist)
  • Fractures of the femur

Recurrent falls are defined as those occurring at least 3 times a year. Co-morbidity is a serious problem both in terms of contributing to the cause of the fall and the outcome. This is one reason why the mortality 3 months after a fall is so high.

Falls can be devastating to the affected individual but are also expensive to manage. Falls, especially when associated with fracture of proximal femur, carry a high morbidity and mortality but even lesser falls lead to loss of self confidence and reduced quality of life. This can also have significant economic consequences because of the cost of inpatient care but also loss of independence and the cost of residential care.The prevention of falls poses a challenge to carers and healthcare in general. Standard 6 in the NSF for the elderly is to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.¹

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 preventive measures. Identification particularly of modifiable risk factors is important in this context.
A literature derived list of risk factors for falls includes:

• High age
• Female gender
• Low weight
• Previous falls
• Dependency in activities of daily living
• Orthostatic hypotension
• Medication (especially psychotropic)
• Polypharmacy
• Alcohol abuse
• Diabetes mellitus²
• 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 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. Such risk factors include:

• Weak bones. With increasing age conditions which predispose to weakness and fracture occur. These include, for example:
  • Osteoporosis
  • Osteomalacia
  • Paget's disease
  • 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 visuo-spatial ability is often associated with increased risk of falling.³
• 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 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 preventive 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. A home assessment is essential. 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. A Cochrane reviews have concluded that there is insufficient evidence to determine the effects of interventions to modify environmental hazards.^4,5

Power and balance

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.^6,7,8 This can sometimes be effectively organised as a group intervention.^9,10
• 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 individuals 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

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.
• 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 coordination will impair mobility and predispose to falls.
• Cognitive impairment may impair coordination. 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. The mini mental state examination can be most revealing.
• Depression is common in the elderly. Recognition and screening for depression can be difficult.

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

• 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.^11,12
• 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
  • Kosakoff's syndrome
• A blood test may confirm, for example:
  • Macrocytosis
  • Abnormal LFTs (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 aging circulation

Visual disturbance

Impaired vision also contributes to falls. 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

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 coordination 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
  • ACE inhibitors
  • Alpha blockers
  • Phenothiazines
  • Tricyclic antidepressants
  • Levodopa
  • Bromocriptine
  • Beta blockers

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 the 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

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 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)
  • MMS score
  • Vision testing

A literature search reveals a somewhat confusing picture in the identification of useful assessment tools:

• A risk assessment called STRATIFY was used to assess patients after stroke but had poor predictive value.¹⁴ Another study found that it was good for medical in-patients.¹⁵
• Clinical history of a fall and biological rather than chronological age are better predictors of future falls than objective assessment of function.¹⁶
• A study from Germany identified risk indicators for falls in institutionalised patients and again found that previous falls were unsurprisingly a good predictor of further falls.¹⁷
• A Cochrane review was fairly positive about the outcome of falls prevention programmes but critical of methodology.¹⁸
• Consistency in risk assessment tools is called for in the development of prevention programmes.^19,20
• Such tools have been developed for particular circumstances, for example one developed in Holland for nursing home patients with dementia.²¹ T
• Trials are underway of multidisciplinary assessments and interventions to prevent falls.²²
• It is likely that different assessment tools and certainly different interventions will be needed for different subgroups of patients.²³

Care pathways are being developed for those at risk of falls, perhaps after they have arrived at hospital because of a fall. Protocols will probably include neurological assessment including gait assessment, cardiovascular assessment and perhaps looking at risk factors for injury such as a DEXA scan for osteoporosis. Ophthalmic assessment is very important and someone should visit the home to assess risks and possible aids including handles, rails and the use of walking sticks and frames around the home.
Those whose self confidence has been challenged by a fall must be dissuaded from doing less and sitting for longer as this will have an adverse effect on muscle weakness, proprioception and balance.

Who should be involved in prevention?

Many PCTs now have a multidisciplinary falls team who can assess and treat those at risk. Anyone who has been admitted to hospital as a result of a fall should be assessed. There are many causes of falls and any individual may have a number of predispositions. It is said that a falls team should tackle both primary and secondary prevention in the community. Primary prevention is much more difficult as the risk is always much lower than with secondary prevention. Community nursing staff can make assessment of those thought to be at risk but not yet fallen. Balance training may be beneficial but evidence of exercise programmes in primary prevention is uncertain as is the desired level of exercise.²⁴

What measures are effective?

A Cochrane review concluded that there is evidence that interventions to prevent falls are likely to be effective and costs per fall prevented have been established for 4 of the interventions.²⁵ What is not certain is that reduction in falls can be extrapolated to reduction in injuries.
There is much work still to do. The cost of falls in enormous both in financial terms of hospital and community care along with the cost of residential care but also in terms of effect on quality of life. Old people value their independence enormously. A cost/ benefits analysis is needed for interventions for both primary and secondary prevention of falls. The costs of introducing such a programme would be very great but the benefits may possibly be greater. Sound methodology is essential for a reliable evidence base.