Falls in Older Adults are Serious PDF

Indian Journal of Orthopaedics (2020) 54:69–74 https://doi.org/10.1007/s43465-019-00037-x REVIEW ARTICLE Falls in Older Adults are Serious Raju Vaishya1 · Abhishek Vaish1 Received: 16 December 2019 / Accepted: 18 December 2019 / Published online: 24 January 2020 © Indian Orthopaedics Associat...

Indian Journal of Orthopaedics (2020) 54:69–74 https://doi.org/10.1007/s43465-019-00037-x REVIEW ARTICLE Falls in Older Adults are Serious Raju Vaishya1 · Abhishek Vaish1 Received: 16 December 2019 / Accepted: 18 December 2019 / Published online: 24 January 2020 © Indian Orthopaedics Association 2020 Abstract Background Falls in older adults are a reasonably common occurrence and about 10% of these experience multiple falls annually. These falls may be serious and may cause significant morbidity and mortality. These can also threaten the inde- pendence of older people and may be responsible for an individual’s loss of independence and socioeconomic consequences. These falls may add extra burden to the health care and to direct and indirect costs. Methodology An extensive search of literature was done on the important data bases of PubMed, SCOPUS, and Google Scholar on this topic and all the useful information was derived from the relevant articles for this review. Results We found that the falls in older individuals are often multi factorial and hence a multidisciplinary approach is required to prevent and manage these falls. The risk factors leading to the falls could be divided into extrinsic, intrinsic and situational factors. The commonest and serious injuries are to the head and fractures, due to fragility of bones. Discussion The falls in elderly are on rise and taking the shape of an epidemic. Prevention of these falls is far better than the management. Safe living environment of the elderly people helps in prevention of these falls. The management of the falls should focus on the causative factors, apart from treating the injuries caused by the falls. Keywords Fall · Older adults · Geriatrics · Fractures · Prevention · Risk factors Background independence. It may, therefore, lead to a cascade of socio- economic and personal consequences. Moreover, there is a Falls in older adults are a common occurrence and may lead significant impact of falls in older adults to health care and to serious injuries (like head injury and fractures). Recur- to direct and indirect costs. The direct costs are the payments rent falls are also frequent and are responsible for significant related to the treatment of falls, and the indirect costs could morbidity and mortality in older adults. It points toward an be related to the financial loss from the absence from work overall poor physical and cognitive status of the individual. (of the individual and the family caregiver), injuries related In addition to physical injury, recurrent falls may result disability and dependence. Injuries related to the falls in in fear and psychological trauma (“post-fall syndrome”), people of 65 years or more cost $31 billion (in 2015) and is where an elderly refuse to move for fear of recurrent falls estimated to cost 74 billion (by 2030), in the USA. and injury. It is estimated that about one-third of these individuals experience one or more falls each year, while 10% experience multiple falls annually [1, 2]. The risk is Risk Factors more significant in Octogenarians and Nonagenarians, in which the annual incidence of falls can reach 50% [3–6]. In older adults, there occur the age-related changes in These falls can have a severe impact on the elderly as these the nervous system, e.g., impairment of vision and hear- may lead to significant morbidity and may jeopardize their ing, reduction of proprioceptive and vibratory sensation, increased sway, altered gait, and poor positional control. These changes alone may not be responsible for a fall but * Raju Vaishya significantly contribute to it. Problems like a physical ail- [email protected] ment, cognitive decline, medications, and environmental 1 Department of Orthopaedics and Joint Replacement hazards may be responsible factors for it. Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India 13 Vol.:(0123456789) 70 Indian Journal of Orthopaedics (2020) 54:69–74 The fall is a symptom and not a disease and is often type of ambulatory aid, as well as the patient’s gait type and multifactorial and interrelated. Hence, a multidisciplinary mental status [7, 8]. approach is required to prevent and to treat any injuries sus- tained due to these falls. The falls often occur due to a simple fall (e.g., falling from a standing, or an exposed Injuries Related to the Falls position such as on the ladders). A history of previous fall is perhaps the best predictor of the falling in elderly, how- The older adults most commonly suffer injuries due to fall- ever, these people rarely have a single cause or risk factor ing. The majority of older adults fall due to slipping, (Table 1) and are often multifactorial due to interaction of tripping, and stumbling. However, fall risks differ based on several factors, as follow: their living situation. People living in the community may fall from the stairs, getting entangled in loose rugs or electric Extrinsic factors (environmental hazards). cords and due to poor lighting. Nursing home residents Intrinsic factors (age-related decline in function, disor- are also at risk of falls secondary to wet floors, restraints, ders, and adverse drug effects). bed rails, or ties such as tubing and catheters. Even elderly Situational factors (related to the activity done, e.g., rush- patients in an inpatient hospital setting are at risk of falling. ing to the bathroom). About 30%–50% of these falls result in minor injuries, but about 10% sustain major injuries. About 1% of all falls The risk of falls is increased by the environmental factors in the elderly result in hip fractures, which pose a significant (Table 1) independently or by interacting with the intrin- risk for post-fall morbidity and mortality [10, 11]. Around sic factors. The incidence of falls increases substantially 20% of the falls in the elderly cause a serious injury like a when a greater postural control and mobility is required fracture or a head injury. In the United States of America, (e.g., walking on an uneven or a slippery surface) and if it every year around 800,000 patients need hospitalization is unfamiliar to an elderly (e.g., relocating to a new home). for the management of fall-related injuries and 300,000 Age-related changes can also impair the nervous system, require treatment of hip fractures. It is estimated that which is involved in maintaining balance and stability and the falls were the leading cause of traumatic brain injury- therefore increase the risk of falls. Age-related decline in related deaths in persons aged 65 or older. However, vision, changes in muscle power and velocity may impair less than half of older patients who fall tell their doctors the ability to maintain or recover balance in response to about these falls. Repeated falls not only increases the any perturbation (e.g., stepping onto an uneven or slippery risk of injury and hospitalization but may be catastrophic to surface). Any muscle weakness is a significant predictor of an older individual. It is because these people are frail and falls. Some chronic and acute disorders and the use of drugs mostly have osteoporosis. It is estimated that over 50% of (Table 1) are responsible risk factors for falls. Certain situ- these falls result in an injury. The major injuries are fractures ational activities may also increase the risk of falls and fall- and head injuries. The fractures sustained due to these falls related injuries. The Morse Fall Scale (MFS) is often used to may be serious, especially of the hip and spine and may identify and score fall risk factors. It takes into consideration require surgical intervention. The head injury may present whether or not the patient has a history of falls, any second- acutely or delayed, as headache and altered sensorium with ary diagnoses, any intravenous (IV) access, and any use and or without seizures and minimal focal neurological deficits. Table 1  Risk factors for falls in older adults Extrinsic factors Intrinsic factors Situational factors Poor lighting and glare from the lamps A disease which alters the gait and mobility Walking while talking (e.g., Parkinson’s disease, Knee and Hip arthritis, Feet problems, Neuromuscular and Vestibular diseases) Poor or no personal aid equipment Several medicines (e.g., sedatives and cardiac Being distracted by multitasking drugs) Unfavorable flooring (e.g., loose carpets, Visual impairment (e.g., Cataract, Glaucoma, Failing to notice an environmental hazard uneven and slippery floors, low lying objects) Macular degeneration and Retinopathy) (e.g., a curb or step) Obstacles (e.g., electric cords, steps, hedge, low Hypotension (e.g., cardiac or postural causes) Rushing to the bathroom (especially at night) lying furniture, etc.) Slippery shoe wares Increasing age? Rushing to answer the telephone 13 Indian Journal of Orthopaedics (2020) 54:69–74 71 Chronic subdural haemorrhage may also present with pro- a hip fracture related to a fall may not recover the same level gressive dementia. of mobility. There may be a fear of repeat fall, in an elderly, The severity of an injury and its outcome is determined especially if they have experienced a fall before. This may by an individual’s frailty and not the age. Frailty means lead to reduced mobility due to lack of confidence in them, an older adults’ decreased physiologic reserve (e.g., ability to the extent that many may avoid activities of daily living to walk up a flight of stairs or carry a bag of groceries, etc.). like shopping and cleaning. Ultimately, a decreased activ- A frail elder has a higher likelihood of falling and a greater ity may lead to muscle weakness and stiffness of the joints, risk of injury from a fall. The patient’s frailty index is which further contribute to their reduced mobility. There- the most accurate predictor of adverse events after a fall, fore, the emphasis should be on maintaining the mobility of even more, accurate than the patient’s age or injury severity the elderly and preventing the falls and their related injuries. score (ISS). One significant difference in the geriatric population is skeletal fragility, , which occurs as their bones become Preventive Measures more susceptible to the mechanical forces of trauma. Con- sequently, elderly patients will sustain more severe injuries The prevention of fall is not only important clinically, but is with lower force mechanisms than their younger counter- an essential public health issue as well since the frequency parts, who have greater bone density. Even when a fall does of falls and their complications are increasing significantly. not result in death, fall injuries can cause significant mor- Several strategies could be used to prevent these falls like bidity and impede an older person’s functional status and fall-related education, environmental assessment, and modi- overall health. fication, interventions to improve strength, balance, endur- Fractures are a major complication of falls in this popu- ance, and modification of medication regimens. In older lation, with 10% of falls causing a fracture, and 2% of the adults, prevention of a fall (Table 2) is to be preferred than fractures involving the hip. An estimated 75% of all verte- the treatment of the injuries, sustained by these falls. The bral and nonvertebral fractures occur in those aged 65 years risk of fall can be reduced by appropriate correction of the or older, and more than 75% of hip fractures affect seniors environmental hazards at home and by using an assistive aged 75 years or older. Fractures are an independent device (e.g., cane or walker). Those with restricted mobil- predictor of long-term mortality. After a hip fracture, an ity may benefit from the combined use of environmental, elderly person has a 27% chance of dying within one year rehabilitative, and medical measures. The incidence of hip ; following a proximal femur fracture, 50% of affected fractures can be reduced with the use of ‘hip protectors’, seniors will experience a functional decline within 1 year especially in high-risk individuals. An appropriate flooring. Other post-fall fracture sites in older people include the is crucial in preventing the falls, as a compliant flooring proximal humerus, pelvis, vertebrae, distal radius, and ver- (e.g., firm rubber) can help dissipate the impact force, but a tebral bodies. Also, fractures surrounding or involving floor that is too compliant (e.g., soft foam) may cause imbal- a prosthesis (periprosthetic fractures) have become increas- ance for an elderly and the risk of fall. ingly common among older patients [20, 21]. After age Drugs, known to increase the risk of falls should be 50 years, the lifetime risk for hip fractures ranges from 6 to stopped, or their dosage adjusted. The optimization of vision 17%. In the elderly, more than 95% of hip fractures are and hearing, control of dizziness, and the low heels or rub- caused by falls. ber soles in the shoes are crucial factors in the prevention The quality of life may deteriorate significantly after a of falls. If osteoporosis is noted on evaluation, then it fall, as the majority of older people who were mobile before should be treated adequately, to prevent the fractures from Table 2  Preventive measures for the falls in older adults Preventive interventions Action required Safety devices Grab handles, high friction floors, and Footwear, low power lighting at night Regular exercise Lower limb muscle strengthening exercises, Other exercises to improve gait, balance, coordination and functional tasks Review Monitoring of medications and ongoing medical problems Supplementation Vitamin D supplementation in presence of its deficiency Tackling environmental issues Review of current living conditions Minimizing the impact of fall Hip protectors Decreasing the risk of fracture Treatment of Osteoporosis 13 72 Indian Journal of Orthopaedics (2020) 54:69–74 a fall. Moreover, any other disease or factor which may lead The American Academy of Orthopedic Surgeons (AAOS) to falling must be identified and corrected in time. The risk provides a strong recommendation for regional anaesthesia of falls may further be reduced with adequate pain control, in their 2015 guidelines for the management of hip fractures physiotherapy, and sometimes with joint replacement sur- in elderly patients. gery in patients with severe knee or hip arthritis. The older It has been reported that compared to intravenous and adults should also be counselled on the ways to reduce the oral pain medications in elderly patients with hip fractures, risks arising from the situational factors and are taught about femoral nerve blocks resulted in significant reductions in what to do if they fall and cannot get up. pain scores and opioid requirements. Lateral cutaneous femoral nerve blocks have also been shown to provide rea- sonable pain control without systemic side effects. Local Management (Table 3) anaesthesia offers the benefit of superior pain control with a much smaller side effect profile than that of IV or oral pain The management of a fall in an elderly requires a multidis- medications. Despite the use of local anaesthetics, many ciplinary approach, as these patients are a different subset individuals may require post-fall systemic pain control. Non of individuals compared to the younger population. Their Steroidal Anti Inflammatory Drugs (NSAIDs) are the most medical problems need to be managed by a Geriatric phy- commonly used drugs because they work quickly and reduce sician and if surgical management is needed then the ser- acute inflammation; however, these drugs can also cause vices of an Anesthetist and a surgeon (Orthopaedic/Neu- renal and gastrointestinal toxicity in older people. Hence, rosurgeon) is often required. A detailed history should be renal function must be checked before giving NSAIDs to followed by a targeted physical examination, functional older adults. NSAIDs may be used in conjunction with mis- assessment, and appropriate diagnostic tests (if required). oprostol to decrease the risk of gastrointestinal bleeding. Assessment of a fall includes a detailed history pertaining It is to be kept in mind that many antihypertensive medi- to the circumstances leading to a fall and medical history. cations function via renal prostaglandins, which NSAIDs Few self-efficacy tests are known to assess the fear of falling. inhibit. The physical examination should assess the nature of injury Acetaminophen is also a common analgesic choice in along with the patients’ vision, gait, balance and condition older patients. However, in the natural course of ageing, of the weight-bearing joints like hips and knees. A detailed hepatic blood flow, and the number of functional hepato- neurological examination should follow to assess the sensory cytes decrease. As a result, the elderly are at risk for aceta- and motor function of the limb along with the brain func- minophen toxicity owing to a greater than 50% reduction in tioning. A detailed cardiac assessment is also necessary for the metabolism of this drug. There is often a hesitation in older patients. prescribing opiate medications in older adults because of A good physical therapy and exercise program is their side effects (e.g., constipation, nausea, sedation, delir- extremely beneficial to the individuals who have a history ium). However, these agents are relatively safe, and the side of previous falls and those who have problems of balancing effects can often be managed. Although fears of delirium due and coordination. In order to optimize the outcomes of hip to opiate use are well-founded, inadequate pain control has a fractures in the elderly, the priority should be pain control; higher likelihood of causing delirium than narcotic medica- however, analgesia in this population can be challenging. tions. Other causes of delirium include hospitalization, Table 3  Management of an elderly due to a fall History Identify the cause of fall and elicit any history of recurrent falls Note the existing medical co-morbidities A detailed drug history Find out the living environment, to identify the risk factors Physical examination Assessment of the injuries General examination Functional assessment Investigations Appropriate laboratory tests Relevant radiological examination (X-ray, CT, MRI, Ultrasound etc.) Medical management Physical therapy Pain Control (Oral medications, Regional blocks, etc.) Regulate the ongoing medical treatment, if necessary Splint the fracture Surgical management Suturing of the wounds Fractures (e.g. hip) often require internal fixation or replacement Brain injury with significant haematoma requires surgical evacuation 13 Indian Journal of Orthopaedics (2020) 54:69–74 73 dehydration, and visual/auditory impairment. It is essential Ethical Approval This article does not contain any studies with human to avoid prescribing standing doses of preoperative/postop- or animal subjects performed by any of the authors. erative narcotics in elderly patients because of the risks of Informed Consent For this type of study an informed consent is not dehydration, acute kidney injury, and oliguria. required. Many elderly patients who suffer falls require surgery. The best way to control pain in patients with a hip fracture is to perform early surgery, if indicated, as delayed surgery is associated with poor outcomes. Studies have shown References that geriatric patients with hip fractures are best managed early by a medical team that includes a geriatrician and an 1. Nevitt, M. C., Cummings, S. R., Kidd, S., & Black, D. (1989). Risk factors for recurrent nonsyncopal falls. A prospective study. orthopaedic surgeon. 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