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Images courtesy of Nicole Cimino-Fiallos, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above computed tomography (CT) scans reveal a 3-mm right frontal, parietal, extracalvarial, subdural hematoma (arrows) found in a 95-year-old female after a ground-level fall.

The most common mechanism of injury in the elderly population is falling.[1] An estimated 10% of all falls in seniors cause major injuries, including intracranial injuries (ICIs) and fractures. One percent of all falls in this population result in hip fractures, which pose a significant risk for post-fall morbidity and mortality.[2,3] In 2019, according to the Centers for Disease Control and Prevention (CDC), falls were the leading cause of injury-related death in persons aged 65 years or older.[4]

Less than half of older patients who fall tell their clinician that they have had a fall.[5]

Image courtesy of Nicole Cimino-Fiallos, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above image shows a distal radius fracture, a common injury after a fall onto an outstretched hand.

Risk Factors

Fall risk factors include age over 85 years, male sex, White race/ethnicity, and a history of falls.[6] Advancing age alone is not necessarily responsible for an increased risk of falling. Rather, the overall health status of an elderly person is most strongly associated with the risk of a fall and subsequent injury.[6] Alcohol use is also a predictor for fall risk and may be underrecognized in the elderly.[6,7]

Factors associated with greater rates of fall injuries in seniors include previous medical diagnoses (eg, cerebrovascular accidents/transient ischemic attacks), arthritis, fractures, dementia, diabetes, vitamin D deficiency, anemia, arrhythmia, neuropathy, impaired vision/hearing, recent hospital discharge, higher body mass index, poor sleep/obstructive sleep apnea, and urinary incontinence.

Adapted Morse Fall Scale (MFS), from the Agency for Healthcare Research and Quality (AHRQ).

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

Various fall risk assessment tools are available for both clinical facilities and the patient's home. The Modified Morse Fall Scale (MFS) is often used to identify and score fall risk factors in hospitalized patients and in persons in clinical care settings. It takes into consideration a history of falls, secondary diagnoses, any intravenous (IV) access, and any use and/or type of ambulatory aid, as well as the patient's gait type and mental status.[8,9]

The STRATIFY fall score has also been used to assess the risk of falls in elderly patients and was revalidated in a study of hospital inpatients and nursing home residents.[10]

Management of Patient Risk Factors

Management of environmental factors is crucial, with attention paid to potential obstacles, slippery surfaces, and trip risks within the dwelling, as well as to improvement of lighting. Elimination of ill-fitting or inappropriate footwear and inappropriate assistive devices is also necessary.[11]

Image courtesy of Nicole Cimino-Fiallos, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above radiograph demonstrates a right femoral neck fracture.

Attention to medication choice and polypharmacy is also critical. Sedatives/hypnotics are significantly associated with fall risk, and antidepressants cause the highest risk of falls among seniors.[11] Other medications associated with an increased fall risk include diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and antihypertensives. The American Geriatrics Society (AGS) publishes an updated list of medications to be avoided in the elderly, known as the Beers Criteria Medication List.[12]

Other strategies that may be useful in reducing polypharmacy include a yearly review of medications; an approach to dosing known as "start low and go slow" may also be helpful in polypharmacy.[13]

Image from Wikimedia Commons | Shoyuramen.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

Slipping, tripping, and stumbling are major causes of falls in the elderly (about 30% of all falls). For elderly patients living in the community, hazards that contribute to fall injuries include stairs, bathtubs without handlebars, the presence of electrical cords, clutter, inappropriate lighting, and loose rugs.[2] Nursing home residents are at risk of falls secondary to wet floors and medical devices such as tubing and/or catheters. The use of restraints, bed rails, fall-alert bracelets, and bed alarms remains controversial. While one meta-analysis saw a decrease in falls with these interventions, other studies have shown lack of benefit and potential harm.[2,14]

(1) Adapted chart from Rosen T, Mack KA, Noonan RK. J Inj Violence Res. 2013;5(1):61-9. [Open access.] PMID: 22868399, PMCID: PMC3591732. (2) Center image of a house cutaway from Dreamstime | Tele52.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

Falls often involve the transition areas between carpets and rugs or noncarpeted sections and rugs; they also frequently occur on wet carpets or rugs or when seniors are hurrying to the bathroom.[15]

Frailty is a critical factor in determining fall risk and severity in the elderly. Assessing an older person's frailty may include evaluating the individual's ability to walk up a flight of stairs or carry a bag of groceries. Some seniors will seem frail in their 70s, whereas others may remain active and vital into their 90s. An elder who is frail has a higher likelihood of falling and a greater risk of injury from a fall.[16]

Multiple frailty indexes exist that can aid clinicians in selecting appropriate disposition for elderly patients who are discharged from the hospital or in predicting an elderly patient's risk of fall and serious fall-related injury.[17]

Image comparing bone density between normal bone and osteoporotic bone from Wikimedia Commons | BruceBlaus.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

Morbidity and Mortality

Relative to adults in other age groups, elderly patients who present to the emergency department (ED) following a fall have a unique bodily injury pattern, a higher injury severity score (ISS), worse outcomes, and higher mortality.[18] Elderly patients are more likely to suffer from osteoporosis and reductions in bone density, rendering them more susceptible to fractures and bony injuries.[19] Consequently, elderly patients will sustain more severe injuries with lower-force mechanisms than their younger counterparts, who have greater bone density.

Image from Pixabay | cocoparisienne.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

Injuries resulting from a fall can cause significant morbidity. Fractures are a major complication of falls, with 10% of falls causing a fracture and 2% of the fractures involving the hip(s). An estimated 75% of all vertebral and nonvertebral fractures occur in persons aged 65 years or older, and more than 75% of hip fractures affect seniors aged 75 years or older.[20]

Fractures are an independent predictor of long-term mortality. After a hip fracture, an elderly person has a 27% chance of dying within 1 year;[21] following a proximal femur fracture, 50% of affected seniors will experience a functional decline within 1 year.[22]

Image from the CDC.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

Clinical Evaluation

Clinicians must recognize signs of elder abuse/neglect, which affects about 10% of all seniors each year.[23,24] Take special note of bruising patterns involving the face, back, and areas not over bony prominences. The presence of decubitus ulcers, urine burns, intraoral lesions/injuries, and/or patterned injuries (eg, bite marks) also warrants investigation, as do lack of hygiene and poor control of medical conditions despite access to medical care and medications.[23]

Providers should also seek a medical explanation for dehydration, malnutrition, and/or mismanagement of medications that result in a fall. Unexplained fractures or delays in seeking medical attention should be addressed as well.

Image from Wikimedia Commons | James Heilman, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above CT scan demonstrates a large left frontal parietal subdural hematoma with midline shift.

The common use of anticoagulants and antiplatelet agents in elderly patients increases their risk of a significant ICI following a fall and is therefore a major concern.

In older patients who fall, head trauma is the most common cause of mortality.[25] If the patient presents at his/her baseline mental status after a fall, the chance of finding an ICI on CT scanning is low. However, the presence of dementia or cognitive decline may make determinations regarding baseline mental status challenging.

Because the risk of mortality is significant in elderly patients, clinicians must maintain a high suspicion for ICI in seniors, even in the presence of low-force mechanisms (eg, a fall from standing).

Image courtesy of Nicole Cimino-Fiallos, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above CT scan shows intraparenchymal and intraventricular hemorrhages, with resultant midline shift.

Diagnostic Studies

On the basis of history and physical examination findings, obtain screening laboratory and/or imaging studies to evaluate elderly patients who have fallen.[2] Initial tests may include a basic metabolic panel, a complete blood count (CBC), coagulation studies, assessment of vitamin B12 levels, thyroid function studies, and electrocardiography. Obtaining a urinalysis is important, as a urinary tract infection may induce subtle changes to balance, strength, and mentation, which may increase fall risk. Clinicians should have a low threshold for obtaining radiologic studies, particularly CT imaging of the central nervous system.

Images courtesy of Nicole Cimino-Fiallos, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

An acute minimally displaced femoral neck fracture is seen above on a radiograph (left) and CT scan (right).

In the elderly, more than 95% of hip fractures are caused by falls.[26] The initial diagnostic test for suspected hip fractures is plain radiography.

Occult hip fractures are present in up to 10% of all ED trauma patients with hip pain and negative radiographs, and they are more common in the geriatric population.[18,27]

Magnetic resonance imaging (MRI) has always been the imaging study of choice for identifying occult hip fractures.[27] Although MRI is still the preferred study, research has found that multidetector CT scanners are able to detect most occult hip fractures, with such scans more widely available and less time consuming to obtain.[27,28]

Image from Wikimedia Commons | PhilippN.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above image demonstrates the administration of an ultrasonographically guided femoral nerve block.

Pain Management

In elderly patients with hip fracture, early control of pain is essential. However, the use of opioids and systemic analgesics comes with significant risk in this population.

In studies comparing IV and oral pain medications in elderly patients with hip fractures, femoral nerve blocks placed by ED staff resulted in significant reductions in pain scores and opioid requirements.[29] Ultrasonographically guided lateral cutaneous femoral nerve blocks have been shown to provide good pain control without systemic side effects.[30]

The American Academy of Orthopaedic Surgeons (AAOS) provides a strong recommendation for multimodal analgesia that incorporates preoperative nerve block, in the 2021 update to its guidelines for the management of hip fractures in older patients.[31]

Image courtesy of Nicole Cimino-Fiallos, MD.

Falls in the Elderly: Causes, Injuries, and Prevention

Michael K Abraham, MD; Nicole Cimino-Fiallos, MD, FACEP, FAAEM | November 23, 2022 | Contributor Information

The above radiograph shows an impacted humeral neck fracture. The patient, a 90-year-old female, fell onto her left arm while walking. The image also reveals osteoarthritis.

Recurrent Falls/Anticoagulants

Approximately 5% of patients seen in the hospital for a fall will be hospitalized for another fall within 6 months.[1] Individuals using psychoactive or sedative drugs are at even higher risk of a recurrent fall or other adverse event,[32] whereas patients on anticoagulants are at higher risk of death from bleeding injuries after a fall.

Patients and their doctors must discuss the risks/benefits of restarting anticoagulation after a fall.[1] The HAS-BLED and CHA2DS2-VASc scores can be helpful in making such decisions for patients on blood thinners for atrial fibrillation.[33] Guidance also exists for anticoagulation used for other indications.

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