Prevention of Falls in the Elderly

Falls, fall-related injury, and fear of falling are important public health problems in an ageing society. Falls and mobility problems are the most common causes of referrals to intermediate care services.

Falls in the elderly are a problem for two 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) and Fractures of the femur

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

Falls can be devastating to the affected individual but are also expensive to manage. In particular, when associated with fracture of the proximal femur, they carry a high morbidity and mortality. 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 and also the loss of independence and the cost of residential care. Loss of independence requiring admission to a residential home is so dreaded by many elderly people that they regard it, quite literally, as a fate worse than death. Studies suggest that about 50% of patients who live independently before sustaining a hip fracture are unable to do so afterwards. 5-12% of hip fracture patients discharged to a post-acute care facility are re-admitted to the hospital within six weeks. About 5-10% of patients die within one month, whilst around 20-30% die within one year. Fragility fracture management alone is estimated to cost £1.7 billion per annum in the UK.Current estimates are that falls cost the NHS more than £2.3 billion per year.

The prevention of falls poses a challenge to carers and healthcare in general. 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. Standard 6 in the National Service Framework (NSF) for the elderly was to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen. Subsequent Department of Health strategies, including the latest guidance from the National Institute for Health and Care Excellence (NICE), have re-emphasised the importance of this.

Epidemiology

For a local population of 320,000:

• 15,500 will fall each year; 6,700 people will fall twice.
• 2,200 will attend accident and emergency departments or minor injuries units.
• A similar number will call an ambulance.
• 1,250 will have a fracture of which 360 will be hip fractures.

Injuries due to falls are the most common cause of mortality in people aged over 75 in the UK.

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.

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:

• Age >80.
• Female gender (this may be a true gender difference or a result of women being more likely to seek medical care and advice after a fall).
• Low weight.
• A history of fall in the previous year.
• Dependency in activities of daily living.
• Orthostatic hypotension – one study reported a 69% increased risk of having an injurious fall during the first 45 days following antihypertensive treatment.
• Medication – the leading culprits are psychotropics (especially benzodiazepines, antidepressants, antipsychotics), blood pressure lowering drugs, and anticonvulsants.
• Polypharmacy – a 14% increase in fall risk in one study with the addition of each medication beyond a four-medication regime, irrespective of the group of drugs studied.
• Alcohol abuse.
• Diabetes mellitus.
• Confusion and cognitive impairment.
• Disturbed vision.
• Disturbed balance or co-ordination.
• Gait disorders.
• Urinary incontinence.
• Inappropriate footwear.
• Environmental factors including home hazards.
• Muscle weakness.
• Depression.

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
• 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.

Poor self-protection
This is common in the elderly. Examples include:

• Lack of protective subcutaneous fat.
• Neurological problems (preventing 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 and stiff joints, drugs and environmental factors are a common combination of factors).

Presentation

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 previous year.

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? Was alcohol involved?
• What caused the fall? Sometimes the fall is attributed simply to tripping over a loose rug or a trailing electrical 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 – eg, 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 vertebrobasilar insufficiency. Older people should be discouraged from climbing on chairs or ladders since they are 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.
• 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.
• Was there any warning before the fall? Was there any loss of balance? 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 postictal 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, stroke, 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.

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

• Mental state:
  • Does the patient seem 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 in sitting and standing, especially if there is any suggestion of postural hypotension. A drop of more than 20 mm Hg in the systolic blood pressure 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 stenosis or regurgitation or mitral stenosis or regurgitation.
• Neurological and locomotor examination:
  • Note muscle wasting that may reflect disuse atrophy, often secondary to arthritis.
  • Note muscle tone.
  • A 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 vertebrobasilar 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 the left and right.
  • Check for nystagmus and briefly for co-ordination.
  • 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.

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

• Timed Up and Go Test: request that the patient rise from a chair without the support of their arms, walk three 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.

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. Falls should be considered a symptom rather than a diagnosis, so that when a patient, usually an elderly person, presents with a history of falls, effort should be made to find the cause or causes.

Environmental factors

Falls caused by accidents related to the patient’s environment can often be prevented. NICE recommends that all people at risk of falls should be offered a home assessment and interventions to modify environmental hazards. For example:

• Loose rugs or mats (especially on a slippery floor).
• Electricity leads (trailing across the floor).
• Wet surfaces (especially in the bathroom).
• Lighting.
• Furniture.
• Fittings such as handholds.

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

Rising from a chair and walking around the room require 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. A Cochrane review found some evidence to support certain types of exercise (eg, those directed towards improving balance and gait) whilst there was insufficient evidence to draw any conclusions about general physical activity.
• 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 t’ai 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 (abnormal posture, freezing of gait, frontal impairment, poor leaning balance and leg weakness are independent risk factors).
• Neuropathy may occur with, for example, diabetes.
• Proximal myopathy (from, for example, thyrotoxicosis, Cushing’s syndromeand 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 Six Item Cognitive Impairment Testcan 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

• 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 psychosis.
• 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 (LOC)

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 tachycardias, narrow complex tachycardias).
  • 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).
• TIAs (there may be weakness or confusion for a few seconds or several minutes with no residual neurological signs).
• Orthostatic hypotension (a 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.^[5] Gradual loss of vision has many causes. These 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 co-ordination and cause falls). 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).
  • Angiotensin-converting enzyme (ACE) inhibitors.
  • Alpha-blockers.
  • Phenothiazines.
  • Tricyclic antidepressants.
  • Levodopa.
  • Bromocriptine.
  • Beta-blockers.
  • Insulin.

Investigations

• Basic blood tests including:
  • FBC (macrocytosis may indicate alcohol abuse).
  • U&Es.
  • LFTs – abnormal LFTs may indicate alcohol abuse, especially gamma GT.
  • TFTs.
  • Vitamin B12.
  • Random blood glucose.
• 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.

Putting prevention into practice

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.

Who should be involved in prevention?

Many clinical commissioning groups 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.  One study found that encouraging patients to manage their own exercise-based falls prevention programme improves compliance and that physiotherapists should become ‘enablers’ rather than ‘experts’.

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?

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 and risk of falling but uncertainty over contribution that it makes to fracture reduction means NICE refrains from making a firm recommendation at the moment).
• Hip protectors (equivocal results in trials).

Falls prevention in hospital

NICE recommends that the following patients should be considered at risk of falls (prior use of risk assessment tool not necessary):

• All patients over the age of 65.
• All patients aged 50-64 judged by a clinician to be at risk of falls by virtue of their condition.

A multifactorial assessment should be performed which should include:

• Cognitive impairment.
• Continence problems.
• Falls history, including causes and consequences (such as injury and fear of falling).
• Footwear that is unsuitable or missing.
• Health problems that may increase their risk of falling.
• Medication.
• Postural instability, mobility problems and/or balance problems.
• Syncope syndrome.
• Visual impairment.

Multifactorial interventions should be offered which should:

• Promptly address the patient’s identified individual risk factors for falling in hospital.
• Take account of whether the risk factors can be treated, improved or managed during the patient’s expected stay.

Education and information giving

• Compliance is best achieved by involving patients in decisions about their care and finding out how much change they are prepared to make to prevent falls.
• Information should be available in languages other than English.
• Information – both oral arid written – should be given to patients and carers and should include:
  • Measures that can be taken to prevent further falls.
  • The importance of persevering with falls prevention strategies such as exercise or strength and balancing components.
  • The physical and psychological benefits of modifying falls risk.
  • Sources of further information.
  • How to summon help in the event of a fall.