Falls

Definition

Falls are any unplanned motions in which people drop from one position to another, usually to the floor or ground. A fall does not have to be of great distance to cause injury. Falls are a major health concern for seniors.

Description

As people age, many changes take place in their bodies. Their bones and muscles become weaker, and coordination and reflexes deteriorate. Changes in sight and hearing also take place. Some seniors develop balance problems due to certain diseases or medications. Any of these changes, as well as others, can lead to falls.

Everyone has fallen at some time in their lives. But as people get older, even a minimal fall can do damage. Slower reflexes can make it harder for an elderly person to react in time to fall safely and they may strike the head. As people age, they are also more likely to have osteoporosis (a disease that weakens the bone) and are more likely to break a bone from a minor fall or injury. Elderly persons are more likely to be alone where no one can notice they have fallen, and may lie unattended for hours or days. Falls from high hospital beds have been reported as problems among older patients in hospitals and nursing homes .

Demographics

Falls cause more injuries to older adults than any other kind of accident. Each year, more than 30% of adults over age 65 who live at home fall, and 50% of people age 85 and older fall each year. Approximately 50% of adults who fall have multiple falls. Accidental falls account for more than 1.8 million emergency room visits each year in the United States. According to the American Academy of Orthopaedic Surgeons, about 60% of the falls that occur each year among senior citizens occur at home and 30% happen in the community. The remaining 10% occur in institutions such as nursing homes. Although the rate of hip fractures resulting from falls has declined in women since 1996, the number of people dying after falls actually rose 55% between 1993 and 2003. The risk of falling is thought to be greater in women than in men.

Causes and symptoms

There are several reasons why falls become more common as people age.

• Reduction in physical abilities. Changes in balance, coordination, and strength increase the risk of falling. Muscle strength usually declines as people age, particularly in the lower extremities. Older adults who remain physically active are at less risk of falling than those who exercise and stay active on a regular basis.

• Changes in vision and hearing. As people age, they may experience reduced contrast sensitivity (difficulty discriminating between objects), and poor depth perception (difficulty judging distance between objects). Hearing difficulties can prevent an older person from hearing a warning or cause them to hurries toward a doorbell or phone ring that has just been heard.
• Dizziness and unsteadiness. Some medications cause dizziness; taking four or more medications is considered a major risk factor for falling. Medications can also affect blood pressure. Low blood pressure can make a person unsteady, even when moving from a sitting to standing position.
• Foot pain. As people age, they may develop corns, bunions, dry and cracked skin or other complications. Foot pain may make a person walk differently to compensate and increase fall risk. For some people, and in persons with diabetes, some loss of sensation in the feet can occur.
• Performing hazardous activities. Attempts to climb a ladder or standing in a precarious position can lead to falls. Poor judgment, over-ambition, or an older person's desperation to accomplish a task on his own is often the cause.
• Prior illness or injuries. A history of stroke or bone fractures can affect the ability to walk or stand.
• Occurrence of new medical conditions. A stroke, heart attack, or infection may cause an inability to stand.

Symptoms from a fall will vary depending on the type of fall, cause of the fall, where the fall occurred, severity of injuries, a person's prior condition, and other factors. A person may have any combination of bruising, pain , difficulty using a part of the body, damage to skin, dizziness , unsteadiness, or confusion. Symptoms may not reflect the severity of injury since a simple bruise may be quite painful, while a person with slow bleeding inside the skull may initially appear quite normal. A person with dementia, or with a prior stroke and difficulty speaking may not be able to easily explain new symptoms. A person with two simultaneous injuries may focus on the one that is more painful, but perhaps less serious, than the other.

Diagnosis

Unless a fall has been witnessed, a caregiver or health professional usually has to rely on the person who fell to describe what happened. Unfortunately, many people who fall may be unable to describe the event, or may fail to mention the accidents, so minor injuries could go undiagnosed. Older people should be asked about falls, risk factors for falling, and fear of falling at least once a year.

Once a fall has occurred, the patient should be assessed for injuries to the head, spine, trunk, and extremities. A full clinical examination may be ordered, which focuses on cardiovascular and neurological areas, as well as the bones and joints. The exam and any tests ordered depend on factors specific to the patient and the circumstances of the fall. The exam may look for injuries and for causes of the fall. Sometimes, an ordinary x ray of an area such as the hip may not detect a fracture, and a further test such as computed tomography (CT) scans may be necessary. At other times, ordinary x rays can detect even small fractures that may occur in seniors with osteoporosis.

Treatment

Treatment following a fall depends on the injuries a person may sustain, the cause of the fall, and the patient's prior condition. Hip fracture, for example, normally requires surgery, unless a patient has other conditions that make surgery too risky or pointless. Treatment also may address the condition that led to the fall. For example, if low blood pressure was the cause, then correction of the blood pressure may prevent future falls.

Nutrition/Dietetic concerns

Eating regularly and drinking plenty of fluids helps prevent dehydration , low blood pressure, or other conditions that might increase fall risk. Limiting use of alcohol also can reduce the risk of falling. There is no evidence that vitaminD and calcium can reduce falls in elderly people. However, good nutrition and eating recommendeddaily amounts of calcium throughout life can help prevent or delay onset of osteoporosis, which can cause bones to break or fracture if a person falls.

Therapy

Therapy following an actual fall varies, depending on the cause of the fall and the resulting injuries. After a condition such as a stroke, a person may need therapy to regain proper balance and gait. Physical and occupational therapy can help restore functions that prevent future risk of falling. Therapy may involve mild weight-bearing exercise or participation in leisure and social activities to help maintain muscle strength, balance, and gait. Therapy also may involve teaching people who are susceptible to dizziness how to get up or bend over in ways that prevent unsteadiness.

Some types of therapy teach seniors how to fall to minimize injury and how to get up and recover more safely after falling. The general recommendation is to:

1. Try to remain calm.
2. Remain lying down for a few moments, do not get up quickly.
3. Assess any injuries.
4. Move to a seated position if there are no injuries and it seems safe to get up without assistance.
5. Roll to the hands and knees, which makes it easier to get up without help.
6. Crawl to a sturdy chair that can provide support for the body's weight.
7. Grasp the chair and slide one foot into a flat position on the floor while the other knee remains kneeling.
8. Slowly turn the body and sit on the chair.

Nearly one-half of older adults who fall fear they will fall again. For some people, this fear is debilitating and interferes with their activities. Early physical rehabilitation from injuries sustained in a fall combined with counseling can help lessen the fear.

Prognosis

The prognosis depends on the patient's overall condition and extent of injury. Falls can be fatal or cause injuries that lead to reduced quality of life, such as disability or loss of independence .

Prevention

Older adults can prevent falls or lessen the risk of falling, by following these steps:

• Participate in exercise programs to strengthen muscles and bones. Swimming and walking are good choices for seniors.
• Use care when doing daily activities. Take time to do them carefully and always recover balance when rising from a chair or bed.
• Have vision and hearing evaluated and corrected. Take time to adjust to new glasses or other corrections in senses, as small changes can make a person less stable for a short time.
• Attend regular medical check-ups. Talk with the doctor about side effects of new medications and any sensations of dizziness or unsteadiness.
• Wear proper footwear such as low-heeled, rubber-soled shoes. Suggested walking aids such as canes, walking sticks, or walkers can improve steadiness and should be used.
• Evaluate the home for fall and tripping hazards. Reducing clutter, keeping commonly-used items in easy reach, improving lighting, keeping electrical cords out of the way, and many other checks can minimize hazards. Many senior centers, senior agencies, and cooperative extension services provide free lists to help check the home for fall hazards.

QUESTIONS TO ASK YOUR DOCTOR

• How can I assess and lessen my risk of fracture from a fall?
• Is there a local system for special emergency necklaces or other emergency calling I can wear if I fall and can't get to a telephone?
• Do you have information removing fall hazards from my home?

In 2008, the American Academy of Neurology issued new guidelines recommending that physicians routinely ask patients about falls and use screening measures and tests of the patients' mobility to assess risk and need for prevention.

A bone mineral density measurement can determine the strength of an older person's bones and the risk of fracture. A physician can prescribe medications to help delay osteoporosis and lessen risk of fracture from a fall.

Caregiver concerns

It is often difficult for older adults to depend on loved ones and others for help with some activities, particularly physical ones they can no longer safely perform. Some falls occur because older people take chances instead of asking for help or as a dignity choice. Many senior agencies offer tips on safety not only to prevent falls, but other accidents, as seniors may experience hearing and vision deficits. Agencies may also provide assistance with remodeling homes to make them safer. Home improvements range from installing safety rails on stairways and in bathrooms to major construction for wheelchair ramps and wider doorways.

Caregivers need to be alert for signs that a person has fallen, such as new bruises or scratches, or sudden signs of confusion. They should stay in touch with seniors who live alone and check in with them, especially if they have not been heard from. Family and friends of seniors in nursing homes should visit frequently, ask questions, take note of, and follow up on any possible signs or symptoms that indicate the patient may have fallen.

KEY TERMS

Occupational therapy —Therapy used to learn or relearn how to do everyday activities that may have been impaired due to illness or injury. Therapists may introduce assistive devices and help modify the home to make it safe and easy to maneuver.

Osteoporosis —A condition in which bone mass decreases and bones become porous and brittle causing them to fracture easily.

Physical therapy —Use of physical techniques such as manual manipulation, exercise, and massage to restore or improve body function after injury or illness.

Stroke —Injury to the brain that results from blocked blood flow to the brain tissue.

Resources

PERIODICALS

“Clinical Review—Falls in the Elderly.” GP June 22, 2007:42.

“Elderly Have More Fatal Falls.” Harvard Reviews of Health News May 11, 2007.

“Help Your Elderly Patients Prevent Falls.” Hospital Home Health May 1, 2005.

OTHER

“Falls and Fractures.” Age Page. April 2007 [cited April 6, 2008]. National Institute on Aging. http://www.nia.nih.gov/HealthInformation/Publications/falls.htm.

“Bathrooms Checklist.” AARP.org. [cited April 6, 2008]. AARP. http://aarp.org/families/home_design/bath/a2004-03-02-b-checklist.html.

Tremblay, Kenneth B. Jr. “Preventing Falls.” Colorado State University Cooperative Extension. November 27, 2007 [cited April 6, 2008]. http://www.ext.colostate.edu/pubs/columnha/ha0403.html.

ORGANIZATIONS

Administration on Aging., One Massachusetts Ave., Washington, D.C., 20201, (202) 619-0724, http://www.aoa.gov.

American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL, 60018, (847) 823-7186, (847) 823-8125, [email protected], http://www.aaos.org.

National Institute on Aging, Building 31, Room 5C27, 31 Center Drive, Bethesda, MD, 20892, (301) 496-1752, (800) 222-4225, (301) 496-1072, http://www.nia.nih.gov.

Teresa G. Odle