Falls in the Elderly

Dr. Saad M. Alsaad, MBBS, SBFM, ABFM, Geriatrics

Assistant Professor and Consultant
Department of Family & Community Medicine
King Saud University
Outlines:
 Definition
 Falls in community dwelling.
 Prevalence.
 Consequences.
 Causes.
 Evaluation.
 Prevention.
 Management.
By The end of session Students will be able
to:
• Define falls and the mechanism of falls (mechanical vs.
nonmechanical)
• Discuss the prevalence (local studies vs. international)
• Explain falls risk factors (both intrinsic such as gait and
extrinsic such as environmental hazards)
• Discuss the consequence of falls such as hip fractures,
lacerations, wounds, bleeding
• Demonstrate the ability to identify falls and recurrent falls
(Falls risk assessment) i.e. history and physical examination
• Falls prevention and management in community dwelling
elderly.
 Definition:

What is a fall?
An unintentional event that results in a person
coming to rest on the ground, or another lower
level, not as a result of a major intrinsic event
such as stroke or epilepsy) or an overwhelming
hazard (such as being pushed).
Kellogg, 1987
 Falls
Community Dwelling In the Hospital
 Prevalence

- 30% of community-dwelling people over the age

of 65 years fall each year.
-50 %for those 80 years and older .

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics
Query and Reporting System (WISQARS) [online]. Accessed August 15, 2013.
 Prevalence in Saudi Arabia

• The 1-year prevalence of falling

among old Saudis (>=60 years) was
49.9%.

• 74% of the participants who

experienced falls had post fall
injuries.
 Recurrent Falls

• 60 % of those with a history of a fall in the

previous year will have a subsequent fall.

• No1 risk factor of a fall is a previous fall.

.Nevitt MC, Cummings SR, Hudes ESSOJ Gerontol. 1991;46(5):M164

 Gender
• female  male.

• Falls are more likely to result in injury in

women.
 ?When do falls occur

• Statistics show that most falls occur in the

daytime when people are more active.

• around 11am and between 4pm and 6pm.

?Where do they fall
 Consequences of falls

• Significant morbidity and mortality may result

from falls in older individuals.
 Consequences of falls

• Physical injury
• Emotional trauma
• Psychological problems
• Social consequences
• Financial impact
  Consequences of falls

• ½ falls result in injury (10-15% in fractures).

• ¼ of all fallers limit their activities and lifestyle

due to fear of falling.

Nevitt, MC et al. J Gerontol 1991; 46:M164.

Tinetti et al. J of Gerontol A bio Sci Med Sci .1998; 53: M 112.
 Consequences of falls
 Consequences of falls

# Hip
• 1-2% of falls result in a fractured hip.
• 50% Of those who suffer fractured femurs will
not fully recover.
• 25% will die within 12 months.
 # Hip
• ‘’80 % of older women preferred death to a
"bad" hip fracture that would result in nursing
home admission ‘’.

Salkeld G,et al.BMJ.2000;320(7231):341.

  Consequences of falls
Costs of Fall

• In US alone, the total cost of fall injuries for

people 65 and older was $30 billion in 2012.

• (The cost covered 2.4 millions ER visits for non

fatal injuries and more than 722,000
hospitalizations.)
 Indirect Cost
• Quality of life.

• Loss of independence.

• Caregiving requirements.
Falls often go without clinical
attention
 :for a variety of reasons

• the patient never mentions falls.

• there is no injury at the time of the fall.
• the provider fails to ask the patient about a
history of falls.
• believes that falls are an inevitable part of the
aging process.
• treatment of injuries resulting from a fall does
not include investigation of the cause of the fall.
 Causes of Falls
 Causes Of Falls

A fall in a geriatric patient should be perceived

as a symptom of a disease, to be investigated
.like any other serious symptom
 Theory of Why People Fall
• Falls occur when:

• Older adults who are predisposed because of

accumulated effect of diseases / impairments
(intrinsic)

• Are exposed to precipitating challenges (extrinsic)

 Physiological
Changes with
aging

Underlying
illness Falls Medication
side effects

Environmental
factors
This study found that the three main factors that
:affect older persons’ likelihood of falling are
.number of medications taken per day-1
.sedentary lifestyle-2
.use of assistive devices -3
 Case
• Mrs.Fatmah is a 75year old lady was brought
by her daughter. The daughter tells you her
mother had a fall last week.

• What questions do you want to ask about the

fall?
 History

• Describe the fall

• Ask questions to R/O syncope , pre fall

symptoms .

• Use systematic method to look into etiology of

falls
 Describe the fall
• Accidental Fall occurs when a patient is oriented but rolls out of bed or
trips / slips due to environmental risk factors, or an infant is dropped by a
parent or caregiver.

• Assisted Fall means that the patient was being assisted when the fall took
place. While any fall is bad, assisted falls generally result in less injury than
do unassisted falls.

• Near Fall describes a sudden loss of balance that does not result in a fall
or other injury. This can include a person who slips, stumbles or trips but
who is able to regain balance; a near miss.

• Unwitnessed Fall describes the event when a patient is found on the floor
and neither the patient nor anyone else knows how he / she got there.
Mechanism of Falls
 Case
• lives alone in her 2 story house

• Patient fell 2 days earlier while rushing to answer the phone

as she was putting away the groceries.

• Felt unsteady just prior to the fall as she tripped on kitchen

mat. Was wearing shoes. Adequate lighting. Was able to get
up right way. Uses no assistive walking devices at baseline

• Reports new left arm pain immediately after the fall.

Scattered bruising and swelling of Left forearm.
 Hx
• No Head trauma, LOC, syncope or presyncope,
vertigo, visual changes, bowel or bladder
incontinence, eating and drinking as usual, no
medication changes.

• Prior fall was 1 year ago while rushing down the

stairs. No injury was incurred.

• Had many near falls while running barefooted on

waxed, wooden floors.
 PMHx
• DM • Insulin
• HTN • Lisinopril+ Amlodipine.
• Atrial fibrillation. • Warfarin + digoxin
• Lt hip osteoarthritis • Tylenol regular+ Tylenol
• Depression #3 PRN
• Insomnia • Citalopram
• Zolpedem Q HS
 P/E
• Check orthostatic
• Perform a visual exam
• Evaluate cognition ,NEUROLOGICAL EXAM.
• Gait Assessment:
• Motor + Balance + Coordination
Timed up & Go test
(>12 Seconds)
functional reach test
 :Coordination Assessment
• Coordination Assessment:
• Abnormal if:
• Hesitant start
• Broad-based gait
• Path deviates
• Heels do not clear toes of other foot
• Extended arms
Second Chair Stand Test-30
4-Stage Balance Test
 P/E
• Orthostatic: 135/70 88 sitting. Standing 120/65 100
• Eye: +cataract. visual acuity: 20/40 L and 20/80 R. Corrected with
bifocals
• Gait:
• -Motor: Bilateral Quad weakness+, decrease sensation in her feet.
• TUG test :18 Sec
• -Balance: semi tandem and tandem stances <10 sec, one leg stand< 10
secs
• -Gait: Hesitant at start but walks with normal path, walks with
extended arms, no wide based gait, no foot drop, heel clears toes of
other foot. Slow turn with outstretched hands
• Cognition: 1/3 on 3 item recall
• Neuro: No Parkinsonian features or focal weakness
 Case
• What are the possible predisposing ‘intrinsic’
risk factors and ‘extrinsic’ precipitants of her
fall?
• Multi-factorial

• Unmodifiable predisposing factors:

• Age, female and prior history of falls

• Modifiable predisposing and precipitating

factors
Modifiable predisposing and precipitating factors

• Mild weakness + moderate balance impairment

• Has cataracts + refractive error +wears bifocals

• Takes 4+ medications, including high risk meds Bp meds, digoxin,

citalopram and zolpedem
• Borderline orthostasis

• ?Cognitive impairment, depression

• ?Unsafe environment and behaviors

• (kitchen matt, waxed floor. barefoot, rushing)
 Case
What evidenced-based interventions can you
recommend to prevent future falls for this
?patient
 Multifactorial Assessment
With Targeted Intervention
• Most commonly studied & consistently
effective.

• 20+ trials showing 27% (2-37%) fall risk

reduction for community dwelling older adults
 USPSTF recommendation for prevention

• Annual question about falls

• exercise or physical therapy and vitamin D
supplementation to prevent falls in community-
dwelling adults aged 65 years or older who are at
increased risk for falls.
Release Date: May 2012
Falls Prevention
Exercise
Home Safety
 Vitamin D

Many older adults will need higher supplement

levels (eg, at least 1000 IU daily) to achieve 25
hydroxyvitamin D levels sufficient for falls and
.fracture prevention

The American Geriatrics Society

 PREVENTING THE COMPLICATIONS OF
FALLS
• Assistive devices .
 PREVENTING THE COMPLICATIONS OF
FALLS
• Hip protectors .
• Effectiveness??
• Compliance
• Setting.
 PREVENTING THE COMPLICATIONS OF
FALLS
• Time on floor .
 Summary
• It is common in elderly.
• The cause is always multifactorial.
• The most important risk factor is a previous fall.
• The prevention is Multifactorial Assessment
With Targeted Intervention.
• We need to know the risk of falls in any patient
in the hospital at all times.
Thank you