ReviewRisk factors for falls among older adults: A review of the literature
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.
References (140)
- et al.
Gait variability and fall risk in community-living older adults: a 1-year prospective study
Archives of Physical Medicine and Rehabilitation
(2001) - et al.
The epidemiology of falls and syncope
Clinics in Geriatric Medicine
(2002) - et al.
Serious falls in hospitalized patients: correlates and resource utilization
American Journal of Medicine
(1995) - et al.
Falls and gait disorders in geriatric neurology
Clinical Neurology and Neurosurgery
(2010) - et al.
Incidence of functional limitation in older adults: the impact of gender, race, and chronic conditions
Archives of Physical Medicine and Rehabilitation
(2002) - et al.
Self-report of missteps in older adults: a valid proxy of fall risk?
Archives of Physical Medicine and Rehabilitation
(2009) - et al.
Associations of visual function with physical outcomes and limitations 5 years later in an older population: the Beaver Dam eye study
Ophthalmology
(2003) - et al.
A comparison of community-residing older adults with frontal and parkinsonian gaits
Journal of the Neurological Sciences
(2006) - et al.
Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome
Autonomic Neuroscience
(2011) - et al.
Balance and gait in older adults with systemic hypertension
American Journal of Cardiology
(2003)
Clinical practice: preventing falls in elderly persons
The New England Journal of Medicine
Medicare nonpayment, hospital falls, and unintended consequences
The New England Journal of Medicine
The cost and frequency of hospitalization for fall-related injuries in older adults
American Journal of Public Health
Mortality after admission to hospital with fractured neck of femur: database study
BMJ
Visual factors should be assessed in older people presenting with falls or hip fracture
Age and Ageing
How best to fix a broken hip. Fractured Neck of Femur Health Outcomes Project Team
Medical Journal of Australia
Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90
BMJ
Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people
Age and Ageing
International comparison of cost of falls in older adults living in the community: a systematic review
Osteoporosis International
Epidemiology of falls
Age and Ageing
Cost of falls in old age: a systematic review
Osteoporosis International
Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept
Journal of the American Geriatrics Society
Will my patient fall?
JAMA
The patient who falls: “It's always a trade-off”
JAMA
Defining a fall and reasons for falling: comparisons among the views of seniors, health care providers, and the research literature
Gerontologist
Forgetting falls. The limited accuracy of recall of falls in the elderly
Journal of the American Geriatrics Society
Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus
Journal of the American Geriatrics Society
The prevention of falls in later life. A report of the Kelloggs International Work on the prevention of falls by elderly
Danish Medical Bulletin
Frailty and injuries in later life: the FICSIT trials
Journal of the American Geriatrics Society
Development of the common data base for the FICSIT trials
Journal of the American Geriatrics Society
Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study
Age and Ageing
Ginter SF. Risk factors for falls among elderly persons living in the community
The New England Journal of Medicine
Fatalities and injuries from falls among older adults – United States, 1993-2003 and 2001-2005
Morbidity and Mortality Weekly Report (MMWR)
An epidemiological study of falls on integrated general medical wards
International Journal of Clinical Practice
Falls in hospital – impact on resource utilization
Australian Health Review
Orthopaedic injuries following falls by hospital in-patients
Gerontology
Falls in the nursing home
Annals of Internal Medicine
Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons
Journal of the American Geriatrics Society
The epidemiology of domestic injurious falls in a community dwelling elderly population: an outgrowing economic burden
European Journal of Public Health
Falls risk among a very old home-dwelling population
Scandinavian Journal of Primary Health Care
The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk?
Expert Review of Neurotherapeutics
Preventing falls among community-dwelling older persons: results from a randomized trial
The Gerontologist
Ethnicity and falls in older men: low rate of falls in Italian-born men in Australia
Age and Ageing
Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis
Epidemiology
Compensatory stepping: the biomechanics of a preferred response among older adults
Experimental Aging Research
Stressing the postural response: a quantitative method for testing balance
Journal of the American Geriatrics Society
Age-related changes in compensatory stepping in response to unpredictable perturbations
Journals of Gerontology Series A: Biological Sciences and Medical Sciences
Age influences the outcome of a slipping perturbation during initial but not repeated exposures
Journals of Gerontology Series A: Biological Sciences and Medical Sciences
Control of rapid limb movements for balance recovery: age-related changes and implications for fall prevention
Age and Ageing
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