Key learning points:
– Older people who have fallen in the last year or have problems with gait and balance should be referred for a multifactorial falls assessment
– Unexplained falls often have an underlying treatable medical disorder
– Head and facial injuries indicate a loss of consciousness rather than a fall
It is well recognised that falls are a huge concern. For an individual, falls cause embarrassment, psychological and physical injury, a reduced quality of life, an increased risk of long-term care placement and an increased risk of death.1-4 For society, falls and their consequences are one of the most costly medical conditions, taking £2 billion from the NHS every year.5,6 Unfortunately, the prevalence of falls is increasing due to the expanding older population.7
Why falls occur
Everyone will fall at some point in their life. However, the people we tend to see in the clinical setting are those for whom the consequences of falling are more severe; older people. As we age, we accumulate more risk factors for falling alongside an age-related reduction in compensatory mechanisms. For example, our ability to rapidly vary our focus on near and far objects declines with age, so an older person may not see an uneven paving stone and catch their foot on it. In an older person, reaction times and balance are reduced, making them more likely to fall when a young person may stumble.8 Therefore, falls occur when the accumulation of risk factors outweigh our ability to compensate.9
Screening for falls
This is not as simple as it sounds. There is no single screening tool that can reliably identify people at risk of falling. This is most likely because there are several hundred different risk factors for falls.10 One study in a UK based general practice screened individuals aged over 70 years, then invited those at risk of falls to have an assessment and, if appropriate, a falls prevention intervention.11,12 However, the uptake was so low and the drop out rate was so high, that the screening programme had little benefit.
Support for secondary prevention is much stronger and recently there has been a greater emphasis on case identification. Indeed, The National Institute for Health and Care Excellence (NICE) 2013 guideline: assessment and prevention of falls in older people CG161, recommends that all older people (aged over 65 years) who come into contact with a healthcare professional should be asked, as a matter of routine, whether they have fallen in the last year.13 Those who report falls should be offered a multidisciplinary falls assessment. However, the British and American Geriatric Societies go further, rather than a proactive case finding approach, they recommend annual screening of all older people, with high risk cases being those who have fallen in the last year or who report subjective gait or balance problems.14
However, active case identification is flawed because one third of older people will not remember having fallen within the last three months.15 Moreover, the stigma attached to falling may cause people to deny falls.16
In those identified as higher risk a more detailed falls assessment should be undertaken. There is very good evidence from a Cochrane review that a multifactorial assessment and intervention significantly reduces the number of falls.17 This approach is recommended by NICE, the joint British and American Geriatrics Society guideline and the European Falls Prevention Network.13,14 It should usually be performed in a dedicated falls service with access to a multidisciplinary team.13
The main components of a multifactorial assessment can be found in the NICE guidelines but having access to a multidisciplinary team including physiotherapists, occupational therapists, optometrists and podiatrists is essential.
Falls that cause injuries
Falls that result in either significant injury or recurrent minor
injury must be taken seriously as they signify a possible underlying serious medical disorder. There are a few clues from the history which should trigger a medical assessment, these are displayed in Table 1. In older people it becomes increasingly difficult to distinguish between falls and syncope. For example, if we consider vasovagal syncope older people are more likely to present with unexplained falls than episodes of fainting.18 Therefore, all older people with injurious falls should be referred for a multidisciplinary falls assessment that includes a medical assessment.
Falls with fracture
A fragility fracture occurs either spontaneously or from minor trauma. A fall from standing height or less is considered as a minor trauma. Usually these individuals would enter secondary care services where they may be offered a multidisciplinary falls assessment and/or osteoporosis assessment. NICE guidelines on the secondary prevention of fragility fractures recommend that all post-menopausal women who have a fragility fracture should be assessed for osteoporosis. But for those who are aged over 75 years, treatment should be considered without confirming the presence of osteoporosis.19
For those who have fallen but have not had a fracture, a risk assessment can be undertaken as part of the multifactorial assessment to identify whether any bone protection intervention is needed. Online risk assessment tools are available, Fracture Risk Assessment Tool (FRAX) and QFracture are recommended in NICE guidance.20
Medical causes of falls
Some medical conditions may directly and obviously cause falls, such as peripheral neuropathy, cataracts or postural hypotension. But other conditions that cause syncope often present as unexplained falls in older people. It is a misconception that transient ischaemic attacks (TIA) cause syncope; it is rare for a TIA to affect blood flow to the brain to such an extent that it results in syncope.21
However, a TIA or a stroke may be associated with a fall if it causes leg weakness or dizziness. The most common medical causes of falls are vasovagal syncope, postural hypotension, arrhythmia and carotid sinus syndrome.
Other medical conditions that are most commonly associated with falls include Parkinson’s disease, arthritis and cognitive impairment. Medication is another important factor in causing falls. The biggest risk being associated with antipsychotics, antidepressants, sedatives, antihypertensives or simply taking a combination of four or more medications.22
Anticoagulation and falls
As always, the decision to start or stop anticoagulants should be taken between the patient and prescriber after considering the benefits and risks. One study of older people taking warfarin for atrial fibrilation found that an individual would need to fall 295 times per year for the bleeding risk to outweigh the benefit of treatment.23 These findings are supported by a systematic review which demonstrated that approximately half of people who would benefit from anticoagulation are not being offered it, the most common reason for this being their risk of falls.24 Of course prescribers should use their clinical judgement, but they should also consider using anticoagulation while implementing falls prevention strategies.
Older people who have fallen within the last year or have problems with gait or balance should be offered a multifactorial falls assessment and intervention. For those who sustain significant injury an underlying medical disorder should be identified or excluded. In most cases it is safe to continue anticoagulation but this should be decided on discussion about risks with the patient. Not all falls can be prevented, in which case those at risk should be educated about how to get up after a fall and how to call for help.
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2. Delbaere K, Crombez G, Vanderstraeten G, Willems T, Cambier D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age and Ageing. 2004;33(4):368-373.
3. Andresen EM, Wolinsky FD, Miller JP, Wilson MM, Malmstrom TK, Miller DK. Cross-sectional and longitudinal risk factors for falls, fear of falling, and falls efficacy in a cohort of middle-aged African Americans. Gerontologist. 2006;46(2):249-257.
4. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age and Ageing. 1999;28(2):121-125.
5. Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA. International comparison of cost of falls in older adults living in the community: a systematic review. Osteoporosis International 2010;21(8):1295-1306.
6. Carroll NV, Slattum PW, Cox FM. The cost of falls among the community-dwelling elderly. Journal of Managed Care Pharmacy. 2005;11(4):307-316.
7. Cigolle CT, Ha J, Min LC, et al. The epidemiologic data on falls, 1998-2010: More older americans report falling. JAMA Internal Medicine. 2015;175(3):443-445.
8. Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in older community-dwelling women. Journal of the American Geriatrics Society 1994;42(10):1110-1117.
9. Steinweg KK. The changing approach to falls in the elderly. American Family Physician. 1997;56(7):1815-1823.
10. NHS Centre for Reviews and Dissemination, Nuffield Institute for Health. Preventing falls and subsequent injury in older people. Effective Health Care Bulletin. 1996;2(4):1-6.
11. Conroy S, Kendrick D, Harwood R, et al. A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls. Age and Ageing. 2010;39(6):704-710.
12. Irvine L, Conroy SP, Sach T, et al. Cost-effectiveness of a day hospital falls prevention programme for screened community-dwelling older people at high risk of falls. Age and Ageing 2010;39(6):710-716.
13. CG161 N. Falls: Assessment and Prevention of Falls in Older
People. London: National Institute for Health and Care Excellence, 2013.; 2013.
14. Panel on Prevention of Falls in Older Persons AGSaBGS. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society 2011;59(1):148-157.
15. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited accuracy of recall of falls in the elderly. Journal of the American Geriatric Society 1988;36(7):613-616.
16. Dickinson A, Horton K, Machen I, et al. The role of health professionals in promoting the uptake of fall prevention interventions: a qualitative study of older people's views. Age and Ageing 2011;40(6):724-730.
17. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2012;9:CD007146.
18. Duncan GW, Tan MP, Newton JL, Reeve P, Parry SW. Vasovagal syncope in the older person: differences in presentation between older and younger patients. Age and Ageing. 2010;39(4):465-470.
19. NICE TA160. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women London: National Institute for Health and Care Excellence, 2008; 2008.
20. CG146 N. Osteoporosis: assessing the risk of fragility fracture. London: National Institute for Health and Care Excellence, 2012; 2012.
21. Nadarajan V, Perry RJ, Johnson J, Werring DJ. Transient ischaemic attacks: mimics and chameleons. Practical Neurology. 2014;14(1):23-31.
22. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of Internal Medicine 2009;169(21):1952-1960.
23. Man-Son-Hing M, Nichol G, Lau A, Laupacis A. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Archives of Internal Medicine 1999;159(7):677-685.
24. Garwood CL, Corbett TL. Use of anticoagulation in elderly patients with atrial fibrillation who are at risk for falls. Annals of Pharmacotherapy 2008;42(4):523-5
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