Continuing Education Activity

Falls account for one of the most common and serious issues contributing to a disability, especially among elderly individuals. Tinetti et al. in 1988 defined a fall as an event that results in a person coming to rest on the ground or other lower-level unintentionally, which is not as a result of a major intrinsic event (such as stroke) or overwhelming hazard. This activity reviews the evaluation and management of falls and highlights the role of the interprofessional team in managing patients who present after a fall or multiple falls.

Objectives:

• Identify the etiology of falls in the elderly.
• Describe the patient history associated with falls in the elderly.
• Summarize the management considerations for patients presenting with falls.
• Review the importance of collaboration and communication among the interprofessional team to improve outcomes for patients affected by falls.

Introduction

Falls account for one of the most common and serious issues contributing to a disability, especially among elderly individuals. Tinetti et al. in 1988 defined a fall as an event that results in a person coming to rest on the ground or other lower-level unintentionally, which is not as a result of a major intrinsic event (such as stroke) or overwhelming hazard. There is a direct correlation between falls and mortality, morbidity, and reduced functionality. Falls occur with high frequency in the elderly, children, and athletes. Among the elderly, associated medical comorbidities correlate to an increased propensity to fall, and in turn, increased susceptibility to injury.[1]

Etiology

Normal gait results from effective coordination of the following neural components: basal ganglia brainstem system, regulated muscle tone, and functional processing of sensory information such as vision, hearing, and proprioception. The risk of falling is increased in the elderly because (1) these functions decline with age (2) the probability of accumulating medical issues increases with age, and (3) associated medications are often increased as well. With aging usually comes a wide-based gait, along with a decrease in gait velocity, step length, and lower limb strength. A fall most often results from interactions between these long-term predisposing factors and short-term predisposing environmental factors such as an adverse drug reaction, acute illness, or a trip on an irregular surface.

Risk factors for falls in order of evidence strength include a history of falls, impairment in balance, reduced muscle strength, visual problems, polypharmacy (defined as taking over four medications) or psychoactive drugs, gait difficulty, depression, orthostasis or dizziness, functional limits, age over 80 years, female sex, incontinence, cognitive difficulties, arthritis, diabetes, and pain.

Fall risk escalates as the number of risk factors increases. The 1-year risk of falling doubles for every added risk factor. It starts at 8% with no risk factors and increases by up to 78% with four risk factors. Medications related to falls include antihypertensives, neuroleptics and antipsychotics, sedatives and hypnotics, antidepressants, nonsteroidal anti-inflammatory drugs, and benzodiazepines.[2]

Epidemiology

Over 30% of individuals who are over the age of 65 fall every year. In approximately half of the cases, the falls are recurrent. This percentage increases to around 40% in individuals aged 85 years and above.[3] Approximately 10% of falls result in serious injuries, including fracture of the hip, other fractures, traumatic brain injury, or subdural hematoma.[4][5] Falls are the most common type of accidents in people 65 years of age and older, and are the major cause of hospitalization related to injury in this age group. Injuries that are caused by falls are associated with increased mortality. Associated use of ambulance services, social care, and hospital care results in substantial financial costs.[6]

Pathophysiology

An important cause of falls in the elderly population is the presence of sarcopenia. Sarcopenia can be related to a food decline, a long hospital stay, and/or a long illness. Generally, the elderly have a decrease in mass volume and coordination, with phenotypic changes, such as selective loss of white fibers.

Another cause of falls is the presence of cognitive impairment that is often found in the elderly, especially in those with a long illness, pain, or mood changes.

Postprandial hypotension is a non-physiological reason that causes falls in elderly subjects, probably due to an autonomic system dysfunction or the declining function of the cardiovascular system.

Obesity in the elderly is another cause linked to the increase in falls, probably due to a further decline in muscle mass and neuromuscular function.

Osteoporosis can cause rupture of the femoral neck in elderly subjects, and this event can often confuse the providers, particularly when the patient is uncooperative.

Another cause that leads to motor instability and an increase in the percentage of falls is the decline in the strength of the diaphragm muscle. A decrease in strength and function of the diaphragm causes instability in the back area and leads to falls.

Histopathology

Basically, the phenomenon of sarcopenia begins from the 4th decade, to arrive at a 50% muscular loss (inactive elderly) in the elderly with 80 years of age. The causes are different: decrease in anaerobic or white fibers; decline in protein synthesis (maintenance or hypertrophy), increase in connective tissue and fat within muscle fibers, mitochondrial alteration and increase in free radicals (ROS), increase in an inflamed cell environment, neurological, central and peripheral remodeling.

Toxicokinetics

Cysteine (Cys) is a non-essential amino acid, sulfur-containing, HOOCCH (NH2) CH2SH; it can be derived by biosynthesis from serine or methionine after it has been transformed into cystathionine. One of its deficiencies leads to muscle weakness and imbalances in protein synthesis. Cysteine is essential (together with glycine and glutamic acid) for the synthesis of glutathione (GSH); the latter is fundamental for the detoxification of the metabolites of paracetamol. In elderly people with chronic pain, taking acetaminophen is very frequent; according to studies, the depletion of GSH and cysteine to clean the liver site causes sarcopenia in the long run.

History and Physical

When the history of the present illness is taken, it is important to understand the intrinsic and extrinsic causes of falls. Tailoring questions to the following causes can help provide an accurate assessment of a patient's fall risk.

Intrinsic Causes

• History of falls: Predisposes one to an increased risk of recurrent falls
• Age: Increased age is associated with decreased reaction time, particularly in step initiation and execution timing.
• Gender: In most elderly individuals, women fall more often than men
• Race: Studies show that Whites fall more often than Africans, Caribbeans, Hispanics, and South Asians.
• Drugs: If more than four medications are taken, the risk of falls is raised significantly. The use of benzodiazepines in the elderly increases the risk of night falls and hip fractures by 44%. Drugs such as antiarrhythmics, digoxin, diuretics, sedatives, and psychotropics also increase the risk of falling substantially.
• Solitary lifestyle: Living alone appears to be a risk factor in falls. Injuries and consequences can be increased if the fallen individual cannot get up from the floor.
• Medical conditions associated with an increased risk in falls include vascular diseases, arthritis, thyroid dysfunction, diabetes, depression, and chronic obstructive pulmonary disease. Vertigo and incontinence are common in populations with falls.
• Impairment in gait and mobility: After the age of 30, strength and endurance decrease by 10% per decade. When strength, power, and endurance are decreased, a slip or trip can turn into a fall. Any lower limb disability can increase the risk of falling, and difficulty rising from a seated position in a chair is associated with an increased risk as well.
• Immobility/Deconditioning: Sedentary individuals fall more than those who are relatively active.
• Fear of falling: Among individuals with a recent fall, up to 70% report fears of falling. Of these individuals, 50% may limit or exclude physical or social activity because of this fear, thereby increasing their fall risk.
• Poor nutrition: Deficiencies in nutrients can result in low body mass index, which is associated with an increased risk of falls. Vitamin D deficiency can result in muscle weakness, osteoporosis, and impaired gait patterns.
• Cognitive disorders: Dementia, poor memory, and a score of under 26 on the Mini-Mental State Exam are all related to an increased risk of falls.
• Impaired vision: Glaucoma, cataracts, visual acuity, the field of vision, and contrast sensitivity lead to an increased risk of falls.
• Foot issues: General pain when walking, calluses, long toe deformities, ulcers, and nail deformities increase balance difficulty and risk of falling.

Extrinsic Causes

Environmental factors correlated with falls in the elderly population include poor lighting, uneven surfaces, and floors that are slippery. Studies show that these factors account for 30%-50% of falls in this population. Missed steps, slips, and trips occur with more frequency in elderly populations.

Physical Exam

The physical examination should correlate to the above-mentioned causes of falls and is tailored to the patient's history of present illness. Blood pressure and postural changes can rule out orthostatic hypotension. Examination of the feet can point to any foot deformities. A targeted neurological exam may reveal visual acuity deficits or eighth cranial nerve deficits that can point to possible vestibular issues. Manual muscle motor testing can point to generalized or lower extremity weakness.[1]

Screening Tools

To date, none of the screening tools is able to accurately assess the fall risk among elderly individuals. There are many tools available. Some of which are: The Tinetti Gait and Balance Assessment Tool and The one-legged and tandem stance assessments. Neither of these tests accurately identifies fall risks and are poor predictors.[7][8][9]

Activities of Daily Living

Because patients with difficulties with basic or instrumental activities of daily living (ADLs) are at increased risk of falling, assessment of the patient's functional status should be completed in detail. Assessment of basic ADLs should include bathing, toileting, dressing, feeding, grooming, and ambulation. Assessment of instrumental ADLs should include shopping, cooking, managing their own finances, telephone use, laundry, housekeeping, and transportation. Asking patients about any difficulties completing these activities can provide valuable information.[10]

Evaluation

Given the various causes of falls, prevention, and management must be multidimensional and interprofessional. The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary instrument used in the evaluation of elderly patients at risk of falling. In addition to the history and physical examination, assessment of pain with visual analog scale and pharmacological history should be completed as well. Evaluation scales included in the CGA assessment include the Berg Balance Scale to evaluate static and dynamic balance, the Falls Efficacy Scale to assess the fear of falling, and the Timed Up and Go Test to assess a patient's mobility. Other scales may include the 6 minutes Walking Test and the 10 meters Walking test when indicated.[11]

While there is no standard diagnostic testing for an individual at high risk for falls, based upon the history and physical examination, laboratory tests such as electrolytes, hemoglobin, and glucose concentration may help determine causes of falling such as dehydration, anemia, and diabetes respectively. Serum vitamin D levels can help identify patients who may benefit from vitamin D supplementation.

Treatment / Management

The management of falls can be complicated. A combination of interventions such as medication review, an exercise program, vitamin D supplementation, and home assessment for groups of elderly people has been suggested. Given that the causes of falls are often multiple, the treatment should be tailored to each patient based on the history and physical examination. The existing evidence specifies that an exercise program should always be part of the management. There is also support for other treatment measures such as treatment of cataracts and home assessments. Both single and multiple intervention approaches have been considered for patients who have fallen.[12]

Single-factor Interventions

Home Assessment:

When elderly patients at elevated risk of falls are discharged from the hospital, an environmental home assessment should be considered. Studies demonstrate that home visits by occupational therapists can be instrumental in preventing falls among elderly people who are at an increased risk of falling.[13][14]

Exercise Programs:

• Exercise programs help prevent falls with no differences between types of exercise interventions, including endurance, platform balance, tai chi, resistance, and flexibility.[15]
• Tai chi is a time-honored martial art that involves slow, rhythmic movements, including rotation of the trunk, shifting weight, coordination, and a gradual progression to narrowing the lower extremity stance. It has gained recognition as a good exercise choice for the elderly. Studies have shown tai chi improves postural stability more so than other exercises. It also offers multiple musculoskeletal and cardiopulmonary benefits. Patients with a history of fractures are unfortunately not candidates for participation in tai chi.[16]
• Balance focused exercises, specifically (1) walking heel to toe, and (2) standing on one foot, in combination with coordination exercises, are also proposed for fall prevention.[17]

Medication Review:

Several common medications have been implicated as important contributors to the risk of falling in the elderly. All medications should be reviewed in patients with falls. Particular attention should be paid to patients who receive four or more medications and to those taking psychotropic medications, as these medications have specifically been linked to a strong chance of a future fall. The use of antidepressants, sedatives, hypnotics, and benzodiazepines demonstrates a significant correlation to falls in elderly people. Side effects of specific medications and interactions between medications are a potential reason for falls in the elderly. In medicines that could be attributed to causing falls, the risks and benefits of continuance must be carefully evaluated, and any unnecessary medications should be discontinued.[18]

Vitamin D Supplementation:

Vitamin D has benefits for improved muscle strength and balance. For community-dwelling or long term care residents, vitamin D supplementation in doses from 700 IU/d to 1000 IU/d can reduce falls by 19% after 2-5 months of starting treatment.[19]

Interventions Targeting Multiple Factors

Based on the initial assessment, a combination of interventions may be used to address multiple factors. Evidence suggests that this tailored treatment is more effective than standardized treatment for community-dwelling elderly adults. Specifically, research demonstrates that home safety interventions, vitamin D supplementation in those individuals with low vitamin D levels, and individually tailored interventions were correlated with fewer falls in community-dwelling individuals who had risk factors for falling.[13] Fall prevention clinics involving an interprofessional team, along with a community step-down program, can be instrumental in reducing fall rate and related injuries.[20]

Differential Diagnosis

The history of a fall is crucial to the diagnostic process. Both pre and post-fall symptoms should be considered in detail. It is essential to be able to diagnose any other condition that may present with a fall.

Syncope: If an unwitnessed fall is not accidental, or due to a “slip or trip,” then the patient most likely experienced a syncopal event and had a loss of consciousness. Under these circumstances, an evaluation of unexplained syncope must be pursued.[21]

Other conditions that may present with a fall include:

• Transient ischemic attack (TIA)
• Stroke
• Seizure
• Acute coronary syndrome
• Orthostatic hypotension
• Arrhythmia
• Pulmonary embolism
• Endocrine disorders
• Metabolic derangements
• Infection/Sepsis

In the elderly, age-associated memory impairments may obscure recall, and history of prodromal symptoms or whether or not loss of consciousness occurred can be difficult to ascertain. In the absence of a witness, the differential diagnosis between falls, syncope, TIA, and epilepsy can be difficult. Utilizing the combination of history and physical exam findings can help narrow the differential diagnosis.[21]

Prognosis

Falls are a serious problem in the elderly. Recurrent falls lead to a rise in morbidity and mortality in this population, as well as premature nursing home admission, and reduced functionality. Given the mental, emotional, and physical toll caused by falls, early intervention is recommended to prevent them.[1]

Complications

Fall complications include hospitalization, fracture, traumatic brain injury, subdural hematoma, pain, admission to a care home, surgical intervention, decreased overall functional ability, a fear of falling, and poor quality of life.[1][22]

Deterrence and Patient Education

Patient education is of prime importance for preventing falls. Information that can be given to patients includes:

• Home exercise program
• Home safety precautions
• Diet recommendations
• Medications and their side effects
• Emergency contacts
• Balance training [22]

Enhancing Healthcare Team Outcomes

The Comprehensive Geriatric Assessment (CGA) increases diagnostic accuracy when evaluating the elderly for fall risk. An interprofessional team is involved, including providers specialized in internal medicine, geriatrics, orthopedics, cardiology, physical medicine and rehabilitation, endocrinology, neurology, primary care providers, nurses, physical therapists, occupational therapists, speech therapists, and psychologists. Several studies show the effectiveness of a CGA compared to conventional treatment, due to the global evaluation and specific treatments.[11]

Studies have demonstrated that complex falls prevention interventions delivered to a residential aged care population can possibly reduce fall risk when additional staffing, expertise, or resources are available. Organizations should determine how to best allocate resources for fall prevention and management.[23] [Level 1]