ICD-10 R29.6 | ||
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Falls in older adults are a significant cause of morbidity and mortality and are an important class of preventable injuries. The cause of falling in old age is often multifactorial, and may require a multidisciplinary approach both to treat any injuries sustained and to prevent future falls. Falls include dropping from a standing position, or from exposed positions such as those on ladders or stepladders. The severity of injury is generally related to the height of the fall. The state of the ground surface onto which the victim falls is also important, harder surfaces causing more severe injury. Falls can be prevented by ensuring that carpets are tacked down, that objects like electric cords are not in one's path, that hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated and that shoes have low heels or rubber soles.
Contents
- Definition
- Signs and symptoms
- Causes
- Intrinsic factors
- Extrinsic factors
- Diagnosis
- Prevention
- Hospital
- Screening
- Epidemiology
- Economics
- Research
- References
A review of clinical trial evidence by the European Food Safety Authority led to a recommendation that people over age 60 years should supplement the diet with vitamin D to reduce the risk of falling and bone fractures. Falls are an important aspect of geriatric medicine.
Definition
Researchers have tried to create a consensual definition of a fall since the 1980s. Tinneti et al defined a fall 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.” Other definitions are more inclusive and do not exclude "major intrinsic events" as a fall. Such falls are clearly of accidental origin, which might include a large number of causes, such as slips, trips and over-balancing.
A 2006 review of literature identified the need for standardization of falls taxonomy due to the variation within research. The Prevention of Falls Network Europe (ProFane) taxonomy for the definition and reporting of falls aimed at mitigating this problem. ProFane recommended that a fall be defined as "an unexpected event in which the participants come to rest on the ground, floor, or lower level." The ProFane taxonomy is currently used as a framework to appraise falls-related research studies in Cochrane Systematic Reviews.
Signs and symptoms
Causes
Falls are often caused by a number of factors. The faller may live with many 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 includes 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 in fall prevention.
Intrinsic factors
Extrinsic factors
Diagnosis
When assessing a person who has fallen, it is important to try to get an eyewitness account of the incident. As the faller may have had some loss of consciousness, they may not give an accurate description of the fall. However, in practice, these eyewitness accounts are often unavailable. It is also important to remember than 30% of cognitively intact older people are unable to remember a documented fall three months later. Important points of inquiry:
Prevention
A large body of evidence shows that a multi-disciplinary approach to assessment and treatment results in the best outcome.
Possible interventions include:
Interventions to minimize the consequences of falls:
Hospital
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.
Screening
American Geriatrics society (AGS)/British Geriatrics Society (BGS) 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.
Many health institutions in 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 reports falls should be asked about the circumstances and frequency. They should have an assessment of gait and balance. Older persons who present for medical attention because of a fall, or who report recurrent falls in the past, fail the gait & balance test, or report difficulties in walking & balance should have a multifactorial fall risk assessment. A multifactorial fall risk assessment is done by a clinician and includes focused history, physical exam, functional assessment and environment assessment.
Epidemiology
The incidence of falls increases progressively with age. According to the existing scientific literature, approximately one-third of the elderly population experiences one or more falls each year, while 10% suffer multiple falls. The risk is even greater in people older than 80 years, in which the annual incidence of falls can reach 50%.
Economics
The health care impact and costs of falls in older adults is significantly rising all over the world. The cost of falls are categorized into 2 aspects: direct cost and indirect cost.
Direct costs are what patients and insurance companies pay for treating fall-related injuries. This includes fees for 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 hospital emergency 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.
Research
A fall occurs when a person's centre of mass goes outside of the base of support. A majority of research on postural instability has focused on the anterior/posterior directions due to the structure of the legs and the frequency of falls in those directions. Maki, Holliday, & Topper (1994) has stated that sway in the medial/lateral directions can be just as important, “Results show strong evidence linking deficits in postural balance related to the control of the m–l stability with an increased risk of falling”. The mechanisms of postural instability are not fully understood, but research has suggested that disorders affecting sensory input and efferent motor signals are the primary causes.
Furthermore, a recent 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.