Falls in the Elderly
September 1, 2000
Falls in the Elderly
Part I: Risk Factors and Reasons
Author: Jeffrey Arnold, MD, Attending Physician, Department of Emergency Medicine, Cedars-Siani Medical Center, Los Angeles, CA; Assistant Clinical Professor of Medicine, University of California—Irvine Medical Center, Orange, CA.
Peer Reviewer: David B. Carr, MD, Associate Professor of Medicine, Washington University School of Medicine, St. Louis, MO.
During the course of aging, falls are common events and often result in significant morbidity or mortality in persons ages 65 years or older. There are myriad implications of falls in the elderly. A fall may be a symptom of a new or worsening medical condition, an expression of an underlying disability, a marker for the beginning of functional decline, or the proximal cause of a spectrum of injuries or death.
Falls also are one of the most common reasons why elderly patients seek emergency care. The multifactorial and multi-consequential nature of falls in the elderly routinely challenges the emergency physician to combine concepts and practices from geriatric medicine, internal medicine, cardiology, and traumatology for the care of a single patient. Accordingly, the emergency physician must have a comprehensive understanding of the implications of falls in the elderly and an organized approach to the evaluation and management of these patients. Part one of this two-part series will examine the epidemiology and etiology of falls. Part two will cover the consequences of falls, including various fall-related injuries, emergency department (ED) evaluation, and fall prevention.
— The Editor
Definitions
A fall is defined as the unintentional, sudden descent to the ground, floor, or other lower level (e.g., from stairs or a piece of furniture).1-4 An injurious fall is one that results in fracture, dislocation, sprain, laceration, or an internal injury requiring hospitalization.1 Serious injury due to fall is defined variably in the medical literature as those injuries that lead to an emergency department (ED) visit, physician visit, hospitalization, or the sequelae of an injurious fall (listed above).1-4,8
The majority of falls in the elderly are from a standing height of 6 feet or less ("low mechanism fall").5-7 Hu and associates evaluated 473 elderly patients who presented to EDs for falls and found that only 3% fell from heights greater than 6 feet.6 Norton and colleagues reported that of 780 elderly patients who fell and sustained hip fractures, only 8% fell from higher than a standing height.7
Epidemiology of Falls in the Elderly
Incidence of Falls. One out of three persons ages 65 years or older who live in the community falls every year.8,9 Multiple studies have shown that the incidence of falls increases with increasing age.10-13 When the elderly who fall are considered by age subgroup, 32% of those ages 65-74 years, 35% of those 75-84 years, and 51% of those older than 85 years fall each year.10,13 Ciccone and associates compared the relative risks of falling from the same level between the two older age groups and the age 65-74 year group. They found that persons ages 75-84 years had a relative risk of 1.3, and those ages 85 years or older had a relative risk of 1.8 of falling each year in comparison to those younger than age 74.11
Older women fall more frequently than older men. For example, in the 65-74 year age group, 42% of women annually fell, vs. 20% of men in that age group.14 The incidence of falls also varies with the functional status of the faller. Speechey and colleagues observed that 52% of the physiologically frail elderly fell vs. only 17% of the more active vigorous elderly in a one-year observational study.15
Incidence of Fall Injuries. A significant number of falls are associated with injury. Overall, 5-15% of falls in older patients result in serious injuries requiring medical attention.4,9,12,16-20 Approximately 4-6% of falls result in fractures, with hip fractures occurring in 1-2%.9,12,17,18,21 Another 2-10% of falls result in other significant injuries, such as lacerations, head injuries, and internal injuries.9,17,18 About 30-55% result in minor soft-tissue injuries, such as bruises or abrasions.4,12,13,17,18
The incidence of injurious falls increases with increasing age.11,22 Ciccone et al compared the relative risks of fall-related sequelae, such as hip fractures, open scalp wounds, fractures of the neck and trunk, and fractures of the lower limb, among the three age subgroups, and found that the relative risks for these injuries increased with increasing age.11
Women who fall injure themselves more frequently than men. Tinetti and colleagues found that elderly women are more likely than elderly men to sustain both serious injuries and fractures when they fall.8 Ryynanen and associates found that elderly women who fall were more likely to seek medical attention (4.4%) than elderly men (2.5%) during a one-year study of older patients who fell in Finland.19
The incidence of injury resulting from falls is greater in the vigorous elderly (22%) than the frail elderly (6%), probably because of the tendency of the former to fall during displacing activity, in the presence of environmental hazards, and on stairways.15 As might be expected, the incidence of injurious falls in the ambulatory elderly is more than twice that found in those who are nonambulatory.23 Overall, the number of older persons with fall-induced injuries is increasing at a rate unexplained by the increases in the number of elderly persons alone.3
Effect on the Emergency Care System. Falls are the single most common reason why elderly patients in the community seek emergency medical care for trauma. Spaite and associates examined 1154 EMS dispatches for trauma in patients ages 70 years or older over a 12-month period in Tucson; they found that 61% were for falls vs. only 22% for motor vehicle collisions.24 Hu and colleagues looked at the presenting complaints for 6759 ED visits by community-dwelling elderly patients during a 10-month period at eight hospitals in Taipei and found that 57% of those presenting with complaints related to trauma were for standing-level falls.6 Furthermore, in the same study by Hu et al, standing-level falls were the single most common reason why elderly patients sought emergency medical care (7%); falls exceeded cerebrovascular accidents, cardiovascular disease, acute respiratory infections, and acute abdominal pain as reasons why elderly patients went to EDs during the study period.6
Falls are also a typical reason for nursing home patients to seek emergency medical care. Ackermann and associates examined 1488 ED visits in 873 nursing home patients, and found that falls comprised 122 presenting complaints (8.2%). Of these patients who fell, 11.5% required hospitalization.25
According to a population-based analysis by Sattin and associates in 1990, 42% of elderly patients who fell required hospitalization for a mean length of stay of 11.6 days. Patients with hip fractures were hospitalized for an average of 15.5 days, while patients with intracranial injury were hospitalized for a mean of 11.2 days. One-half of all patients who were admitted because of injurious falls occurring at home were discharged to a nursing home.22
Causes of Falls in the Elderly
The majority of falls in the elderly are associated with multiple risk factors, which can be categorized broadly as either intrinsic (host risk factors related to aging, concurrent disease, or medication) or extrinsic (environmental risk factors). (See Table 1.)
| Table 1. Risk Factors for Falls in the Elderly | |
| Intrinsic risk factors | Extrinsic risk factors |
| • Increased age | • Indoors |
| • Female sex | Steps and stairs |
| • Frail functional status | Chairs and furniture |
| • Acute medical conditions | Loose rugs, mats, and flooring |
| Syncope | Electrical cords |
| Presyncope | Walkers and crutches |
| Dizziness | Footwear |
| Delirium | Long bathrobe |
| Stroke | Pets |
| Seizure | Doors and door fixtures |
| • Preexisting medical conditions | Clutter |
| Dementia | Poor lighting |
| Impaired visual acuity | Absence of bathtub grab bar |
| Impaired auditory acuity | Absence of hand rail |
| Impaired proprioception | • Outdoors |
| Impaired neurological function | Pathway irregularity |
| Impaired musculoskeletal function | Steps and stairs |
| Impaired balance | Pets |
| Impaired gait | Wet or slippery surface |
| Orthostatic hypotension | |
| • Medications | |
| Multiple medications (> 4) | |
| Psychotropic medications | |
| Antihypertensives | |
| Diuretics | |
| • Previous fall | |
Since a fall typically is a complex multifactorial event, its cause is often difficult to characterize. Nevertheless, certain generalizations can be made about the etiologies of falls: 1) intrinsic risk factors appear to play a larger role than extrinsic risk factors in their relative contribution to causing falls;7,9 2) the risk of falling increases with the number of risk factors;9,10,26 3) risk factors for falling vary with age subgroup, sex, and functional status;10,27 and, most importantly, 4) many risk factors for falls are potentially remediable.
Intrinsic Risk Factors for Falls. The majority of falls in elderly persons are associated with intrinsic risk factors.7,9 Important categories of intrinsic risk factors include acute medical conditions, preexisting medical conditions, previous falls, a fear of falling, and medications.
Acute medical conditions are an important and not infrequent concomitant of falls in the elderly.7,9,24,28 Tinetti et al found that 10% of falls in the elderly occur during acute illness, while Spaite and colleagues found that 10% of falls in the elderly that resulted in EMS transport were associated with suspected medical conditions.9,24 Norton and associates found 16% of falls that resulted in hip fractures were associated with acute medical conditions.7 A number of acute medical conditions are associated with falls in the elderly, including syncope, delirium, dizziness, vertigo, dehydration, stroke, seizure, and lower extremity weakness.
Impaired mobility is a major risk factor for falls and includes neurological and musculoskeletal impairment.9,26 Neurological disability may be due to peripheral neuropathy (e.g., diabetes and alcoholism), stroke, or Parkinson’s disease.10,12,16,36 Musculoskeletal disability may occur as a consequence of joint disease, such as arthritis, muscle weakness, or other lower limb or foot problems.4,9,10,12,38 Quadricep strength frequently is used as a measure of lower limb muscle strength.38
Impaired balance is an important risk factor for falls and is suggested by difficulty with standing after sitting in a chair, postural sway, or the inability to balance on one foot for 5 seconds.2,4,10,12,26,38,39 Balance, or postural control, is a complex function, stemming from the central integration of proprioceptive, vestibular, and visual input. Elderly patients who lack balance control have reduced selective attention and longer choice reaction times, suggesting that poor balance primarily is a problem of central integration.40
With 15% of persons older than 60 having some type of gait disorder, gait impairment is a significant cause of falls in the elderly.9,10,12 Important causes of gait disorders in the elderly include Parkinson’s disease, stroke, diminished proprioception, vitamin B12 deficiency, cervical spondylosis, gait apraxia, cerebellar degeneration, Binswanger’s disease, and low pressure hydrocephalus.16 Gait impairment is suggested by difficulty with performing a tandem walk.12
Medications contribute to falls in the elderly by causing sedation, imbalance, ataxia, dizziness, and postural hypotension.10,16,46-53 Psychotropic medications, such as sedative-hypnotics (especially benzodiazepines and barbiturates), antidepressants and antipsychotics, may impair mental alertness, mobility, and balance, and are the most commonly implicated medications in falls.16,47,49-52 Antihypertensives (including alpha-receptor blockers used for prostatic hypertrophy) may increase the risk of falling by causing postural hypotension.10,29 The use of diuretics predisposes some patients to falls, possibly through volume or electrolyte depletion.46,48,54 A recent change in medication dose or increase in the total number of prescriptions has been associated with an increased risk of falling. Taking multiple medications also increases the risk of falls.9,50,52 Taking appropriately prescribed heart medication may protect the elderly from falls.13 The role of alcohol as a risk factor for falls in the elderly remains uncertain.13,55
Preexisting postural hypotension also may predispose the elderly to falling.41 As many as 30% of community-dwelling persons older than 75 years have orthostatic hypotension.42 Dizziness upon standing may be a particularly significant risk factor for initial and recurrent falls.26 Schwartz and associates found that the likelihood of falling was increased three-fold in older Mexican-American women who had fainted within the past year.4
Cognitive impairment remains a major risk factor for falling, and commonly is associated with chronic conditions, such as dementia.9,16 Impaired vision, hearing, and proprioception also are important risk factors for falling.16,37,38
Syncope is associated with 2-15% of falls in elderly patients.16 Syncope is characterized by a sudden loss of consciousness accompanied by a loss of postural tone, and should be considered as the potential cause of any unwitnessed fall. The causes of syncope comprise a diverse group of disorders that can be categorized according to their acute effects on cardiac output, peripheral vascular tone, cerebral blood flow, central nervous system (CNS) substrate levels, and other cerebral function.29
In the elderly, syncope tends to be a multifactorial event that commonly occurs during postural change. A number of factors limit blood pressure homeostasis in this age group and predispose older patients to syncope, including aging physiology, preexisting disease, and medications. O’Mahony and associates looked at 41 patients with unexplained syncope and found that their syncope ultimately was attributed to vasovagal syncope (in 12), arrhythmias (in 5), hypotensive medication (in 3), orthostatic hypotension (in 2), anxiety with hyperventilation (in 1), and uncertain causes (in 10).30 Underlying hypertension is an important but often overlooked risk factor for syncope, since it may reset the cerebral perfusion pressure below which syncope occurs.31
Carotid sinus syndrome (CSS) is an under-appreciated cause of syncope and falls in the elderly; it is caused by hypersensitivity of the carotid sinus to external stimuli. Cardioinhibitory CSS occurs when carotid sinus massage (CSM) produces asystole exceeding 3 seconds, vasodepressor CSS occurs when CSM produces a 50 mmHg or greater drop in systolic blood pressure, and mixed CSS occurs when CSM leads to both phenomena. McIntosh and associates evaluated 17 elderly patients with unexplained falls who denied syncope and found that 12 lost consciousness during CSM.32 Dey and colleagues investigated the cause of sudden loss of postural tone without loss of consciousness (drop attacks) in 35 consecutive elderly patients and determined that 50% actually had CSS, suggesting the underlying importance of CSS in the differential diagnosis of the causes of falls.33
Vertigo also plays a role in falls in the elderly. In a study of 26 elderly patients presenting to the ED after falls, with either a history of recurrent falls or unexplained loss of consciousness, benign positional vertigo was identified as a risk factor for falling in 8%.34
Delirium is another important cause of falls in the elderly.16 An estimated 10% of elderly patients presenting to EDs meet criteria for delirium.35 Delirium is caused by a spectrum of acute medical conditions, including pulmonary disease (e.g., pneumonia, chronic obstructive pulmonary disease [COPD], pulmonary embolism), cardiac disease (CHF, myocardial ischemia, or infarct), CNS disease (stroke or hypertensive encephalopathy), infection (urinary tract infection or sepsis), hypoglycemia, hyperglycemia, hyponatremia, hypothyroidism, hypothermia, heat stroke, and a variety of sensorium-altering medications.16
A number of preexisting conditions have been associated with an increased risk of falling in the elderly.2,9,10,12,36 Several of these conditions, such as increased age, female sex, overall frailty, and certain chronic medical diseases, also are markers for other preexisting conditions that predispose to falls.2,17 Some of the chronic medical diseases that predispose patients to falls include: anemia, stroke, cardiac disease, pulmonary disease, and hyperthyroidism.2,4,12,36 Most of the preexisting conditions leading to falls can be categorized according to their tendency to cause impaired cognition, sensation, mobility, balance, or gait.
A number of studies have shown that past falls predict future falls.2,12,43,44 For example, Davis and associates found that elderly Japanese women who fell within the past year were twice as likely to fall again.2 Elderly persons afraid of falling also were more likely to fall.17,45
Extrinsic Risk Factors for Falls. Extrinsic risk factors play an important role in causing falls, with 20-44% of falls occurring in the presence of environmental hazards.7,9,56 The risk of falling associated with each environmental hazard depends on the nature of the hazard, the susceptibility of the older person, and how often the elderly person is exposed to the hazard. Norton et al evaluated the causes of falls leading to hip fractures in 653 elderly patients, and found that environmental objects played a role in 43%.7 Permanent hazards, such as stairs or an uneven walkway, tend to be associated with a greater risk of falling, while transient hazards, such as wet surfaces or poor lighting, tend to make a smaller overall contribution to falls. For example, in the Norton study of falls resulting in hip fractures, only 10% were associated with a wet or slippery surface.7
Environmental hazards occur both inside and outside the home. Physically active elderly persons tend to fall outdoors (vigorous fallers), while inactive elderly persons tend to fall indoors. Nursing home patients are a subgroup of inactive elderly patients who fall almost exclusively indoors.
Norton et al reported that a specific object contributed to falls in 41% of cases and resulted in 653 hip fractures. Eighty-four percent of falls resulting in hip fractures occurred at home. Of the falls occurring at home, 37% were associated with a specific object, including steps and stairs (15%), chairs and other furniture (14%), loose mats and flooring (13%), electrical cords (8%), walkers or crutches (6%), footwear (6%), pets (5%), and doors and door fixtures (4%). Falls occurring outdoors were most likely associated with pathway irregularities (27%), steps and stairs (22%), and pets (10%).7
Sattin et al found that clutter potentially was related to 38% of falls, while cords and wires contributed to 17% of falls. In this study, eight persons sustained injuries from slipping in bathtubs in which no grab bar was present.56
Most falls occur in older patients during usual activities, such as walking or changing position.16 Tinetti et al found that only 5% of falls occur during hazardous activity.9
Causes of Fall Injuries in the Elderly
Although most falls do not cause injury, falls leading to injury have much greater clinical relevance. These so-called injurious falls also have risk factors that can be categorized as intrinsic or extrinsic, and importantly, may differ from the risk factors for falling described above. Since fractures are one of the major adverse sequelae of falls, it is not surprising that many of the risk factors for injury also are independent risk factors for sustaining fractures. (See Table 2.)
| Table 2. Risk Factors for Injurious Falls in the Elderly | |
| Intrinsic risk factors | Extrinsic risk factors |
| • Increased age | • Kinetic energy of fall |
| • Female sex | Height of fall |
| • Vigorous functional status | • Direction of fall |
| • Decreased protective capabilities | Sideways: hip fracture |
| Impaired cognition | Backwards: wrist fracture |
| Impaired visual acuity | • Capacity of surface to absorb injury |
| Impaired balance | Hard surface |
| Impaired gait | |
| Loss of consciousness | |
| Insomnia | |
| Long-acting benzo-diazepines | |
| Decreased body mass index | |
| • Previous fracture | |
| • Decreased tissue threshold for injury | |
| • Osteoporosis | |
| Caucasian | |
| Immobility | |
| Muscle weakness | |
| Chronic corticosteroid use | |
| Smoking | |
| Alcohol abuse | |
| Excess caffeine intake | |
Injury always represents a complex interaction between a host and its environment. Similarly, the likelihood of suffering an injury due to a fall depends on the susceptibility of the elderly patient to injury and the capacity of the environment to inflict damage. The key determinants for injury in the elderly include the protective responses of the faller, the injury threshold of tissue, the kinetic energy of the fall, the fall direction, and the capacity of the environment to absorb kinetic energy from the fall.8,17,57 The risk of injury from a fall increases with the number of determinants present.58
Intrinsic Risk Factors for Fall Injuries. A number of independent risk factors for fall injuries may be associated with a decreased ability to protectively respond to falls. These include older age, cognitive impairment, poor visual acuity, decreased reaction time, peripheral neuropathy, muscle weakness, impaired balance, impaired gait, at least two chronic medical conditions, and the presence of specific diseases, such as diabetes or stroke.8,27,39,57,59
Cognitive impairment also may predispose elderly patients to engage in more hazardous activities.8 When loss of consciousness is associated with fall, the risk of major injury increases six-fold, and is presumably secondary to the loss of protective reflexes.18 Insomnia is another risk factor for fall injury in the vigorous elderly, although the exact mechanism remains unclear.27 The association of decreased body mass index with fall injury may reflect, in part, a lack of body cushioning.2,8,59 Previous fractures are predictive of subsequent fractures in elderly patients who fall.58
The association between medications and fall injuries has been more difficult to demonstrate. Koski and associates found an increased risk of injurious fall in disabled elderly patients taking long-acting benzodiazepines,27 while Cummings and colleagues similarly found that elderly women taking long-acting benzodiazepines were at greater risk of sustaining hip fractures.37 Tinetti et al noted a trend toward greater number of medications in patients injured by falling.8 Nelson and associates found no association between fall injury events in the elderly and average weekly alcohol intake.60
Aging is associated with a number of physiological changes that decrease the threshold of tissue to injury and limit the adaptive response to injury. These changes include degeneration and atrophy of the pulmonary, cardiovascular, neurologic, renal, hematological, immune, musculoskeletal, integumentary, and thermoregulatory systems. Elderly patients also are more likely to have underlying disease states, which diminish the ability of these systems to withstand or respond to injury.16,62
Decreased bone mineral density (BMD) or osteoporosis predisposes the elderly to fractures of all types, including spine, rib, pelvic, and extremity fractures. BMD refers to the mass of calcium per unit bone volume and is inversely proportional to the amount of force required to fracture bone.65 Decreased bone mass density is the major reason why the elderly are susceptible to serious fractures, such as multiple pelvic fractures or odontoid fractures, by simply falling down. This is in marked contrast to the younger patient, who typically requires much higher-energy mechanisms to fracture the pelvis or cervical spine.66,67
A number of factors are associated with osteoporotic fractures, including: advanced age, female gender, white race, prolonged immobilization, muscle weakness, cognitive impairment, chronic corticosteroid use, alcohol abuse, cigarette smoking, and excess caffeine consumption.2,68 With declining estrogen levels, women are at high risk for osteoporotic fractures, and typically lose about 50% of their BMD during their lifetimes (at rates as high as 2-4% per year in the first 5 years after menopause).68 Short stature is an interesting risk factor for osteoporotic fracture in elderly Japanese women that appears to reflect the presence of multiple vertebral compression fractures.2
Changes in brain structure with age also predispose the elderly patient to injury. Subdural bridging veins become more fragile and susceptible to tearing, predisposing older patients to subdural hematoma with even minor head injury. But because the brain also atrophies with age, losing approximately 10% of its weight between the ages of 30 and 70 years, the resulting increase in subdural volume makes subdural hematomas more difficult to detect.63 In contrast, epidural hematomas are unusual in the elderly due to the adherence of dura to underlying skull.64
The skin, underlying soft tissues, and small vessels also are more fragile in elderly patients, accounting for a variety of soft-tissue injuries seen in the elderly, such as lacerations, skin tears, hematomas, and contusions.69
Extrinsic Risk Factors for Fall Injuries. Key external determinants of injury include the kinetic energy of the fall at the time of impact, the fall direction, and the energy-absorbing capacity of the surface upon which the faller lands.8 The kinetic energy of the fall at the time of collision depends on the height of the fall, the fall velocity, and the mass of the faller.17
Fall direction affects injury by determining the location of impact. For example, Norton and associates found that 72% of patients with hip fractures fell sideways, while only 10% fell backward and 7% fell forward.7 Greenspan and colleagues similarly reported that a fall to the side was associated with significantly higher risk of sustaining a hip fracture in ambulatory nursing home patients.65 In contrast, Nevitt et al found that women who fractured their wrists were more likely to have fallen backward.57
The ability of the surface upon which the faller lands to absorb energy is an important determinant of injury. Sattin and colleagues found that the absence of carpeting contributed to 14% of falls, and Nevitt and associates found that landing on a hard surface increases the risk of hip fracture three-fold.56,57
Activity at the time of fall is a complex external risk factor for injury that probably combines a number of determinants, such as fall velocity and direction and the ability of the faller to protectively respond. Ambulation is the activity most commonly associated with fall injury. In Norton and colleagues’ study of falls that resulted in hip fractures, moving forward was the most common activity at the time of fall (in 47%).7 Cali and associates evaluated 296 fall-related fractures in residents of a long-term care facility and found that 66% occurred during ambulation. Another 32% of these fall-related fractures occurred during the time of transfer from the bed, chair, wheelchair, or commode.70
Summary
Falls are a complex event, involving a number of risk factors, and identification of these risk factors is as important as identifying fall-related injuries. A careful review of the cause of a fall can lead to appropriate interventions to reduce the risk of future falls and fall-related injuries.
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