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ELDERLY FALL PREVENTION
Epidemiology, Risk Factors (continued)
Guideline for the Prevention of Falls in Elderly Persons: Table 1 Results of Univariate Analysis of Most Common Risk Factors for Falls Identified in 16 Studies That Examined Risk Factors
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Falls can occur due to physical problems such as poor vision, strength, or balance. Some falls occur in the course of normal activity such as bending, turning, or rising whereas others occur with risky behavior or from environmental issues such as loose rugs, stairs, and poor lighting.[7] This table presents the number of studies showing a risk factor as significant over the total number of studies conducted. Muscle weakness (OR 4.4), prior falls (OR 3.0), gait deficit (OR 2.9), and balance problems (OR 2.9) are the most important intrinsic factors. They are easily screened and modifiable in some cases. Various studies have examined gait speed, stride length, arc of sway when standing, and the ability to stand on one leg with eyes open and closed. The studies found that while walking alone did not vary between healthy elderly fallers and non-fallers, when a “dual task” was required (carrying a full glass of water while walking), fallers had slower gaits with shorter strides. In one study, “Identification of healthy elderly fallers and non-fallers by gait analysis under dual-task conditions.”[8], dual-task gait assessment found that fallers walked -0.12 m/s slower; stride length was -5.6 cm shorter; stride time was 0.1 seconds longer. In balance tests the results found that participants with a fall history placed their foot on the floor 4.0±3.8 times with eyes open and 9.6±5.5 times with eyes closed. Participants that had no history of falls placed their foot on the floor 1.1±1.3 times with eyes open and 5.6±1.6 with eyes closed. P= 0.003 for eyes open; P= 0.004 for eyes closed. The study concluded that single leg balance tests and dual-task walking tests may help detect underlying gait disorders that may put a person at risk for falls.
Depression and antidepressants have both been associated with an increased risk of falls. In a cross-sectional study of 21,900 community-dwelling adults 60 years of age and over falls occurred with 24% of participants, fall related injuries with 11%, and 8% sought medical attention. The risk for multiple falls was associated with antidepressant use (OR 1.46) and depression (OR 1.32). In the study patients that had four or more fall risk factors were three times more likely to fall. The authors conclude that clinicians should screen depressed patients for risk factors and refer them for appropriate intervention. Falls, Depression and Antidepressants in Later Life: A Large Primary Care Appraisal[9] Medication side effects and management suggestions will be discussed further in a later section.
Dementia is an independent risk factor for falls, associated with an annual fall rate of 70 to 85%. Dementia is associated with reduced judgment as well as postural instability, poor visual spatial perception, gait impairment, and psychotropic medications.[7]
Other risk factors may require further screening for chronic diseases such as arthritis, circulatory disorders, peripheral neuropathy, use of any psychotropic medications and polypharmacy, and poor vision. It is important, as well, to consider cardiovascular causes of falls due to syncope. There is on-going research relating to syncope, cardiac arrhythmias and falls.[6]
Three studies evaluating the impact of multiple risk factors found that the annual risk of falling increased from 10-27% with no or one risk factor to 69-100% with three or four risk factors. One of these studies found evaluated the predictive value of different risk factors and found the combination of risk factors that led to a 100% predictive value: hip weakness, unstable balance, and ≥ 4 medications.[4]
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