Who is at risk for falling and what can we do about it?

Introduction:

Falls have a large impact on the overall health and quality of life in older adults.  It has been estimated that 30-60% of older, community-dwelling adults experience a fall each year and that approximately half of these individuals experience multiple falls.  This number appears to be the highest in those who are 80 years of age and older, and increases as high as 75% in individuals who live in a nursing home.¹   Multiple variables have been determined to predict the risk for falling and this article is to provide a comprehensive review of these factors as well as what we can do in an attempt to prevent them.

Fall Risk Factors:

A 2010 systematic review by Deandrea et al.² set out to analyze the results of 74 prospective studies conducted to assess fall risk factors in older adults.   Out of these studies, the authors found 31 risk factors to be considered.  They concluded that the variables demonstrating the strongest association for fall risk include: history of falls, gait problems, use of walking aids, vertigo, Parkinson’s disease and antiepileptic drug use.  The researchers suspected that additional risk factors may be present but are underreported, especially if the associated fall did not result in injury.

One of the variables found in this study, “gait problems”, is a factor which we often analyze and treat as Physical Therapists.   But despite this notion, there is currently a lack of uniformity in the diagnosis of gait abnormalities.  So in 2009, Verghese et al³ set out to quantify gait markers of falls in older adults, with the ultimate goal of improving diagnostic, gait assessments by the practicing clinician.   Their study included 597 older adults (>70 yo) and baseline measurements of gait speed, cadence, stride length, swing, double support, stride length variability, and swing time variability were taken.  The participants were followed over a long period and within 20 months, 226 of the 597 (38%) adults experienced a fall.   When analyzing the baseline measurements in those who fell, it was found that slower gait speed at baseline (< 100 cm/s or 2.2 mph) was associated.  Additional fall predictors included:  worse performance on swing, double-support phase, swing time variability and stride length variability, even after accounting for cognitive status and disability.

In a third study, researchers set out to determine whether a disease-specific diagnosis resulting in cognitive loss (such as dementia) is predictive as a fall-risk factor, and compared it to measures of global cognition as well as other impairments in specific cognitive domains (i.e. executive function).⁴  This systematic review included 27 studies and using an inverse-variance method of data analysis found: executive function impairment, even subtle deficits in community-dwelling older adults, was associated with an increased risk for fall as well as falls resulting in serious injury. A diagnosis of dementia, without specification of dementia subtype or disease severity, was also associated with risk for fall but did not appear to be associated with falls resulting in serious injury.

Treating Fall Risk:

So with the above known as risk-factors for falling, what can we do about it?  Well, the current consensus varies within the research community.

According to a 2008 systematic review published in the British Medical Journal⁵, the researchers conclude that our current knowledge and ability to prevent falling is limited.   This study assessed research performed on multifactorial fall prevention programs in primary care, community and emergency care settings, and found the quality of studies in this area not to be high and most trials performed are ridden with methodological flaws.

A Cochrane review (159 trials and 79,193 participants)⁶ which assessed the effects of interventions designed to reduce the incidence of falls, found more encouraging results.  The researchers concluded that multiple-component group and home exercise programs significantly reduced the rate of falls and risk of falling.  In addition, home safety assessment and modifications demonstrated similar results.  Additional variables which showed some effectiveness included:  pacemakers (in those with carotid sinus hypersensitivity), the first cataract surgery (additional surgeries did not reduce incidence or risk), gradual withdrawl of psychotropic medications, etc.

In conclusion, we currently have some good guidelines in determining who is at-risk for falling but need additional, quality research to determine how to reduce the risk, as well incidence rates.

1. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141–158.
2. Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010; 21: 658-668.
3. Verghese J, Holtzer R, Lipton RB, et al. Quantitative gait makers and incident fall risk in older adults. J Gerontol A Biol Sci Med. 2009; 64: 896-901.
4. Muir SW, Gopaul K, Odasso MMM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age and Ageing 2012; 0: 0-10.
5. Gates S, Fisher JD, Cooke MW, et al. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. 2008 BMJ; 336: 130.
6. Gillespie LD, Robertson MC, Gillepsie WJ, et al. Interventions for preventing falls in older people living in the community. The Cochrane Collaboration. DOI: 10.1002/14651858.CD007146.pub3.