Falls 

Timothy C. Hain, MD

Last update: 7/02

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Falls are common, especially in the elderly. About 30% of persons over the age of 65 fall once or more per year. Women fall more often than men. Two thirds occur around the home. About 5% of falls cause fractures of the wrist, collar bone, rib, hip and pelvis. About 1% are associated with hip fracture. About 10% of falls are associated with bruises and other soft tissue injuries. Falls are mentioned as a contributing factor in 40-60% of admissions to nursing homes. Injury from a fall increaases with age, and is more frequent in men.

Predictors of falling: The strongest predictor for falls is previous falls. Other important factors are age, cognitive impairment, poor vision, chronic medical condition that affects lower extremity power, poor gait and balance. Medications that contribute to falling are mainly long-acting sedatives, but antidepressants, cardiovascular drugs also add risk. Situations where one is both attempting to balance and do something else seem to be particularly dangerous (Teasdale and Simoneau, 2001). In a recent study of risk factors by Richardson (2002), age and prescription medicatons were found to be strong predictors of falls. Both prescription analgesics and minor tranquilizers were found to increase fall probability substantially. Previous studies have also suggested that minor tranquilizers increase fall risk (Tinetti et al, 1988). These agents may increase comfort but reduce vigalance.

Falls can be broken down into those that are preventable and those that cannot be prevented.

Some falls can't be prevented. For example, persons with irregular heart rates will fall when their heart stops working. Persons with certain neurological problems, for example TIA or transient ischemic attack, cannot be prevented from falling. Persons with "otolithic crises" due to an inner ear disease named "Meniere's snydrome", will fall if they have an attack at the wrong time. Persons with falls that can't be prevented should consider safety modifications to their home, and modify their behavior as much as possible to avoid potentially injurious falls. We will not discuss this category further.

Some falls can be prevented. Preventable falls are due to a combination of loss of one's balance, followed by an ineffective protective reaction to regain balance. To avoid losing balance one needs good senses such as vision, inner ear and position sense, and a good set of postural reflexes. Once one's balance is lost, one must have enough strength, flexibility and traction to do something about an impending fall (such as taking a step or reaching out to break a fall).

Some people are more liable to get hurt than others. Frail persons, such as those with osteoporosis (thin bones), are more likely to be injured. Interestingly, being overweight is protective against injury from a fall. People who are unable to get up after a fall are more likely to be injured.

It is desirable to prevent potentially injurious falls. Methods of avoiding falls fall into 6 categories: 1). Avoiding dangerous situations 2). Improving senses such as vision 3). Improving reflexes 4) Improving strength and flexibility. 5) Assistive devices. 6) Safety modifications to the home. Usually a combination of these methods is advised for individual persons.

1). Avoid Dangerous Situations

Not a bad idea under any circumstances, but especially relevant to persons with unsteadiness. Dangerous situations occur when senses are overloaded such as in a crowd, too much is happening too fast or when traction is poor such as in slippery weather.

2). Improve Your Senses

Often balance is impaired by loss of vision, position sense, or sensation of movement.

Vision: Acuity at all distances and ability to focus on near objects declines with age. By the age of 40, most of us need reading glasses for near viewing. Depth perception declines with age because of inability to focus on objects throughout one's visual space.

In regards to visual acuity, 80 year olds receive on average only 25% of the light that reaches the retina of a 30 year old. There is also a progressive yellowing of the lens of the eye, which decreases vision even further for blue light. Glaucoma, cataract and macular degeneration are common in the elderly. As vision goes, depth perception is reduced.

Aged or not, research shows surprisingly that persons with good vision in one eye and moderate impairment in the other are at the highest risk, considering all types of visual impairment. Apparently this is because people with good vision in one eye can get around quite well, but have impaired depth perception.

 

What can be done about visual impairments ?

Glasses:

Lighting

Position sense: Position sense declines with age. By the age of 80, most persons are unable to detect a vibrating tuning fork on the ankles. Your position sense should be checked by your doctor. If diminished, there may be a correctable medical disorder which impairs position sense. Several common medications (such as Dilantin), impair position sense and balance. You might need to have blood tests, an MRI scan, or a muscle test called an "EMG" to have these evaluated.

Conditions that impair position sense include:

What can you do ?

Balance sense (Vestibular sensation): Balance sensation from the inner ear also declines with age, and is affected by disease and medication. Avoiding medications that decrease balance sensation may be an important thing to do. For example, use of tranquilizer based sleeping pills is associated with a 28 fold increased risk of falling.

What can you do about loss of vestibular sensation ?

3). Improve Your Reflexes

There are many disorders of the central nervous system which can impair balance. For example about 1% of persons over the age of 50 have Parkinson's disease. Strokes, seizures, Alzheimer's disease and cerebellar degenerations are all accompanied by greatly increased frequency of falls. Confusion increases the risk of falls by a factor of 5. See a neurologist if your internist or family doctor thinks any of these diseases are likely. There are also several things that you yourself can do to improve the functioning of your nervous system.

Avoid medication which may lead to falls:

 

4). Improve Strength and Flexibility

To Improve Strength and Flexibility:

To reduce Fragility:

5) Assistive Devices

Shoes:

* The best shoe is a well constructed sturdy leather tie shoe, with a rubber or crepe sole (Note that in certain conditions such as Parkinsonism this general advice does not apply).

* Certain shoes are good for arthritis (e.g. Rockport Vibram soles), because they have good shock absorption characteristics, but are poor for balance. Vibram soles are particularly bad for persons with sensory deficit. Consult your physician or therapist.

Appliances: Simple appliances such as canes or walkers can be bought from your drug store. More complicated "orthoses" are usually prescribed by rehabilitation doctors. Be certain that whatever appliance you use is adjusted to the proper height.

Useful appliances:

6). Safety Modifications

Two thirds of falls occur around the home. These suggestions may prevent a fall. Home visits may be available from physical therapy organizations (such as the Rehabilitation Istitute of Chicago for those persons living here).

General:

* Make safety rounds. Identify areas of poor lighting, poor footing, unsteady furniture, poor or absent rails.

Lighting:

* See lighting recommendations above under section 2.

Floors:

Furniture:

Stairs: Stairs are where most falls happen.

Bathroom:

 

References

Acknowledgements: We thank our patients for reviewing this pamplet.

Copyright (c) Timothy C. Hain, MD. 1991-2002. You are free to copy this pamphlet if you like for non-commercial use. We would also like to incorporate your suggestions regarding methods of avoiding falling, so write to us if you think we have left an important one out !

Revisions: 6/7/91, 6/21/91, 6/26/91 7/31/91, 8/11/91, 8/23/91, 4/23/92, 7/27/92, 11/27/92, 5/18/93, 1/7/00, 7/2002