Elderly Fallers: What Do We Need To Do?

Elderly Fallers: What Do We Need To Do? Si Ching Lim, MB. ChB, MRCP (UK) Department of Geriatric Medicine, Singapore General Hospital, Singapore Abstract Falls are very common among the elderly. Furthermore, the incidence of falls increases as the age increases. As clinicians, we encounter elderly fallers very frequently in the outpatient clinics, accident and emergency departments as well as the inpatients. The approach to managing elderly fallers is often complex and time consuming. The inpatient fallers carry with them the possibility of complaints from family members and often cause a lot of fear and guilt among the hospital staff. Keywords: elderly, falls, inpatient falls, intervention for falls, risk factors for falls Introduction Epidemiology Falls are a very common problem among the elderly over the age of 65. It is estimated that more than one third of the elderly over the age of 65, living in the community fall every year. Of those, half have recurrent falls 1. Fall risk increases as age advances and approximately 50% of the elderly over the age of 80 fall every year. Although the majority of the fallers do not sustain any injuries, approximately 10% of these falls result in serious injuries, such as hip fractures, subdural haematomas, serious lacerations and even death 2. The prevalence of falls among the community dwelling Singaporeans aged 65 and above is 17.2%. Two thirds of these fallers had single falls while the remaining one third had recurrent falls. Among the elderly in Singapore who experienced a single fall, these falls tended to occur outdoors, during the day, be accidental, and they were more likely to seek medical attention 3. Consequences of falls Fall-related mortality increases substantially with age, especially among those older than 70. It is estimated that about 1% of the elderly fallers sustain a hip fracture. These elderly who fracture their hips have a mortality rate of 20 30% within one year of the fracture 4. In Singapore, the incidence of closed hip fractures for those over the age of 50 (per 100,000) was estimated to be 164 for men and 442 for women, compared to the United States White rates of 187 in men and 535 in women, and the number has increased significantly since the 1960s 5,6. The elderly are more likely to sustain injuries after a fall. The reasons for this may include a high prevalence of chronic diseases, such as osteoporosis, and age related changes in physiological responses like a slowed reaction time and slowed protective responses 2. Falls among the elderly often leave a significant proportion of elderly (30 73%) with a fear of falls. This fear may be out of proportion leading to self restriction in mobility, reduced function, increased dependency on carers for activities of daily living, depression and anxiety. Repeated falls are a common reason for admission to long term care institutions 7. Causes and risk factors for falls Falls among the elderly are often multifactorial. The majority of cases arise from a background 154

The Elderly Fallers: What Do We Need To Do? Predisposing Factors Intrinsic Factors Previous falls Visual impairment Gait and balance Medical illnesses Peripheral neuropathy Age Arthropathy Drugs, >4 med, psychotropics Vestibular dysfunction Dementia, depression Impaired ADL Extrinsic Factors Footwear, environment, restraints Precipitating factors Trips & slips Drop attacks Syncope Dizziness FALL Fig. 1. Causes of falls. of interacting long and short term predisposing factors, precipitated by an event, often in the environment. The predisposing factors are often divided into intrinsic and extrinsic factors. The intrinsic factors are inherent to the individual patients and the extrinsic factors are factors like footwear and environmental hazards (Fig. 1). Accidental falls are the most common cause of falls, accounting for 25 40% of all falls. Accidental falls are more common among the community dwelling elderly 8. These falls are triggered by environmental factors alone. Most of the accidental falls are due to interactions between the accumulated risks, and precipitated by an environmental hazard or hazardous behaviour. An analysis of 16 fall risk factors studies, with quantitative risk data, summarised the relative risks for falls in the elderly 8. Among the risks, objectively tested leg weakness increases the odds of falling by 4 times. A positive history of previous falls increases an elderly individual s future fall risk by threefold 8. Gait and balance disorders affect 20 50% of the elderly over the age of 65 9. Gait and balance disorders are associated with a threefold increase in fall risk. Furthermore, the use of an assistive device increases the fall risk by 2.6 times 8. The presence of visual impairment increases the fall risk by 2.5 times 8. Bilateral low visual acuity is present in about 4.4% of the Malay population, aged 40 79, in Singapore. Bilateral blindness in the same study is present in 0.3%. The main causes for visual impairment in Singapore include cataract, uncorrected refractive error, diabetic retinopathy, macular degeneration and glaucoma 10. The presence of lower limb arthritis increases the fall risk by twofold. This is probably due to gait abnormality and weakness 8. Functional impairment is another major risk factor for falls. The inability 155

to perform basic activities of daily living (ADL) doubles one s fall risk 8. Depression increases one s fall risk by twofold. This could either be due to inattention to the environment, risk taking behaviours or it could be secondary to a previous fall 8. The usage of psychotropic medications, for example antidepressants, neuroleptics and benzodiazepines significantly increases the fall risk 11. Other groups of medications which have been shown to predispose the elderly to falls include Class 1a antiarrythmics, digoxin, diuretics and the usage of three or more medications 12. Confusion and dementia are frequently related to falls. This may reflect an underlying metabolic or systemic process as well as dementia. Dementia predisposes elderly to falls by causing impairment of judgment, impaired visuospatial perception, and disorientation. The presence of aberrant behaviour in the demented patients such as wandering, trying to climb out of bed, etc may also predispose them to falls 13. Several studies have shown that the fall risk increases dramatically as the number of risk factors increases. Tinetti and colleagues showed that the percentage of persons falling among the community dwelling elderly increases from 8% among those with no risk factors to 78% among those with 4 or more risk factors 1. Clinical fall risk assessment The objective is to identify risk factors and implement interventions to reduce further falls. The risk factors identified may be modifiable (such as postural hypotension, medication side effects) or nonmodifiable (such as hemiplegia). Clinical assessment of an elderly faller should be multidimensional and comprehensive. The information should include the circumstances of falls (including a witness s account, if available), medical comorbidity, functional assessment and the complete medication list. Clinical examination should include vision, hearing, cardiovascular assessment, postural blood pressure, gait and balance, neurological examination which includes cognitive assessment and muscle strength, joint function of the lower limbs and mobility assessment. Other components included in this multidimensional risk assessment include the elderly individual s home environment and functional status 14. Investigations Basic laboratory investigations suggested for all fallers include full blood count, urea and electrolytes, serum glucose level and thyroid function test. These tests are readily available, inexpensive and abnormalities, if present, suggest the presence of a treatable problem. Neuroimaging is not routinely indicated unless there is head injury, focal neurological deficits or on the suspicion of an active neurological process. Similarly, electroencephalogram is only useful if there is a suspicion of seizures. Ambulatory cardiac monitoring is helpful only if there is evidence of arrythmias as suggested by previous cardiac events or electrocardiography abnormalities 13. Interventions Fall prevention involves identifying the various risk factors and treatment of the reversible disorders. Often, a multifactorial approach, involving education, medication review and modification, exercises, home modification, etc is more successful than single modality interventions 14. Exercise can improve muscle strength, balance, and gait in the healthy, cognitively intact elderly. Most exercise regimes aim to improve muscle strength, balance and aerobic conditioning. Exercise can either be performed as a group or individualised. Group exercise is held several times a week, and supervised by a trained therapist or instructor. Individual exercise programmes are also supervised by a trained professional but performed in the individual s home 16. Tai Chi is a form of exercise which has been shown to improve balance and reduce falls in the elderly. Tai Chi has been shown to improve balance, muscle strength, feeling of well being, greater flexibility and sleep enhancement. However the evidence is not strong 17. Environmental assessment and modification involve assessing and removing hazards in order to improve safety and mobility. For cognitively intact elderly individuals with low to average risk, a checklist is adequate. For high risk individuals, a 156

The Elderly Fallers: What Do We Need To Do? trained professional is often required to do a home visit to assess and if necessary recommend changes to improve safety at home 18. Vitamin D supplementation has been shown to reduce fall risk by more than 20% among the ambulatory and institutionalised elderly. The hypothesised mechanism is from a direct effect of vitamin D on the neuromuscular function 19. Hip protectors have been shown to reduce hip fractures among the nursing home elderly. The community dwelling elderly are less compliant with the hip protectors, therefore, fracture risk reduction is not demonstrated 20. Hospital Falls Falls are common among inpatients with a rate of 9 13 falls per 1,000 bed days 21. About 30% of the inpatient fallers sustain injuries, including fractures, head and soft tissue injuries, which may lead to morbidity and impaired rehabilitation 22. In the local setting, the inpatient fall rate ranges from 0.68 to 1.44 per 1,000 patient days, and 27.4% to 71.7% of fallers sustained injuries 23. Inpatient falls are associated with increased inpatient length of stay (LOS), higher discharge rate to long term institution care, increased cost to the hospitals, and anxiety and guilt among the staff. Falls in hospitals may result in complaints or litigation from the family members. Falls are also associated with fear of falling, anxiety and depression and loss of confidence and function 24,25. The inpatients going through an acute illness have a higher transient risk of fall. Risk factors for falls among the inpatients include, use of psychotropic drugs, history of previous hospital falls, gait instability, lower limb weakness, urinary incontinence or need for frequent toileting, impaired judgement or confusion, agitation, and lower limb weakness 26. Most of the hospital falls occurred during ambulation (19.1%), getting out of bed (10.9%), while sitting down or getting up (9.3%), and while using toilet or bedside commode (4.4%) 27. There is no consistent evidence for the efficacy of any particular single or multiple interventions to prevent hospital falls. Most of the literature on fall interventions is on falls among the community dwelling elderly. It is not known if management strategies associated with falls among the community dwelling elderly can be extrapolated to the elderly inpatients. Furthermore, as the elderly are only in hospital for a short time,the effectiveness of long term interventions (for example, exercise programmes) is uncertain. Although reversal of acute risk factors and medication review may be amendable to interventions. Environmental safety measures are recommended 28. The removal of physical restraints showed no evidence of significant effects on falls or fractures among the residents in nursing homes or hospital inpatients. These studies were widely heterogeneous 29. Summary The elderly fallers often have multiple complex preexisting factors, precipitated by an acute illness or environmental factor which predisposes them to falls. The approach to managing an elderly faller needs to be comprehensive, identifying the risk factors and modifying the remediable factors as much as possible to prevent future falls. References: 1. Tinetti ME. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701 7. 2. Tinetti ME. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995;43(11):1214 21. 3. Chan KM. Epidemiology of falls among the elderly community dwellers in Singapore. Singapore Med J 1997 Oct;38(10):427 31. 4. Magaziner J. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol 1990;45(3):M101 7. 5. Lau EM. The incidence of hip fractures in four Asian countries: the Asian Osteoporosis Study (AOS). Osteoporosis Int. 2001;12(3):239 43. 6. Koh LK. Hip fracture incidence rates in Singapore 1991 1998. Osteoporosis Int. 2001;12(4):311 8. 7. Tinetti ME. Fear of falling and fall related efficacy in relationship to functioning among community-living elders. J Gerontol 1994;49(3):M140 7. 8. Rubenstein LZ. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:141 58. 9. Alexander NB. Gait disorders in older adults. J Am Geriatr Soc 1996;44(4):434 51. 10. Wong TY. Prevalence and causes of low vision and blindness in an urban Malay population: the Singapore Malay Eye Study. Arch Ophthalmol. 2008;126(8):1091 9. 11. Leipzig RM. Drugs and falls in older people: a systemic review and meta-analysis. I. Psychotropic drugs. J Am Geriatr Soc 1999;47(1):30 9. 12. Leipzig RM. Drugs and falls in older people: a systemic review and meta- analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47(1):40 50. 157

13. Van Doorn C, Gruber-Baldini AL, Zimmerman S, Hebel JR, Port CL, Baumgarten M, et al. Dementia as a risk factor for falls and injuries among nursing home residents. J Am Geriatr Soc 2003;51(9):1213 8. 14. American Geriatric Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons panel on Falls Prevention. Guideline for prevention of falls in older persons. J Am Geriatr Soc 2001;49(5):664 8. 15. Tinetti WE. Preventing falls in elderly persons. N Engl J Med 348;1:42 9. 16. Lord SR. The effect of a 12 month exercise trial on balance, strength, and falls in older women: a randomized controlled trial. J Am Geriatr Soc 1995;43(11):1198 206. 17. Kuramoto AM. Therapeutics benefit of Tai Chi exercise: research review. WMJ 2006 Oct;105(7):42 6. 18. Cumming RG. Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. J Am Soc 1999;47(12):1397 402. 19. Bischoff-Ferrari HA. Effect of vitamin D on falls: a metaanalysis. JAMA. 2004;291(16):1999 2006. 20. Parker MJ. Hip protectors for preventing hip fractures in the elderly. In: The Cochrane Database Syst Rev 2003;3: CD001255. 21. Morse JM. Preventing patient falls. London: Sage Publications; 1995. 151 p. 22. Rhymes J. falls-prevention and management in institutional setting. Clin Geriatr Med. 1988;4(3): 613 22. 23. Koh SS. Fall incidence and fall prevention practices at acute care hospitals in Singapore: a retrospective audit. J Eval Clin Pract. 2007 Oct;13(5):722 7. 24. Bates D. Serious falls in the hospitalized patients; correlates and resource utilization. Am J Med 1995; 99(2):137 43. 25. Liddle J. The emotional consequences of falls for patients and their families. Age and ageing 1995;24:P17. 26. Oliver D. Risk factors and risk assessment tools for falls in hospitals in-patients: a systematic review. Age and ageing 2004; 33(2):122 30. 27. Hitcho EB. Characteristics and circumstances of falls in hospital setting: a prospective analysis. J Gen Intern Med 2004;19(7):732 329. 28. Oliver D. Do hospital fall prevention programmes work? A systematic review. J Am Geriatr Soc 2000;48(12):1679 89. 29. Oliver D. Strategies to prevent falls and fractures and care homes and effect of cognitive impairment: systemic review and meta-analysis. BMJ 2007 Jan 13;334(7584):82. Epub 2006 Dec 8. 158