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Epidemiology [7]
For a local population of 320,000:
15,500 will fall each year; 6,700 people will fall twice.
2,200 will attend accident and emergency departments or minor injuries units.
A similar number will call an ambulance.
1,250 will have a fracture of which 360 will be hip fractures.
Injuries due to falls are the most common cause of mortality in people aged over 75 in the UK.
Other groups - young children and athletes - also have high incidence of falling but are less susceptible to injury
(have less chronic diseases and age-related physiological changes) and recover more quickly.
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Risk factors
Risk of falls
These are many and varied with often more than one risk factor in the individual affected. It is essential to
consider these when looking at preventative measures. Identification, particularly of modifiable risk factors, is
important in this context.
Risk factors for falls include: [5] [8]
Age >80.
Female gender (this may be a true gender difference or a result of women being more likely to seek
medical care and advice after a fall). [9]
Low weight.
A history of fall in the previous year.
Dependency in activities of daily living.
Orthostatic hypotension - one study reported a 69% increased risk of having an injurious fall during the
first 45 days following antihypertensive treatment. [10]
Medication - the leading culprits are psychotropics (especially benzodiazepines, antidepressants,
antipsychotics), blood pressure lowering drugs, and anticonvulsants. [11]
Polypharmacy - a 14% increase in fall risk in one study with the addition of each medication beyond a
four-medication regime, irrespective of the group of drugs studied. [12]
Alcohol abuse.
Diabetes mellitus. [13]
Confusion and cognitive impairment.
Disturbed vision.
Disturbed balance or co-ordination.
Gait disorders.
Urinary incontinence.
Inappropriate footwear.
Environmental factors including home hazards.
Muscle weakness.
Depression.
Risk of injury
It is also instructive to examine the risk factors for fracture of the proximal femur. In so doing, this reveals risk
factors not just for falls but for falls resulting in injury. Again, an individual may have several risk factors. These
include:
Weak bones
With increasing age, conditions which predispose to weakness and fracture occur - for example:
Osteoporosis
Osteomalacia [14]
Paget's disease of bone
Metastases (to bone)
Predisposition to falls
This includes the risk factors listed above as examples from research literature. Dementia is a particular risk
factor for falls. [15] In those with dementia, impaired visuospatial ability is often associated with increased risk of
falling. [16]
Poor self-protection
This is common in the elderly. Examples include:
Lack of protective subcutaneous fat.
Neurological problems (preventing reflex breaking or cushioning of the the fall).
Falls associated with loss of consciousness (for example, syncope).
Motor and sensory problems.
Page 3 of 10
Multiple contributory factors (for example, slow and stiff joints, drugs and environmental factors are a
common combination of factors).
Presentation
Falling will present either with injuries or as a result of direct questioning. Many older people do not volunteer that
they are falling and guidelines suggest healthcare professionals should routinely inquire about falls in the previous
year. [5] [17]
History
A detailed history is essential. If possible, obtain some collateral history:
Was the fall an isolated event or one of many? If many, is there any pattern? How often do they occur?
Are they getting more frequent? Does there seem to be any common precipitating factor? Was alcohol
involved?
What caused the fall? Sometimes the fall is attributed simply to tripping over a loose rug or a trailing
electrical cable, for example. This is not a medical problem but requires a home safety assessment
with a visit by a health visitor or other suitably trained professional to identify other risks that require
attention. Frequently, multi-agency home safety assessments can be done simultaneously - eg,
identifying fire hazards or home security problems.
What was the patient doing at the time? Was it something involving exertion? Did it involve looking up?
Extending the neck to look inside a low cupboard or to do high dusting risks vertebrobasilar
insufficiency. Older people should be discouraged from climbing on chairs or ladders since they are
more likely to fall in these situations and will fall further, incurring more serious injuries. Postural
hypotension usually occurs on suddenly getting up from sitting or from lying in bed - typically, on
getting out of bed to go to the toilet in the night. Micturition syncope affects men, usually as they stand
up at the toilet, attempting to pass urine nocturnally. Does the patient have a sleep disorder? These
are reasonably common in older people and may contribute to the risk of falling. [18]
Was there any loss of consciousness? A good way of ascertaining this is to ask if the patient
remembers falling. Syncope (or blackouts) can be associated with cardiac or neurological symptoms.
Recognition and assessment of syncope requires skill and often specialist investigation. Assessment
algorithms are available. [19]
Was there any warning before the fall? Was there any loss of balance? If terms like 'giddy', 'dizzy' or
'faint' are used, explore what is meant.
How was the patient after the fall? Whilst they may have felt shaken or injured, features such as
weakness that made getting up again difficult, aching muscles or disorientation may indicate the
postictal phase of a fit. Incontinence is an unreliable sign of epilepsy and can occur with other causes
of loss of consciousness. A bitten tongue is more specific.The weakness of a transient ischaemic
attack (TIA) may last just a few minutes and leave no residue. Difficulty with language may indicate a
TIA.
A witness can describe exactly what happened before, during and after the fall. There may be a
description of tonic and clonic phases of convulsion but this does not necessarily imply epilepsy from
a space-occupying lesion or cerebral degeneration, as cerebral ischaemia from poor cardiac output
due to arrhythmia can produce the same. A witness may be better than the patient at ascertaining
confusion following the fall and noting how long it lasted.
If history suggests tripping over things, ask about eyesight and when last assessed by an optician.
There may be blurred vision or gradual loss of vision. Visual field defects may not be apparent to the
patient.
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General enquiry
Ask about general health:
Is appetite good and weight steady? A negative reply may point to more serious underlying disease.
How is mobility? Is locomotion becoming slow and laboured?
What is the normal functional status of the patient? Do they require assistance dressing, washing,
cooking, for example?
Are mental faculties still sound or is there evidence of cognitive decline?
Examination
Mental state:
Does the patient seem alert and orientated or vague and confused? The mini mental state
examination may be useful.
Decline in mental state may indicate a cause for the falls or it may be the result if head
injury has caused a chronic subdural haematoma.
Visual impairment:
If there is suggestion of poor sight then examination of the eyes should at least include
reading a Snellen chart.
Macular degeneration and visual field defects should be considered as other possibilities.
Cardiovascular examination:
Examination of the pulse may reveal irregularities suggestive of atrial fibrillation, variable
heart block or just bradycardia. Tachycardia may be a feature of congestive heart failure. In
fast atrial fibrillation the irregularity may be difficult to detect.
Record blood pressure in sitting and standing, especially if there is any suggestion of
postural hypotension. A drop of more than 20 mm Hg in the systolic blood pressure on
standing is significant.
Listen for bruits over the bifurcation of the carotid arteries but also in the posterior triangle of
the neck to detect bruits from the vertebral arteries.
Auscultation of the heart may give better indication of irregularities than the radial pulse and
it may indicate aortic stenosis or regurgitation or mitral stenosis or regurgitation.
Neurological and locomotor examination:
Note muscle wasting that may reflect disuse atrophy, often secondary to arthritis.
Note muscle tone.
A brief assessment of the sensory system may indicate a peripheral neuropathy. Loss of
vibration sense can be a marker for posterior column disease with associated loss of
proprioception.
Asymmetrical tendon reflexes and any extensor plantar response are significant.
Try to reproduce vertebrobasilar symptoms by asking the patient to extend their neck to the
full and to hold it for several seconds and repeat with flexion and full rotation to the left and
right.
Check for nystagmus and briefly for co-ordination.
Note how the patient gets up from the chair. There may be proximal myopathy but, in the
elderly, disuse atrophy is more common. Is gait normal? Is there asymmetry? Some gait
abnormalities may be due to arthritis. Look for features that may indicate Parkinson's
disease.
NICE recommends the following as being pragmatic tests which can be used in any situation and without the use
of special equipment: [17]
Timed Up and Go Test: request that the patient rise from a chair without the support of their arms,
walk three metres, turn round and sit down again. A walking aid can be used if required. Completion of
the test without unsteadiness or difficulty suggests a low risk of falling.
Turn 180 Test: request that the patient stand up and step around until they are facing the opposite
direction. If more than four steps are required to do this, further assessment is indicated.
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Environmental factors
Falls caused by accidents related to the patient's environment can often be prevented. NICE recommends that all
people at risk of falls should be offered a home assessment and interventions to modify environmental
hazards. [5] For example:
Loose rugs or mats (especially on a slippery floor).
Electricity leads (trailing across the floor).
Wet surfaces (especially in the bathroom).
Lighting.
Furniture.
Fittings such as handholds.
Measures such as the installation of handles and rails can reduce the risk of falls.The community team may work
in association with the local council to install these without charge to the patient.
Page 6 of 10
Drop attacks
Falls are called drop attacks when the cause is unknown, the event unexpected and there is no loss of
consciousness. The account of a witness is most helpful. Causes may include:
Cardiovascular disease (as for those causes associated with loss of consciousness but in a less
severe form).
Carotid sinus hypersensitivity (tends to cause drop attacks rather than syncope).
TIAs (there may be weakness or confusion for a few seconds or several minutes with no residual
neurological signs).
Orthostatic hypotension (a fall of at least 20 mm Hg in systolic blood pressure or 10 mm Hg in
diastolic blood pressure on moving from a supine to an upright position) may result from:
Dehydration.
Treatment of hypertension.
Autonomic neuropathy.
Reduced adaptability of the ageing circulation.
Page 7 of 10
Visual disturbance
NICE has found no firm evidence that treatment of visual disturbance as a single intervention reduces falls but
agrees it is good practice to treat impaired vision where found. [5] Gradual loss of vision has many causes. These
include:
Cataracts.
Macular degeneration.
Central retinal artery occlusion.
Central retinal vein occlusion.
Visual field defects.
Referral to an optician can be useful in diagnosis and management.
Medication [5]
Drugs can contribute to falls in many ways. Medication needs to be reviewed regularly, taking into account risk
and benefit. Examples of the ways in which drugs can increase the risk of falls include:
Sedative medication, including hypnotics (may impair co-ordination and cause falls). [26] There is a
particular risk of falls in agitated patients with cognitive impairment.
Confusion, particularly from psychotropic medication, may increase the risk of falls.
Polypharmacy is common in elderly patients. The scope for interactions and other effects likely to
cause falls is increased.
Orthostatic hypotension caused by:
Diuretics (can cause dehydration and may cause urgency and falls).
Vasodilators (including calcium-channel blockers and nitrates).
Angiotensin-converting enzyme (ACE) inhibitors.
Alpha-blockers.
Phenothiazines.
Tricyclic antidepressants.
Levodopa.
Bromocriptine.
Beta-blockers.
Insulin. [27]
Investigations
Basic blood tests including:
FBC (macrocytosis may indicate alcohol abuse).
U&Es.
LFTs - abnormal LFTs may indicate alcohol abuse, especially gamma GT.
TFTs.
Vitamin B12.
Random blood glucose.
Urinalysis may reveal unsuspected diabetes to account for vascular disease, neuropathy and poor
vision.
ECG to confirm or suggest:
Atrial fibrillation.
Conduction defects where there is a prolonged PR interval, inferior ischaemia or bundle
branch block.
Ambulatory ECG may be required to discover episodes of bradycardia with possible heart block or
even tachyarrhythmia.
Echocardiography is indicated in heart failure, atrial fibrillation and valvular disease to assess
ventricular or valvular function or to detect atrial thrombus.
Visual assessment by an optician.
Syncope or TIAs require additional investigations including neuro-imaging.
Page 8 of 10
Primary prevention
This means taking measures to prevent falls in people who have not fallen. Examples include:
Increasing exercise and physical activity.
Reviewing medication.
Changing adverse environmental factors.
Improving management of any medical conditions.
Secondary prevention
This means taking measures to prevent further falls in those who have had a previous fall/falls (with or without
injury). Examples are likely to be similar to those for primary prevention but will be more focused in the light of
information about the fall/falls. Those who have already had a fall are at much higher risk of further falls.
Secondary prevention is likely to target resources more effectively.
Page 9 of 10
A multifactorial assessment should be performed which should include:
Cognitive impairment.
Continence problems.
Falls history, including causes and consequences (such as injury and fear of falling).
Footwear that is unsuitable or missing.
Health problems that may increase their risk of falling.
Medication.
Postural instability, mobility problems and/or balance problems.
Syncope syndrome.
Visual impairment.
Multifactorial interventions should be offered which should:
Promptly address the patient's identified individual risk factors for falling in hospital.
Take account of whether the risk factors can be treated, improved or managed during the patient's
expected stay.
Page 10 of 10
20. Glass J, Lanctot KL, Herrmann N, et al; Sedative hypnotics in older people with insomnia: meta-analysis of risks and
benefits.; BMJ. 2005 Nov 19;331(7526):1169. Epub 2005 Nov 11.
21. Ciolac EG; Exercise training as a preventive tool for age-related disorders: a brief review. Clinics (Sao Paulo). 2013
May;68(5). pii: S1807-59322013000500710. doi: 10.6061/clinics/2013(05)20.
22. Howe TE, Rochester L, Neil F, et al; Exercise for improving balance in older people. Cochrane Database Syst Rev. 2011
Nov 9;(11):CD004963. doi: 10.1002/14651858.CD004963.pub3.
23. Latt MD, Lord SR, Morris JG, et al; Clinical and physiological assessments for elucidating falls risk in Parkinson's Mov
Disord. 2009 Jul 15;24(9):1280-9.
24. Ker K, Chinnock P; Interventions in the alcohol server setting for preventing injuries. Cochrane Database Syst Rev. 2008
Jul 16;(3):CD005244. doi: 10.1002/14651858.CD005244.pub3.
25. Miller TR, Spicer RS; Hospital-admitted injury attributable to alcohol. Alcohol Clin Exp Res. 2012 Jan;36(1):104-12. doi:
10.1111/j.1530-0277.2011.01593.x. Epub 2011 Oct 17.
26. Mets MA, Volkerts ER, Olivier B, et al; Effect of hypnotic drugs on body balance and standing steadiness. Sleep Med Rev.
2010 Aug;14(4):259-67. doi: 10.1016/j.smrv.2009.10.008. Epub 2010 Feb 18.
27. Berlie HD, Garwood CL; Diabetes medications related to an increased risk of falls and fall-related Ann Pharmacother.
2010 Apr;44(4):712-7. Epub 2010 Mar 9.
28. Roe B, Howell F, Riniotis K, et al; Older people and falls: health status, quality of life, lifestyle, care networks, J Clin Nurs.
2009 Aug;18(16):2261-72.
29. Robinson L, Newton JL, Jones D, et al; Self-management and adherence with exercise-based falls prevention
programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disabil
Rehabil. 2013 May 28.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.
Original Author:
Dr Richard Draper
Current Version:
Dr Laurence Knott
Peer Reviewer:
Dr Hayley Willacy
Document ID:
2663 (v24)
Last Checked:
16/04/2014
Next Review:
15/04/2019