why old people fall (and how to stop them)

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REVIEW Pract Neurol 2007; 7: 158–171 Why old people fall (and how to stop them) N C Voermans, A H Snijders, Y Schoon, B R Bloem N C Voermans Senior Registrar A H Snijders Senior Registrar B R Bloem Consultant Neurologist and Head of the Parkinson Center Nijmegen Department of Neurology, Radboud University Nijmegen Medical Centre, the Netherlands Y Schoon Consultant Geriatrician and Head of the Falls & Syncope Clinic Department of Geriatrics, Radboud University Nijmegen Medical Centre, the Netherlands Correspondence to: Dr B R Bloem Parkinson Centre Nijmegen (ParC), Department of Neurology, 935, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands; [email protected] F alls in older people are a common, dangerous and frequently incapacitat- ing problem. They are often perceived as being untreatable—but this is an overly negative perspective. In any event, in the next few decades we will increasingly be confronted with elderly fallers as life expec- tancy continues to rise. This applies particu- larly to general practitioners, emergency department staff, geriatricians and neurolo- gists. In this review, we will underscore the clinical significance of falls in the elderly and then outline a practical approach for their management. Core elements of this approach include: N ascertaining whether or not the patient actually fell N reliably classifying the nature of the falls N identifying the causes and associated risk factors for falls N tailoring an individualised treatment to the identified contributing factors, in order to reduce falls and fall-related injuries, or even to prevent them altogether. 158 Practical Neurology 10.1136/jnnp.2007.120980

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Page 1: Why old people fall (and how to stop them)

REVIEWPract Neurol 2007; 7: 158–171

Why old peoplefall (and how tostop them)N C Voermans, A H Snijders, Y Schoon, B R Bloem

N C VoermansSenior Registrar

A H SnijdersSenior Registrar

B R BloemConsultant Neurologist and Head

of the Parkinson Center Nijmegen

Department of Neurology,

Radboud University Nijmegen

Medical Centre, the Netherlands

Y SchoonConsultant Geriatrician and Head

of the Falls & Syncope Clinic

Department of Geriatrics, Radboud

University Nijmegen Medical

Centre, the Netherlands

Correspondence to:

Dr B R Bloem

Parkinson Centre Nijmegen (ParC),

Department of Neurology, 935,

Radboud University Nijmegen

Medical Centre, PO Box 9101, 6500

HB Nijmegen, the Netherlands;

[email protected]

Falls in older people are a common,

dangerous and frequently incapacitat-

ing problem. They are often perceived

as being untreatable—but this is an

overly negative perspective. In any event, in

the next few decades we will increasingly be

confronted with elderly fallers as life expec-

tancy continues to rise. This applies particu-

larly to general practitioners, emergency

department staff, geriatricians and neurolo-

gists. In this review, we will underscore the

clinical significance of falls in the elderly and

then outline a practical approach for their

management. Core elements of this approach

include:

N ascertaining whether or not the patientactually fell

N reliably classifying the nature of the falls

N identifying the causes and associated riskfactors for falls

N tailoring an individualised treatment tothe identified contributing factors, inorder to reduce falls and fall-relatedinjuries, or even to prevent themaltogether.

158 Practical Neurology

10.1136/jnnp.2007.120980

Page 2: Why old people fall (and how to stop them)

WHY ARE FALLS IMPORTANT?Falls in the elderly are a major health problem,

first and foremost for the affected individuals

whose quality of life is markedly reduced, and

also for the public health system because of

the immense costs associated with falls and

the resultant injuries. The risk of falls increases

with age: about one third of those over 65

years of age fall at least once a year, and about

half of them even more often.1 Apart from age,

prominent risk factors include previous falls,

female gender, concomitant neurological dis-

ease, living in a nursing home, fear of recurrent

falling, and regular alcohol intake.2, 3

Falling is serious, for several reasons:

N Falls may cause severe injury, and in upto 25% of elderly fallers this requiresmedical attention.4 Hip fractures arecommon and widely feared, and second-ary complications due to immobility arefrequent.

N Secondary immobility after a fall iscommon, and can be devastating in itsown right as this promotes osteoporosis,which in turn increases the risk offractures following future falls. A drivingfactor behind immobility is a fear ofrecurrent falls, which is regularly experi-enced by elderly fallers and may occur

even after a single and seeminglyinnocent fall. For some patients, this fearof falling is appropriate because theirbalance is severely disturbed, but forothers the degree of fear is dispropor-tionate and leads to unnecessary immo-bility, loss of independence and evensocial isolation.

N Up to 50% of elderly fallers are unable toget up after a fall, not only as a result ofinjury, but more commonly because ofphysical frailty and proximal muscleweakness. Patients who lie on the groundfor a long time may develop dehydration,pressure sores , rhabdomyolys i s ,hypothermia or pneumonia, all of whicheventually may be fatal.

N Falling and fall-related injuries are a pro-minent reason for nursing home admission.

N Falls are often a marker for an underlyingdisease, progression of which may con-tribute directly to the increased mortality,for example in patients with cardiovas-cular or cerebrovascular disease.5

N Not surprisingly, quality of life amongelderly fallers is markedly impaired.6

N Recurrent falls may reduce life expectancy,either directly (for example, subduralhaematoma following head trauma) orindirectly due to complications of the fall.

About one third ofthose over 65 yearsof age fall at leastonce a year

Figure 1The vicious circle of falling in the

elderly. Modified from Bloem BR, van

Vugt JP, Beckley DJ. Postural instability

and falls in Parkinson’s disease. AdvNeurol 2001;87:209–23,

159Voermans, Snijders, Schoon, et al

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A vicious circle of falling, balance problems,

fear of falling, immobilisation and isolation

mainly occurs in those who have recurrent

falls, or who lie on the ground for a long time

after their fall (fig 1).

THE CLINICAL APPROACH TOFALLINGBackgroundMany clinicians regard falls as an unavoidable

accompaniment to normal ‘‘ageing’’. However,

up to 20% of very old individuals still have a

completely normal gait and do not fall despite

their age—indicating that balance and gait

disorders are certainly not an inevitable

consequence of ageing. Indeed, falls in the

elderly should always initially be regarded as

pathological and therefore require the identi-

fication of some underlying disease or risk

factor. Falls tend to deter doctors because of

their complex underlying pathophysiology,

and clinicians are often frustrated in their

approach to elderly fallers because their

accounts, and even those of eyewitnesses,

are often incomplete. Too often falls in the

elderly are perceived as untreatable, and

therefore deemed unsatisfactory to deal with.

We hope this review will remove some of

these false preconceptions so that clinicians

come to regard elderly fallers as a gratifying

challenge, rather than as a frustration.

Bedside history and examinationAs ever, the approach to elderly fallers

requires a thorough history (table 1), careful

review of medical records, eyewitness reports

and fall diaries, as well as a detailed physical

examination.2 Questions should not only

focus on the falls per se, but also on their

consequences; hip fractures are typically

caused by lateral falls, bilaterally damaged

patellas by drop attacks, and wrist fractures

by a fall on the outstretched hand suggesting

that consciousness was preserved while fall-

ing. The medical records should contain a lot

of relevant and readily available information,

including medical history, home circum-

stances and, importantly, use of sedative

drugs or other predisposing medications.

Physical examination (table 2 and fig 2)

should include a careful gait and balance

assessment, preferably using ‘‘functional’’

tests which focus on the performance of

everyday activities, a search for underlying

risk factors, and any physical injuries.2

Evaluation of gait is mandatory because

any walking problems increase the risk of

falling: a shuffling gait increases the risk of

stumbling over obstacles, and episodic gait

disorders commonly lead to falls because

patients are caught unprepared. For example,

freezing of gait, where patients suddenly feel

as if their feet have become glued to the

floor7 is seen in Parkinson’s disease, as well as

other parkinsonian disorders. Assessment of

freezing is notoriously difficult because it is

so often absent in the examination room.

TABLE 1 Key elements of the history in elderly fallers

Classification of fallsl Present falll Earlier falls43

Cause of the falll Nonel Environment (eg, loose carpet)l (Sudden) change of posturel Performing several activities simultaneouslyl Hazardous behaviourl Inappropriate footwearSymptoms preceding the falll Light-headedness or vertigol Loss of consciousnessl Palpitations/chest pain/breathlessnessl Sudden weakness of the legsSymptoms after the falll Inability to stand upl Loss of consciousnessl Physical injuryl Fear of fallingSecondary immobilityUse of walking aidsl Prescribed by whom?l Difficulties in use?l If none, why not?Medical historyl Prior/current diseasesl (Psychoactive) medication and drug combinationsl Intoxication (alcohol)Domestic situationl Stairs, lighting, loose rugs, etc.l Support (partner, relatives, friends)Protective factorsl Exercise levell Adaptive behaviour/activities

Modified from Bloem BR, Boers I, Cramer M, et al. Falls in the elderly.I. Identification of risk factors. Wien Klin Wochenschr 2001;113:352–62.

160 Practical Neurology

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Helpful aids are the use of specific freezing

questionnaires, interviewing the spouse, or

demonstrating to the patient what freezing

actually looks like. Useful tricks to provoke

freezing include asking patients to initiate

gait, to negotiate a narrow passage, and to

walk while performing a ‘‘dual task’’ (for

example, answering questions, or carrying an

object). Perhaps the best test is to ask patients

to turn around 360 ,̊ first in their preferred

direction, and then in the opposite direction—

the latter will provoke freezing much more

often. Recognition of freezing requires insight

into the three different clinical phenotypes:

shuffling with small steps; ‘‘trembling in

place’’ (rapid shuffling movements of the

feet, but without the patient moving for-

ward); or (more rarely) akinesia with complete

inability to start or continue walking.

Standardised rating scales such as the

Tinetti Mobility Index8 and the Berg Balance

Scale9 are useful tools to describe most aspects

of balance and gait, and we also value the

opinion of an experienced physiotherapist who

can review the patient more extensively in

various circumstances, and also judge how

well patients can use their walking aids.

Timed tests (for example, the 6-minute

walking test, timed up and go test, single leg

stance duration) have the advantage of

providing quantitative information, and

scores beyond established cut-off values

may help to predict the risk of falls (table 2).10

Orthostatic hypotension is detected by

measuring blood pressure, first in a recum-

bent position (preferably after a rest), and

again after 1, 3 and 5 minutes of standing.

Meanwhile, the patient should be observed

for signs and symptoms of orthostatic

hypotension such as ‘‘dizziness’’, pallor,

perspiration and stumbling. Note that clini-

cally relevant orthostatic hypotension can be

missed if the blood pressure is only measured

once, and continuous blood pressure record-

ing while patients are passively tilted upright

may even be required.11

Assessment of vision with and without

correction is important because many falls are

related to visual impairment. Paradoxically, poor

vision is probably worse than no vision at all;

poor vision provides false feedback and leads to

incorrect movement planning, while no vision

can at least be replaced by the intact remaining

senses (for example, proprioceptive and vestib-

ular) thanks to the physiological redundancy

between these three afferent systems.

The need for cognitive testing is under-

scored by the accumulating evidence of a

TABLE 2 Key elements of the physical examination in elderly fallers

Physical injuries General inspection (patient undressed)Risk factors Cardiovascular examination

Joints (ankles, knees, hips)Orthostatic hypotension*Carotid sinus hypersensitivityCognitionVision (with/without correction)Vestibular testsStrength of the legsProprioception in the lower limbs

Gait and balance analysis Quiet standingRetropulsion testFunctional tasks:l simple walkingl turning while walkingl rising from chair and sitting downl getting out of bedl picking up objects from floor or cupboardl climbing stairsl tandem gaitl narrow passageMultitasking:12, 44

l cognitive task while walking (eg, talking)l motor task while walking (eg, carrying an

object)l combinations of cognitive plus a motor

task (eg, talking while carrying an object)Quantifiable tests (cut-off values forquantifiable tests are shown in italics):{l ‘‘6-minute walking distance’’45

l ‘‘sit-to-stand test’’46

l ‘‘functional reach’’ test47 ,17 cmassociated with increased risk of falling

l ‘‘get-up and go test’’48,49 .13.5 sassociated with increased risk of falling

l ‘‘one-leg balance test’’50

Standardised rating scales:l Tinetti mobility index8 score ,19

represents high risk of falls and 19–24a moderate risk

l Berg balance test9

*Consider tilt table testing and non-invasive blood pressure recordings whenbedside examination for orthostatic hypotension is negative and where there isa high index of clinical suspicion.{For normal values please see Isles et al10 and Steffen et al.51 A more extensivelist of quantifiable tests and scales can be found on the PrOFaNE website(http://www.profane.eu.org/eu_map/map_views.php).

161Voermans, Snijders, Schoon, et al

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close relation between falls and cognitive

decline (fig 3). For example, falls are related to

being unable to walk and talk at the same

time; inability to perform such seemingly

simple tasks simultaneously has proven to be

a good predictor for future falls.12 Moreover,

some elderly people loose their ability to deal

with complex ‘‘multitask’’ circumstances and

fail to give priority to the most important task

(maintaining balance) at the expense of an

increased risk of falling.13 Falls are common in

patients with cognitive decline caused by

Alzheimer’s disease (for example)14 and they

are exceptionally common in disorders that

combine motor impairment with cognitive

decline, such as progressive supranuclear

palsy. Cognitively impaired people are also

more frequently exposed to dangerous situa-

tions due to their inability to estimate the risk

of falling, and their loss of control of gait

velocity.15 A global impression of cognitive

function can be obtained during the history,

and formal tests for frontal executive dys-

function are particularly important in patients

with gait disorders.16 Additional bedside and

sometimes more elaborate neuropsychologi-

cal tests should be used to detect underlying

conditions such as Alzheimer’s disease or

vascular dementia.

Ancillary investigationsQuantitative gait and balance assessments

(for example, static or dynamic posturo-

graphy) are interesting scientific tools, but

their use in daily practice is generally

precluded by their high costs and insufficient

individual diagnostic value.17 Brain imaging,

preferably with MRI, should be considered in

patients with unexplained falls, mainly to

detect treatable disorders such as hydroce-

phalus, or disorders which might at least

explain the falling even if they are not easily

Figure 2Useful gait and balance tests.

Figure 3Pathophysiology of falling.

162 Practical Neurology

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Page 6: Why old people fall (and how to stop them)

treatable such as periventricular white matter

changes.18, 19 Other tests must be tailored to

the clinical suspicions raised during the

history and examination, and serve to identify

underlying disorders. A more elaborate

work-up may be required for patients whose

falls were preceded by transient loss of

consciousness:

N blood tests to detect electrolyte andglucose disturbances

N electrocardiography for suspectedcardiac syncope, with 24-h monitoringif necessary

N electroencephalography when seizuresare in the differential diagnosis

N carotid sinus massage to detect thecarotid sinus syndrome

N tilt table testing to provoke syncopeunder controlled conditions is useful inthe diagnostic work-up of patients withsuspected orthostatic syncope (commonin the elderly) or vasovagal syncope (rarein the elderly).

DID THE PATIENT REALLY FALL?This question can sometimes be surprisingly

difficult to answer, and it can help to have a

definition for falls: ‘‘any sudden, unexpected

event that caused the person to unintention-

ally land on any lower surface (object, floor or

ground), regardless of any sustained injury’’.

Many older people do not mention their falls,

simply because they accept falling as part of

their ageing process. Others forget their falls,

even if injury occurred, partly because of the

association between memory impairment and

falling.20 And even if patients do recall their

falls, they often find it difficult to recall

exactly under what circumstances the fall

occurred.2 Asking patients and/or their carers

to keep a dedicated falling diary is useful to

record the number and circumstances of the

falls,21 and a ‘‘falls hotline’’, where patients

can report and discuss their falls immediately

after they have occurred, is also helpful.

Whether a fall was preceded by loss of

consciousness can be difficult to ascertain

because syncopal falls are often associated

with amnesia for the fall, even in cognitively

intact elderly people. A useful trick is to ask

the patients whether they recall hitting the

ground after their fall. If not, consider

transient loss of consciousness, even when

patients deny it. Eyewitness accounts should

be helpful, but are commonly unavailable or

incomplete.22

WHAT SORT OF FALL(S) DID THEPATIENT HAVE?Once it has become clear that a patient really

has fallen, the next step is to classify the

nature of the fall(s), which provides the basis

for tailored treatment (fig 4).

A single fall or recurrent falls?This is important, because single falls with an

obvious extrinsic cause (like ice on the

pavement) merely require treatment of any

associated injuries, without further analysis

into the cause of the fall. But if no obvious

extrinsic cause can be found, or if a patient

has had recurrent falls, further investigations

are justified.

Is there a pattern to the falls?For patients with recurrent falls, the next step

is to identify any stereotypical pattern. For

example, patients may say their falls occur

exclusively immediately after rising from

sitting or lying, and so they could have

orthostatic hypotension, or severe balance

impairment leading to insecure transfers.

Identification of fall patterns also has ther-

apeutic consequences. For example, adapting

the house is a useful approach for patients

who only fall due to trips over doorsteps, or

while climbing stairs. When patients present

with different types of falls, each fall type

should be scrutinised separately.

Were extrinsic or intrinsic riskfactors (or both) involved?The next step is to decide whether the falls

were predominantly related to ‘‘intrinsic’’

(patient-related) factors (yellow boxes in fig 3)

or ‘‘extrinsic’’ (in the environment) factors

(orange box in fig 3). And this process should

Did the patient really fall?

l Ask family or other carers about the falls.l For patients with suspected loss of consciousness obtain an eyewitness

report.l Ask patients to keep a falls diary.l Consider implementing a falls ‘‘hotline’’.

Falling in theelderly is typically amultifactorialproblem, wheremultiple risk factorsjointly contribute tofalls in eachindividual patient

163Voermans, Snijders, Schoon, et al

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Page 7: Why old people fall (and how to stop them)

also focus on identifying specific protective

factors (which will be discussed in the

following paragraph), because this determines

the net risk of falling (green box in fig 3). Note

that falling in the elderly is typically a

multifactorial problem, where multiple risk

factors jointly contribute to falls in each

individual patient. And that falling often

results from interactions between intrinsic

and extrinsic factors. For example, a doorstep

might only create problems when step height

is diminished, as in patients with Parkinson’s

disease or a dropped foot due to ankle extensor

weakness. Therefore, physicians should not

stop when a single risk factor has been

identified, but instead pursue a systematic

search for multiple intrinsic and extrinsic risk

factors, as well as any protective factors.

Extrinsic (environmental) factorsExtrinsic risk factors include freshly polished

floors, wet bathroom tiles, stairs, loose carpets,

uneven pavements, poor lighting, stepping

onto escalators, and dogs or cats in the

household.3 Inappropriate footwear (high heels,

slippery soles or loosely fitting shoes) is another

common extrinsic factor. The risk of falling

indoors is also associated with walking bare-

foot, or in socks. Modern buses and trains with

their fast acceleration and automatic doors can

cause considerable difficulty for elderly people

who may fall before they can find a seat.

Intrinsic (patient-related) factorsMany elderly people cannot identify clear

extrinsic determinants for their fall, and have

repeated falls in seemingly harmless situations.

They merit a thorough work-up of intrinsic risk

factors as there is a high risk of recurrent falls.2

Intrinsic risk factors often include one or more

underlying disorders, in combination with

drugs, alcohol or both (table 3; fig 3).

Use of medication is a prominent risk

factor in the elderly. The underlying

Figure 4A diagnostic algorithm to classify falls.

TLOC, transient loss of consciousness;

COM, centre of mass; BOS, base of

support.

164 Practical Neurology

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Page 8: Why old people fall (and how to stop them)

pathophysiological mechanisms may include

a combination of sedation, cognitive impair-

ment, carotid sinus syndrome, orthostatic

hypotension, urinary incontinence, beha-

vioural abnormalities, extrapyramidal adverse

effects, ataxia, and muscle weakness.

Particularly notorious are benzodiazepines

and antidepressants,23 recent initiation of

new medication and polypharmacy.

Neuroleptics, antihypertensive medication,

and anti-arrhythmics also increase the risk

of falls.24 In Parkinson’s disease, dopaminergic

medication may paradoxically increase the

falling frequency by causing violent dyskine-

sias, sudden freezing of gait, orthostatic

hypotension or confusion.25

Many chronic diseases are associated with

falls (table 3), both acute disorders (for

example, delirium, urinary tract infection with

urge incontinence) and a wide range of

chronic conditions. Note that physical impair-

ments such as urine incontinence or visual

impairment are more important than the

diseases themselves in predicting recurrent

falls. One important example is diabetes

mellitus, which may contribute to the risk of

falling by various mechanisms, including

hypoglycaemia, diabetic retinopathy, poly-

neuropathy, foot ulcers and stroke. Urge

incontinence is also associated with falls,

partly because the underlying disease may

cause incontinence and falls (for example,

stroke), and partly because night-time visits

to the toilet in darkness provide ideal falling

circumstances.26, 27 Osteoporosis should be

suspected in patients who have low-impact

fractures, in nursing home residents, in frail

elderly people and those taking steroids.

Were the falls associated with atransient loss of consciousness?For patients with intrinsic falls, the next step

is to clarify whether they were preceded by

transient loss of consciousness (distinguished

from loss of consciousness occurring after

the fall—for example, due to head injury). If

so, their diagnostic and therapeutic work-up

is completely different from patients who fell

with preserved consciousness; epilepsy, syn-

cope and psychiatric disorders all need to be

considered (table 4).

A major category is syncope, where—by

definition—loss of consciousness is caused by

failure of the cerebral circulation, itself almost

always due to a failure of the systemic blood

circulation. The falls are mostly backwards,

either flaccidly or stiffly. Syncope is typically

preceded by presyncopal features, such as

blurred vision and loss of colour vision

(‘‘greying out’’), loss of control over eye and

other movements, constriction of the field of

vision, and hearing loss. The loss of con-

sciousness usually lasts less than 20 seconds,

and involuntary multifocal jerky movements

may be seen, but in contrast with epileptic

seizures, these are non-rhythmic and asyn-

chronous involving various body parts.11

Urinary incontinence is common (so this does

not differentiate syncope from epilepsy) but a

lateral tongue bite is rare (this does suggest

epilepsy). Patients recover promptly and

spontaneously, with rapid improvement of

behaviour and cognition. In the elderly

however, syncope can present in a less typical

way without all the usual features, and

retrograde amnesia is common. Orthostatic

TABLE 3 Chronic diseases that are often associated with falls, withoutany preceding loss of consciousness

Category ofdisorder Impairment Example of disorder

‘‘Afferent’’disorder

Visual impairment CataractDiabetic retinopathy

Vestibular dysfunction Benign paroxysmal positionalvertigoVestibular neuronitis

Disturbedproprioception

Sensory polyneuropathyVitamin B1, B6 and B12 deficiency

‘‘Efferent’’disorder

Pyramidal Motor strokeExtrapyramidal Parkinson’s diseaseCerebellar Alcohol abuseLower motor neuron Motor polyneuropathyNeuromuscularjunction

Myasthenia gravis

Muscles Steroid myopathySarcopenia

Joints ArthritisCentralprocessingdisorder

Cognitive slowing/decline

Alzheimer’s disease

Impaired alertness Subcortical white matter lesionsMedication Various Psychoactive cardiovascular

combinationsIntoxication Alcohol, benzodiazepines

Modified from Bloem BR, Boers I, Cramer M, et al. Falls in the elderly. I.Identification of risk factors. Wien Klin Wochenschr 2001;113:352–62.

165Voermans, Snijders, Schoon, et al

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Page 9: Why old people fall (and how to stop them)

hypotension and the carotid sinus syndrome

are the most common causes of syncope in

the elderly,28, 29 and it is most important to

identify cardiac syncope because mortality is

doubled due to the underlying heart disease

(we refer to a recent review for further details

of syncope11).

Epilepsy is a less common cause of falls in

the elderly. Eyewitness reports are crucial for

the diagnosis. The characteristic tonic-clonic

with massive, synchronous jerking move-

ments of face and limbs usually occur after

the patient has fallen to the floor. The

duration of the actual seizures is generally

brief, often only a few minutes. However,

unlike syncope, postictal confusion and ante-

rograde amnesia are distinctive features,

typically for at least several minutes, but

often much longer. Seizures in old age call for

a search for an underlying cause, such as a

brain tumour or other focal lesion. Note that

epilepsy is sometimes the result of a fall,

rather than its cause—for example, in the case

of brain concussion or intracranial haema-

toma. Electroencephalography may confirm

the clinical suspicion of epilepsy and help

classify the seizure type, but it is often normal

in the inter-ictal phase. More importantly,

EEG can assist in predicting the risk of

recurrent seizures.

Was the fall preceded by a‘‘funny turn’’?When preceding loss of consciousness is ruled

out, the next step is to ascertain whether the

fall was preceded by a ‘‘funny turn’’ of some

kind. Many elderly people report ‘‘dizziness’’

as the cause of their falls. Try to clarify

precisely what they mean: was it vertigo

(spinning sensations, usually accompanied by

nausea) or light-headedness (perhaps with

presyncopal features)? Ask patients to specify

whether their dizziness was ‘‘in the head’’

(suggesting syncope or vertigo), ‘‘in the eyes’’

(suggesting poor vision) or ‘‘in the legs’’

(suggesting venous insufficiency, or sensory

ataxia due to polyneuropathy). Note that falls

preceded by funny turns do often turn out to

be caused by syncope, even when loss of

consciousness is denied.

Is there any balance or gaitdisturbance?If the fall was the result of an intrinsic factor,

but not preceded by loss of consciousness or

some funny turn, the next question is

whether the patient’s balance or gait is

sufficiently disturbed to explain it. If these

are normal or only minimally impaired, falls

might be caused by drop attacks or, in

younger people, by cataplexy or hyperek-

plexia.11 Note that patients may have episodic

gait disturbances that are easily missed in the

office, but which are notorious causes of falls

because their episodic nature makes it

difficult for patients to adapt their walking

behaviour—for example, freezing of gait in

parkinsonian disorders, and neurogenic clau-

dication due to lumbar stenosis.7

‘‘Base-of-support’’ or ‘‘centre-of-mass’’ falls?Falls caused by balance or gait disturbances

can be subdivided into two categories:

TABLE 4 Falls associated with transient loss of consciousness

SyncopeN Reflex syncope Vasovagal syncope

Postprandial syncopeSituational faintCarotid sinus syndromeCough syncope

N Orthostatic syncope Autonomic failure:l primary autonomic failurel secondary autonomic failure

(drugs, alcohol)Hypovolaemia

N Cardiac or cardiopulmonary syncope Cardiac arrhythmiasCardiac structural abnormalities(with obstruction of outflow)

Non-syncopalN Epileptic seizuresN Metabolic disorders Hypoxia

HypoglycaemiaHyperventilation

N IntoxicationsN Cerebrovascular disordersN MigraineN Vascular—eg, subclavian steal syndrome (rare)

Modified from Bloem BR, Overeem S, van Dijk G. Syncopal falls, dropattacks and their mimics. In: Bronstein AM, Brandt T, Woollacott MH, et al,eds. Clinical disorders of balance, posture and gait. Arnold, London, 2004.(Reproduced in adapted form by permission of Edward Arnold (Publishers) Ltd.)

166 Practical Neurology

10.1136/jnnp.2007.120980

Page 10: Why old people fall (and how to stop them)

N ‘‘base-of-support falls’’ caused by displa-cement of the feet (for example, slips, ortripping over obstacles)

N ‘‘centre-of-mass falls’’ related to trunkinstability, either during self-inducedperturbations (for example, bending,reaching or turning) or caused by exter-nally applied perturbations (for example,a push or collision).30

Making this distinction helps to identify the

underlying problem: base-of-support falls

occur in patients with lower leg weakness

(dropped foot) or distal sensory loss caused

by polyneuropathy. Centre-of-mass falls are

common in parkinsonian patients. This dis-

tinction also has implications for treatment,

because frequent base-of-support falls could

justify a home visit by the occupational

therapist to remove obstacles from the floor.

Conversely, centre-of-mass falls call for

optimised treatment of the underlying bal-

ance deficit in trunk control.

What if patients think they fellspontaneously?What to do when the physician is unable to

pinpoint even a single risk factor for

apparently spontaneous falls is a common

problem:

N One diagnosis to consider is drop attacks,typically in middle-aged women who fallspontaneously during walking, and onlyrarely while just standing, without loos-ing consciousness.11 Men are rarelyaffected. The typical story is of sudden,unexpected falls without preceding lossof consciousness, and without prodromalor postictal symptoms. There is norelation to change in posture, headmovement or any other specific precipi-tating event. Patients typically fallstraight down or forward onto theirknees. Unlike syncope and epilepsy, thereare no associated involuntary move-ments. If no injury occurs, the patientscan get up immediately and resume theiractivities. Most of these drop attacksremain cryptogenic.11

N A second possibility is that the patient didin fact fall due to loss of consciouseness,but failed to recognise this (see above).

N A third option is freezing of gait, whichwe described above. Not all patients canproperly identify their freezing episodes,but instead report ‘‘spontaneous’’ falls.

Asking about the direction of falls can provide

a diagnostic clue: forward falling suggests

freezing of gait in Parkinson’s disease;

(sudden) backward falling suggests progres-

sive supranuclear palsy; and vertical (down-

ward) falling suggests syncope or drop

attacks. Lateral falls have little diagnostic

value, but have great clinical relevance

because these cause hip factures. Inability to

stand up after a fall may suggest a preceding

epileptic seizure or stroke.

HOW TO PREVENT RECURRENTFALLSPrevention of falls and subsequent injuries

requires treatment of any underlying disorder

and elimination of the associated risk factors.

Primary prevention focuses on elderly

people who have not yet fallen, and aims to

eliminate risk factors that are common in the

elderly such as lack of exercise, or unneces-

sary use of psychoactive drugs. Tackling risk

factors that are only weakly associated with

falls, such as inappropriate footwear, may still

be rewarding if they are sufficiently prevalent

in the general population. Preventing osteo-

porosis reduces the chance of fracture should

the patient fall. Various exercise pro-

grammes—walking, Tai Chi and dancing—can

clearly improve strength, endurance and

balance, and several controlled trials have

shown a significant reduction in falling.31

Secondary prevention focuses on elderly

people who have fallen at least once and aims

to avoid recurrent falls. Here, the emphasis is

more on treatment of specific underlying

disorders and eliminating intrinsic or extrinsic

risk factors that are strongly associated with

falls.

What sort of fall(s) did the patient have?

l Did the patient fall once or recurrently?l Is there a pattern to the falls?l Which intrinsic and extrinsic risk factors are involved?l Were the falls preceded by loss of consciousness?l Was the fall preceded by a ‘‘funny turn’’?l Is there a balance or gait disturbance?l Can the falls be characterised as ‘‘base-of-support’’ or ‘‘centre-of-mass’’

induced?l Did the patient think he/she fell spontaneously?

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Tertiary prevention concerns measures that

benefit elderly people who fall very often,

have sustained recurrent injuries, and who

have risk factors for falls that are hardly

amenable to secondary prevention. This

includes frail elderly people in nursing homes,

demented patients, and patients with severe

motor handicaps—for example, end-stage

parkinsonism. Here the aim is to limit the

impact of falls using hip pads, installing

personal alarm systems, or home surveillance

of solitary elderly people.32

Falls prevention should involve a multi-

disciplinary falls team,33 including a clinician

with appropriate skills and experience or

a specialist (for example, geriatrician,

neurologist), physiotherapist, occupational

therapist and specialist nurse. The proposed

interventions should be practical and easy to

implement, and this calls for optimal coop-

eration with the patient and their family.

Patients should receive both verbal and

written information on the preventive mea-

sures. Table 5 lists possible strategies for

secondary prevention.32, 34, 35

Several measures deserve specific attention:

N Drug combinations of any type should beavoided in elderly fallers, and the phar-macist can play an active role here. Arecent randomised controlled trialshowed that when a pharmacist reducedthe number of drugs in elderly care homeresidents, the number of falls wasreduced by 40%.36 Psychoactive drugs(mainly benzodiazepines and antidepres-sants) should be stopped or minimised.Drugs in high doses or with long half-times should particularly be avoided.

N Promoting the use of walking aids alsodeserves specific attention. Many elderlypeople do not use them, either becausethey are not recommended to do so orbecause they are ashamed or embar-rassed. For many older people, the use ofwalking aids can be unsafe but if those atrisk are instructed properly, they are oftenpleased with their regained confidence,mobility and independence. Physio-therapists or occupational therapistscan assist in selecting the appropriatewalking aids, and train patients howto use them properly.37 Physiotherapistscan also teach people to make safertransfers and increase their physicalfitness.

TABLE 5 Possible strategies for secondary prevention

Risk factor/disorder Possible intervention/therapy

Environmental riskfactors

Assessment by occupational therapistRemove loose rugs and doorstepsHandgripsImprove lighting in vital areas (staircase, bathroom)Handrails, stair rails and anti-slip material (toilet,bathroom)Higher chairs and bedsMove to ground floor house

Psychoactive drugs Stop or reduce doseNon-pharmacological treatment of sleep problems

Drug combinations Avoid when possibleVisual impairment Corrective lenses; avoid multifocal lenses while

walkingCataract surgery

Proprioceptiveimpairment

Treat underlying cause if possibleIncrease proprioceptive input with assistive deviceor appropriate footwear

Decreased musclestrength

Referral to physiotherapist for assistive devices andfor gait and progressive balance training

Orthostatichypotension

Stop or reduce causative drugsAdequate hydrationElevate head of the bed (at least 30 )̊Avoid precipitating circumstancesAnti-orthostatic manoeuvres (standing with crossedlegs or regular ‘‘tip-toeing’’)Elastic compression stockingsSodium chloride tabletsFludrocortisoneExercise

Osteoporosis Promote physical exerciseAnti-osteoporotic treatment

Footwear Avoid high and narrow heelsSturdy shoes with leather soleAnkle bracesRefer to chiropody in case of foot abnormalities

Cardiovascular disease Treat hypertensionTreat hypercholesterolaemiaStop smokingDaily exercise/physiotherapy

Balance problems Treat cause if possiblePhysiotherapyPromote walking aidsProvide external support (eg, handrails or walkingaids)

Urge incontinence Treat underlying cause if possibleSymptomatic treatment (eg, oxybutinine)

Cognitive impairment Treat cause if possibleRestrain activities if untreatable dangerousbehaviour

Postural vertigo PhysiotherapyPositional manoeuvres: habituation exercises,Epley’s manoeuvre

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N Home visits by occupational therapistscan reduce domestic hazards. In addition,medical and behavioural risk factors forfalls can be screened at the same time,and replacing unsafe footwear also helpsto reduce the number of falls. However,poor compliance limits the success ofhome visits. Many elderly are reluctant tochange their house or their behaviour, ordoubt that doing so will reduce their fallfrequency. Therefore, their agreement toany preventive measure is essential.38

Another aspect to consider is that homevisits are generally costly and timeconsuming.39

N Prevention of falls associated with loss ofconsciousness mainly involves treatmentof the underlying disorder.11

– Orthostatic hypotension patients shouldbe advised to avoid precipitating cir-cumstances, such as rapid changes inposture or prolonged recumbence. Inaddition, they can be trained to useanti-orthostatic manoeuvres such asstanding with crossed legs or regular‘‘tip-toeing’’, or elastic compressionstockings. A simple pharmacologicalintervention is sodium chloride tablets.If this fails, fludrocortisone and sym-pathomimetics can be used, but onlywhen there are severe disturbances ofblood pressure regulation, because oftheir adverse effects in the elderly.

– Elderly fallers with urge incontinenceshould be scrutinised for vasculardementia, spinal cord compression, ornormal pressure hydrocephalus.

– Proper lighting should be installed forthose who frequently fall during night-time visits to the toilet. A commodenext to the bed or a condom catheterfor men may be needed.

– For benign paroxysmal positional ver-tigo, an Epley manoeuvre (to eliminatethe debris from the semicircular canals)may dramatically improve the debilitat-ing complaints, but is often difficult toperform in elderly people. When thismanoeuvre fails, habituation exercisescan be tried. There are no drugs withproven anti-vertigo efficacy.

– Prevention of osteoporosis is re-commended for elderly fallers.Promoting physical activity increasesbone mineral density and reduces therisk of hip fractures. Oral provitamin

Risk factor/disorder Possible intervention/therapy

Gait impairment Treat underlying cause if possibleGait training/physiotherapyUse of walking aids

Disproportionate fearof falling

Group treatment using behavioural-cognitivetherapyPhysiotherapy to regain confidence

Syncope Treat cause if possibleReferral to cardiologist if necessary

Vascular stealsyndrome

Instruction on reduced arm exerciseStent placement if possible

Epilepsy Symptomatic treatmentAlcohol abuse Stop drinking

Refer to community psychiatric nurseHypoglycaemia Adjust anti-diabetic medication

Refer to diabetic nurseHyperventilation Search for underlying cause, such as renal

insufficiencyBreathing instruction

Basilar migraine Symptomatic treatment

Modified from Bloem BR, Boers I, Cramer M, et al. Falls in the elderly. I.Identification of risk factors. Wien Klin Wochenschr 2001;113:352–62.

TABLE 5 Continued

Useful websites

l http://www.cochrane.org/index0.html http://www.merck.com/mrkshared/mmg/sec2/sec2.jsp (Mercks Manual

chapters on falling)l http://falls-and-bone-health.org.uk/ (Falls-and-bone-health group of the

British Geriatrics Society)l http://www.americangeriatrics.org/products/positionpapers/Falls.pdf

(American Geriatric Association with guidelines on falling)l http://www.icservices.nhs.uk/datasets//pages/falls.asp (UK National Health

Service, with NICE guidelines (National Institute of Clinical Health andEffectiveness) and Older People NSF (National Service Framework)guidelines)

l http://216.119.65.75/members/sig-IPTOP.cfm (American physical therapistson falling)

l http://www.mednwh.unimelb.edu.au/VFCC/VFCC_guidelines.htm (VictorianFalls Clinics Collaboration with guidelines)

l http://www.mednwh.unimelb.edu.au/VFCC/VFCC_References.htm (VictorianFalls Clinics Collaboration with references and abstracts)

l http://mqa.dhs.state.tx.us/qmweb/Falls.htm (Quality Matters Institute, aGeriatric Collaboration in Texas, USA)

l http://www.profane.eu.org/phpBB2/faq.php?mode = falls (Prevention ofFalls Network Europe (ProFaNE). Offers a list of many assessmentmeasures)

169Voermans, Snijders, Schoon, et al

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1a-hydroxyvitamin D3, calcium supple-mentation and alendronate/raloxifenearrest progression of osteoporosis andreduce hip fractures.40

Tertiary preventive measures focus on the

fear of falling and the resulting immobilisation

or social isolation. An electronic warning

system around the neck or wrist can limit

complications in patients who are unable to

stand up after a fall. Fear of falling can of

course be reasonable in patients with severe

balance impairment, and the resultant restric-

tion of mobility can actually serve as an

adequate tertiary preventive measure.

However, for many, the fear is disproportional

to the actual degree of balance impairment and

risk of falls. Reduction of fear and regaining

confidence is important for these people,

because it helps restore mobility and promotes

independence. Group treatment using a beha-

vioural-cognitive approach to change attitudes,

as well as training with a physiotherapist,

might also help. In addition, physiotherapists

play a central role in restoring balance

confidence and reducing the fear of falls.41

However, this positive effect wanes as the

patient becomes more frail.42 An entirely

different approach is required for cognitively

impaired patients who can be too confident

and inappropriately overrate their own balance

ability, resulting in risky behaviour and falls. For

them, restriction of activities might be the best

solution to prevent recurrent falls.

ACKNOWLEDGEMENTSDr Bloem was supported by a ZonMw VIDI

research grant (number 016.076.352), and a

research grant from the National Parkinson

Foundation. We would like to thank Dr J E

Visser for the artwork in figures 1 and 4. This

article was reviewed by Heine Mattle, Berne,

Switzerland.

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l Falls in the elderly are common and can be devastating.l Falls are not an inevitable accompaniment of ageing, but warrant a

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l Most falls in the elderly are multifactorial, so clinicians should not abandontheir diagnostic work-up when a single risk factor has been identified.

l Optimal prevention of falls calls for a multifactorial and multidisciplinarytreatment approach.

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