Falls in the elderly are common. About a third of them happen at home at least once a year. They can have serious consequences for themselves and others.

Falls are one of the leading causes of injury among seniors. We are taking advantage of fall prevention month to remind you that it is possible to act on certain factors that put you at risk.

Epidemiology of falls in the elderly

Falls in older people and athletes are more common than in all other adults. However, the elderly represent a very vulnerable category due to a high prevalence of diseases (eg osteoporosis) and natural age-related alterations (eg slowing down of protective reflexes).

Falls are the leading cause of death in women and the fourth in men aged 65 and over. A third of subjects aged 65 and over have at least one fall per year. They are three times more frequent in a medical institution than at home: half of the residents are affected compared with a third of those living at home.

Falls represent an annual medical cost of more than one billion euros (more than 10 billion in the United States). In Canada, falls among the elderly cost the health care system $2.8 billion each year, including $1 billion in direct care (Source health Canada). They also have an indirect cost since many of them see their quality of life diminished: loss of autonomy and self-esteem, isolation, depression, phobic fear of falling again.

Falls are the number one cause of hip fracture, especially in women with low bone mineral density. The risk of mortality seems higher in men than in women (30% versus 10% one year after a fall). Half of seniors with a hip fracture have difficulty performing daily living tasks.
Nor do they spare elderly people who consider themselves to be in good physical health, since 20% of them fall in the course of a year.

The risk of falling increases with age and in the presence of disorders/diseases of higher functions (motor, cognitive, cardiac functions, etc.).
The risk of recurrence is high since about half of seniors who have fallen will reoffend at least once a year.

The medical community must assess the causes of a fall (which is often a reflection of one or more underlying pathologies), assess the consequences, and take preventive measures to avoid recurrences.

Causes of Elderly Falls

The search for the causes is important to avoid recurrences. They are not easy to detect and several can be associated with the same patient.

Here are listed the factors predisposing to falls:

1. Neurological disorders and diseases 
– Stroke
– Brain tumor
– Parkinson’s disease or other movement disorders
– Normal pressure hydrocephalus (enlargement of the cerebral ventricles and subarachnoid space).
– Damage to the spinal cord caused by vitamin B12 deficiency
– Hypovitaminosis D (<12µg/L)
– Peripheral neuropathies (diabetes, alcohol abuse, nutritional deficiencies and in particular vitamin B12 deficiencies, certain drugs such as vincristine)
– Cognitive disorders impairing judgement, visuospatial perception, and orientation
– Depression and anxiety (particularly in people living alone and feeling devalued)
– Confusion
– Sleep disorders

2. Musculoskeletal disorders and diseases 
– Myopathies caused by hypothyroidism, certain medications (e.g. corticosteroids, hypolipidemics, diuretics), alcohol)
– Muscle relaxants (benzodiazepines…) – Polymyalgia rheumatica (
Horton’s disease)
– Chondrocalcinosis (formation of calcium in the joints)
– Rheumatoid arthritis of inflammatory origin resulting in deformity of the ankle or foot
– Myasthenia gravis (disorders of transmission between the nerve and the muscle)
– Sarcopenia (decrease in muscle mass and increase in fat mass)
– Kyphosis (curvature of the spine)
– Cervical osteoarthritis (progressive destruction of joint cartilage)
– Coxarthrosis (chronic wear of the hip)
– Gonarthrosis (chronic wear of the cartilage of the knee joint)

3. Cardiovascular disorders and diseases 
– Cardiac arrhythmia (ventricular tachycardia, bradycardia; atrial fibrillation)
– Conduction disorders (poor propagation of nerve impulses in the heart)
– Orthostatic hypotension (drop in systolic pressure)
– Heart failure
– Hypertension arterial
– Carotid sinus syndrome
– Aortic stenosis (narrowing of the aortic valve)

4. Vision disorders 
– Cataract (clouding of the lens)
– glaucoma (increased pressure within the eye)
– macular degeneration (atrophy of the retinal pigment epithelium)
– diabetic retinopathy (disease of the retinal capillaries)
– Positional vertigo
– Neuritis vestibular (vertigo caused by a virus or medication)
– Ménière’s disease (disease of the inner ear)

5. Metabolic and encodrine disorders 
– Anemia
– Hypoxia
– Malnutrition (including protein deficiency)
– Dehydration
– Ionic disorders
– Hypoglycemia
– Dysthyroidism

6. Drugs
Elderly people take many drugs with many side effects that can affect walking and balance. Here is a list summarized in this table:

7. Environmental factors 
Elderly people living at home face environmental hazards responsible for 40% of falls. These – avoidable – dangers are listed below:
– Unsuitable shoes and clothing (high heels, slippery soles, clothes that are too long)
– Armchair, bed too high or too low
– Untidy or cluttered rooms with furniture
– Rugs or loose electrical wires
– Uneven or loose flooring
– Insufficient lighting
– Dangerous stairs
– Wet or slippery
floor – Unsuitable bathroom (slippery bath)

Diagnosis of falls in the elderly

After having assessed the seriousness of the fall, the doctor discusses with the patient – ​​or a possible witness to the fall – the following points:
– the circumstances of the fall: the environment in which the patient moves; did a change of position, a physical activity or a meal precede the fall?).
– Associated symptoms (dizziness, muscle weakness, confusion, motor and visual disturbances, etc.).
– Is there loss of consciousness (if yes, how long)?
– The patient’s history is of course clues to be considered: history of stroke, Parkinson’s disease, cardiovascular disease, visual disturbances, drugs taken, any previous falls.

Clinical examinations

The doctor looks for signs of cardiovascular, neurological, motor, metabolic, or sensory disease:
– Taking the pulse.
– Measurement of blood pressure in the lying position, then standing 1,2, and 3 minutes after getting up (orthostatic hypotension?).
– Taking the temperature (fever, hypothermia?).
– Cardiac auscultation (arrhythmia, valve disease?).
– Sensory examination of the head and neck (visual and auditory disorders?).
– Assessment of muscle tone and strength, reflexes.
– Examination of the joints (sign of osteoarthritis, deformities of the feet, etc.?).
– Evaluation of mental functions (confusion, cognitive disorders?).
– Evaluation of proprioception (that is to say, the ability of the individual to evaluate the relative position of the parts of his body in relation to each other and in space) by the Romberg test.
– Evaluation of gait (observation of the patient when he gets up from a chair and sits down again, when he turns on himself, the height of his step, his velocity, and his symmetry).

Para clinical examinations

Para clinical examinations are carried out according to the results of the clinical examination and the anamnesis. They include:
– an electrocardiogram (ECG) to detect any rhythm or conduction disturbances.
– Blood tests (measurement of creatinine, electrolytes, glucose and various blood components).
– Echocardiography.
– Holter-ECG (if suspicion of transient arrhythmia or in case of unexplained syncope) – Electroencephalogram.
– Magnetic resonance imaging or tomography (to exclude or not a cause of serious neurological origin).

Consequences of falls

Falls in the elderly are more serious than in adults for various reasons: slower and less effective reflexes, greater fragility of bones and muscles… Falls lead to serious injuries in 5% of cases (fractures, dislocations, hematomas, etc.) or hospitalization. A quarter of people hospitalized for falls die within a year.

Some complications are sometimes difficult to assess, especially those occurring after a slight head trauma, undetectable during a standard brain X-ray.

They require the help of more precise techniques such as bone scintigraphy or magnetic resonance imaging. A blood test is necessary if the person has remained immobile on the ground for several hours (risk of muscle damage and kidney failure caused by an increase in a muscle enzyme called creatine-phosphokinase).

These complications can be accompanied by neurological disorders – in particular a confusional state – several weeks after a fall. The interrogation of the entourage and a scanner will confirm this hypothesis.
A repetition of falls can lead to the placement in nursing homes of previously independent seniors.

Falls also have psychological consequences: this is called post-fall syndrome. Indeed, a certain number are afraid of reoffending, leading to:
– a decrease in physical activity (the person imposes functional restrictions on themselves).
– Social isolation
– Loss of confidence and self-esteem
– Depressive and/or anxiety disorders
– Exacerbation of neurotic disorders

This syndrome can appear several weeks after the fall.

Assessment of gait and balance

To assess the risk of falls in the elderly, health professionals use the gait and balance assessment test or the fall risk assessment test.

Prevention

After managing the immediate consequences of the fall, the doctor offers the patient an individualized program to prevent any recurrence. This program offers several approaches: medical, behavioral, rehabilitation, etc. It aims to minimize the risk factors to which the subject at risk is exposed.

For example:

• Recommend vitamin D supplements.
• Stopping, changing or reducing the doses of medications that could increase the risk of falls.
• List medications that could interact with each other and cause side effects: drowsy, low blood pressure etc.
• Have your eyesight checked at least once a year.
• Take part in activity programs to strengthen your muscles and improve your balance (e.g. Tai-chi)
• Remove obstacles in your home (e.g. slippery carpet)
• Wear well-fitting socks.
• Call a physiotherapist.

The house must also be refurbished as follows:

• Remove furniture and bulky objects that may obstruct the passage.
• Improve the lighting, especially at night if the person has to get up (old lights from the bedroom to the bathroom).
• Avoid carpets or fix them so as not to trip over them.
• Remove the electric wires, extension cords which obstruct the passage.
• Place non-slip mats and grab bars in the bathroom if necessary.
• Avoid climbing on a chair or on a stepladder.

Falls: the side effects of antihypertensives drugs

The increase in falls is associated with taking antihypertensive drugs, leading to more hip fractures or head injuries.

According to Yale University researchers, those over the age of 70 who took medication had up to a 40% risk of injury.

Side effects of medicines that lower blood pressure (called antihypertensives) include dizziness and balance problems.

“Given the high risk of disease and mortality associated with severe falls, it is necessary to assess the risk/benefit ratio before deciding to treat a patient with hypertension,” says Yale professor Dr. Mary Tinetti.

According to a specialist, there are no classes of antihypertensives that are safer than others. « When treating a patient with an antihypertensive, one should use the lowest dose possible. »

Another researcher does not seem convinced by the results and declares that “it is not excluded that the falls are caused by hypertension and not by its treatment”.

To arrive at these results, the researchers gathered data from 5,000 septuagenarians.

During the 3 years of follow-up, 9% were victims of a fall and about a third took an anti-hypertensive. 

Source: JAMA Internal Medicine, February 2014.