Falls in the elderly

Case

Ms M., an 82-year-old independent woman, presents to her family doctor for a regular checkup. She is asymptomatic and states that she is doing well. However, when asked about falls, she describes falling 3 times in the past 6 months. Her falls were at home shortly after getting out of bed and were not associated with a loss of consciousness or an injury. Her history includes an old lacunar stroke, hypertension, knee osteoarthritis, and depression. Ms M. takes 25 mg of hydrochlorothiazide, 100 mg of atenolol, and 200 mg of ibuprofen all once daily, and 2 mg of lorazepam twice daily.

Falls are a main cause of morbidity and disability in the elderly. More than one-third of persons 65 years of age or older fall each year, and in half of such cases the falls are recurrent.¹ The risk doubles or triples in the presence of cognitive impairment or history of previous falls.² In Canada, falls are the most common cause (85%) of injury-related hospital admissions among those aged 65 years or older.³

Many view falls as merely a risk factor for fractures, disregarding the fact that falls can lead to irreversible health, social, and psychological consequences, with profound economic effects.⁴

Sources of information

MEDLINE was searched using terms relevant to falls among the elderly in the community and in institutions. Relevant English-language papers published from 1980 to July 2010 were reviewed. Relevant geriatric society guidelines were reviewed as well.

Pathophysiology

A fall is a complex multifactorial phenomenon. In order to understand the mechanism of falls, it is essential to understand the prerequisites of normal gait. Essential substrates for a normal gait include fine neural networks such as the cortical–basal ganglia loop and the basal ganglia–brainstem system, exquisite musculoskeletal structures with appropriately regulated muscle tone, and proper processing of sensory information (ie, cerebral cortex, vision, hearing, fine touch, and proprioception).⁵ Effective coordination of those components, along with adequate cognition and concentration, is needed to prevent falls and maintain gait.

It is not surprising that many of those functions show at least some decline with aging, thus increasing the risk of falls. Moreover, as a person ages, the likelihood of accumulating medical problems and their associated medications increases, and so does the risk of falling. Many changes occur in gait with aging, such as a decrease in gait velocity and step length, a wider base, and a decrease in lower limb strength. These changes are most pronounced when older people walk on irregular surfaces.⁶

A fall usually results from interactions between long-term or short-term predisposing factors and short-term precipitating factors (such as a trip, an acute illness, or an adverse drug reaction) in a person’s environment.⁷

Risk factors

Independent risk factors for falling include the following (arranged in order of evidence strength): previous falls, balance impairment, decreased muscle strength, visual impairment, polypharmacy (more than 4 medications) or psychoactive drugs, gait impairment and walking difficulty, depression, dizziness or orthostasis, functional limitations, age older than 80 years, female sex, incontinence, cognitive impairment, arthritis, diabetes, and pain.¹ The risk of falling increases with the number of risk factors: 1-year risk of falling doubles with each additional factor, starting from 8% with none, and reaching 78% with 4 risk factors.¹ A recent meta-analysis identified the following risk factors as having the strongest association with falling: history of falls, gait problems, walking aid use, vertigo, Parkinson disease, and antiepileptic drug use.⁸

A recent study has shown that the risk of falling increases in proportion to the severity of chronic musculoskeletal pain, the number of joint groups affected, and the amount of interference with daily activities.⁹

In a prospective study, white-matter lesions seen on magnetic resonance imaging were found to be strong predictors of risk factors for falls.¹⁰

Postural hypotension is common among the elderly, and can predispose to gait problems and falls.¹¹ Measuring postural blood pressure is easy, noninvasive, inexpensive, and quick; however, it is performed in less than 40% of older adults admitted with syncope, and is much more likely to affect diagnosis and management than more expensive and cumbersome tests are.¹² Postural hypotension is defined as a decrease in systolic pressure of at least 20 mm Hg or in diastolic pressure of at least 10 mm Hg within 3 minutes of standing. Patients should remain supine for at least 2 minutes before measuring supine vital signs, and remain standing for at least 1 minute before measuring standing vital signs.¹³

Obstructive sleep apnea was reported recently to be a reversible culprit in 4 elderly patients with daytime sleepiness and falling-asleep-related injurious falls.¹⁴

The risk of falling quadruples for the first 2 weeks after discharge from hospital,¹⁵ highlighting the vulnerability of this patient population and the adverse effects hospitalization might have on older adults. Moreover, in patients who have sustained falls while in hospital, 29% will fall at home, 35% will be readmitted for falls, and 5% will die within a month.¹⁶ This might be related to a variety of precipitating factors, such as acute illness, environment change, or adverse drug reactions.

Medications

Medications are a well established risk factor for falls. However, it is important to consider the reason for taking a medication before deciding to stop or withdraw a medication for the purpose of fall prevention, because the condition the drug is used to treat might itself be a risk factor for falling. Depression, pain, and cognitive impairment are examples. Therefore, each medication should be examined individually, and the benefits and risks of stopping or continuing its use should be weighed carefully.

Medication classes that have been associated with an increased risk of falls include the following: antihypertensive agents, sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, and nonsteroidal anti-inflammatory drugs. Narcotics, however, have not been associated with increased risk of falls.¹⁷

In a population-based cohort study, which used health care databases from Ontario, the use of cholinesterase inhibitors was associated with increased rates of syncope, bradycardia, pacemaker insertion, and hip fracture in older adults with dementia.¹⁸ These findings highlight this class of medications as a potential risk factor for falls; these risks should be weighed carefully and discussed with patients and caregivers.

Screening and assessment

Very quick screening can be carried out in any medical practice by inquiring about falls in the past year and gait or balance problems. Individuals who are 65 years of age or older have an annual pretest probability of falling of 27%. Patients who have fallen in the past year are more likely to fall again (likelihood ratio 2.3 to 2.8), as are those who have clinically detected abnormalities of gait or balance (likelihood ratio 1.7 to 2.4). The presence of any of these factors brings the annual risk to 50%, and therefore should prompt a full assessment.¹³

A full assessment should include the following.

Guidelines

In 2010, the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS) issued fall prevention guidelines, which have been endorsed by the American Medical Association, the American Occupational Therapy Association, and the American Physical Therapy Association.²⁰ Recommendations in this review are in keeping with those guidelines.¹⁹ The guidelines urge primary care physicians to screen their patients yearly and to implement tailored, multifaceted interventions for at-risk patients.²⁰ The guidelines, however, are somewhat conservative in what would prompt a full falls assessment, requiring the patient to have either a history of at least 2 falls in the past year or to present with a fall. It is not unreasonable to have a lower threshold (ie, a single fall in the past year) for initiating a full assessment.¹⁹

Prevention

Various interventions have been shown to decrease the risk and the rate of falls. They are generally divided into single and multicomponent interventions.

Conclusion

Ms M. has a 50% annual risk of falling again; therefore, a full assessment is warranted (Figure 1). This should include assessment of her depression. Gradual reduction of her antihypertensive medications should be attempted to eliminate the orthostatic blood pressure drop, perhaps starting with the β-blocker, given her low heart rate. Gradual and slow withdrawal of benzodiazepines should be tried as well. She should be evaluated for the presence of pain and treated accordingly. Regular use of acetaminophen is a safer alternative than ibuprofen, and low-dose narcotics could be considered. Ms M. should be referred to occupational therapy for a home assessment and intervention, as well as to physical therapy for structured exercises. Tai Chi is a reasonable alternative. She should also be prescribed 1000 IU of vitamin D daily. Ms M. should be screened for osteoporosis in order to minimize fracture risk from future falls.

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Figure 1

Suggested approach to falls screening, evaluation, and prevention

When Ms M. presented to her family doctor, she did not volunteer her history of falls, which is not uncommon. It therefore behooves medical professionals to be proactive in inquiring about falls, given how common this problem is, its high likelihood of recurrence, and the profound effects of its consequences. Risk factors for falls should be viewed as potentially reversible, and falls should not be perceived as an inevitable part of aging.