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Care Homes Case study Rónán Donohoe, 20 Dec ‘10

Falls in Older People


1. Quick facts
2. Risk Factors
3. Dizziness
4. Meniere's Disease
5. Treatment & Physiotherapy

1. Quick Facts
• Injury due to falls is the leading cause of mortality in older people aged over 75 in the UK.
• Over 85% of all fatal falls are in people over the age of 65. More than half of the over 85’s will fall at least
once a year.
• Every 5 hours someone dies after an accidental fall in the home.
• 86,000 hip fractures occur annually in the UK. 20% of all orthopaedic beds are used by hip fracture
• It is estimated that the overall direct healthcare cost to the NHS from falls is £15 million every year.
• 95 % of all proximal hip fractures are as a result of a fall; mortality at one year following hip fracture for
age 75 and over is 25-30%.
• Falls can cause distress, pain, injury, loss of confidence and loss of independence.
• After a fall, 48% of older people report a fear of falling and 25% have a functional decline
• Standard six of the NSF for Older People is devoted to the prevention and management of falls & sets out
a plan to develop localised services for falls prevention. Physiotherapists are identified as essential
members of specialised falls prevention teams

2. Risk Factors
Causes of falls in older people are usually multifactorial but include:1
• Accident and environmental hazards (31%)
• Gait and balance disorders or weakness (17%)
• Dizziness and vertigo (13%)
• Drop attack (9%)
• Confusion (5%)
• Postural hypotension (3%)
• Visual disorder (2%)
• Syncope (0.3%)
• Other specified causes incl: arthritis, acute illness, drugs, alcohol, pain, epilepsy & falling from bed (15%)
• Unknown (5%)

Other risk factors include:

• A history of fall in the last year
• Age (>80 years)
• Use of an assistive device, e.g. a walking stick
• Depression
• Low body mass index (less than 22 Kg/m2 – Tinetti). (High body mass index seen to be protective against
injurious falls 2)
• Polypharmacy
Arguments: - risk is that of chronic disease and multiple pathology vs. medication
- the risk of falling increases with the number of medications, where at least one medication
is considered a drug associated with falling.
• Psychotropic medication (benzodiazepines, antidepressants, antipsychotics)
• Blood pressure-lowering drugs
• Anticonvulsants
• Intrinsic psychological and social factors (fear, depression, anxiety, low self-confidence, reduced self-
efficacy, and social isolation)

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Care Homes Case study Rónán Donohoe, 20 Dec ‘10

3. Dizziness

Dizziness is very common

• Older people have more dizzy problems
• 30% lifetime prevalence of dizziness requiring medical
• Dizziness is the chief complaint in 2.5% of all primary care

Dizziness divided into:

• Otologic Dizziness (Dizziness from Ear)
• Non-otologic Dizziness (Dizziness from other sources)

Diagnostic Categories
Category Examples
Otological BPPV (about 50% otologic, 20% all)
Meniere’s disease (about 20% otologic)
Vestibular neuritis & related conditions (15%)
Bilateral vestibular loss (about 1%)
Neurological Stroke & TIA,
Head Trauma
CSF pressure abmormalities
Medical Cardiovascular (Orthostatic hypotension, Arrhythmia)
Infection The labyrinth is composed of the semicircular canals,
the otolithic organs (i.e., utricle and saccule), and the
Medication cochlea. Inside their walls (bony labyrinth) are thin,
Hypoglycemia pliable tubes and sacs (membranous labyrinth) filled
Psychological Anxiety with endolymph
Undiagnosed Post--traumatic vertigo

Inner Ear anatomy refresher

The utricle & saccule are the two otolith organs of the inner ear. These use small stones and a viscous fluid to
stimulate hair cells to detect motion and orientation.
• is larger than the saccule and is of an oblong form, compressed transversely, and occupies the upper and
back part of the vestibule
• contains called hair cells that distinguish between degrees of tilting of the head

• a bed of sensory cells situated in the inner ear.
• translates head movements into neural impulses which the brain can interpret
• sensitive to linear translations of the head, specifically movements up and down (think about moving on a

Any orientation of the head causes a combination of stimulation to the utricles and saccules of the two ears.
The brain interprets head orientation by comparing these inputs to each other and to other input from the eyes
and stretch receptors in the neck, thereby detecting whether only the head is tilted of the entire body is tipping.
The inertia of the otolithic membranes is especially important in detecting linear acceleration

3. Meniere’s disease
• "Meniere" refers to French physician Prosper Meniere, who first
described the symptoms in 1861.
• The cause of this disease is unknown but is thought to be associated
with changes in fluid volume within parts of the labyrinth. Endolymph

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Care Homes Case study Rónán Donohoe, 20 Dec ‘10
buildup interferes with the normal balance and hearing signals between the inner ear and the brain
causing vertigo & other symptoms
• Meniere's affects roughly 0.2% of the population
• Usually affects only one ear.
Meniere's disease is associated with episodic, fluctuating:
• episodes of vertigo
• irregular hearing loss
• tinnitus (a ringing or buzzing in the ear
• a feeling of fullness in the ear.

• Preceded by fullness in one ear
• Hearing fluctuation or changes in tinnitus may also precede an attack.
• generally involves severe vertigo, imbalance, nausea and vomiting.
• The average attack lasts two to four hours.
• Following a severe attack, most people find that they are exhausted and must sleep for several hours.
• There is a large amount of variability in the duration of symptoms.
• High sensitivity to visual stimuli (visual dependence) is common.
• Nystagmus present during the attack

“Otolithic crisis of Tumarkin”

• Typically occur without warning.
• They are attributed to sudden mechanical deformation of the otolith organs (utricle and saccule), causing
a sudden activation of vestibular reflexes.
• Patients suddenly feel that they are tilted or falling (although they may be straight), and bring about much
of the rapid repositioning themselves.
• This is a very disabling symptom as it occurs without warning and can result in severe injury.

Compensatory mechanisms
• Patients may develop visual dependence – an abnormal sensitivity to complex visual surrounds. May cause
difficulty in driving / shopping. Results from an unsophisticated compensation strategy in which the individual
down-weights vestibular information in favor of visual input.
• Incliniation to stiffen the neck in order to reduce the speed of head-motion. This both reduces vestibular
stimulation as well as makes head orientation more predictable. While this strategy can be effective, can
result in neck pain and discomfort.

3. Treatment & Physiothearpy

• Meniere's disease does not have a cure, but some of the treatments may help sufferers cope with the
• Episodes may occur in clusters; that is, several attacks may occur within a short period of time. However,
years may pass between episodes. Between the acute attacks, most people are free of symptoms or note
mild imbalance and tinnitus.

The main risks to persons with Meniere’s disease is of injury associated with sudden, unpredictable bouts of
dizziness, for which no amount of balance training is likely to prevent. Although Physiotherapy cant address
the underlying disease process there are a number of ways physiotherapy can help

Physical therapy goals for patients with Meniere’s disease.

• Improve baseline balance
• Educate patients how to avoid injury due to imbalance or vertigo
• Rehabilitate patients after destructive treatments that result in static unilateral or bilateral vestibular loss.
• Treat the “spin-offs” of Meniere’s disease
o Visual dependence
o Neck stiffness
o Depression and anxiety

Medications such as meclizine, diazepam, glycopyrrolate, and lorazepam can help relieve dizziness and
shorten the attack.
Salt restriction and diuretics. Limiting dietary salt and taking diuretics may help lower fluid volume and
pressure in the inner ear.

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Care Homes Case study Rónán Donohoe, 20 Dec ‘10
Other dietary and behavioral changes. Some people claim that caffeine, chocolate, and alcohol make their
symptoms worse. Not smoking also may help lessen the symptoms.
Cognitive therapy. To help cope with unexpected nature of attacks & reduces anxiety about future attacks.
Injections. Injecting the antibiotic gentamicin into the middle ear helps control vertigo but significantly raises
the risk of hearing loss. Alternatively a corticosteroida may be used.
Pressure pulse treatment. The U.S. Food and Drug Administration (FDA) recently approved a device for
Ménière’s disease that fits into the outer ear and delivers intermittent air pressure pulses to the middle ear. The
air pressure pulses appear to act on endolymph fluid to prevent dizziness.
Surgery. If all else fails decompression of the endolymphatic sac or severing the vestibular nerve, although
this occurs less frequently.
Alternative medicine. Little evidence to show the effectiveness of acupuncture or acupressure or tai chi.

What is the outlook for someone with Ménière’s disease?

Estimates that six out of 10 people either get better on their own or can control their vertigo with diet, drugs, or
devices. However, a small group of people with Ménière’s disease will get relief only by undergoing surgery.

References / Links
1. Rao SS; Prevention of falls in older patients. Am Fam Physician. 2005 Jul 1;72(1):81-8. [abstract]
2. Malmivaara A, Heliovaara M, Knekt P, Reunanen A, and Aromas A. (1993) Risk Factors for Injurious Falls
Leading to Hospitalization or Death in a Cohort of 19,500 Adults. American Journal of Epidemiology

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