Falls in older adults: averting a disaster

Women older than age 80 years are at a very high risk of falling.
Women older than age 80 years are at a very high risk of falling.

At a glance

  • The rate of falls begins to accelerate at age 65 years and continues to climb thereafter.
  • Three factors have been associated with very high risk of falling: (1) unstable balance on standing; (2) use of more than four prescription medications; and (3) hip weakness.
  • Immobility leads to further functional decline.
  • Assistive devices may be helpful but must be appropriately fitted, and training is essential for safe use.

Injuries sustained in falls are a common source of serious morbidity and mortality in older adults; in fact, falls are a leading cause of death in the elderly population. A major contributor to skilled nursing facility admissions, falls are among the most common reasons for decline in the ability to manage one's own daily activities. Like all geriatric syndromes, they are multifactorial and thus more difficult to study and avert. No single intervention can be completely effective, so strategies must be appropriately targeted to the individual and his or her unique set of risks and adaptations. Intrinsic and extrinsic (environmental) factors combine to result in this potentially disastrous event.

Primary-care practitioners (PCPs) can minimize falls by being aware of the risk factors, identifying those persons at greatest risk, and designing a treatment plan. PCPs must also be able to identify when referral to such other health-care professionals as physical and occupational therapists is necessary. Advocacy for safer public areas is yet another role health-care professionals can assume.

Definition and prevalence

A fall is the unintentional coming to rest at a lower level with or without loss of consciousness. The older adult may or may not remember the circumstances of the event, making evaluation more difficult. In long-term-care (LTC) facilities, persons found sitting or lying on the floor are assumed to have fallen.

Falls may occur at any age but are more common at the extremes of life. Many age-related changes contribute to render older individuals more susceptible to falling and to sustaining injuries from a fall. Medical problems common in older adults increase fall risk, as do many commonly prescribed medications. The rate begins to accelerate at age 65 years, develops a steep angle of ascent at age 70 years, and continues to climb thereafter.1 Older adults in LTC facilities fall more often than their healthier counterparts in the community, of whom 30%-40% older than age 65 years fall annually.2 Most falls occur during periods of high activity, often during transfers from bed to chair or chair to standing. About one in 10 falls results in such serious injury as hip fracture or head injury.1

Risk factors

Three factors have been associated with very high risk of falling: (1) unstable balance on standing; (2) use of more than four prescription medications; and (3) hip weakness. An individual with one of these factors faces a 12% increase in risk over one year; having all three puts the person at 100% risk of a fall.2

Other risks include a history of previous falls, age >80 years, female gender, decreased muscle strength, visual impairment, depression, dizziness or orthostatic hypotension, functional disabilities, low BMI, urinary incontinence, cognitive impairment, arthritis, diabetes mellitus, and the presence of pain.

Age-related changes

Humans rely on a complex interplay of sensory input from vision, proprioception, hearing, and the vestibular system to maintain upright posture and balance. All of these senses decline with age. Since the most well-preserved is usually vision, older adults tend to rely on it, while younger people use proprioception.

Vision. Even without disease, the aging eye cannot accommodate as readily as it used to, leading to glare susceptibility. In addition, the pupil does not dilate as fully, limiting light transmission to the retina. There is some clouding of the lens, without cataract development, so older adults need more light than younger persons to see as well. Peripheral vision is lessened, and visual-spatial processing may be less accurate.

Hearing. Hearing loss is nearly universal in aging and can be problematic, especially in traffic situations. The vestibular system functions less well, so older adults have difficulty with this mechanism for balance.

Proprioception. Vibratory sense and loss of foot position in space is usually lost by age 70 or 75 years, forcing older persons to rely increasingly on their vision. Such inappropriate footwear as very thick-soled shoes can lessen what small sensation may remain and should be avoided.

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