Falls in the Elderly

Miryoung Lee, MPH

Dept. of Epidemiology
University of Pittsburgh
 Learning Objectives

 Identify the scope of the problem e.g.

impact of falls in the elderly
 Describe the contributing factors for falls
 Address fall prevention, and intervention
programs
 Performance Objectives

 Understand the seriousness of problems

and contributing factors of falls, and
fractures
 Develop effective strategies to prevent falls
 Introduction
Falls
• Unintentional injuries
• External causes of the injury
• Multifactorial causes
e.g. falls due to intrinsic factors vs. extrinsic
factors
How serious is the problem of
falls?
 Incidence rates of Falls in U.S.
Per person annually

Community 0.2 - 0.8

Hospital 0.6 - 2.9
Long term- 0.2 - 3.6
Care (per bed)
One of every three adults
over 65 years fall in every year
Where are people likely to fall?

For people 65 years old or older…..

Nursing Home 10%

Home 60%
Public Places 30%
Consequences of Falls
 Mortality
 Morbidity
 Fractures
 Soft tissue injuries
 Head trauma
 Joint distortions and dislocations
 Loss of confidence - fear of falling
 Restricted activity
 In 1994, estimated fall-related injury cost
was $20.2 billion.
 Unintentional Fall Death Rates by
Gender, Age 65 +, U.S. 1996
140
120
100 Men
Per 100,000

80 Women

60
40
20
0
65-74 75-84 85+
Source: National Center for Health Statistics, Vital Statistics
 Unintentional Fall Age-Adjusted Death
Rates, Age 65 +, gender and race U.S.
35
White, Men
30

25
Black, Men
20

15
White, Women
10

5
Black, Women
0
1981
1982
1983

1985

1987
1988

1990

1992

1995

1997
1984

1986

1989

1991

1993
1994

1996

1998
Source: National Center for Health Statistics, Vital Statistics
Fractures
• 3% of all falls cause fractures.
• Approx. 95% of hip fractures in older
people aged over 65 years are the result of a
fall
• People who have a hip facture are 5 ~20%
more likely to die in the first year following
the injury than any other reason in the same
age groups
Common Types of Fractures
 Forearm (Wrist) Fracture
 Spine Fracture
 Hip Fracture (pelvis, hip, femur)
 Ankle Fracture
 Upper arm, forearms, hand
 Rate of hospitalization for hip
fractures, aged  65 years, 1996
Men ( n=68,783) Women(n=270,909)
Rates Rates
Age (years)
65-74 168.0 501.1
75-84 682.1 1,620.3
 85 2,256.2 3,958.3

Per 100,000 population

Source: National Center for Health Statistics, CDC
Fear of Falling

• Loss of self confidence

• Decrease of physical activity level and
quality of life
• Fear of not being able to get up after a fall
 Risk Factors

Intrinsic (Personal) factors for Falls

• Aged (over 65 years)
• Female
• Low mobility or fragility – lower extremity
weakness, and poor grip strength
• Functional impairments - limited Activities of
Daily living (ADL)
• Poor gait and balance
• Low body weight
• Cognitive impairment or dementia
• Chronic illness
- Parkinson disease, visual difficulties, stroke,
hypertension, or urinary incontinence
• Psychoactive medication
- tranquilizers or antidepressants
• Previous falls
• Heavy drinking
 Relative risk ratio (RR) or Odd Ratio (OR) of Fall
5,0 4,4
4,5
4,0
Mean RR or OR

3,5 2,9 2,9 3,0

3,0 2,5 2,6
2,5
2,3 2,2 2,4
2,0 1,7 1,8
1,5
1,0
0,5
0,0

J Am Geriatr Soc. 2001

Extrinsic or Environmental Factors
• Polypharmacy – four or more prescription
medications combination
• Home hazards
– Clutter, or loose rugs
– Poor lighting on stairs and hallways
– Lack of bathroom safety, e.g. grab bars in bathtub
• Footwear
• Busy street or elevated walkways
 Mechanisms of Fall
Contributing
Intrinsic : factors Extrinsic :
Aging, poor balance Home hazards

Occurrence of falls

No injuries
Fall Outcomes

Soft tissues Loss of Disability,

Fractures
injures, Confidence reduced
trauma quality of life
 Dimension of Fractures

Force

Bone Fragility Fall itself

Source: National Osteoporosis Foundation

Fall itself
 Loss of footing or loss of traction
 Changes of reflex with age
 Changes of muscle mass and body fat
 Loss of muscle strength
 Changes in vision and hearing
 Chronic conditions with medications
Force and Direction of a Fall

 Fall  400~ 500J of potential energy

 Being tall is related to increased risk of
hip fractures
 How you land and on what surface
increases risk of fracture
 Fall directions and Hip Fracture
Circumstances Odds Ratio 95% CI
Hit hip/thigh when fall 48.6 22.5-105
Hit hand when fall 0.42 0.23-0.76
Hit knee when fall 0.26 0.14-0.49
Fell sideways vs other 3.17 1.78-5.66
directions
Fell forward vs other 0.22 0.12-0.38
directions
Fell backward vs other 1.03 0.53-1.99
directions

Age adjusted OR; Schwartz et al. 1998

 Fragile Bone
 Osteoporosis, or brittle bones
 Fall induced fractures
Normal
Normal Bone
Bone Osteoporotic
Osteoporotic Bone
Bone

Dempster et al., JBMR 1986

 Prevention/Intervention

Assessment of Risk
• “Get-up and Go” Test (Mathias et al., 1986)
Check for balance, gait, and mobility
• Review
Chronic medical conditions
Medications
Visions and hearing ability
Foot disabilities
• Evaluate environmental hazards
Home hazards

J Am Geriatr Soc. 2001

Personal Prevention
 Home Safety – Reducing hazards
Check for Safety List (CDC)
 Balance Exercise Lessen Fall impact – hip
protectors
 Healthy Life Style
Assistant Devices
• Hip pads
• Mobility aids
– Cane
– Walkers
– Wheelchairs
• Bathroom aids
- Raised toilet seats
- Grab bars
Intervention Programs
• Exercise or physical therapy to
increase/gain muscle strength, balance, and
gait
• Assessment of home fall hazards
• Evaluation of medical condition,
medications, and nutrition
• Support groups
 Community Intervention
Example
• The Frailty and Injuries:Cooperative Studies of
Intervention Techniques (FICSIT) meta-analysis
 Incorporated exercises study – seven studies
 Intensive strength, endurance training, or balance
training
 Overall significant reduction of fall
e.g. “Tai Chi C’uan” reduced the rate of falls during the 4
months follow up in women at moderate risk of falls.

Province et al., 1995 JAMA

Nursing Home Intervention
• Physical rehabilitation program
• Staff education
• Environmental assessments and
modification
• Reduce medications, or physical restraints
Conclusions
• Falls, and related injuries, e.g. fractures are
significant health hazards to the aging
society.
• Identifying fall risk factors help to evaluate
the problems, and to plan personal, and
community intervention strategy.
• Intervention studies has mostly focused on
white men and women, and on hip fractures
outcomes.
Resources
• CDC’s National Center for Injury Prevention
and Control
• National Resource Center on Aging and Injury
• WHO –Ageing and Life Course
• National Fire Protection Association
• National Women’s Health Information Center
• Elder Web
• Additional Reading List