Falls in Senior Adults: Demographics, Cost, Risk Stratification, and Evaluation

Abstract

Falls occur at staggering rates across the country, with 25% of Americans over 65 reporting annual falls. The fall rate in Missourian older adults is 27.3%. Eighty-six percent of fall-related deaths happen over the age of 65. There are many intrinsic and extrinsic factors that contribute to falls, with some factors that can be targeted and optimized by physicians. There are nuances to the history and physical that can help physicians identify these risk factors.

This Feature Review is Part I discussing falls in adults and identifying demographics, cost, risk stratification, and evaluation.

Falls in Senior Adults: A Growing, Costly Problem

Every year, a growing number of senior citizens throughout the United States are negatively impacted by the life-altering, catastrophic effects of falls. Indeed, more than one out of four Americans over the age of 65 experience a fall annually.¹ According to Centers for Disease Control (CDC) data, this ultimately results to over 30 million falls, seven million injuries, three million emergency room visits, 800,000 hospitalizations, and 38,000 deaths each year. ^1–3 The incidence of falls continues to escalate as the number of baby boomers advance in age. Additionally, falls place a costly economic burden on our health care system and society at large. A study conducted by the CDC in 2018 reported the direct medical costs for falls are approximately $50 billion annually, including $28.9 billion paid by Medicare, $8.7 billion paid by Medicaid, and $12 billion paid by private insurance and other payers. This collective figure is projected to rise to $100 billion annually by 2030.^4–7 In 1950, one in twelve Americans were aged 65 or older. By 2000, that proportion had grown to one in eight, and it is projected to increase to one in every five, or an estimated 88.5 million senior citizens, by 2050.^8,9

To address falls in older adults at the state level, public health departments have made a strategic and concerted effort to quantify the magnitude of the problem and have launched a variety of initiatives to prevent falls. Each year in Missouri, the percentage of older adults that sustain a fall was roughly in-line with the national average at an estimated 27.3%.¹⁰ Fall-related mortality in Missouri was greatly over-represented among the elderly, with 86% of fall-related deaths occurring in those over the age of 65.^2,5 To tackle this problem, the Missouri Chapter of AARP (American Association of Retired Persons), in conjunction with the Missouri Department of Health and Senior Services initiated Show Me Falls Free Missouri Coalition in late 2007.¹¹ This group has grown to form a coalition of over 50 stakeholder organizations seeking to provide the community with resources on fall prevention strategies.

Missed Opportunities: Identifying Patients at Risk

Physicians, particularly primary care physicians (PCPs), are optimally positioned to play a much more decisive role in mitigating fall risk through managing underlying risk factors. There are, however, several limiting dynamics that are oppositional to this idealized standard of care. Quite frequently, falls experienced by senior adults go unreported by the patient to their physician. This reporting oversight is commonplace and secondary to numerous factors, including personal embarrassment on the part of the patient, the patient not believing the fall (or near-miss) was worth mentioning to their PCP since no major injury was sustained, fear of repercussion (e.g. the patient may fear that the next step is the nursing home), or because the patient forgot the fall took place due to underlying cognitive deficits. In addition, fall risk assessment is often neglected in clinical practice due to the limited amount of time allotted to each patient visit and the fact that other competing priorities will always take precedent.

Given these barriers, a validated, systematic method of screening elderly patients for increased fall risk should be adopted and implemented in appropriate clinical settings to successfully identify non-reporters. The Centers for Disease Control (CDC) has recommended the use of their published Stay Independent brochure, which is a quick and thorough risk assessment tool developed by the Los Angeles VA Geriatric Research Education Clinical Center.¹¹ This brochure provides a 12-point checklist with a weighted-scoring system whereby patients who score 4 or higher are identified as being at increased risk for falling and should therefore undergo further evaluation with more aggressive risk management. Patients who are identified as having a low fall risk (i.e. scores <4) may still benefit from basic individualized education with an emphasis on primary prevention including education regarding fall risk factors, strengthening and balance exercises, and vitamin D supplementation.

Root Cause Analysis of Falls

It is important to recognize that falls in the elderly rarely have a single, unifying cause. Rather, they are the result of a complex interplay of intrinsic and extrinsic risk factors as seen in Tables 1 and 2. Intrinsic risk factors are quite varied. While some elements are non-modifiable (e.g. age, gender, and prior history of falls), others can be easily changed (e.g. physical inactivity/disability, incontinence, and polypharmacy). Extrinsic risk factors that result in falls are much more amenable to modification and include elements such as environmental lighting, use of assistive devices, footwear, etc. Patients are often quick to attribute falls to underlying environmental causes (e.g. slipped on a wet floor or tripped over a pet or object) and/ or social factors (e.g. being in a hurry or not paying attention). However, they fail to recognize the significant role played by intrinsic elements, where physicians can have their greatest impact. Thus, the ability to recognize and calculate the vast array of risk factors is paramount with respect to addressing the high morbidity and mortality associated with falls in the elderly.

Table 1.

Intrinsic Factors of Falling.

I. Deconditioning Physical inactivity Diminished aerobic function Myopathy Obesity

II. Sensory deficits Decreased visual acuity/depth perception Non-modifiable visual deficits Proprioceptive deficits Hearing deficits

III. Inherent Female gender Age Prior fall history

IV. Neurological/Neuromuscular Changes in gait, including reduced arm swing, decreased step length, slowed reaction time, slower movements Parkinson’s disease (rigidity, bradykinesia and inability to correct perturbations in balance quickly) Stroke (visuospatial defects, impaired peripheral sensation, cerebellar dysfunction, muscle weakness, etc.) Normal pressure hydrocephalus Tremors/movement disorders Vertebrobasilar insufficiency Cerebellar dysfunction Vertigo Cognitive impairment (e.g. delirium, dementia) Spasticity/contractures Impulsivity Depression/anxiety/psychosis

V. Musculoskeletal Foot disorders Amputation Osteoarthritis/rheumatoid arthritis Post-orthopedic surgery

VI. Cardiovascular Syncope Orthostasis/dehydration Congestive heart failure PAD/intermittent claudication

VII. Nutritional Hypovitaminosis D B12/folate deficiency

VIII. Endocrine Thyroid disease Diabetes/insulin use

IX. Medication or Substance Use Polypharmacy Drug interactions resulting in dizziness, confusion/impaired judgement, weakness/impaired gait, sedation/slowed reaction time Alcohol/drug use

X. Other medical Incontinence Infection

Table 2.

Extrinsic Factors of Falling.

I. Home conditions Environmental lighting Area rugs/floor runners/loose mats Wet floors Hard-to-reach personal items Toilet proximity to bedroom Low toilet seat Lack of handrail/grab bar supports in the bathroom Bed height and bed firmness Room/walkways free of cords and clutter Access to items in the kitchen Pets Unsafe shoes or slippers Hard-to-manage clothing Walk-in shower vs tub-shower combo Stairs vs home access ramp Steps inside the home vs home lift Flooring (slip vs non-slip) Exercise/diet

II. Requirement of Durable Medical Equipment Assistive devices (e.g. canes, walkers, wheelchairs) Prosthetic devices Incorrect wheelchair fit/inadequate wheelchair seating/broken or missing parts

III. Hospital conditions High patient-to-staff ratios in hospitals, rehabilitation facilities, skilled nursing facilities, and long-term care facilities New/novice staff Access to the call light Presence of grab bars

A Comprehensive History Assessment for Increased Fall Risk

Falls, especially among the elderly, are often underreported. There are multiple explanations for this phenomenon as discussed previously.

To obtain useful information and guide further management and treatment with respect to falls in older adults, care providers should ask additional questions during the historical interview. Clinicians should investigate the cause or etiology of the fall with a goal towards prevention, which can be elucidated through an assessment of risk factors. Asking a patient about their previous fall history can help provide valuable information. If two or more falls have occurred within the past 12 months, the patient should have a comprehensive fall risk assessment. A previous history of falls can lead to a fear of falling, which is associated with a higher risk of falls.¹² Knowing whether they live at a facility or living at home can help ascertain the level of supervision that is currently assigned to the patient, and may indicate the need for a higher level of care.

The patient’s symptoms prior to the fall can help determine the etiology of the fall. “Dizziness” with “lightheadedness” can be indicative of orthostatic hypotension, which is most often due to dehydration, but could also be a sign of autonomic instability. If a patient reports being “off-balanced” or that they lean more to one side can indicate disequilibrium. Feeling like “the room is spinning” could indicate possible disorders of the inner ear (such as labyrinthitis or benign paroxysmal positional vertigo) but could also be the result of central causes, such as a vertebrobasilar stroke. Loss of consciousness can point to the need for further examination of neurologic or cardiac causes. Cardiac causes are associated with a higher risk of mortality.¹³

The location of the fall is an important factor within the fall risk assessment. Location can signal environmental factors and challenges, including lighting, flooring, throw rugs or carpets, door-to-flooring thresholds, railings, and the presence of gravel or uneven ground outside of the home, which can all contribute to poor footing and increased likelihood of falls. One Australian study found when the faller is walking, the highest rate of falls is caused by slipping on an uneven or slippery surface (29%), followed by tripping over an obstacle, such as shoes, steps, road gutters, or pets (27%).¹⁴ A home evaluation may be warranted to further improve the patient’s living situation.

Falls can be more common at certain times of the day for many reasons, such as medication effects that accumulate throughout the day (e.g. antihypertensive use at night as opposed to earlier in the day, or improper insulin management resulting in hypoglycemia and an increased chance of falls).¹⁵

Medication changes can significantly impact fall risk. If a patient has recently changed their anti-hypertensive or anti-hyperglycemic regimen, or recently taken another medication that can increase somnolence and/or decrease orientation (medications on the Beer’s criteria), their risk of falling could increase. Polypharmacy can also increase fall risk and lead to a myriad of other adverse effects.¹⁶

Healthcare providers should also inquire about the type of mobility or assistive devices used by their patients. A patient’s assistive device might not be appropriate for their current level of mobility, which would require further assessment. The current state of the assistive device should also be assessed, as it may need repair or replacement and could pose an additional fall risk if not addressed. Patients may also require further training for their given assistive device to ensure they can use it safely.

It can be helpful to question certain patients, especially those with foot deformities, such as diabetic patients with Charcot foot, about their footwear and other orthoses. Certain orthoses such as slip-resistant soles, shoes with a low heel height, beveled heels, fastening mechanisms, and supported heel collars can play an important role in fall prevention.

Depression can alter gait through its effect on concentration and attention, which can in turn increase the risk of falling.¹⁷ However, conservative, non-pharmacologic measures with neuropsychology should be maximized prior to initiation of anti-depressants, as certain anti-depressants can increase the likelihood of falls.

The Physical Exam and Gait Assessment of Elderly Patients

A person’s gait is a significant contributing factor to their fall risk and overall instability. However, before completing a gait assessment, it is important to evaluate other urgent etiologies, such as autonomic or cardiovascular instability. Vestibular dysfunction can also be monitored when vertiginous symptoms are involved, especially when these symptoms are associated with rapid positional changes. Once these factors have been thoroughly investigated, clinical providers should conduct a comprehensive gait assessment.

One test that can be performed in the office is the “Get-Up-and-Go Test.” As an added benefit, this test does not require extensive training and can be performed with minimal materials. In this test, the individual is asked to stand up from a chair, walk three meters, turn around, walk back to the chair, and sit down without using their upper extremities. This test can grade muscle weakness, balance issues, and gait abnormalities (on a scale of 1 to 5, with 5 indicating severe impairment). If a patient must use their upper extremities to stand, they might be experiencing hip extensor weakness. This test can also be timed. If the patient is unable to complete the test within 12 seconds, they are at an increased risk of falling. Incorporating the time component tests gait velocity, which also plays an important role in fall risk.¹⁸ A printable document is available through the CDC ‘s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program for ease of use in a clinical setting.¹⁹

The 30-Second Chair Stand Test also assesses both strength and balance. Patients are asked to cross their arms over their chest while seated in a chair. If the patient requires the use of their arms to stand, hip extensor weakness could be the cause. This test evaluates the patient’s balance and strength, especially with respect to their hip flexors and extensors. The provider should record how many times the patient can fully stand and sit within a 30-second time interval. This test can also assess a patient’s strength with transfers with the up and down movements out of the chair. For patients who are between 75–79 years of age, <11 stands within men and <10 stands within women is considered to represent an increased fall risk. A printable document is also available as part of the STEADI program from the CDC, and has grading guidelines scaled to the patient’s age.²⁰

A third test is the 4-Stage Balance Test, where patients are asked to stand for at least 10 seconds in the following positions: feet adjacent, semi-tandem stance, tandem stand, and on one foot. Patients unable to perform the semi-tandem test for at least 10 seconds are at an increased risk of falling. Other tests, including the Functional Reach test, Berg Balance Test, and Performance-Oriented Mobility Assessment are not commonly used in the clinic, but are utilized in research studies to better quantify neuromuscular support. Impaired performance on these tests has been linked with a higher fall risk in the elderly as well.^{21, 22}

Screening tools are available, including the Morse Fall Scale and the St. Thomas’ Risk Assessment Tool. The Morse Fall Scale has been shown to be useful in studies for assessing fall risk.²³ The Morse Fall Scale is composed of six items, namely a history of falling within the past three months, the presence of a secondary diagnosis, the use of an ambulatory aid, the requirement of IV therapy, an abnormal gait, and an impaired mental status. Scores range from 0 to 125. Patients who score above 45 have a higher risk of falling, with higher scores indicating an even higher risk. Another screening tool is St. Thomas’s Risk Assessment Tool, or STRATIFY. A caveat with STRATIFY is that one study found it could predict fall risk in those under the age of 75, however, was unable to predict fall risk in people over the age of 75 when administered at the hospital bedside.²⁴ One systematic meta-analysis recommended that STRATIFY not be used in isolation, but pointed out that it could be helpful when used in conjunction with other testing.²⁵

Gait patterns, with appropriate assistance either by device or staff, can help ascertain specific compensatory strategies, as seen in Table 3. Spasticity can cause leg circumduction and rigid, fixed deformities (such as equinovarus, which can be due to rigid spasticity, particularly within the posterior tibialis, lateral and medial gastrocnemius, and soleus). Patients with amputations can also exhibit an altered gait depending on the level of their amputation as well as their prosthetic device. The provider should also assess whether or not the prosthetic is properly fitted to the patient and ensure that there are no signs of skin breakdown at the amputation site. If the provider is comfortable with the design of the prosthetic, all parts of the prosthetic should be carefully inspected and monitored to ensure they are in proper working order. Should any questions arise, consultation to a physiatrist with a regular practice in lower-extremity prosthetics and gait pattern analysis as well as a prosthetist/orthotist is warranted. Another cause of an altered gait pattern is cerebellar ataxia, which can increase truncal sway to the extent that the patient requires a broad base of support when moving. Parkinsonism can lead to a shuffling gait with reduced arm swing. A significant amount of research has been conducted on freezing of gait (FOG), commonly found in parkinsonian syndromes, to better understand its underlying pathophysiology and better determine its diagnosis. Currently, certain medications have been shown to help with FOG but should be studied further.²⁶

Table 3.

Gait Patterns

Gait Type	Physical Gait Description	Muscles/Structures Affected
Antalgic	Limited weightbearing through painful lower extremity	Dependent upon site of injury
Steppage	Increased hip flexion for clearance of weakened ankle dorsiflexion	Ankle dorsiflexors (anterior tibialis)
Trendelenberg	Shift in weight over weakened hip	Hip abductors (gluteus medius, gluteus minimus)

Laboratory and Diagnostic Testing: Focusing on Physiologic Determinants of Falls

To further evaluate an elderly patient who has experienced a fall, certain laboratory and diagnostic testing may be required to confirm the etiologies, especially reversible causes. Many of these reversible causes can affect the patient’s mental status. These tests include a metabolic panel for renal function assessment with serum sodium, BUN, and creatinine and a diabetic status test with glucose and hemoglobin A1c for longer glucose management assessment. A complete blood count for hemoglobin assessment for anemia can also be helpful. Further cardiovascular testing and assessment includes an echocardiogram to investigate any suspected valvular conditions with or without a bubble study to monitor for shunts as well as a Holter monitor in those with suspected paroxysmal arrhythmias. When clinically appropriate, dual-energy X-ray absorptiometry (DEXA) scans are important to further assess for bone density, especially in patients who are particularly at risk for osteoporosis. In the event of a fall, osteoporotic fragility fractures could result in long-term debility.

Falls have been an ongoing source of morbidity and mortality, especially in senior adults. As advocates of public health, there are a multitude of interventions physicians can provide to prevent falls, not only pharmacologically but also through risk identification and stratification as well as environmental modification. The follow up to this Feature Review will provide further information on treatment plans and therapy to reduce falls in senior adults.