Elsevier

Maturitas

Volume 75, Issue 1, May 2013, Pages 51-61
Maturitas

Review
Risk factors for falls among older adults: A review of the literature

https://doi.org/10.1016/j.maturitas.2013.02.009Get rights and content

Abstract

Falls are one of the major causes of mortality and morbidity in older adults. Every year, an estimated 30–40% of patients over the age of 65 will fall at least once. Falls lead to moderate to severe injuries, fear of falling, loss of independence and death in a third of those patients. The direct costs alone from fall related injuries are a staggering 0.1% of all healthcare expenditures in the United States and up to 1.5% of healthcare costs in European countries. This figure does not include the indirect costs of loss of income both to the patient and caregiver, the intangible losses of mobility, confidence, and functional independence. Numerous studies have attempted to define the risk factors for falls in older adults. The present review provides a brief summary and update of the relevant literature, summarizing demographic and modifiable risk factors. The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors. Recommendations for the clinician to manage falls in older patients are also summarized.

Introduction

Falls are a leading cause of injury and death among older adults and a significant public health issue [1]. Falls affect one in three adults over the age of 65 annually [2], and 50% of adults over the age of 80 [3]. Twenty to thirty percent of these patients will suffer moderate to severe injuries interfering with their ability to continue living in the community, require hospitalization and have an increased risk of death [4]. In 2009, 2.2 million nonfatal fall injuries occurred among older adults in the United States that required treatment in emergency departments and more than 581,000 of these patients were hospitalized [5]. In the same year, over 19,000 older adults died from unintentional fall injuries making falls the fifth leading cause of death in adults above age 65[5].

Older individuals have an increased susceptibility for injury due to the higher prevalence of comorbidities, age-related physiological changes, and delayed functional recovery, which in turn leads to further de-conditioning and more falls [6]. About 30–50% of falls result in minor lesions such as bruises or lacerations, however, 5–10% of falls lead to major injuries such as fractures [7] or traumatic brain injury (TBI) [6]. Falls are the most common cause of TBI in older adults, and also account for 46% of all fall related deaths in TBI patients [5]. Although the rate of hip fractures following a fall is only 1%, 90% of all hip fractures are caused by a fall [7]. In the first year following a hip fracture, 25% of older patients will die [8], 76% will have a decline in their mobility [9], 50% will have a decline in their ability to perform activities of daily living (ADL) [8] and 22% will move into a nursing home [9]. Among the older adults who fall, approximately one-half are unable to get up and remain on the ground [10]. These “long-lies” lead to dehydration, rhabdomyolysis, pressures sores, and pneumonia [10]. In addition, many older adults who fall will also develop a marked fear of falling, and up to 40% will restrict their activities of daily living. This set up a vicious spiral with further declines in physical fitness, social isolation and depression [11] and in turn, further increases the risk of falls.

Falls and their consequences are responsible for a large part of preventable health care costs. In the United States, the total direct medical costs for fall-related injuries among older adults in 2008 were US$23.3 billion, and the fall related costs were reported to be US$1.6 billion in the United Kingdom [12]. These expenditures are expected to approach $55 billion by 2020 as the population ages globally, increasing the at-risk sample [5]. Furthermore, falls or fall related medical events, account for 40% of nursing home placements and contribute to further increases in healthcare costs [13]. National fall related costs of prevalence-based studies are 0.85–1.5% of total healthcare expenditures [14].

Here we review the factors that contribute to fall risk in older adults.

Section snippets

Methods

Though there have been many studies that have reported various risk factors for falls; the results have been mixed. In a recent review of 12 studies that examined fall risk factors, Inouye et al. identified older age, prior history of falls, functional impairment, use of a walking aid or assistive device, cognitive impairment or dementia, impaired mobility or low activity level, and balance abnormalities as the main causes for falls in older adults [15]. However in an earlier review of 12

Definition

The medical and lay communities do not always perceive falls similarly, especially if there is no injury [18]. There is evidence that 75–80% of all falls without injury are not reported at all [10]. Retrospective studies may also suffer from under-reporting of falls. In a prospective study of 304 ambulatory patients, Cummings et al. found that between 13 and 32% denied having had a fall depending on how long after the event they were questioned; longer intervals were associated with lower

Epidemiology

About one-third of community-dwelling older adults above age 65 fall every year [2], [24] while 40% of those over age 80 experience one or more falls [25]. Patients who have fallen in the past year are more likely to fall again [likelihood ratio range: 2.3–2.8] [16], [26]. Among hospitalized patients, fall rates vary from 3 to 20 per 1000 bed-days [27]. Falls in a hospital often result in increased mortality and morbidity [28], [29]. In a 3-year retrospective study of 900 falls, Nadkarni and

Risk factors

Fall risk factors are often categorized as person specific (or intrinsic) and environmental (or extrinsic) [32]. Personal factors include characteristics of the individual such as age, functional abilities, chronic diseases and gait disturbances [33]. Environmental risk factors refer to fall hazards in and around the home such as poor fitting footwear, slippery floor or loose rugs, tripping hazards, lack of stair railings or grab bars, unstable furniture, and poor lighting [34]. The risk of

Assessment

A simple clinic based assessment of gait and fall risk could include chair rise and subsequent observation of the walking pattern. Asymmetrical, slow or shuffling gait, wide-based stance or walk, stooped postures and swerving from side to side as well as the use of an assistive devices for balance or mobility may all suggest an increased risk of falling during transfers or ambulation [16]. To more objectively quantify fall risk, many functional performance-based tests have been developed. A

Recommendations

The current recommendations from the American and British Geriatric Societies are that all older individuals should be asked if they fell in the past year or have experienced difficulties with walking or balance [32]. In those who respond positively or do poorly on a standardized gait and balance test, a trained clinician should conduct a multi-factorial fall risk assessment (see Table 2). This assessment should also include the individual's perceived functional ability and fear related to

Summary and conclusions

Falls in older adults are common but are not necessarily an inevitable by-product of aging. Falls have been associated with a number of different risk factors. Some of these, like age or gender, cannot be altered. However, many other fall risk factors are amenable to interventions (e.g., muscle strength, balance, number of medications, cognitive function). Appropriate assessments can help to identify those subjects who have an increased risk of falls, the underlying causes, and, ultimately,

Contributors

Anne Felicia Ambrose created concept and framework for the paper, gathered references and wrote the first draft, and each subsequent draft, Formatted the paper to fit into journals requirements.

Geet Paul did the preliminary database searches and wrote the sections on cardiovascular disease (5.8) medications (5.9).

Jeffrey Hausdorff wrote section on assessment (6) and recommendations (7), provided editorial input.

Competing interests

The authors declare no conflict of interest.

Funding information

The authors have not received any funding for this article.

Provenance and peer review

Commissioned, externally peer reviewed.

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