Gait and balance. Older adults have changes in their gait that predispose them to loss of balance and increase their likelihood of encountering environmental obstacles. They do not lift their feet as much as younger persons, leading to easier stumbling over objects or uneven surfaces. They exhibit more body sway on standing, making them inherently less stable than younger individuals. Due to tendencies toward shorter step length and more variable stride, older people have greater difficulty traversing rocky or bumpy terrain. Older women develop a narrow-based waddling gait, partially explaining their greater risks of falling and fracture compared with their male counterparts, whose steps are more wide-based and thus more balanced. Although men are less prone to developing osteoporosis, by age 85 years, they also exhibit age-related bony fragility. Slower righting reflexes increase risk for both genders when balance is lost and a fall is imminent.
Common medical problems
Disorders of almost any organ system can contribute to falls in the elderly (Table 1). Premonitory falls result from an acute illness—usually an infectious process or exacerbation of a chronic disease such as congestive heart failure. These falls may be the only presenting sign of an adverse event as well as a delirium equivalent, so clinicians should be alert to these possibilities when evaluating someone who has fallen.
Some persons suffer a minor fall and conclude that the best way to avoid further accidents is to avoid activity. This is a very poor strategy, however, since immobility leads to worsening chronic disease, muscle deconditioning, social isolation, and further functional decline. This “fallophobia” actually increases the possibility of injury and carries all the risks of immobility, such as deep venous thrombosis, pneumonia, and pressure wounds.
Commonly implicated medications
Decreasing the number and types of medications taken by older adults is one of the simplest—yet most treacherous—interventions a PCP can perform to reduce fall risk. Such psychoactive medications as sedatives, antipsychotics, and antidepressants are strongly associated with increased fall risk, as are anticonvulsants and antihypertensives (especially alpha-blockers and nitrates). Acetylcholinesterase inhibitors, used in the treatment of dementia, have been linked to bradycardia, syncope, and increased risk of hip fracture.3 Dementia itself increases the risk for falls, so clinicians must weigh the benefits of the drugs for the patient versus the potential risk.
A thorough review of the side effects of each individual medication must be undertaken while keeping the medical condition of the patient in consideration. Patient and family preferences must also be taken into account, and most will want to do everything possible to decrease fall risk. Table 2 lists common medications that have been linked to increased fall risk in the elderly.
The patient’s physical environment often contains hazards that contribute to a fall. Stairs are a particularly dangerous area, especially the top and bottom steps. Other rooms in the home that pose threats are the bedroom (a high-transfer area), bathroom (tub and toilet), and kitchen (where individuals may attempt to reach high cabinets, placing them off balance). The kitchen and bath also are highly likely to serve as locations for liquid spills, increasing the likelihood of slips and trips.
Further perils include pets underfoot, poor lighting, a high bed, a low toilet seat, and unstable furniture. Cords on the floor or other clutter and improper footwear (worn soles, thick-soled shoes, high heels) may interact with age-related changes or medical problems, leading to falls.