Introduction

Falls are common among the older persons. It is a major cause of injury and trauma in the elderly. Falls could lead to significant morbidity and mortality in elderly, thus affecting the quality of life of the older persons. The consequences of falls and fractures can lead to further functional decline in elderly. However, many falls and injuries can be prevented and consequences minimized. Therefore, screening for risk of fall is very important in the elderly especially among those with higher risks to prevent future falls and its consequences.

Risk-factors for falls

In the elderly, a fall is usually caused by a complex interaction among several risk-factors:

• Intrinsic factors (individual disorders or chronic diseases)

• Extrinsic factors (environmental hazards) and

• Situational factors (related to the  daily life activity being performed)

A fall is rarely due to single factor. It is usually due to accumulated effect of multiple impairments of intrinsic and extrinsic effects. The elderly with multiple risks-factors have higher risk of fall:

• 27% risk with one risk-factor

• 78% risk with four risk-factors

Risk of falls

In elderly, risk of falls is usually caused by a complex interaction among intrinsic factors, extrinsic factors and situational factors. For example, an elderly woman with osteoarthritis of knee (intrinsic factors) may trip over the edge of a rug (extrinsic factor) while walking to the toilet at night (situational factor). The main contributor to the risk of falls is the presence of intrinsic factors.

Intrinsic factors

Intrinsic factors include age-related changes and disorders that affect functions needed to maintain balance in the elderly. These functions include balancing, visual, cognition (higher mental function) and musculoskeletal function, for example:

• Age-related decline in body functions

• Poor vision

• Postural hypotension with dizziness

• Lower limb weakness

• Poor grip strength

• Chronic diseases e.g.

  • Osteoarthritis (with associated pain and limited range of motion and strength)

  • Parkinson’s Disease (with tremor and stiffness)

  • Stroke (with body weakness)

  • Cognitive impairment/ dementia (with associated lack of judgment, distraction and confusion)

  • Uncontrolled diabetes with increased frequency and nocturia (associated with falls because the elderly person has difficulty getting up and walking to the bathroom quickly at night)

  • Anemia (with giddiness)

  • Heart disease (e.g. heart failure especially if symptomatic with reduced effort tolerance)

• Acute illness e.g.

  • Urinary tract infection

  • Pneumonia

  • Dehydration

• Medication (specific classes):

  • Psychoactive drugs (most commonly reported as increasing the risk of falls and hip)

  • Diuretics

  • Anti-hypertensives drugs

  • Diabetic drugs e.g. glibenclamide, insulin

• Recent medication dosage adjustment

• Polypharmacy – the risk of falling increases with the number of prescribed drugs

Extrinsic / Environmental factors

Extrinsic factors are usually implicated in up to 50% of falls in elderly. Elderly living in the community tend to be exposed to greater environmental challenges and tend to be less physically impaired. Thus, extrinsic factors contribute the most to risk of falls and fall-related injury. For example:

• Poor lighting

• Loose carpets

• Lack of bathroom safety equipment

• Obstacles

• Absence of grab rail

• Height of steps and furniture

Situational factors

Situational factors also affect the severity of a fall-related injury. For example:

• An elderly person is more likely to be seriously injured when falling from an upright position, because more energy is dissipated or when falling laterally, because impact on the hip is direct

• When changing positions (eg, transferring, turning)

• When the patient takes risks (eg. walking in stocking feet)

• When patient is relocated to a nursing home

Conclusion

The risks of falls are related to the complex interaction among intrinsic factors, extrinsic factors and situational factors and majority are preventable. Therefore, screening could identify older persons with risk of falling and prevent future falls and its’ consequences especially in these high-risk groups. In view of the fact that falls generally result from multiple risk-factors, therefore, effective intervention must target multiple factors to prevent fall in elderly.

References

1. Ayse O, Hulya D, Nihal G, Mehtap O, Didem K. The relationship between risk factors for falling and the quality of life in older adults. BMC Public Health 2005, 5:90 doi:10.1186/1471-2458-5-90.

2. Connelv BR, Wolf SL. Environmental and behavioural circumstances associated with falls at home among healthy elderly individuals. Atlanta FICSIT group. Arch Phys Med Rehabil.1997;78:179-86.

3. National Institute for Health and clinical Excellence. Falls. The assessment and Prevention of falls in Older People. London: National Institute for Health and Clinical Excellence 2004.