geriatrics
Falls in Older Adults
Etiology of Falls
The most consistent predictor of falling is a previous fall. However, falls in older adults rarely have a single cause or risk factor. A fall is usually multifactorial, caused by a complex interaction among the following: Intrinsic factors (age-related decline in function, disorders, and adverse effects of medications) Extrinsic factors (environmental hazards) Situational factors (related to the specific activity or circumstances of an activity—eg, rushing to the bathroom in the middle of the night) Age-related changes can impair systems involved in maintaining balance and stability (eg, while standing, walking, or sitting) and increase the risk of falls. Visual acuity, contrast sensitivity, depth perception, and dark adaptation decline. Sensory loss or disturbances and cerebellar dysfunction can diminish postural reflexes and impair balance. Changes in muscle activation patterns and ability to generate sufficient muscle power and velocity may impair the ability to maintain or recover balance in response to perturbations (eg, stepping onto an uneven surface, being bumped). In fact, muscle weakness of any type is a major predictor of falls. As cognitive impairment increases with age, so does the risk of falls, partly because older adults with cognitive impairment may not remember to take the safety measures that reduce falls. Chronic and acute disorders (see table) and use of medications (see table) are major risk factors for falls. The risk of falls increases with the number of medications taken. Several classes of medications increase risk, but psychoactive medications are most commonly reported as increasing both risk of falls and fall-related injuries. Risk of a traumatic fall that results in a fracture is increased by Osteoporosis and age-related changes in bone quality, which increase bone fragility Loss of muscle (sarcopenia), which reduces protective responses to perturbations Environmental factors can increase the risk of falls independently or, more importantly, by interacting with intrinsic factors. Risk is highest when the environment requires greater postural control and mobility (eg, when walking on a slippery surface) and when the environment is unfamiliar (eg, when relocated to a new home). Certain activities or decisions may increase the risk of falls and fall-related injuries. Examples are Walking while talking Being distracted by multitasking and then not noticing an environmental hazard (eg, a curb or step) Rushing to the bathroom (especially at night when not fully awake or when lighting may be inadequate) Rushing to answer the telephone Dementia can exacerbate many of these hazardous situations that lead to falls. Impaired cognition, judgment, and hazard awareness can cause older adults to become distracted, rush, and not notice environmental hazards, significantly increasing fall risk. Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death in older adults who are frail and have preexisting disease comorbidities (eg, osteoporosis) and deficits in activities of daily living (eg, incontinence). Longer-term complications can include decreased physical function, fear of falling, and institutionalization. Each year, approximately 36 million falls are reported in older adults, resulting in more than 32,000 deaths, and each year, emergency departments treat approximately 3 million older adults for injuries due to falls. Most falls do not cause serious harm, but about 20% cause a serious injury such as fractures or a head injury. Each year, at least 300,000 older adults are hospitalized for hip fractures, which result from falling in> 95% of cases. Women tend to fall more often than men, and about 75% of all hip fractures occur in women ( Etiology references ). About half of older adults who fall cannot get up without help ( Etiology references ). Remaining on the floor for Function and quality of life may deteriorate drastically after a fall; up to 60% of older adults do not recover their previous level of mobility ( Etiology references ). After falling, older adults may fear falling again, so mobility is sometimes reduced because confidence is lost. Some people may even avoid certain activities (eg, shopping, cleaning) because of this fear. Decreased activity can increase joint stiffness and weakness, further reducing mobility. 1.Centers for Disease Control and Prevention (CDC): Keep on Your Feet—Preventing Older Adult Falls. Accessed 10/18/23. 2.Gurley RJ, Lum N, Sande M, et al: Persons found in their homes helpless or dead.N Engl J Med334 (26), 1710–1716, 1996, doi.org/10.1056/nejm199606273342606 3.Haslam-Larmer L, Donnelly C, Auais M, et al: Early mobility after fragility hip fracture: a mixed methods embedded case study.BMC Geriatr21 (1):181, 2021. doi: 10.1186/s12877-021-02083-3 