Recurrent Falls

Falls, fall-related injury and fear of falling are important public health problems in an aging society.

Falls should be considered a symptom rather than a diagnosis so that when a patient, usually an old person, presents with a history of falls, effort should be made to find the cause or causes. Falls may indicate underlying pathology or simple locomotor inadequacy but place the individual at risk of injury-related morbidity, mortality and loss of independence. Much effort has been placed into fall prevention but completely abolishing falls among older people is an impossible and undesirable prospect, since this would place undue restriction on their activity and autonomy. An acceptable balance between prevention and living with risk needs striking.¹

Over 30% of people over 65, living in the community, have at least 1 fall a year and half of them fall at least twice. 5% of the falls result in a fracture or hospitalisation. The risk increases with increasing age - for those aged over 75, the rates of falling and associated complications double.²
Other groups - young children and athletes - also have high incidence of falling but are less susceptible to injury (have less chronic diseases and age-related physiological changes) and recover more quickly.
The implications of falls has considerable impact in terms of health service demand (both upon acute inpatient and long term care provision) and cost. Fragility fracture management alone is estimated to cost £1.7 billion per annum in the UK.¹ In the US, fall-related injuries account for 6% medical spending on those over 65 years.²

Risk factors

The multifactorial aetiology of most falls makes identifying a single retrospective cause frequently very difficult. Identifying prospective risk factors can be a more productive enterprise.
Important individual risk factors for falls include:²

• Muscle weakness
• Balance deficit
• Gait deficit
• Visual impairment
• Mobility limitation
• Cognitive impairment
• Impaired functional status (reduced activities of daily living)
• Postural hypotension

Other risk factors include:³

• A history of fall in the last year
• Age (>80 years)
• Use of an assistive device e.g. walking stick
• Arthritis
• Depression

Polypharmacy (the use of multiple medications) has been considered to be a significant risk factor for falling. Some contend that the risk is that of chronic disease and multiple pathology rather than medication.⁴ Others have counter-argued that even when this is controlled as a confounding factor, the risk of falling increases with the number of medications, where at least one medication is considered a drug associated with falling.⁵
Culprit drugs associated with increased risk of falling:⁶

• Psychotropic medication (benzodiazepines, antidepressants, antipsychotics)
• Blood pressure lowering drugs
• Anticonvulsants

Falling will present either with injuries or as a result of direct questioning. Many older people do not volunteer that they are falling and guidelines suggest healthcare professionals should routinely inquire about falls in the last year.⁷

History

A detailed history is essential. If possible, obtain some collateral history.

• Was the fall an isolated event or one of many? If many is there any pattern? How often do they occur? Are they getting more frequent? Does there seem to be any common precipitating factor?
• What caused the fall? Sometimes the fall is attributed to simply tripping over a loose rug or a trailing electric cable, for example. This is not a medical problem but requires a home safety assessment with a visit by a health visitor or other suitably trained professional to identify other risks that require attention. Frequently multi-agency home safety assessments can be done simultaneously e.g. identifying fire hazards or home security problems.
• What was the patient doing at the time? Was it something involving exertion? Did it involve looking up? Extending the neck to look inside a low cupboard or to do high dusting risks vertebro-basilar insufficiency. Older people should be discouraged from climbing on chairs or ladders since they more likely to fall in these situations and will fall further, incurring more serious injuries. Postural hypotension usually occurs on suddenly getting up from sitting or from lying in bed - typically, on getting out of bed to go to the toilet in the night. Micturition syncope affects men, usually as they stand up at the toilet, attempting to pass urine nocturnally. Does the patient have a sleep disorder? These are reasonably common in older people and may contribute to the risk of falling.⁸
• Was there any loss of consciousness? A good way of ascertaining this is to ask if the patient remembers falling. Syncope (or blackouts) can be associated with cardiac or neurological symptoms. Recognition and assessment of syncope requires skill and often specialist investigation. Assessment algorithms are available.⁹ Was there any warning before the fall? If terms like 'giddy', 'dizzy' or 'faint' are used, explore what is meant.
• How was the patient after the fall? Whilst they may have felt shaken or injured, features such as weakness that made getting up again difficult, aching muscles or disorientation may indicate the post ictal phase of a fit. Incontinence is an unreliable sign of epilepsy and can occur with other causes of loss of consciousness. A bitten tongue is more specific.The weakness of a transient ischaemic attack (TIA) may last just a few minutes and leave no residue. Difficulty with language may indicate a TIA.
• A witness can describe exactly what happened before, during and after the fall. There may be a description of tonic and clonic phases of convulsion but this does not necessarily imply epilepsy from a space occupying lesion or cerebral degeneration, as cerebral ischaemia from poor cardiac output due to arrhythmia can produce the same. A witness may be better than the patient at ascertaining confusion following the fall and noting how long it lasted.
• If history suggests tripping over things, ask about eyesight and when last assessed by an optician. There may be blurred vision or gradual loss of vision. Visual field defects may not be apparent to the patient.

Past medical history

• Look at medical history and current medication.
• Note history of heart disease and diabetes. Is the patient at increased risk of arrhythmias, TIAs, peripheral neuropathies or hypoglycaemic episodes, for example?
• Most modern treatments for hypertension are less likely to produce postural hypotension than older ones but it may still occur. Alpha blockers, including phenothiazines can drop blood pressure. Review all drugs, especially those that may cause confusion or sedation. In general, the risk presented by benzodiazepine hypnotics outweighs benefit in the elderly.¹⁰

General enquiry

Ask about general health:

• Is appetite good and weight steady? A negative reply may point to more serious underlying disease. How is mobility? Is locomotion becoming slow and laboured?
• What is the normal functional status of the patient? Do they require assistance dressing, washing, cooking, for example?
• Are mental faculties still sound or is there evidence of cognitive decline?

Examination

Examination usually starts with inspection and assessment of any injuries sustained in the recent fall.

• Mental state:
  • Is the patient seems alert and orientated or vague and confused? The mini mental state examination may be useful.
  • Decline in mental state may indicate a cause for the falls or it may be the result if head injury has caused a chronic subdural haematoma.
• Visual impairment:
  • If there is suggestion of poor sight, then examination of the eyes should at least include reading a Snellen chart.
  • Macular degeneration and visual field defects should be considered as other possibilities.
• Cardiovascular examination:
  • Examination of the pulse may reveal irregularities suggestive of atrial fibrillation, variable heart block or just bradycardia. Tachycardia may be a feature of congestive heart failure. In fast atrial fibrillation the irregularity may be difficult to detect.
  • Record blood pressure sitting and standing, especially if there is any suggestion of postural hypotension. A drop of more than 20 mmHg in the systolic BP on standing is significant.
  • Listen for bruits over the bifurcation of the carotid arteries but also in the posterior triangle of the neck to detect bruits from the vertebral arteries.
  • Auscultation of the heart may give better indication of irregularities than the radial pulse and it may indicate aortic valve disease or mitral valve disease.
• Neurological and locomotor examination:
  • Note muscle wasting that may reflect disuse atrophy, often secondary to arthritis.
  • Note muscle tone.
  • Brief assessment of the sensory system may indicate a peripheral neuropathy. Loss of vibration sense can be a marker for posterior column disease with associated loss of proprioception.
  • Asymmetrical tendon reflexes and any extensor plantar response are significant.
  • Try to reproduce vertebro-basilar symptoms by asking the patient to extend their neck to the full and to hold it for several seconds and repeat with flexion and full rotation to left and right.
  • Check for nystagmus and briefly for coordination
  • Note how the patient gets up from the chair. There may be proximal myopathy but in the elderly disuse atrophy is more common. Is gait normal? Is there asymmetry? Some gait abnormalities may be due to arthritis. Look for features that may indicate Parkinson's disease.
  • The 'Get Up and Go' screening test is advocated by some. Observe for unsteadiness as the patient rises from their chair without using their arms, walks 10 feet, turns around, walks back and resumes a sitting position. The process should take less than 16 seconds. Patients who have difficulties are at an increased risk of falling and need fuller evaluation.

• Basic blood tests including:
  • FBC
  • U&Es
  • LFTs
  • Thyroid function tests
  • Vitamin B₁₂
  • Random blood glucose
  Macrocytosis and/ or abnormal liver function tests, especially gamma GT, may indicate unsuspected alcohol abuse.
• Urinalysis may reveal unsuspected diabetes to account for vascular disease, neuropathy and poor vision.
• ECG to confirm or suggest:
  • Atrial fibrillation
  • Conduction defects where there is a prolonged PR interval, inferior ischaemia or bundle branch block.
  Ambulatory ECG may be required to discover episodes of bradycardia with possible heart block or even tachyarrhythmia.
• Echocardiography is indicated in heart failure, atrial fibrillation and valvular disease to assess ventricular or valvular function or to detect atrial thrombus.
• Visual assessment by an optician
• Syncope or TIAs require additional investigations including neuro-imaging.

Management is dependent upon the cause - see prevention of falls in the elderly.

The National Service Framework for the Elderly, standard 6, recommended the establishment of multidisciplinary teams to deal with the management of falls.¹¹ Most areas now have 'Falls Clinics' or the equivalent. They may be helpful with the diagnosis of the cause of the falls and have the resources to reduce the risk of recurrence.

• Loss of self confidence and independence - this may become a vicious cycle leading to reduced activity and increased risk of falling. Periods spent unable to get up following a fall or waiting for help are particularly undermining. Consider an alarm system with the patient.
• Fractures especially on a background of pre-existing osteoporosis. Fractured hips are a major cause of loss of independence and morbidity and even mortality. The expectation of life after a fractured hip is markedly truncated but this may be due not so much to the fracture, operative treatment and complications from this, as the underlying cause of the fall. Osteoporosis needs to be considered and prevented in advance of fractures occurring.
• Loss of independence requiring admission to a residential home is so dreaded by many old people that they regard it, quite literally, as a fate worse than death.¹² The East Anglian Hip Fracture Study, cited by Bandolier¹³ found that at 3 months following a hip fracture, 18% were dead and less than a quarter had returned to pre-fracture level of function. 42% of survivors were receiving extra help with at least half of their daily living activities, 21% required an increased level of residential or hospital care and of patients who returned home 35% required additional community health and social service visits.

See related record on prevention of falls in the elderly.

There is good evidence of the effectiveness of multi-component programmes in reducing rates of subsequent falls^14,15 - these usually combine general approaches with targeted interventions and form the basis of current guidelines.^7,16

Individual interventions likely to be beneficial include:¹⁵

• Muscle strengthening and balance retraining
• Home hazard modification
• Withdrawal of psychotropic medication
• Pacing for those with carotid sinus hypersensitivity
• Tai Chi

For other interventions (e.g. nutritional supplementation, cognitive behavioural therapy), efficacy is unknown and others such as brisk walking programmes in women with a recent (<2 years) upper limb fracture may be harmful.¹⁵
There is poor evidence looking specifically at risk reduction in those with cognitive impairment (dementia or delirium) who are particularly prone to falling and constitute a high proportion of those falling in hospital or nursing homes.¹⁷
There is no good evidence for the efficacy of hip protectors in preventing fractures in older people who fall whilst living independently. They may be effective in those living in institutional care who are at high risk of hip fracture but acceptance and adherence is poor¹⁸ as they are uncomfortable and difficult to get on and off quickly.¹⁹ Potentially the design of new, patient-friendly hip protectors will improve their usefulness.²⁰

The key message to elderly patients is to keep as active as possible. Activity should be aimed at keeping muscles strong and with this goes maintenance of proprioception and balance. Activity also slows osteoporosis and helps to prevent weight gain, which further impairs mobility.
For primary care doctors, practice should include routine enquiry about falling in older patients, referral for multifactorial falls risk assessment where needed and consideration of osteoporotic risk and prevention.