Approach to recurrent falls in the elderly, with emphasis on prevention and management

A fall is defined as an “unexpected event in which the patient comes to rest on the ground, floor, or lower level”. Recurrent falls means two or more falls in twelve months.

About one-third of community-dwelling adults aged 65 and above fall every year. Among nursing home residents, one in two falls each year.

One in five falls causes serious injury such as a fracture or head trauma. In the United States falls cause 3 million emergency visits and 800,000 hospitalisations yearly.

Common injuries are fractures of the hip, femur, humerus, wrist and ribs, soft-tissue injury, and subdural haematoma. Neurological signs appearing days to weeks after a fall should raise suspicion of subdural haematoma.

Even without injury, falls cause disability through fear of falling, loss of self-confidence and restricted walking, and are an important reason for institutionalisation.

Falls are a geriatric syndrome. There is usually an acute trigger acting on multiple chronic impairments that have destroyed the person’s ability to compensate. A fall is rarely due to a single factor.

Causes are divided into intrinsic (ageing neuromuscular physiology, disease) and extrinsic (medications, environment) factors. Risk rises exponentially as factors accumulate.

The mnemonic AGAIN I’VE FALLEN is used to check risk factors systematically: Again fallen, Gait and balance problems, ADL loss, Impaired mental status, Number and type of drugs, Illness, Vestibular disorders, Eyes/Ears, Foot disorders, Alcohol, Lower extremity weakness, Low blood pressure, Environmental hazards, Neurological disorders.

Medication is the commonest and the most modifiable risk factor. High-risk classes are benzodiazepines, non-benzodiazepine hypnotics, antipsychotics, all antidepressants (TCA, SSRI, SNRI, trazodone, bupropion), antihistamines and anticholinergics, opioids and NSAIDs, muscle relaxants, alpha blockers, digoxin, amiodarone, antihypertensives and diuretics, insulin, Parkinson drugs and cholinesterase inhibitors.

Risk is highest in the days to weeks immediately after a drug is started or its dose is changed. New drugs should ideally be started during periods of increased supervision.

In hospital, delirium is the leading cause of falls. In the community, environmental triggers are wet floors, poor lighting, uneven surfaces, rugs, steps and unstable furniture.

The first step in history is to decide whether the event was a fall, a syncope or a seizure, since management differs completely.

The CDC STEADI algorithm (Stopping Elderly Accidents, Deaths & Injuries) is the recommended step-wise approach. Ask every older adult about falls in the past year, or screen with the Stay Independent 12-item questionnaire or the three key questions.

Those who screen positive get a risk assessment using three performance tests: Timed Up and Go Test (TUGT), 30-second chair stand and four-stage balance test.

There is no routine need for laboratory or imaging tests in a fall assessment. MRI brain only if a treatable neurological cause is suspected (infarcts, demyelination, posterior fossa malformation, cerebellar degeneration, hydrocephalus). EEG is rarely helpful and only if seizure is strongly suspected.

The minimum investigations in a patient who falls are lying and standing blood pressure and a 12-lead ECG. A medical cause must be actively sought: postural hypotension, vasovagal syncope, carotid sinus hypersensitivity.

Principles of management: (i) assess and treat physical injury, (ii) treat the underlying conditions, (iii) prevent future falls by physiotherapy and education — gait and balance retraining, muscle strengthening, ambulation aids, properly fitted shoes, adaptive behaviours, and (iv) alter the environment — safe furniture of correct height, removal of loose rugs and obstacles, proper lighting, rails on stairs and in the bathroom.

Exercise is the single most effective intervention. In the Cochrane review by Sherrington, balance and functional exercise reduced the rate of falls by 24% (RR 0.76), multiple exercise types (balance plus resistance) by 34% (RR 0.66), and tai chi by 19% (RR 0.81). Walking alone or resistance training alone without balance work has uncertain benefit.

Vision: routine screening alone did not help, but assessment and treatment of vision impairment combined with exercise reduces falls. Cataract surgery reduces falls in older women (second-eye surgery does not give the same benefit). Replacing multifocal with single-vision lenses for outdoor use helps.

Home hazard assessment and modification reduces falls, especially with severe visual impairment, and is more effective when done by an occupational therapist — grab bars, better lighting on stairs, removal of rugs, socket covers, cupboard locks.

Reducing high-risk medication, particularly withdrawal of psychotropics, is validated as effective. Vitamin D does not help all older adults but benefits those with low baseline levels and nursing home residents.

What does not work: physical restraints (they worsen delirium, pressure ulcers and aspiration), chemical restraints, bed rails and bed alarms. Hip protectors give a small reduction in hip fracture in care homes (RR 0.82) but no clear benefit in the community; adherence is the main barrier.

Cardiac pacing is an effective single-factor intervention in patients with carotid sinus hypersensitivity.