Falls

Many older people fear falling. And with good reason. Falls are common among older people. About one third of older people who live at home fall at least once a year. Those who are hospitalized or live in a nursing home fall more often.

Falls often cause injuries. Some of the injuries, such as a broken hip, can be serious. Older people are more likely to break bones in falls because many older people have porous, fragile bones (osteoporosis).

Fear of falling can lead to problems. People may worry about doing their usual activities and thus lose their self-confidence and even their independence. As Gabriel García Márquez said in Love in the Time of Cholera, "Old age begins with the first fall and ends with the second."

Older people can do many things to help overcome their fears and to reduce their risk of falling. Knowing what causes falls can help.

Causes

Falls can be caused by a person's physical condition, hazards in the environment, or potentially hazardous situations. Most falls occur when several causes interact. For example, a person with Parkinson's disease and impaired vision (the person's physical condition) may trip on an extension cord (an environmental hazard) while rushing to answer the telephone (a potentially hazardous situation).

A person's physical condition is affected by changes due to aging itself, physical fitness, disorders present, and drugs used. A person's physical condition probably has a greater effect on the risk of falling than do environmental hazards and hazardous situations. Not only does the person's physical condition increase the risk of falls, but it also affects how the person responds to hazards and hazardous situations.

Hazards in the environment are involved in many falls. Falls may occur when a person does not notice a hazard or does not respond quickly enough after a hazard is noticed. Environmental hazards include:

• Inadequate lighting
• Throw rugs and slippery floors
• Electrical or extension cords or objects that are in the way of walking
• Uneven sidewalks and broken curbs

Most falls occur indoors. Some happen while a person is standing still. They sometimes result from fainting. But most occur while a person is moving—getting in and out of bed or a chair, getting on or off a toilet seat, walking, or going up or down stairs. While moving, a person may stumble or trip, or balance may be lost. Any movement can be hazardous. But if a person is rushing or if a person's attention is divided, movement becomes even more hazardous. For example, rushing to the bathroom or to answer the telephone or talking on a cordless phone can make walking more hazardous.

For additional detail on this topic, see Risk Factors for Falling.

Symptoms

Often before falling, a person has no symptoms. When an environmental hazard or a hazardous situation results in a fall, there is little or no warning. However, if a fall is partly or completely due to a person's physical condition, symptoms may be noticed before falling. Symptoms may include dizziness, light-headedness, or irregular or rapid, pounding heartbeats (palpitations). Before falling the first time, a person may have had a close call, almost falling but being able to prevent it.

After a fall, pain is common because injuries are common. Over half of all falls result in at least a slight injury, such as a bruise, sprained ligament, or strained muscle. More serious injuries include broken bones, torn ligaments, deep cuts, and damage to organs such as a kidney or the liver. About 2% of falls result in a broken hip. Other bones (in the upper arm, wrist, back, and pelvis) are broken in about 5% of falls. Some falls result in loss of consciousness or a head injury.

Falls can cause even more pain if a person cannot get up right away or summon help. Such a situation may be frightening and may make a person feel helpless. Remaining on the floor, even for a few hours, can also lead to problems such as dehydration and skin sores due to pressure (pressure sores).

The effects of a fall may last a long time. About half of people who could walk before they fell and broke a hip cannot walk as well afterward, even after treatment and rehabilitation. People who have fallen may develop a fear of falling that robs them of their self-confidence. As a result, they may stay at home and give up activities, such as shopping, visiting friends, and cleaning. When people become less active, joints can become stiff and muscles can become weak. Stiff joints and weak muscles can further increase the risk of falling and make remaining active and independent more difficult. For all these reasons, falls can greatly reduce a person's quality of life. Falls seem to be an important consideration in the decision of many people to move to a nursing home or another assisted living facility.

Rarely, falls result in death. Death may occur immediately—for example, when the head hits a hard surface and causes uncontrolled bleeding in the head. Much more commonly, death occurs later, resulting from complications of serious injuries caused by the fall.

Diagnosis

People who have fallen may be reluctant to discuss the problem with anyone, including a doctor, especially if they have not been injured. But even people who have been seriously injured during a fall and have been treated in an emergency department may be reluctant to admit they have fallen. People may be reluctant because they think falling is just part of getting older. And they do not want others to think they are helpless and now must move from their home into a more supervised environment such as a nursing home. Because of this reluctance, many doctors routinely ask all of their older patients if they have fallen in the recent past.

If a person has fallen, doctors try to identify the cause of the fall. To do so, they ask about the circumstances of the fall, including any symptoms experienced just before the fall and any activities that may have contributed to the fall. Doctors also ask about the use of drugs—prescription and nonprescription—that may have contributed to the fall. Doctors may ask people who witnessed the fall what they noticed.

Doctors perform a physical examination first to check for injuries and to obtain information about possible causes of the fall. Blood pressure is measured. If it decreases when a person stands up, the fall may be caused by orthostatic hypotension. With a stethoscope, doctors listen to the heart for evidence of abnormal rhythms and heart failure. They assess muscle strength and the ability to fully move various parts of the body (range of motion). Vision and some aspects of the nervous system, including the senses of position and balance, are also assessed. Doctors sometimes ask the person to do some usual activities, such as sitting in a chair and then standing up or stepping up on a step. Observing these activities may help doctors identify conditions that contributed to the fall.

If the fall resulted from an environmental hazard and no major injury occurred, no tests may be done. However, if the person's physical condition could have contributed to the fall, tests may be needed. For example, if the physical examination detected evidence of a heart problem, heart rate and rhythm may be recorded using electrocardiography (ECG). This test may last a few seconds and be done in the doctor's office. Or the person may be asked to wear a portable ECG device (Holter monitor) for 1 or 2 days. If a person has been experiencing dizziness or light-headedness, blood tests, such as a complete blood count and measurements of electrolyte levels, may be helpful. If the nervous system appears to be malfunctioning, computed tomography (CT) or magnetic resonance imaging (MRI) of the head may be helpful.

Prevention

Older people can do many simple, practical things to help reduce the risk of falling.

• Exercising regularly. Weight training or resistance training may help strengthen a weak limb and thus may improve steadiness during walking. Tai Chi and balancing exercises such as standing on one leg can help improve balance.
• Wearing appropriate shoes. Shoes that have firm, nonslip soles and low heels are best.
• Standing up slowly after sitting or lying down and taking a moment before starting to move. This strategy can help prevent dizziness because it gives the body time to adjust to the change in position.
• For some older people who feel dizzy when they move, learning a simple head maneuver, called the Epley maneuver. It involves turning the head in specific ways. Doctors usually perform the maneuver the first time, but people can learn how to do it themselves if it needs to be repeated.
• For older people who feel dizzy when they stand (because blood pressure decreases), wearing support stockings.
• Asking a doctor or another health care practitioner to review all prescription and nonprescription drugs being taken to see if any of the drugs could increase the risk of falling. If such drugs are being used, the doctor may be able to lower the dose or discontinue the drug.
• Having vision checked regularly. Getting the correct glasses and wearing them can help prevent falls. Treatment of glaucoma or cataracts, which limit vision, can also help.
• Consulting with a physical therapist about ways to reduce the risk of falling. Some older people need a physical therapist to train them to walk, particularly if they need to use a walker or cane.

Falls cannot always be prevented. So, people who are likely to fracture a hip—such as those who have osteoporosis and fall frequently—may consider wearing a hip protector to prevent hip fractures. The most effective type is a thigh-length undergarment with plastic and foam padding inserted along its sides.

Hazards in the environment can sometimes be removed or corrected. For example, lighting can be improved by increasing the number of lights or changing the types of lights. Light switches can be positioned so that they are easily reached. Or lights that turn on when they are touched or when they detect nearby motion can be used. Adequate lighting for steps (inside and outside) and for outdoor areas used at night is particularly important. Steps should have sturdy, secure handrails. Electrical or extension cords that are in the way of walking can be eliminated by adding more electrical outlets, or the cords may be tacked over doorways. Other items that clutter floors and stairways can be stored out of the way of walking.

Grab bars can be installed next to toilets, tubs, and other places for people who need something to hold onto when they stand up. Grab bars must be installed properly, so that they do not pull out of the wall. Raised toilet seats can also help. Loose throw rugs can be removed or taped or tacked down. Nonslip mats should be used in the bathroom and kitchen. Frequently used household items can be stored in cabinets, cupboards, or other spaces between waist and eye level, so that they can be reached without stretching or bending.

Learning how to safely handle potentially hazardous situations may be more important than removing an environmental hazard. Sometimes people need only to think about ways to accomplish daily tasks more carefully. For example, they can install an intercom so that they do not have to rush to answer the door. They can place cordless phones around the home so that they do not have to rush to answer phone calls.

Knowing what to do if a fall occurs can help older people be less afraid of falling. If they fall and cannot get up, they can turn onto their stomach, crawl to a piece of furniture (or other structure that can support their weight), and pull themselves up.

Older people should also have a good way to call for help. People who have fallen several times may keep a telephone in a place that can be reached from the floor. Another option is installing a personal emergency response system (a medical alert device) that signals someone to check in on them. Most of these systems include an alert button worn on a necklace. Pressing the button calls for help.

See the sidebar Preventing Falls in the Home.

Treatment

When a person falls, the first priority is treatment of injuries, such as fractures, sprained ligaments, and strained muscles. The next priority is to prevent subsequent falls and injury due to falls.

Disorders that may have contributed to the fall are treated. For example, if a person who has fallen has a very slow heart rate accompanied by light-headedness, a pacemaker for the heart may be implanted. If possible, potentially harmful drugs are discontinued, the dose is reduced, or another drug is substituted.

Physical and occupational therapists can help improve a person's self-confidence after a fall. They can provide tips on how to avoid falling. Therapists can also encourage the person to remain active. Physical therapy and supervised weight training and stretching can help improve muscle strength and balance.