S4: Falls and their Consequences Flashcards
Define a fall
- The definition of a fall is an event that results in a person coming to rest inadvertently on the ground, floor or other lower level below knee.
- It is where a person’s centre of mass goes outside their base support and an unintentional, unexpected loss of balance.
- It is different from syncope and collapse, this is because syncope implies loss of consciousness and both are a result of a medical problem whereas a fall may not be.
- Elderly population >2 falls a year is classified as a recurrent faller.
Facts about falls
- Falls are the most common cause of injury related death in people over 75. It is also the leading cause of injury related admission to hospital in those over 65. Thus understandably the cost of falls is massive, £2.3 billion a year/4.4 billion dollars. 5% of older people that fall sustain a fracture or are hospitalised.
- 1 in 3 over 65s living at home will fall at least once year with half of these falling more often than that (having falls increases likelihood of subsequent fall).
- Half of those over 80 will fall at least once a year, falls are also more common in care homes than those who live in the community. So age also increases falls.
Why do we fall?
- Incorrect shifting of bodyweight is the most common cause for falls (41%).
- Trip or stumble (21%). This can be because of: difficulty raising a foot or foot catching on the ground (31%),foot catching on equipment (29%), foot catching on furniture (25%), foot catching on other foot (6%) or being tripped by another person (6%).
- Loss of external object support (11%).
- Hit or bump (11%).
- Loss of consciousness or collapse (11%).
Describe the 3 main categories of factors contributing to falls
There are both intrinsic factors (that is about ourselves) and extrinsic factors (relating to our surroundings) why we fall. These can be summarised in a basic manner by the following acronym ACE:
- Age related changes (e.g. brain changes).
- Co-morbidities (inc. medications).
- Environment.
Describe age related neurological changes contributing to falls
- The neurological system undergoes age related changes that include brain atrophy, a loss of neurones (functional neurones) that cannot be regenerated. There is reduced synaptic transmission due to demyelinated neurones with slower processing speed and increased latency thus they communicate less well. There is also a decrease in brain weight (20%). As a consequence of these changes, we see a slower processing speed of the nervous system, there is a loss of proprioceptive activity (normally important in keeping adequate tone).
- Impairment of the vestibular system.
- Sensory impairment (fine touch/vibration/proprioception).
- All of these neurological deficits will functionally lead to balance impairment and bradykinesia (slow movement).
Describe age related muscle changes contributing to falls
- Our muscles also age and this can make us more likely to fall.
- Sarcopenia occurs with age and there is a loss of skeletal muscle mass and strength. This loss of muscle mass is not equal/uniform and generally the loss of muscle bulk in the legs is worse than the arms. Thus it increases chance to fall.
- Muscle mass <2.s.d. lower than healthy adult.
Describe age related posture changes contributing to falls
- With age, there are changes in posture: lumbar lordosis, thoracic kyphosis and cervical lordosis. Women lose 5 cm and men 3 cm in height by age 60.
- Changes in posture is due to less elastin in tissue, weaker abdominal muscles and changes in bone and ligaments. As a result it can make individuals less steady and also if the cervical lordosis is very severe it can mean the neck flops downwards so can’t see upwards.
Describe age related gait changes contributing to falls
With age there are changes in gait increasing risk of falling:
- Reduced stride length.
- Reduced gait speed.
- Increased time in double support phase (two legs in their walking cycle –> for stability).
- Reduced hip flexion and extension.
- Gait starts to become wider.
- Cadence unaffected.
Describe age related audio and visual changes contributing to falls
- Hearing also changes with age, the normal process of hearing loss is called presbycusis.
- The eye also undergoes many normal changes with age. There is:
- Steady deterioration in static acuity (perceiving detail of static objects).
- A more significant loss of dynamic visual acuity (perceiving detail of moving objects).
- Lens becomes opaque.
- Slower reaction to light changes.
- Reduced sensitivity to colour contrast (finding it more difficult to distinguish colours close to each other on spectrum).
- Long sightedness.
- These normal age related eye changes are very commonly seen with visual co-morbidities.
Describe system co-morbidies contributing to falls
Cognition~: - Dementia. - Delirium. CVS~: - Orthostatic hypotension. - Postural hypotension. - Arrhythmias. - Valvular heart disease. Balance~: - Stroke. - Parkinsonism. - Arthiritis. - Neuropathy, neuromuscular disease. - Vestibular disease. Visual impairment (very important) ~: - Cataracts. - Glaucoma. - Macular degeneration. - Retinopathy. Incontinence (e.g. slip). Onychogryphosis (severely overgrown nails) can increase the risk of falling as difficult to walk.
Describe drug co-morbidies contributing to falls
The elderly also tend to take many drugs. Understandably medications can increase the risk of falling due to their effects and side effects. Drugs including:
- Benzodiazepines e.g. diazepam , temazepam.
- Hypnotics e.g. zopiclone.
- Sedating antidepressants e.g. Amitryptiline, mirtazepine.
- Opiates e.g. codeine , tramadol.
- Anti-epileptics e.g. Phenytoin, Carbemaxepine.
- Alpha blockers e.g. Tamulosin, dozazocin.
- Diuretics e.g. Bendroflumethazide, indapamide.
- Beta blockers e.g. Atenolol, bisoprolol.
- ACE inhibitors e.g. Ramipril, lisinorpil.
- Sedating antihistamines e.g. piriton.
Describe how environment can contribute to falls
This generally refers to hazards at the home that are extrinsic factors, like poor lighting rails, rugs/carpets, clothing and footwear, mobility aids, pets.
Why is falling a problem?
This generally refers to hazards at the home that are extrinsic factors, like poor lighting rails, rugs/carpets, clothing and footwear, mobility aids, pets
Describe morbidity and mortality from falls
- Injury based.
- Morbidity and mortality from falls generally stems from fractures and head injuries sustained from the fall.
Describe psychosocial effects on falling
- Psychologically older people following a fall can be left with reduced confidence, a loss if independence and even fall into depression. There can be social isolation.
- Fear of falling syndrome: Falling may change gait –> less heelstrike –> shuffling–> increases likelihood of falling. Cautious gait –> muscles aren’t being used as much –> deconditioning –> risk of falling. It is a cycle where all the outcomes increase risk of falling which then increases the fear of falling syndrome.
