Falls in the Elderly: Causes, Injuries, and Management

Risk Factors

Unavoidable fall risk factors include age over 85 years, male sex, white race/ethnicity, and having a history of falls.[6] Even so, advancing age in itself is not necessarily responsible for an increased risk of falling. Rather, the overall health status of the elderly is most strongly associated with the risk of a fall and subsequent injury.[6] People older than 85 years who are in excellent health are at no greater risk of falls than those aged 65-84 years.

Other factors associated with greater rates of fall injuries in seniors include previous medical diagnoses (eg, cerebrovascular accidents/transient ischemic attacks), arthritis, fractures, dementia, diabetes, vitamin D deficiency, anemia, arrhythmias, neuropathy), impaired vision/hearing, recent hospital discharge, higher body mass index, poor sleep/obstructive sleep apnea, and urinary incontinence. Alcohol use is also a predictor for fall risk; therefore, clinicians should attempt to elicit an alcohol history from elderly patients.

The Morse Fall Scale (MFS) is often used to identify and score fall risk factors. It takes into consideration whether or not the patient has a history of falls, any secondary diagnoses, any intravenous (IV) access, and any use and/or type of ambulatory aid, as well as the patient’s gait type and mental status.[7,8] With the rapid expansion of electronic medical records, some clinicians have advocated for the inclusion of this screening tool in each elderly patient’s virtual chart. Versions of this tool are available from the Agency for Healthcare Research and Quality (AHRQ) at http://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf and from the US Department of Veterans Affairs (DVA) at http://www.patientsafety.va.gov/professionals/onthejob/falls.asp.

The STRATIFY fall score has also been used to assess the risk of falls in elderly patients and was revalidated in a 2015 study of hospital inpatients and nursing home residents.[9]

Some factors can be addressed to reduce the risk of falls in older people, including optimizing medical conditions/regimens (eg, polypharmacy increases fall risk) and managing environmental issues (eg, inappropriate lighting, slippery floors, ill-fitting footwear, inappropriate assistive devices) in those predisposed to falling.

Many elderly patients are prescribed multiple medications; polypharmacy not only increases their risk of falls but also affects their treatment and outcome. Sedatives/hypnotics are significantly associated with fall risk, and antidepressants cause the highest risk of falls among seniors.[10] Other medications associated with an increased fall risk include diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and antihypertensives. The American Geriatrics Society (AGS) provides updates to the Beers Criteria, a list of medications that should be avoided in the elderly, which may be helpful to practitioners. The 2015 update strongly recommends avoiding the following drugs in older patients[11]:

  • The blood thinners aspirin for the prevention of cardiac events and dabigatran
  • The psychiatric medications mirtazapine, antipsychotics, serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs)
  • The anticonvulsant drugs carbamazepine and oxcarbazepine
  • The chemotherapy agents carboplatin, cyclophosphamide, cisplatin, and vincristine
  • Diuretics

The strength of the Beers Criteria recommendations for avoidance of prasugrel and vasodilators are noted as “weak.”[11]

Other strategies may also decrease the risks of polypharmacy, including yearly review of medications and “starting low and going slow” when initiating new medications.[12]

Surprisingly, narcotic medications have been shown to only minimally increase the risk of falls in the elderly, and these agents appear to be safer than some of the drugs mentioned above with regard to fall risk. Although some medications do not increase the risk of falls (eg, cholinesterase inhibitors), they do raise the potential for a hip fracture in the event of a fall.

The AP radiograph demonstrates an unstable pertrochanteric fracture after a simple fall by an elderly male patient who subsequently developed thigh compartment syndrome.

The primary mechanisms of falling (≈30%) in older patients are slipping, tripping, and stumbling. However, fall risks differ on the basis of the senior’s living situation. For elderly patients living in the community, hazards that contribute to fall injuries include stairs, bathtubs without handlebars, electrical cords, clutter, inappropriate lighting, and loose rugs.[2] Nursing home residents are at risk of falls secondary to wet floors, restraints, bedrails, or ties such as tubing and/or catheters. Unfortunately, even elderly patients in an inpatient hospital setting are at risk of falling.

Evidence has been lacking that initiatives such as the addition of rails (shown) and the use of restraints, fall-alert bracelets, and bed alarms reduce the risk of falls,[2] although a 2015 meta-analysis is an exception, suggesting that these measures may decrease the number of recurrent fallers by 21%.

Clinicians have long known that if an elderly person falls, his/her frailty will determine the severity of an injury and its outcome, not the patient’s age.[14] Frailty describes a senior’s decreased physiologic reserve; assessing an older person’s frailty may include evaluating their ability to walk up a flight of stairs or carry a bag of groceries. Some seniors will seem frail in their 70s, whereas others may remain active and vital into their 90s. An elder who is frail has a higher likelihood of falling and a greater risk of injury from a fall.[14]

Researchers have developed several variations of a “frailty index,” in which clinicians use a scoring system to determine if an individual is frail; this tool can help predict a geriatric patient’s chance of being discharged from the hospital to a nursing home or rehabilitation center after a fall.[15]

The patient’s frailty index is the most accurate predictor of adverse events after a fall, even more accurate than the patient’s age or injury severity score (ISS).[16] If a patient is identified as frail, clinicians should consider extra precautions to prevent complications, as well as dedicate additional resources to protecting the patient from an adverse outcome.

Relative to adults in other age groups, elderly patients who present to the emergency department (ED) following a fall have a unique bodily injury pattern, higher ISS, worse outcomes, and higher mortality.[17] One major difference in the geriatric population is skeletal fragility (right),[18] which occurs as their bones become more susceptible to the mechanical forces of trauma. Consequently, elderly patients will sustain more severe injuries with lower force mechanisms than their younger counterparts, who have greater bone density (left).

Some studies have looked at adding vitamin D to the medication regimens of elderly patients identified to be at risk of falling. Although more data are needed, evidence exists to suggest that prescribing vitamin D may lower the risk of falls and decrease the risk of injury in the event of a fall, especially in adults found to be vitamin D deficient.

Slide 1

The most common mechanism of injury in the elderly population is falling.[1] About 30%-50% of falls in the elderly result in minor injuries, including bruises, abrasions, and lacerations, but an estimated 10% of all falls in seniors cause major injuries, including intracranial injuries (ICIs) and fractures. One percent of all falls in this population result in hip fractures, which pose a significant risk for postfall morbidity and mortality.[2,3] In addition, according to the Centers for Disease Control and Prevention (CDC), between 2006 and 2010, falls were the leading cause of traumatic brain injury-related deaths in persons aged 65 or older.[4]

Less than half of older patients who fall tell their clinician they’ve had a fall.[5]

The anteroposterior (AP) radiographs show a left proximal humeral fracture in a 79-year-old female following a fall in the bedroom.

Images courtesy of Parker S, Afsharpad A. Case Rep Orthop. 2014;2014:164632. [Open access.] PMID: 25431716, PMCID: PMC4241333.

Slide 2

Risk Factors

Unavoidable fall risk factors include age over 85 years, male sex, white race/ethnicity, and having a history of falls.[6] Even so, advancing age in itself is not necessarily responsible for an increased risk of falling. Rather, the overall health status of the elderly is most strongly associated with the risk of a fall and subsequent injury.[6] People older than 85 years who are in excellent health are at no greater risk of falls than those aged 65-84 years.

Other factors associated with greater rates of fall injuries in seniors include previous medical diagnoses (eg, cerebrovascular accidents/transient ischemic attacks), arthritis, fractures, dementia, diabetes, vitamin D deficiency, anemia, arrhythmias, neuropathy), impaired vision/hearing, recent hospital discharge, higher body mass index, poor sleep/obstructive sleep apnea, and urinary incontinence. Alcohol use is also a predictor for fall risk; therefore, clinicians should attempt to elicit an alcohol history from elderly patients.

The radiograph shows an intertrochanteric fracture of the right femur in a 75-year-old male following a fall.

Image courtesy of Aqil A, Desai A, Dramis A, Hossain S. J Med Case Rep. 2010;4:390. [Open access.] PMID: 21118535, PMCID: PMC3012042.

Slide 3

The Morse Fall Scale (MFS) is often used to identify and score fall risk factors. It takes into consideration whether or not the patient has a history of falls, any secondary diagnoses, any intravenous (IV) access, and any use and/or type of ambulatory aid, as well as the patient’s gait type and mental status.[7,8] With the rapid expansion of electronic medical records, some clinicians have advocated for the inclusion of this screening tool in each elderly patient’s virtual chart. Versions of this tool are available from the Agency for Healthcare Research and Quality (AHRQ) at http://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf and from the US Department of Veterans Affairs (DVA) at http://www.patientsafety.va.gov/professionals/onthejob/falls.asp.

The STRATIFY fall score has also been used to assess the risk of falls in elderly patients and was revalidated in a 2015 study of hospital inpatients and nursing home residents.[9]

Some factors can be addressed to reduce the risk of falls in older people, including optimizing medical conditions/regimens (eg, polypharmacy increases fall risk) and managing environmental issues (eg, inappropriate lighting, slippery floors, ill-fitting footwear, inappropriate assistive devices) in those predisposed to falling.[10]

Adapted MFS courtesy of AHRQ.

Slide 4

Many elderly patients are prescribed multiple medications; polypharmacy not only increases their risk of falls but also affects their treatment and outcome. Sedatives/hypnotics are significantly associated with fall risk, and antidepressants cause the highest risk of falls among seniors.[10] Other medications associated with an increased fall risk include diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and antihypertensives. The American Geriatrics Society (AGS) provides updates to the Beers Criteria, a list of medications that should be avoided in the elderly, which may be helpful to practitioners. The 2015 update strongly recommends avoiding the following drugs in older patients[11]:

  • The blood thinners aspirin for the prevention of cardiac events and dabigatran
  • The psychiatric medications mirtazapine, antipsychotics, serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs)
  • The anticonvulsant drugs carbamazepine and oxcarbazepine
  • The chemotherapy agents carboplatin, cyclophosphamide, cisplatin, and vincristine
  • Diuretics

The strength of the Beers Criteria recommendations for avoidance of prasugrel and vasodilators are noted as “weak.”[11]

Other strategies may also decrease the risks of polypharmacy, including yearly review of medications and “starting low and going slow” when initiating new medications.[12]

Surprisingly, narcotic medications have been shown to only minimally increase the risk of falls in the elderly, and these agents appear to be safer than some of the drugs mentioned above with regard to fall risk. Although some medications do not increase the risk of falls (eg, cholinesterase inhibitors), they do raise the potential for a hip fracture in the event of a fall.

The AP radiograph demonstrates an unstable pertrochanteric fracture after a simple fall by an elderly male patient who subsequently developed thigh compartment syndrome.

Image courtesy of Kanlic EM, Pinski SE, Verwiebe EG, Saller J, Smith WR. Patient Saf Surg. 2010;4(1):13. [Open access.] PMID: 20723263, PMCID: PMC2933643.

Slide 5

The primary mechanisms of falling (≈30%) in older patients are slipping, tripping, and stumbling. However, fall risks differ on the basis of the senior’s living situation. For elderly patients living in the community, hazards that contribute to fall injuries include stairs, bathtubs without handlebars, electrical cords, clutter, inappropriate lighting, and loose rugs.[2] Nursing home residents are at risk of falls secondary to wet floors, restraints, bedrails, or ties such as tubing and/or catheters. Unfortunately, even elderly patients in an inpatient hospital setting are at risk of falling.

Evidence has been lacking that initiatives such as the addition of rails (shown) and the use of restraints, fall-alert bracelets, and bed alarms reduce the risk of falls,[2] although a 2015 meta-analysis is an exception, suggesting that these measures may decrease the number of recurrent fallers by 21%.[13]

Image courtesy of Wikimedia Commons | Shoyuramen.

Slide 6

Clinicians have long known that if an elderly person falls, his/her frailty will determine the severity of an injury and its outcome, not the patient’s age.[14] Frailty describes a senior’s decreased physiologic reserve; assessing an older person’s frailty may include evaluating their ability to walk up a flight of stairs or carry a bag of groceries. Some seniors will seem frail in their 70s, whereas others may remain active and vital into their 90s. An elder who is frail has a higher likelihood of falling and a greater risk of injury from a fall.[14]

Researchers have developed several variations of a “frailty index,” in which clinicians use a scoring system to determine if an individual is frail; this tool can help predict a geriatric patient’s chance of being discharged from the hospital to a nursing home or rehabilitation center after a fall.[15]

The patient’s frailty index is the most accurate predictor of adverse events after a fall, even more accurate than the patient’s age or injury severity score (ISS).[16] If a patient is identified as frail, clinicians should consider extra precautions to prevent complications, as well as dedicate additional resources to protecting the patient from an adverse outcome.

Image courtesy of Pixabay | cocoparisienne.

Slide 7

Relative to adults in other age groups, elderly patients who present to the emergency department (ED) following a fall have a unique bodily injury pattern, higher ISS, worse outcomes, and higher mortality.[17] One major difference in the geriatric population is skeletal fragility (right),[18] which occurs as their bones become more susceptible to the mechanical forces of trauma. Consequently, elderly patients will sustain more severe injuries with lower force mechanisms than their younger counterparts, who have greater bone density (left).

Some studies have looked at adding vitamin D to the medication regimens of elderly patients identified to be at risk of falling. Although more data are needed, evidence exists to suggest that prescribing vitamin D may lower the risk of falls and decrease the risk of injury in the event of a fall, especially in adults found to be vitamin D deficient.[19,20]

Image comparing bone density between normal bone and osteoporotic bone courtesy of Wikimedia Commons | Aisha Huseynova.

Slide 8

Even when a fall does not result in death, fall injuries can cause significant morbidity and impede an elderly person’s functional status and overall health. Fractures are a major complication of falls in this population, with 10% of falls causing a fracture, and 2% of the fractures involving the hip(s). An estimated 75% of all vertebral and nonvertebral fractures occur in those aged 65 years or older, and more than 75% of hip fractures affect seniors aged 75 years or older.[21]

Fractures are an independent predictor of long-term mortality. After a hip fracture, an elderly person has a 27% chance of dying within 1 year[22]; following a proximal femur fracture, 50% of affected seniors will experience a functional decline within 1 year.[23] Other postfall fracture sites in older people include the proximal humerus, pelvis, vertebrae, distal radius, and vertebral bodies.[24] In addition, fractures surrounding or involving a prosthesis have become increasingly common among older patients.[24,25]

Findings from a retrospective analysis of data from the National Electronic Injury Surveillance System-All Injury Program showed that most falls in the elderly occurred in the bathroom, followed by the bedroom, kitchen, and living room (shown), often involving the transition areas between carpets and rugs or noncarpeted sections and rugs; on wet carpets or rugs; and when seniors were hurrying to the bathroom.

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