This articleis missing information about prognosis/consequences, see e.g.CDC fact sheet &doi:10.1007/s11556-013-0134-8. Please expand the article to include this information. Further details may exist on thetalk page.(December 2022)
Falls in older adults are a significant cause ofmorbidity andmortality and are a major class ofpreventable injuries. Falling is one of the most common accidents that cause a loss in function, independence, and the quality of life for older adults, and is usually precipitated by multiple risk factors.[1][2] The cause offalling inolder age is often multifactorial and may require a multidisciplinary approach both prevent and treat any injuries sustained.[3] Falls definition tends to vary based on who is reporting the fall and the audience. It is generally accepted that falling includes dropping from a high position to a low one, often quickly. A fall doesn't necessarily mean someone falls to the ground, but could fall back into a chair or bed, and the fall can be assisted by another person to help slow down the fall and hopefully avoid injury. The severity of injury is generally related to the height of the fall and the person's health, such as the presence of osteoporosis. The type of surface onto which the person falls is also important, harder surfaces causing more severe injury. Generally, falls can be prevented by ensuring that interior surfaces are free of clutter, are dry, carpets are tacked down, paths are well lit, that hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated and that shoes have low heels or rubber soles.[4] External surfaces are harder to control, but ideally to reduce falls, walking on surfaces that are not wet or icy, are well light, are flat and having hands and arms free to help regain balance or protect from a fall can be helpful.
A review ofclinical trial evidence by theEuropean Food Safety Authority led to a recommendation that people over the age of 60 years shouldsupplement the diet withvitamin D to reduce the risk of falling and bone fractures.[5] Falls are an important aspect ofgeriatric medicine. In 2018, the United States Preventive Service Task Force actually recommended against vitamin D supplementation as it relates to fall prevention citing lack of association or conflicting results between the supplement and reduced falls in older adults.[2]. Rather, older adults should be screened for osteoporosis and if diagnosed the need to slow or stop bone loss is paramount. This can be accomplished through proper nutrition, lifestyle changes, exercises, fall prevention strategies and some medications.[3]
Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall.[6] Falls are of concern within medical treatment facilities. Fall prevention is usually a priority in healthcare settings.[7]
A 2006 review of literature identified the need for standardization of fallstaxonomy due to the variation within research.[8] The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem.[9] ProFane recommended that afall be defined as "an unexpected event in which the participants come to rest on the ground, floor, or lower level."[9] The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews.[10][11][12]
Soft tissue injuries. Bilateral orbital haematomas (two black eyes) suggests that the faller was probably not conscious as they fell, as they did not manage to protect their face as they hit the ground.
Falls are often caused by a number of factors such as intrinsic vs extrinsic or modifiable vs non-modifiable. The older adult who may fall could have risk factors for falling and only have problems when another factor appears. As such, management is often tailored to treating the factor that caused the fall, rather than all of the risk factors a patient has for falling. Risk factors may be grouped into intrinsic factors, such as existence of a specific ailment or disease. External or extrinsic factors include the environment and the way in which it may encourage or deter accidental falls. Such factors as lighting and illumination, personal aid equipment and floor traction are all important infall prevention.[13]
Modifiable risk factors can include items such as gait, strength, and balance deficits, medication used, home hazards, orthostatic hypotension, vision and hearing problems, foot issues or inappropriate footwear and the presence of comorbidities. This is the basis the US Center for Disease Control (CDC) STEADI (STEADI-Stopping Elderly Accidents, Deaths and Injuries) fall prevention initiative.[4] Evidence supports the need for early identification or screening for fall risk, assessment of fall risk factors for the appropriate referral to evidence-based interventions that are patient-specific[5]
There is a list of high-risk medication related to falls in older adults that is derived from the Beer's list; general categories include antihypertensives, antihistamines, benzodiazepines, sedatives, antihyperglycemics and anticonvulsants[7]
Bifocals and trifocals can increase the risk of falling as the lower portion of corrective lenses are optimized for distances approximately 18 in (46 cm), thus precluding clear vision of one's feet/floor, approximately 4.5–5.5 ft (1.4–1.7 m) below one's eyes.
Hanging straps with triangular handles in a modern Japanese commuter trainGrab rails on a longer-distancecommuter train catering for mainly seated passengersA staircase with metal handrails
Poor lighting due to lowluminance of existing lights or lamps, so preventing hazard identification and avoidance. Eyesight deteriorates with age, and extra lighting will be needed where seniors move frequently. The luminance provided by the bulbs used should be higher than normally accepted.
Stairs with inadequatehandrails, or too steep, encouraging trips and falls. The steps should be spaced widely with low risers, and surfaces should be slip-resistant. Softer surfaces can help limit impact injuries by cushioning loads.
Doorways with adequate headroom so that the user's head does not hit thelintel. Doorways of low headroom (less than about 6 ft (1.8 m)) are common in old houses and cottages for example.
Rugs/floor surfaces with lowfriction, causing poortraction and individual instability. All surfaces should have a highfriction coefficient with shoe soles and limited clutter.
Clothing/footwear poorly fitted, shoes of low friction against floor. Rubber soles with ribs normally have a high friction coefficient, so are preferred for most purposes. Clothing should fit the user well, without trailing parts (hems falling below the heel and loose shoelaces) which could snag with obstacles.
Lack of equipment/aids such aswalking sticks or walking frames, such asZimmer frames so as to improve user stability.Grab bars andhanging straps should be supplied plentifully, especially in critical areas where users may be vulnerable.
When assessing a person who has fallen, an eyewitness account of the incident is helpful. However the person who fell may have been temporarily unconscious, and may not be able to give an accurate description of the fall. In practice, these eyewitness accounts are often unavailable.
The relationship between the person at risk of falling and their environment is important for determining the risk falls and taking measures to prevent falls. An assessment with an occupational therapist may be helpful to determine an appropriate rehabilitation plan to prevent falls by taking into consideration both the person and their living environment.[14][15] A large body of evidence shows that efforts to include exercise decrease the risk of falls,[16][17] and yet the fear of falling can lead to a decrease in participation in physical exercise.[14]
Regular exercise: lower limb strengthening exercise to increase muscle strength.[19] Other forms of exercise, such as those involving gait, balance, co-ordination and functional tasks, may also help improve balance in older adults.[20]
A 2014 review concluded that exercise interventions may reduce fear of falling (FOF) in community-dwelling older adults immediately after the intervention, without evidence of long-term effects.[21]
Monitoring of medications and ongoing medical problems. For example, people withpolymyalgia rheumatica often take long-term steroids, leading toosteoporosis. Research in the UK has also suggested that these people would benefit from a falls assessment when first diagnosed, and regular treatment reviews.[22][23]
Improvements to footwear and use oforthotic devices if required.[24]
Supplementation withvitamin D is not recommended in those without vitamin D deficiency for fall prevention in older adults.[17]
Cognitive behavioral therapy (CBT) has been suggested as a prevention approach to improve confidence and help older people reduce the fear of falling.[25] There is moderate evidence to suggest that this technique can be effective at reducing the fear of falling for up to and beyond 6 months.[25] CBT appears to have a positive effect on activity avoidance and risk of depression; however, it is not clear whether CBT reduces the incidence of falls in older people.[25]
Interventions to minimize the consequences of falls
Hip protectors may decrease risk of hip fractures slightly, although they may slightly increase the risk of a pelvic fracture in older adults living in nursing care facilities. Little or no effect reported on other fractures or falls.[26]
People who are hospitalized are at risk for falling. A randomized trial showed that use of a tool kit reduced falls in hospitals. Nurses complete a valid fall risk assessment scale. From that, a software package develops customized fall prevention interventions to address patients' specific determinants of fall risk. The kit also has bed posters with brief text and an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.[27]
TheAmerican Geriatrics Society and theBritish Geriatrics Society recommend that all older adults should be screened for "falls in the past year". Fall history is the strongest risk factor associated with subsequent falls.[28] Older people who have experienced at least one fall in the last 6 months, or who believe that they may fall in the coming months, should be evaluated with the aim of reducing their risk of recurrent falls.[29]
Many health institutions in the USA have developed screening questionnaires. Enquiry includes difficulty with walking and balance, medication use to help with sleep/mood, loss of sensation in feet, vision problems, fear of falling, and use of assistive devices for walking.
Older adults who report falls should be asked about their circumstances and frequency to assess risks from gait and balance which may be compromised. A clinician performs a fall risk assessment, to include history, physical exam, functional capability, and environment.[30]
Prevention approaches that target the whole population of older people in a particular area are defined as population-based interventions. These include policies put in place by governments for vitamin supplementation, maintenance programs to reduce risks in public spaces and homes, public health programs offering exercise classes and sharing resources widely (not just to people identified as being high risk), improving access to gyms (for example allowing seniors to access a gym for free if over a certain age).[31] The evidence supporting population-based interventions is weak. It is not clear if population-based interventions that improve access to medications or nutritional program are effective.[31]
The incidence of falls increases progressively with age. According to the existing scientific literature, around one-third of the elderly population experience one or more falls each year, while 10% experience multiple falls annually. For people over 80, the annual incidence of falls can reach 50%.[32][33][34][35][36]
Researchers have tried to create a consensual definition of a fall since the 1980s. Tinneti et al. defined afall as "an event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard."[37]
The health care impact and costs of falls in older adults are significantly rising all over the world. The cost of falls is categorized into two aspects: direct cost and indirect cost.
Direct costs are what patients and insurance companies pay for treating fall-related injuries. This includes fees for the hospital and nursing home, doctors and other professional services, rehabilitation, community-based services, use of medical equipment, prescription drugs, changes made to home and insurance processing.
Indirect costs include the loss of productivity of family caregivers and long-term effects of fall-related injuries such as disability, dependence on others and reduced quality of life.
In the United States alone, the total cost of falling injuries for people 65 and older was $31 billion in 2015. The costs covered millions of hospitalemergency room visits for non-fatal injuries and more than 800,000 hospitalizations. By 2030, the annual number of falling injuries is expected to be 74 million older adults.[38]
Furthermore, a 2012 systematic review has demonstrated that performing dual-task tests (for example, combining a walking task with a counting task) may help in predicting which people are at an increased risk of a fall.[3]
^Eibling, D. (2018). Balance disorders in older adults.Clinics in GeriatricMedicine,4(2), 175–181. doi:10.1016/j.cger.2018.01.002
^Bao X., Qiu Q.-X., Shao Y.-J., Quiben M., Liu H. Effect of Sitting Ba-Duan-Jin Exercises on Balance and Quality of Life among Older Adults: A Preliminary Study.Rehabil. Nurs.. 2020;45(5):271-278. doi:10.1097/rnj.0000000000000219
^abSarofim M (2012). "Predicting falls in the elderly: do dual-task tests offer any added value? A systematic review".Australian Medical Student Journal.3 (2):13–19.
^Ficalora, Robert D.; Paul S. Mueller; Thomas J. Beckman; et al., eds. (2013).Mayo Clinic internal medicine board review (10th ed.). Oxford: Oxford University Press. p. 762.ISBN978-0-19-994894-9.OCLC822991632.
^abLamb SE, Jørstad-Stein EC, Hauer K, Becker C (2005). "Development of a Common Outcome Data Set for Fall Injury Prevention Trials: The Prevention of Falls Network Europe Consensus".Journal of the American Geriatrics Society.53 (9):1618–1622.doi:10.1111/j.1532-5415.2005.53455.x.PMID16137297.S2CID19526374.
^Hopewell S, Adedire O, Copsey BJ, Sherrington C, Clemson LM, Close JC, Lamb SE (2016). "Multifactorial and multiple component interventions for preventing falls in older people living in the community (Protocol)".Cochrane Database of Systematic Reviews.doi:10.1002/14651858.CD012221.
^Sherrington C, Tiedemann A, Fairhall NJ, Hopewell S, Michaleff ZA, Howard K, Clemson L, Lamb SE (2016). "Exercise for preventing falls in older people living in the community (Protocol)".Cochrane Database of Systematic Reviews.doi:10.1002/14651858.CD012424.S2CID78199547.
^abcDepartment of Health,National service framework for older people; Standard 6 – Falls, Crown Copyright, 24 May 2001,[1] accessed:19/5/2008
^abGrossman, David C.; Curry, Susan J.; Owens, Douglas K.; Barry, Michael J.; Caughey, Aaron B.; Davidson, Karina W.; Doubeni, Chyke A.; Epling, John W.; Kemper, Alex R.; Krist, Alex H.; Kubik, Martha; Landefeld, Seth; Mangione, Carol M.; Pignone, Michael; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien-Wen (24 April 2018)."Interventions to Prevent Falls in Community-Dwelling Older Adults".JAMA.319 (16):1696–1704.doi:10.1001/jama.2018.3097.PMID29710141.
^Tinetti ME, Speechley M, Ginter SF (Dec 1988). "Risk factors for falls among elderly persons living in the community".N Engl J Med.319 (26):1701–7.doi:10.1056/NEJM198812293192604.PMID3205267.
^"Costs of Falls Among Older Adults". Centers for Disease Control and Prevention, Home and Recreational Safety, U.S. Department of Health & Human Services, Bethesda, MD. 2016. Retrieved2 December 2016.
