Causes of Falls in Older Adults

Submitted by Dr S. Patel on 4 April 2024
An elderly man on the floor, being assisted by a woman, with his cane on the floor next to him and text overlay on blue strip Causes of Falls in Elderly

The demographic of the world's population is shifting towards older age groups. The prevalence of falls and associated injuries and morbidity is on the rise, posing a significant global challenge. Knowing the causes of falls in elderly can help create awareness and aid prevention. Let’s find out a bit more about the causes of falls in elderly. 

Professor Bernard Isaacs, a giant in geriatric medicine said, ‘It takes a child one year to acquire independent movement and ten years to acquire independent mobility. An old person can lose both in a day’.

The causes of falls in elderly is usually multifactorial.

INTRINSIC FACTORS

  1. Age-related functional decline

    Altered vision (cataract, glaucoma, retinal degeneration, decreased vision etc.): Visual impairment can cause challenges with identification of hazards and lead to falls in elderly. 
    Mitigation: A timely vision check at least once a year may help avoid the same. If one does have any altered vision or blurring, they should visit the eye specialist to avoid related falls.

    Slowed reaction time: With increasing age, the reaction time decreases due to decline in muscle coordination, loss of muscle, declining cognition and sometimes brain fog. This may often lead to falls as one may not be able to stop the fall in time. Getting up from bed at night may sometimes cause falls due to delayed reaction time and lack of complete awareness. 
    Mitigation: Avoiding sudden movements and ensuring sure footing helps prevent falls. Identifying potential hazards and risks at home like slippery mats and clutter and reducing potential risks will help. 

    Sarcopenia/Muscle loss and weakness: Loss of muscle may occur as early as the 30s, and muscle can decrease by 3–8% per decade thereafter. There is a more rapid rate of decline post the age of 60. This may cause an inability to manage the center of gravity and recover from impending falls.
    Mitigation: Regular muscle strengthening and core strengthening exercises coupled with a high protein diet help in maintaining muscle tone. 

    Hearing loss: This is also a potential cause of falls in elderly, even mild degree of hearing loss increases the risk of an accidental fall three times, and the risk increases by 140 percent for every 10 decibels of hearing loss. 
    Mitigation: Hearing assessment using audiometry helps to identify any change in hearing capacity and related falls may be avoided.

    Osteopenia and osteoporosis: Both lead to weakening of bones and may also cause potential falls and related fractures.
    Mitigation: Following up with the doctor for keeping tabs on vitamin D , calcium levels and bone density (DEXA scan) can help in early identification and proper management of these causes and thus prevent related falls and injuries. Additionally, engaging in consistent physical activity can aid in the prevention of osteopenia by mitigating bone loss and enhancing bone well-being. Strengthening bones and mitigating bone loss can be achieved through weight-bearing exercises like walking, stair climbing, or dancing. By exerting tension on your bones using muscles and tendons during weight-bearing exercises, an increase in bone tissue production is observed. This has the potential to enhance bone strength and density, thereby mitigating the likelihood of osteoporotic fractures.

    Arthritis (Senile/age related , rheumatoid etc.): They can cause stiffness in joints and falls may occur when standing from sitting positions due to sudden stiffness and/or pain.
    Mitigation: Maintaining a healthy weight, as excess weight puts stress on your joints, regular exercises it may help in preventing joint stiffness and muscle strengthening and protecting joints from any injuries and that increase the risk of osteoarthritis.

    Orthostatic Hypotension: It’s more common in the elderly. It is a drop of at least 20 mmHg in systolic blood pressure (SBP) and/or 10 mmHg in diastolic blood pressure (DBP) within three minutes of standing up. This may cause dizziness and sudden falls.
    Mitigation: Regular monitoring of blood pressure and standing up gradually, thus avoiding any sudden change in position from lying down or sitting to standing position, may prevent a sudden fall of blood pressure and dizziness.

  2. Chronic illnesses that impair balance and mobility 

    Parkinson's disease that affects the balance and gait (walking style). Short steps and imbalance may lead to falls.
    Dementia can cause confusion and, afterwards, is often related to issues related to balance, mobility and strength.
    Mitigation: Regular visits to the doctor and checks for any symptoms like changes in walk, balance, forgetfulness or delayed thinking may lead to early diagnosis and management. Physiotherapy helps to train muscles and improve balance and is a powerful tool to prevent related falls.

    Other causes of dizziness, like low sodium and dehydration, may also lead to falls. 
    Mitigation: Regular health checks, consuming a balanced diet, maintaining hydration are some ways to ensure more balance of electrolytes. Also discuss with your doctor any potential side effects of medications that may cause changes in sodium levels and dehydration, as may be seen with diuretics and some blood pressure medications.

    Diabetic neuropathy, particularly diabetic peripheral neuropathy (DPN), can result in muscle weakness, reduced ankle reflexes, and impaired balance, coordination, and gait control. This, in turn, increases the likelihood of falling and sustaining injuries related to falls. Elderly with diabetic peripheral neuropathy are 23 times more likely to fall. Also, dizziness from low blood sugar levels after taking medications or skipping meals may cause falls.
    Mitigation: Regular checks with the endocrinologist, regular strength training exercises and diligent sugar management may help avoid related falls.

    Read about prevention and management of falls in people with dementia: https://www.patientsengage.com/conditions/leading-causes-precautionary-interventions-falls-persons-dementia

    More about Diabetic Neuropathy here: https://www.patientsengage.com/condition/diabetic-neuropathy

  3. Adverse effects of medications:

    Many medications may cause issues like dizziness, fall in blood pressure and/or slowed thinking and reduced alertness, which may lead to potential falls.

    Antibiotics (like Streptomycin, Gentamycin)- may cause ear damage and hearing loss, which may cause accidents and falls.

    Some pain killers (especially opioids like Buprenorphine and Tramadol) - may cause sedation, fall in blood pressure on sitting up/standing from lying position(orthostatic hypotension) and also low sodium causing dizziness.

    Antiarrhythmics (drugs used to correct heart rhythm like procainamide, quinidine, and sotalol) - May accentuate the fall in blood pressure on sitting up/standing from a lying position(orthostatic hypotension).

    Anticholinergics (Tricyclic antidepressants like amitriptyline, escitalopram, paroxetine, sertraline) - may cause dizziness, lightheadedness, cognitive impairment, and changes in vision that cause loss of visual accommodation.

  4. Drug interactions (polypharmacy)

    Elderly people who take four or more prescription medications on a daily basis are at 1.5–2 times higher risk of falling. This is known as polypharmacy. Polypharmacy may also cause issues like drug interactions.

    Read more about polypharmacy here: https://www.patientsengage.com/conditions/risks-polypharmacy-elderly

EXTRINSIC FACTORS

1. Environmental hazards.

  • Home hazards encompass clutter, loose rugs or mats, absence of stair railings, inadequate lighting, and lack of grab bars in the bathroom.
  • When it comes to outdoor conditions, variations in ground level, the presence of uneven surfaces, the existence of litter, and the occurrence of slippery surfaces may cause a fall.
  • Among the other environmental factors are air pollution, which can cause a lack of proper vision, tiredness, and dizziness sometimes, and excessive heat, which may lead to excessive sweating and lowered blood pressure that can further cause dizziness and falls 

How to prevent falls at home: https://www.patientsengage.com/conditions/fall-proofing-home-older-adults

2. Situational factors:

  • Engaging in conversation while strolling may cause one to lose focus.
  • Being engrossed in multitasking and subsequently failing to perceive an environmental hazard like a curb or step.
  • When in a hurry to use the restroom, especially at night or when lighting conditions are insufficient.
  • Rushing to answer any call.
  • Sometimes there may be a combination/interaction of intrinsic and extrinsic factors leading to fall.


Image Source: https://www.physio-pedia.com/Falls

How are falls evaluated?

  • Clinical evaluation: Examination of mental and physical wellbeing. 
  • Performance testing: Examination of mobility, strength, and gait. The Performance-Oriented Assessment of Mobility, the Timed Get-Up-and-Go test are helpful in identifying issues related to balance and stability during walking or The Dynamic Gait Index (DGI) is a score based on eight tasks including gait with varying speed, gait with transverse and sagittal head movements, and gait over and around obstacles, among others. Many such tools are used for individualized assessment at the doctor’s office/clinic.
  • Sometimes laboratory testing: When probable deficiency or morbidities are suspected. Tests like blood count, sugar profile, electrolytes, etc. are done.

Taxonomy used in the World Falls Guidelines

Here are a few terms that may be commonly used by your doctor or professionals in relation to assessment for falls in elderly.

Fall - An unexpected event in which an individual comes to rest on the ground, floor, or lower level.

Recurrent falls - Two or more falls were reported in the previous 12 months.

Unexplained fall - When no apparent cause has been found for a fall on performing a multifactorial falls risk assessment and a failure to adapt to an environmental hazard or by any other gait or balance, abnormality cannot explain it.

Severe fall - Fall with injuries that are severe enough to require a consultation with a physician; result in the person lying on the ground without capacity to get up for at least one hour; prompt a visit to the emergency room (ER); associated with loss of consciousness.

Fall related injury - An injury sustained following a fall. This includes an injury resulting in medical attention, including hospitalization for a fall such as fractures, joint dislocation, head injury, sprain or strain, bruising, swelling, laceration, or other serious injury following a fall.

Fall risk increasing drugs (FRIDs) - Medications known to increase the risk of falls.

Multi-component exercise - This type of program combines strength, aerobic, balance, gait and flexibility training.

Physical activity - Any bodily movement produced by skeletal muscles results in energy expenditure. The energy expenditure can be measured in kilocalories. Physical activity in daily life can be categorized into occupational, sports, conditioning, household, or other activities.

References:

Community
Alzheimer's and Dementia
Dermatological (Skin) and Opthalmology (Eyes) conditions
Diabetes
Muscle, Bone and Joint (earlier named Arthritis)
Neurological Conditions
Parkinsons Disease and Movement Disorder PDMDS
Condition
Arthritis
Dementia
Diabetes
Neuropathy
Osteoporosis
Parkinson Disease