Health Articles

Because elderly persons frequently fail to report falls, they should be asked about them as a routine part of screenings. When a patient does report a fall, the first step is to assess and, if necessary, treat any acute injury. Then the fall should be evaluated like any symptom, with a history and physical examination (see TABLE 7-3). The routine use of laboratory tests, electrocardiograms, and Holter monitoring is not recommended unless a specific clinical indication exists. The evaluation of a fall may also include an assessment of environmental hazards. The evaluation of falls associated with syncope differs from that of falls without syncope (see also Ch. 6).
History: The initial inquiry concerning the circumstances of a fall should be made using open-ended questions. Then more specific questions should be asked about when and where the fall occurred and what the patient was doing. Did the patient experience any symptoms such as palpitations, shortness of breath, chest pain, vertigo, or lightheadedness at the time of the fall? Did the patient lose consciousness? Were any obvious environmental hazards involved? Does the patient have a history of falls? The history should also explore present and past medical problems and medication use. Any witnesses to the fall should be questioned as well.
Physical examination: The physical examination should be comprehensive enough to exclude obvious intrinsic causes of falling and to help distinguish syncope from other causes, such as tripping. The pattern of injury is useful, but not conclusive, evidence in determining the cause.
Emphasis should be placed on examining the cardiovascular, musculoskeletal, and neurologic systems. Blood pressure should be measured with the patient both supine and standing to rule out orthostatic hypotension. Examining the cardiovascular system helps exclude arrhythmia, valvular heart disease, and heart failure. The extremities should be evaluated for arthritis and podiatric problems that could impair gait. Neurologic findings may suggest cerebrovascular disease, tumor, Parkinson’s disease, myelopathy, peripheral neuropathy, or proximal myopathy. Mental status testing may suggest dementia, delirium, or depression. Vision and hearing should be checked as well. Because falling may be an atypical presentation of an acute illness, occult problems such as infection, myocardial infarction, dehydration, and anemia also should be reasonably evaluated.
A set of simple clinical tests, in which patients perform position changes and gait maneuvers during daily activities, can identify those at greatest risk of falling. This type of evaluation is more likely than a formal neurologic examination to detect fall-related risk factors. The patient is observed getting into and out of a chair, turning around, bending down and picking up objects from the floor, and reaching up to get something from a shelf. Aside from revealing abnormalities that might not have been apparent on a routine inspection of gait (eg, proximal muscle weakness that may be apparent only when the patient rises from a chair), this testing also helps establish functional abilities.
Gait should be observed with the patient rising from a chair, walking at least 20 ft, turning, returning, and sitting down. The clinician can walk alongside the patient for safety. In the circumduction gait, the lower extremity assumes triple extension at the hip, knee, and ankle,and the person swings the leg in an outward arc to ensure ground clearance. This type of gait occurs in patients with hemiplegia. Bilateral upper motor neuron lesions may cause a scissoring gait, which is essentially a bilateral circumduction gait.
The festinating gait is a symmetric shuffling of the feet with poor ground clearance, typically seen in Parkinson’s disease. Frequently, festination is seen only when the person starts to walk and when the person reaches an obstacle or attempts to turn. The parkinsonian patient also tends to assume a forward-flexed posture and have little or no arm movement while walking. Severe postural instability in the parkinsonian patient leads to an inability to maintain balance when pushed from the back or front, known as propulsion and retropulsion, respectively.
The cerebellar gait is a broad-based gait with irregular steps. The patient veers to either side, forward, or backward. In severe cases, the patient is not able to stand unsupported, even with open eyes. This form of ataxia is common in chronic alcoholics and in persons with paleocerebellar atrophies, progressive supranuclear palsy, multiple sclerosis, and cerebellar tumors. When such ataxia has an acute onset in an older person, the cause is almost always vascular.
Frontal lobe apraxia causes a broad-based gait that in many respects resembles the parkinsonian gait. The person assumes a forward-flexed posture, and the steps are short, slow, and shuffling; at times, the feet appear to be glued to the floor. However, a bedside examination reveals normal power in the legs, and the patient may be able to perform complex movements with the legs, such as drawing a figure 8 on the floor. This gait disorder frequently precedes the dementia and incontinence that complete the triad of normal-pressure hydrocephalus. Because this neurologic condition is potentially treatable with a shunt procedure, it should be considered when a patient presents with an apraxic gait.
Sensory ataxia is a broad-based, foot-stamping gait. The person constantly looks at his feet as he walks to compensate for the lack of proprioception from visual input. When asked to stand with his feet together and eyes open, the patient can maintain the stance, but when asked to close the eyes, the patient loses balance—a positive Romberg test. In the elderly, this condition is caused by disorders affecting the posterior columns, such as vitamin Bn deficiency (posterolateral sclerosis), cervical spondylosis, and paleocerebellar degeneration.

Children and young adults, who have a higher incidence of falls than all but the very frail elderly, rarely sustain substantial injury or die from a fall. In the elderly, the propensity for injury is associated with age-related osteoporosis and slowed protective reflexes, which can make even a relatively mild fall dangerous.
About 5% of falls in older persons, whether community-dwelling or institutionalized, result in a fracture. Another 10% to 20% result in severe soft tissue trauma, such as lacerations, hematomas, sprains, and joint dislocations; about half of these injuries require medical care. About 7% of persons > 75 yr visit hospital emergency departments for fall injuries each year, accounting for 70% of emergency department visits for injuries in this age group. Older persons have the highest rate of acute care hospitalization for injuries. Of elders hospitalized for a fall, only 50% live for 1 yr thereafter.
The humerus, wrist, pelvis, and hip are the most common sites of fractures caused by the combination of osteoporosis and falls. Hip fractures are the most serious, and more than 250,000 of them occur each year in persons > 65 yr. The rate of hip fracture increases exponentially with age and is highest among white women. Whites have about twice the rate of hip fractures as persons of all other races. About 20% of women who reach age 80 have suffered a hip fracture. The risk of falling and fracturing a hip doubles with the use of certain psychoactive drugs, such as antipsychotics and long-acting benzodiazepines.
About 5% of hip fractures result in death during hospitalization; the overall mortality in the 12 mo following a hip fracture ranges from 12% to 67%, depending on the population studied. At least half of those who could walk before sustaining a hip fracture cannot walk afterward, and half are unable to live independently; thus, their quality of life drastically deteriorates. An older person who remains on the floor for a time after a fall may suffer serious physical and psychologic effects. Dehydration, pressure sores, rhabdomyolysis, hypothermia, and pneumonia can develop from lying for prolonged periods after a fall.
Even the 90% of falls that do not result in injury may have serious consequences. The fear of another fall can make elders lose confidence, self-esteem, and a sense of well-being and thus impose restrictions on their mobility. About 40% of older persons have a fear of falling, and about 20% avoid activities such as shopping and cleaning because of this fear. This reduced mobility after a fall is referred to as posrfall syndrome. Decreased activity can lead to increased joint stiffness and weakness, further compromising mobility. Functional decline increases the burden on caregivers, which partially explains why falls are a contributing factor in 40% of admissions to nursing homes.

Environmental hazards are implicated in 33% to 50% of falls. Common extrinsic hazards in the home are clutter, electrical cords in pathways, inadequate lighting, throw rugs, low chairs, soft chairs, uneven surfaces, raised thresholds, and slippery surfaces. Stairs are a common site of falls, and the first and last steps are the most dangerous. Indoor falls occur most often in the bathroom, bedroom, and kitchen. Frequent sites of outdoor falls are curbs and steps. The most frequent sites of falls in institutions are the bedside (during transfers into or out of bed) and the bathroom. Although institutions are generally considered safer environments, the patients are frailer, and therefore, subtle environmental hazards may pose greater risks.
Epidemiology
Falls are the leading cause of accidental death (and the seventh leading cause of death) in persons > 65 yr. In the USA, 75% of deaths caused by falls occur in the 12% of the population > 65 yr. The rate of death from falls rises exponentially with increasing age for both sexes and all racial groups > 75 yr. Falls occur more often in women until age 75; after age 75, the frequency is similar in both sexes. However, white men > 85 yr have the highest death rate associated with falls.

The incidence and prevalence of falls vary according to the population. About 33% of generally healthy community-dwelling elders fall each year, as do about 67% of nursing home residents, despite their limited activity and protection from many environmental risk factors. The rate of falls for elderly hospital patients is between those for elders in the community and elders in nursing homes. The higher rates of falls in nursing homes and hospitals are partially explained by the greater frailty of these populations but may also reflect increased reporting. Also, the use of restraints may actually increase the risk of falls because patients struggle to free themselves and accidentally fall. Similarly, bedrails may increase the risk of falls because patients try to climb over them.
Most falls occur indoors. No specific time of day, time of the year, or location is associated with falling. In older persons, most falls occur during usual activities such as walking. About 5% of falls occur during hazardous activities such as standing on chairs, climbing ladders, or participating in sports. About 10% of falls occur on stairs, with descent being more hazardous than ascent.

Cognitive impairment is associated with an increased risk of falling. Confusion, impaired judgment, distraction, agitation, and lack of awareness increase a person’s exposure to hazardous situations. Also, neurologic deficits, which frequently occur in dementia, can cause balance and gait abnormalities and psychomotor retardation. The risk of falling appears to increase as the number of chronic medical conditions increases (see TABLE 7-2). Orthostatic hypotension, a common chronic condition in older persons, is probably not a common cause of falls; frequently, it causes elders to sit down because of lightheadedness. Falls related to standing up from a sitting or lying position are more likely to result from physical instability rather than changes in blood pressure. About 80% of older persons experience nocturia, and frequent nocturia has been associated with falls, probably because of the physical difficulties of getting up and walking to the bathroom quickly at night. Neurologic conditions, such as Parkinson’s disease, normal pressure hydrocephalus, and hemiparesis, cause gait disorders and commonly are associated with falls. Parkinson’s disease, for example, increases the risk of falling tenfold. Muscle and joint abnormalities also contribute to the risk of falling. Many older persons have reduced muscular strength and tone. Also, proximal muscle weakness can result from thyroid disease, polymyositis, or corticosteroid use, making it difficult to arise from a chair and climb stairs. Both osteoarthritis and inflammatory joint diseases, especially involving the knees and hips, can lead to pain and joint instability. Foot deformities such as corns, calluses, and bunions can lead to pain on ambulation, destabilizing gait.

Medications are associated with an increased risk of falls and fall-related injuries. The risk of falling increases with the number of prescribed medications. In epidemiologic studies, psychoactive drugs such as long-acting benzodiazepines, phenothiazines, and tricyclic antidepressants have been reported to increase the risk of falls and hip fractures among elders in the community and nursing homes. About 14% of hip fractures are attributed to psychoactive medications. Codeine and propoxyphene have also been shown to increase the risk of hip fractures. Drug effects such as decreased alertness, impaired judgment, compromised neuromuscular function, and dizziness may be the mechanisms. Diuretics may contribute to falls by causing somnolence, volume depletion, electrolyte disturbance, or an urgency to rush to the bathroom. Antihypertensives may cause decreased alertness, postural hypotension, or somnolence.
At least 40% of older persons are alcohol users, and 5% to 10% are heavy drinkers. Alcohol is a risk factor for falls in people < 60 yr, and the assumption that alcohol’s effects on cognition, gait, and balance would be more pronounced in the elderly and contribute significantly to falls seems sensible. However, the association has not been convincingly shown in studies. This failure to show a clear association may result from underreporting of alcohol consumption or premature mortality from alcohol consumption.

The factors responsible for falls can be classified as intrinsic (eg, related to the host) or extrinsic (eg, related to the environment). Intrinsic factors include age-related physiologic changes in balance and gait, cognitive impairment, medical conditions, and the use of certain medications. Intrinsic factors may be chronic, predisposing the older person to repeated falls, or acute, increasing the risk of falls only transiently. Extrinsic factors include environmental hazards such as slippery floors, inadequate lighting, and a lack of handrails. Falls usually have more than one cause, and distinguishing between intrinsic and extrinsic ones is difficult (eg, a frail older woman with osteoarthritis and Parkinson’s disease trips over the edge of a rug). In older patients, a fall may be a nonspecific presenting sign of many acute illnesses—such as pneumonia, urinary tract infection, or myocardial infarction—or an acute exacerbation of a chronic disease.