Falls in Community-Dwelling Older Persons

Mary B. King, MD‘ and Mary E. Tinetti, M D t

F alls are common, often dreaded events in the lives of older

people and are an important focus of both research and
clinical care. Nonsyncopal falls have been defined as events
about 4 to 6% of falls, one-fourth being hip frac-
tures. 10.1 1.1 3 J 4 Other major injuries requiring hospitalization
or immobilization occur in an additional 2 to 10% of
“which result in a person coming to rest inadvertently on the
ground or other lower level and other than as a consequence Death is a less frequent consequence of falling; however,
of . . . sustaining a violent blow, loss of consciousness, complications caused by falls are the leading cause of death
sudden onset of paralysis, as in a stroke, [or] an epileptic from injury in men and women older than age 65.” In one
seizure.’” The majority of nonsyncopal falls do not have well large epidemiologic study of people older than 65 who sought
defined etiologies and are often felt to be the result of multiple emergency medical care after falling, 2.2% of injurious falls
interacting factors. Although most people who fall do not were fatal. Men who died after a fall injury were more likely
suffer major adverse consequences, falls can result in serious than women to have had a brain injury; almost half of both
injuries, including fractures, or death. More often, falls result men and women who died had sustained hip fractures.’“
in restriction of mobility or activity and can lead to loss of Pulmonary embolism occurs in almost 13% of those who die
independence. after fall-related injuries.’“ The rate of death in people seek-
There have been a number of recently published reviews ing medical care due to an injurious fall increases greatly with
about falls in older and falls in the nursing home.’ age and is higher in men than women. White men aged 85
This review will center on developments in the study of years and older have the highest rate of death attributable to
nonsyncopal falls among community-dwelling older adults falls, exceeding 180 deaths per 100,000 population.’s
since 1987, as several large, prospective studies of risk factors The cost of fall-related injuries is substantial; lifetime
for falls and interventions to prevent falls have been pub- costs for persons older than age 65 has been estimated at
lished in the past 8 years. The adverse consequences of falls, $12.6 billion.” There is significant health care utilization for
and the complex relationship of falls, fall injuries, and func- injurious falls; almost 8% of persons older than age 70 seek
tional decline, will be discussed. Factors that increase the risk emergency room care each year for a fall-related injury.I6
of falling and the risk of injury with a fall, as well as their Approximately 30 to 40% of older persons treated in an
implications for medical care, will be examined. Interven- emergency room for a fall injury are subsequently hospital-
tions to reduce the risk of falls and injury in older people will ized, with an average length of stay of 8 to 15 day^.'^*'^*'^
be reviewed, and future areas of investigation will be ad- Fall-related injuries account for 5.3% of all hospitalizations
dressed. in persons aged 65 years and older”; fallers hospitalized for
injury were more likely than non-fallers to be discharged to a
CONSEQUENCES OF FALLS nursing h ~ m e . ’ ~ , ’ ~
The importance of a fall lies in its effect on an older
person’s health, functioning, and independence. Injuries and Long Lies
death, long lies resulting from inability to get up from the Being unable to get up after a fall is a distressing and
ground or floor, fear of future falls, and decreased activity potentially dangerous consequence of falling; it frequently
and mobility are important potential consequences of falling occurs in falls without serious injury. Older persons found
(Table 1). lying on the floor or ground for long periods of time after a
fall are at risk for dehydration, pressure sores, pneumonia,
Fall lnjuries and Death and rhabdomyolysis, and may have fear of further falls.2o
A fall that results in injury can be quite costly both in Inability to get up after falling is a common finding in
terms of functional loss or death and utilization of health care community studies. In one study, 50% of the fallers were
services. About 30 to 55% of falls in men and women aged 65 unable to get up without help.” Other studies have shown
years and older living in the community result in minor similar results. In a large prospective community falls study,
injury, such as bruises and Fractures occur in 14% of subjects who fell were unable to get up for 5 minutes
or more; 3% of falls resulted in lies of more than 20 min-
Utes.’’ In another study, 41% of subjects treated for falls in
From the ‘Hartford Hospital Geriatrics Program. Hartford, Connecticut and the an emergency room reported being unable to get up within 5
Travelers Center on Aging, University o f Connecticut School of Medicine, Farni- minutes of the fall, and 3% lay on the floor 3 or more hours.”
ington, Connecticur; and tYale University School of Medicine, New Haven, Con-
In one prospective study,” inability to get up was asso-
nccricut.
Address correspondence to Mary King, MD, Hartford Hospital Geriatrics Pro- ciated with signs of physical frailty (age of 80 years or more,
gram, Burlingame sBldg., 2nd floor, 400 Washington St., Hartford. <T06 106. decreased strength, poor balance, arthritis, and dependency

JAGS 43:1146-1154. 199.5

0 199.5 by the American Geriatrics Society 0002-86 14/95/$3..50
 FAILS IN OI.I)ER PERSONS
~-~ ~~
I 147

Global traits such as fearfulness do not predict behavior

Table 1. Consequences of Falling for Community-Dwelling in specific situations well.’x*2yThe concept o f self-efficacy, or
Older Persons
~
confidence in the ability to perform a specific activity in a
Consequences of Falling Percent Affected
specific situation,3””’ has been used to examine the relation-
ship between fear of falling and function.”*2x*’y Question-
Major injury naires have been designed and validated to measure confi-
Fractures dence in one’s ability not to fall during usual activities of daily
Hip 1-2’ livinglx and confidence in maintaining balance during more
Other 3-5” challenging activities.”*’2
Other (lacerations, head injury, 2-1 0’ While many older persons acknowledge fear of falling,
internal injury) the majority are confident that they will not fall during usual
Death 2.2t daily activities, such as light housework, walking around the
Minor injury (bruises, abrasions, sprains) 30-55’ house, and transferring.” In a study comparing strength of
Inability to get up after falling 39-50$ association of fear of falling and confidence in not falling
Lying on floor > 20 minutes up to 3’ (self-efficacy) with measures of function, confidence in not
Fear of falling falling showed strong independent associations with indica-
Fallers 40-73* tors of ADL-IADL, social, and physical function by multiva-
Non-fallers 20-46$ riate analysis; fear o f falling only showed a marginal associ-
Decreased activity 41-43$ ation with ADL-IADL function and n o significant association
with social or physical functioning.13 This suggests that a
* I’rrcmt o f falls. person’s confidence in the ability to perform daily activities
t l’rrcrnt of injuriiius falls in oldcr prrwn\ serking miergency nicdical c‘irr. without falling is closely related to actual performance; self-
f I’erccnt of fallcrs.
efficacy is thus an important target for interventions to im-
in activities of daily living (ADL));fallers who were unable to prove function.
get up were more likely to develop declines in independence
in ADLs o r instrumental activities of daily living (IADL).
Decreased Activity
There was also a trend toward more frequent hospitalization One of the possible consequences o f a fall is limitation of
and death among fallers who were unable to get up than activity, whether as a result of physical impairment from
among those who were able to get up without help. injury or of fear of future falls. Falling in the year before the
study was associated with about 18%)of restricted activity
Fear o f Falling and Self-Eficacy days in a large sample of noninstitutionalized adults aged 65
Whether an individual has fallen previously o r not, fear years and older.’’ In one prospective study, 42%)of fallers
of falling is common. Between 40 and 73%)of older persons restricted their activities at least temporarily because o f in-
who have experienced a recent fall, and 20 to 46% of those ’
jury, fear o f falling, or physician orders.’ Pain or limitation
who have not, acknowledge fear of falling.“’.’ ’*‘x”’-2’ The of activity after a fall were still present 8 weeks later in 43%
interactions among fear o f falling, falls, and function are o f African-American fallers treated in an emergency room;
complex. almost half of these (41%) had not recovered by 7 months.IX
Investigators who used the global question, “are you In a third study, 41 ‘%of older persons who had had a minor
afraid of falling?”, to assess fear found that factors suggesting fall had a lower level of activity, compared with 23% of
frailty - needing assistance to climb stairs, poor vision limit- nonfallers, 6 months after the fall. ”
ing walking,14 IADL restriction,’“’‘ and fair or poor self- As many as half of the older people who are fearful of
rated health’4*27- were independently associated with fear of falling restrict or eliminate social and physical activities be-
falling. Fear has also been associated with falls resulting in ’
cause of that fear.’ However, a significant number of people
f r a c t ~ i r e ~ ~and
. ~ ~with
* ’ ~ falls that occur in circumstances who have not fallen also restrict activities because of fear o f
other than a slip or tripz4 In addition, fear of falling has been falling. Downton and Andrews found that one-third of a
related to decreased poor life satisfaction, and group o f community-dwellers had limited their activities
depressed Fear of falling is more prevalent in because of fear of falling, despite not having fallen in the
women; an association with increasing age has been incon- previous year.”
sistent.2L.L4,2 5 Although older people with fear of falling in
one study also experienced other fears (being robbed o n the Long-Tern Health-Related Outcomes
street, having financial problems, forgetting a n important The Longitudinal Study of Aging (LSOA) is the only
appointment, losing a cherished item), they acknowledged large longitudinal study to date that has sought to address the
fear of falling more often than the other fears (26%compared relationship between falls and health-related outcomes.
with 5-17%).27 About half of the 24% o f study subjects aged 70 years and
Fear may be caused by a realistic perception o f loss of older who fell in the year before the beginning of the study fell
function and resultant vulnerability to falls. Alternatively, two o r more times; multiple falls, rather than single falls,
fear may affect a person’s reactions to postural disturbances, were associated with IADL and ADL disability and poor
resulting in accentuated o r ineffective responses and, there- health outcomes. ”-”At baseline, fallers, particularly repeat
fore, falls. Fear of falling has been associated with poor fallers, were older than individuals who hadn’t fallen, had
performance on tests of balance, including a low score on a greater difficulty with IAD1.s and one o r more ADLs, and
battery of parallel, semi-tandem, and tandem in- were more likely to report poor health.’” T w o years later,
creased spontaneous sway,” and decreased one-legged repeat fallers, more than single fallers, had difficulty with
stance time.’2 additional ADLs, IADLs, o r more physically demanding ac-
1148 KINGANDTINETTI OCTOBER 199.5-VOL. 43, NO. 10 JAGS

t i v i t i e ~ had
, ~ ~ been hospitalized more ~ f t e n , were
~ ~ ’more
~ ~ sification of this type is problematic, however, because of
likely to have had an admission to or placement in a nursing inconsistency in the definition of falls and in the completeness
home or chronic care h o ~ p i t a l , ~ ~and
. ~ ’were more likely to of falls reporting in early studies. Another classification sys-
have died.38 tem, used in a large prospective population study with 1358
At 4 years, persons with a history of repeated falls subjects aged 65 years and over, divided falls into four broad
continued to be more likely to have experienced hospitaliza- categories: extrinsic falls caused by slips, trips, or displaced
tion, nursing home placement, or death than non-fallers or center of gravity (55%); intrinsic falls attributable to poor
one-time faller^.^^.^' However, the increased risk of these mobility, balance, cognitive, or sensory impairment (31 %);
adverse health outcomes, and for increased ADL disability non-bipedal falls, such as a fall out of bed or while using an
associated with multiple falls, diminished and became insig- assistive device (5%); and nonclassifiable falls ( 9%).40Older
nificant when demographic variables, chronic conditions, community-dwelling subjects, like the nursing home subjects
and ADL disabilities were added to a logistic regression in the study by Rubenstein et al., were less likely than younger
These data suggest that multiple falls are a marker subjects to have environment-related falls. While investiga-
for other underlying factors, including chronic disease and tors have used classification schemes to identify differences in
functional disability, that put older people at risk for adverse types of falls by age, gender, and other factors, these schemes
health outcomes rather than the cause of those outcomes. do not take into account the interactions of multiple risk
factors.
DETERMINING WHO IS A T RISK OF FALLING
Because of the potential adverse consequences of falling, Intrinsic and Extrinsic Risk Facton
attempts have been made to classify falls by etiology and to Four community-based prospective studies of risk fac-
identify factors that make older persons more susceptible to tors for falls have been published since 1987 (Table 2).
falling. Finding modifiable risk factors may be of use clini- Identified risk factors independently associated with falling in
cally in reducing the incidence of falls. Since impaired mobil- one or more of these studies include older age, white race,
ity is often associated with having one or more characteristics cognitive impairment, medication use, specific chronic dis-
that are also risk factors for falls, another view has been to eases including arthritis, lung disease, and stroke, foot prob-
regard impaired mobility as a prerequisite for falls, with falls lems, impairments in muscle strength, balance, and gait, and
incidence additionally influenced by attitudinal, social, and dizziness. 10.12.1 3.41 In one study, multiple falls were more
environmental factors. Figure 1 presents an overview of falls predictable than single falls.’O Independent risk factors for
risk. two or more falls included Parkinson’s disease, strength,
balance, and gait impairment, arthritis, previous falls and fall
Falls Classification injury, and white race.” A strength of these four studies is
Investigators have grouped falls by etiology and by con- that a number of very different possible risk factors was
tributing circumstances. In an analysis of seven studies and examined in each. However, the same factors were not ex-
23 12 falls in community-dwelling older people, Rubenstein amined in each study, making it impossible to rank risk
et al. reported that 41% of falls had environment-related factors in overall order of importance. The lack of agreement
causes, and 13% were caused by weakness or a disorder of in significance of specific risk factors across these studies
gait or balance. Other causes included “drop attack,“ dizzi- suggests that other factors play an important role in deter-
ness, confusion, visual disorder, postural hypotension, or mining whether a fall will occur.
unknown.’ This was in contrast to causes of falls in the In other studies of risk factors for falls, retrospective falls
nursing home, where the most frequent causes were weak- reporting (subject to recall bias4’) or a case-control design
ness, gait, or balance disorder (26%)and dizziness or vertigo was used, or subjects of one gender or with a specific chronic
(25%);only 16% of falls were environment-related.’ A clas- disease were studied (leading to results that are not general-
izable). The risk factors found and the limitations of these
studies were reviewed in a study by Robbins et al.43
Balance, or postural control, its measurement and the
Older Person
impact of its impairment on older adults have been the focus
Challenge to
Age-hsociated Changes Postural Control
of recent research and a recent comprehensive review.44
Chronic Disease Environmental Hazards
Postural control is determined by the integration of visual,
Acute IHnt#rs. Hospitslizstion Usual Activities proprioceptive, and vestibular input within the central ner-
Medications Changing Position vous system to effect a motor re~ponse.~’ Impaired sensory,
integrative, or motor functioning will affect balance and
potentially increase the risk of falling. In one prospective,
community-based study of 95 persons aged 59 to 97 years,
Mediating Factors investigators identified physiological determinants of pos-
Risk-Taking Behavior tural stability that discriminated between older persons who
Opportunity fell more than once and those who fell once or not at
Mobility
Those factors were proprioception in the lower limbs, visual
Physical Activ~ty
~ ~
contrast sensitivity, ankle dorsiflexion strength, reaction
4 time, and body sway. In a second prospective study of 414
community-dwelling women, Lord et al. showed that multi-
FALL ple falls were associated with the same physiological fac-
Figure 1. Interactions among intrinsic, situational, and environ- t o r ~Investigators
. ~ ~ employing quantitative balance platform
mental factors that affect risk of falling in older persons. measures of sway found that lateral spontaneous sway am-
JAGS OCTOBER 1995-VOL. 43, N O . 10 FALLS IN OLDER PERSONS 1149

Table 2. Independent Risk Factors for One or More Falls, with the Reported Odds Ratios or Relative Risks with 95% Confidence
Intervals, Identified in Four Prospective Community-Based Studies

Nevitt et al., 1989 Campbell et al., 1989$

n = 325, n = 761,
Tinetti et al., O’Loughlin et al.,
age 260 age 270
1988t n = 335, 19935 n = 409,
Risk Factors One Fall* 2 2 Fallst Men Women age 275 age 265

Demographics
Age 2 8 0 1.5 (1.l-2.2) ns ns 2.5 (1.3-5.0) ns ns
White race 2.3 (1.2-4.4) 2.4 (1 .l-5.3) ns
Neurologic
Cognitive ns ns ns ns 5.0 (1.8-13.7)
impairment
Parkinson’s disease 9.5 (1.8-50.1) ns ns
Stroke history ns 13.6 (2.6-7 .3) ns
Other (palmomental 3.0 (1.5-6.1) 2.0 (1.%2.8)
reflex, dizziness)
Other chronic disease
Chronic lung 2.0 (13-3.1) ns ns
disease
Arthritis ns 2.7 (1.3-5.6) 2.7 (13-5.3) 1.8 (1.1-2. ‘1 ns
Foot problems 1.8 (1.O-3.1)
Impaired physical
function
Balancelstrength 1.6 (1.1-2.1)ll 3.0 (1.2-7.2)fl 2.6-3.4 (1.3-8.4)1,** 1.7 (1.0-2.9)’* 3.8 (2.2-6.7)tt 1.4 (1.O-2.0)55
Gait ns 2.7 (1.1-6.2)# ns ns 1.9 (1.O-3.7)$$ 1.6 (1.2-2.4)1111
Previous falls ns 2.4-3.1 (1.3-6.4) ns ns ns
Medications
2 4 prescriptions ns 4.5 (1.9-1 0.6)
Psychotropics, ns ns ns ns 28.3 (3.4-239.4)
sedatives
Note: Parentheses denote 95% confidence intervals.
Unadjusted relative risks.
t Adjusted odds ratios, multivariate analysis.
+ Relative risks, determined by logistic regression.
S Incidence rate ratios, estimated by adjusted odds ratios, logistic regression analysis.
NS = not significant.
I1 Low grip strength.
1 Unable to rise from chair.
U Poor tandem gait.
* * Increased body sway.
tt Reported problems with strength, sensation, or balance.
$$ 6-7 balance and gait abnormalities by performance testing.
SS Trouble bending down.
1111 Trouble walking 400 meters.

plitude under blindfolded conditions was the best predictor In addition to age-associated and disease-related factors,
of future risk of falling in 100 older persons aged 62 years and factors that vary with time affect susceptibility to falling.
over.48 Greater understanding of postural control and its These include acute illness, such as pneumonia or exacerba-
measurement will be of value in planning future interventions tion of congestive heart failure,2 activity limitation caused by
to decrease the incidence of falls. a health problem,” and recent hospitalization.“8
Medication use is potentially the most modifiable risk The likelihood of falling increases with the number of
factor for falls, and, as such, is of particular interest clinically. intrinsic risk factors present.10,13,41In one community-based
Specific medications, recent change in dose, and total number prospective study, 8% of persons with no risk factors fell,
of prescriptions have been associated with an increased risk whereas 78% of those with four or more risk factors fell the
of Because of impairment of mental alertness, next year.I3 In a second study, the risk of multiple falls in a
long-acting benzodiazepines, barbiturates, antidepressants, year increased with the number of independent factors iden-
and neuroleptics have been implicated in fall^."^^^ The use tified; only 10% of individuals with one or no risk factors fell
of cyclic antidepressants,“”*s6 long-acting benzodiazip- repeatedly, whereas 69% of those with four to seven risk
i n e ~ , ~ ”and
~ ’ n e ~ r o l e p t i c s increase
,~~ the risk of hip fracture factors had two or more falls.’O The same data, however,
with a fall. Antihypertensives may increase the risk of falling show that a significant number of older people fall despite
by causing postural hypotension or fatigue; diuretics may having no or few risk factors for falls. Thus, while accumu-
produce volume depletion or electrolyte imbalance.” lated intrinsic risk factors mark individuals who may benefit
I I50 KING AND TINETTI

from interventions to reduce falls, many older people who fall of that impairment.h'*'.3 Others might pursue activities de-
are not identified by this means. spite concerns about safety because o f lack of family, friends,
Extrinsic factors create challenges to balance that must or caregivers to help. Studenski et al. grouped 306 men by fall
be overcome to avoid falling. The degree to which they pose risk based on a screening test for mobility." Subjects who
a threat depends on the vulnerability of the older person and had poor mobility function (could not stand or sit), and those
the frequency of exposure to the potentially destabilizing with good mobility (able to descend stairs step-over-step
situation. Challenges to balance are posed by environmental without using the handrail, or able to descend stairs plus
hazards (e.g., poor lighting, slippery floor), ordinary activities tandem walk) were grouped together as having a low risk for
(e.g., stair climbing, walking), or by movements that may falling. Subjects with decreased mobility (able to sit but not
lead to loss of control of the center of mass, such as turning or stand, unable to walk well o r descend stairs) were assigned to
transferring from bed to chair. When the demands on pos- the high risk group. A significantly greater percentage (23')/0
tural control are greater than the person's capability, a fall vs 5%,,P < .001) of the high risk, compared with low risk,
occurs. subjects were repeat fallers during the 6-month follow-up
In two prospective community studies, investigators period. Within the high risk group, subjects whose decreased
demonstrated differences in numbers of falls arid the circum- mobility approached that of the impaired, low-risk group,
stances of the fall in subjects grouped by degree of frailty had a lower risk of falling. However, declining mobility was
based on criteria determined by principal components anal- not sufficient to predict risk of falling; an increased risk of
ysis. ( Y W ) In the first study, a strong relationship between repeated falls was also associated with greater exposure to
group assignment and risk of falling was found after a year of environmental hazards at home and preference for risk-
follow-up, with falls experienced by 52% of Frail, 32% of taking. The degree of social support did not affect falls risk.
Transitional, and 17% o f Vigorous subjects." Vigorous sub-
jects tended to fall during activities that posed a significant RISK FACTORS FOR FALL INJURY
challenge to balance. They were more likely to fall on stairs I t is possible to identify older persons at increased risk for
and while away from home, and there was a trend for falls to nonsyncopal falls, based on chronic age-associated and dis-
occur during activities that caused greater displacement of ease-related characteristics, acute illness, exposure to envi-
the center of mass from the area over the base of support. In ronmental challenges to balance, and degree of mobility
contrast, Frail subjects tended to fall at home during routine, impairment. Whether or not an injury results from a fall is
nondisplacing activities. While a greater number of Frail determined both by the characteristics of the faller and by the
subjects fell, a significantly smaller percentage o f the fallers circumstances of the fall. Injuries may be minor, such as
sustained a serious injury compared with the Vigorous fall- sprains, contusions, and lacerations, or major, such as frac-
ers. However, the percentage of subjects in each group who tures and head, spinal cord, and internal injuries.64 With the
had a serious injury was about the same, 6 to 8%. In the exception of research on factors associated with fractures,
second study, the association between home hazards and falls there have been few studies that have examined factors asso-
in the home was examined.'" Subjects were grouped as ciated with major and minor injuries with falls in older
"frail" or "vigorous", and those who were frail were more persons living in the community.
than twice as likely as the vigorous subjects to fall one o r
more times at home during the 52-week follow-up period. Characteristics of the Faller
Vigorous older persons with more home hazards, such as The characteristics of the older person at risk for an
kitchen cabinets that were too high or too low, clutter on the injurious fall are largely the same as those for falls without
floor, and rugs that could slip, were more likely to fall than injury. 12.6.5 Decreased neuromuscular and cognitive func-
vigorous participants who had few home hazards. In con- tion, I I . I 2 as well as both i n c r e a ~ e d ' ~ * ' ~ *and
'' de-
trast, the presence of hazards in the home was not associated creased I2.66,67 activity, have been associated with injurious
with an increased incidence of falls in frail participants. While falls where degree of injury is not specified. In a study that
the external factors contributing to falls differed by subjects' distinguished risk for minor from risk for major injury, minor
degree of frailty in both studies, falls with or without injury injury was predicted by white race, slow hand reaction time,
were a common occurrence even in relatively vigorous older and decreased grip strength.' I Characteristics of fallers
persons. shown by multivariate analysis to be independently associ-
ated with major injury include white race," older age:'
Mobility, Activity, and Falls Risk increased Trail Making B time," fall with fracture in the
Although the accumulation of intrinsic risk factors for previous year,' presence of chronic conditions such as dia-
falls generally occurs in older adults with declining mobility, betes mellitus o r stroke,".'" poor distance vision,'' and low
defining the relationship among falls, physical activity, and body mass index.h5*hX*'y In the Study of Osteoporotic Frac-
mobility remains an important research objective. While tures, a multi-site prospective study of 9516 white women
decreased physical activity and mobility can result from a fall, aged 65 years or older, 16 independent risk factors for hip
they can increase the risk of falling as well. Another approach fracture were identified in addition to decreased bone density.
to the assessment of risk of falling has been to examine the These included history of maternal hip fracture, increased
interaction between mobility and other factors - risk-taking age, fair or poor self-rated health, greater height, use of
behavior, social supports, and presence of environmental long-acting benzodiazepines, anticonvulsants, or caffeine,
hazards - in predicting Older persons who pursue previous fracture after age 50, history o f hyperthyroidism,
risky activities for their level of ability, such as climbing on a and spending 4 hours a day or less standing. Weight gain after
chair to reach a high shelf or running, might d o so because of age 25 and walking for exercise were protective against hip
lack of recognition of their mobility impairment or because o f fractures. Physical findings of inability to rise from a chair
need o r desire to maintain independence despite knowledge without using one's arms, poor depth perception o r contrast
JAGS OCTOBER 199.5-VOL. 43. NO. 10 FALLS IN OLDER PERSONS ~~~
I 15 I
~~

sensitivity, and tachycardia at rest were associated with in- older persons who are at increased risk of falling or of injury
creased risk of hip fracture. The presence of multiple factors with falls. Yet a significant number of fallers possess few, if
further increased the risk of fracture; women who had five or any, identified risk factors for falls, and vigorous fallers may
more risk factors and calcaneal bone density in the lowest suffer injury as frequently as fallers who are frail. Intervention
third for their age had 32% of the hip fractures r e p ~ r t e d . ~ " may thus be warranted for all older persons, though preven-
tive measures for vigorous individuals at low risk for falls will
Circumstances of the Fall differ from programs for older persons identified as having
Once a person is falling, other factors determine the type increased risk of falling. It is not clear whether the most
and extent of injury that will ensue. Minor injuries have been appropriate goal for intervention is reduction in the incidence
associated with falls while going up or down stairs, steps, or of all falls or only of injurious falls. A relevant goal may be to
curbs and with falls while turning around or reaching." improve physical function and mobility rather than to reduce
Major injuries have been associated with falling from at least falls per se, because of the relationships among mobility,
body height6S and landing on a hard ~urface.".~' In two activity, and falls. Intensive interventions are costly; there-
studies, risk of major injury did not differ significantly with fore, it is important to determine the effective intensity and
activity at the time of the fall, falling at home or because of an duration of an intervention program and the best means of its
environmental hazard, use of sedative-hypnotic medications delivery - by an individual or in a group setting, in the
or alcohol before the fall, or with activity-limiting acute community or at home. Finally, an effective intervention is
illness.' In another study, fall injuries occurring indoors one that reduces the long-term incidence of the measured
were more severe than those occurring outside.72 outcome. This may require a commitment to a change in
Other studies have identified characteristics of the fall lifestyle for the older person and continued involvement of
that predict fracture, including the direction of the fall and the interventionist or practitioner. Interventions related to
area of impact, the faller's protective responses, cushioning falling have taken several different approaches, including
the landing, the hardness of the landing surface, the energy of education, exercise to improve balance, strength, and/or en-
the fall, and bone density and Hip fractures durance, assessment and treatment of multiple risk factors,
have been associated with falling sideways or straight down and treatment to reduce injury and other adverse falls out-
on the hip in two community-based prospective case-control comes.
s t ~ d i e s . " ~ .In~ 'one study, women who fell backwards were Four low-intensity, population-based intervention stud-
significantly less likely to break a hip, but more likely to ies in older community dwelling adults have shown mixed
fracture a ~ r i s t . The ~ ' faller's protective responses - grabbing results in reducing falls and fall inj~ries.""*'~-~" Interventions
objects on the way down, taking steps, putting a hand out to have included group-based low intensity e x e r c i ~ e , " ~ * ~ ~
catch oneself - lessen the impact of the fall and decrease group meetings to improve awareness of environmental haz-
fracture risk.7' The potential energy of a fall is determined by ards and medical and behavioral risk factors for
the height from which a person falls and by body mass. Falls development of an individualized risk reduction plan,x0 and
from standing height or higher have more than sufficient individualized home assessments of nutrition, medical condi-
energy to fracture an older person's hip.74 Such falls have tions, and environmental hazard^.^' In one study, the inter-
been associated with increased risk of hip fracture.""*"x vention group reduced the odds of falling during the 23-
Bone density and structure are major determinants of month study by .85, but did not decrease the number of falls
fracture risk with falls. Femoral neck bone mineral density is requiring medical In a second study, there was
the most sensitive indicator of hip fracture risk7." and is an no effect on the incidence of new fractures.7x In a third study,
independent risk factor for hip f r a c t ~ r e . ~ A ~ decrease
' ~ " ~ ~ of there was no difference after 1 year in number of falls, injury,
1 standard deviation of bone density increases the risk of or secondary outcome measures of strength, balance, fear of
fracture 2.7 tirne~."~~"Mechanical factors, including the falling, or perceived health.7' In the fourth study, there was a
length of the femoral neck, angle of the femoral shaft, and significantly lower incidence of falls and fall injuries in the
distribution of bone mass, are also important.77 Greater hip group that was given prescriptions for risk factor reduction
axis length, the distance along the femoral neck axis from the when compared with the group receiving usual care after 1
greater trochanter to the inner pelvic brim, was associated year; this difference disappeared at 2 years.x0
with both femoral neck and trochanteric fractures in older Another strategy to reduce falls, in addition to identify-
women independent of age and bone mineral den~ity.~',~' ing risk factors, is to treat older people with known intrinsic
When used in combination with bone density, geometric and and environmental risk factors. In a small, nonrandomized
mechanical measurements may add information that will study of the effectiveness of a multispecialty falls assessment
improve the estimation of fracture risk. and treatment clinic, the identification and treatment of neu-
rological, cardiovascular, and orthopedic problems, drug
INTERVENTIONS RELATED TO FALLS interactions, and environmental hazards resulted in no fur-
Falls have become a target for preventive efforts because ther falls for 77% of the 36 subjects at 1 year."
they are common and are associated with considerable po- The multi-site, NIA-funded FICSIT (Frailty and Injuries:
tential morbidity. Risk factors for falls and falls with injury Cooperative Studies of Intervention Techniques)x2 has re-
can be readily identified through routine clinical care. While cently been completed. One of the eight sites employed a
the prevention of falls has been the focus of several studies, it multidisciplinary program to reduce identified risk factors for
remains an important topic for future research. falls8-'*"; four of the other sites studied the effects of inter-
The most significant considerations for prevention of ventions that incorporated balance, strength, flexibility,
falls are the population who will benefit from an intervention, and/or endurance exercise in community-dwelling older peo-
the goals of the intervention, and its focus, intensity, and ple.""-H8 As in previous short-term FICSIT inter-
duration. By recognizing risk factors, it is possible to identify ventions designed to improve strength showed meaningful
I 1 52 KING AND TINETTI

gains in strength in both vigorous”’ and frail” older men and relaxation training. Fear, as measured by a global question,
women. Three of the FlCSlT sites trained balance in active did not improve with the intervention; however, subjects
community-dwelling older personsxh-”; the results of these expressed little fear of falling at baseline. Confidence in
individual studies have not yet been published. A meta- avoiding falls was a secondary outcome in the FICSIT study
analysis of individual patient data from seven of the eight reported by Tinetti et al. and was better maintained in the
FICSIT sites, including two nursing home sites, was used to treatment than in the usual care Further research is
assess the efficacy of the exercise interventions, which varied needed to determine effective means of increasing confidence
across the sites.” Compared to controls, subjects assigned to in avoiding falls in older persons.
an exercise intervention were less likely tCJ fall in the fob
low-up period (adjusted incidence ratio (IR) 0.90; 95% con- CONCLUSION
fidence interval (CI)0.81-0.99). The incidence of falls was Falls are common events for older people. Significant
lower, compared with controls, in subjects whose interven- morbidity and healthcare costs can result from injury, restric-
tion included exercise to improve balance (IR 0.83; 95% C1 tion of activity, or fear of subsequent falls. A fall can also be
0.70-0.98). an indicator of underlying disease that has made the older
At the FlCSlT site that studied the effects of a multidis- person vulnerable to loss of balance. In the past 8 years, much
ciplinary risk abatement program on falls in older persons has been learned about characteristics of the faller that in-
living in the community, the rate of falls in the follow-up year crease risk of falling and about circumstances of falls that
was reduced by 31%.x4 In this study, 301 subjects aged 70 make injury more likely. Other consequences of falls, includ-
years and over who had at least one risk factor for falling ing fear, lack of confidence, and inability to get up after
were randomized to receive either social visits or a home falling, have been described. The complex relationships
intervention program. The intervention included an environ- among falls, mobility, and activity are being explored. Treat-
mental hazards assessment, review of medications, treatment ment of older persons to reduce the number or impact of
of postural hypotension, and/or physical therapy to improve identified risk factors holds promise as a means of decreasing
upper and lower extremity strength, range of motion, and the incidence of falls. Much has yet to be learned, however,
balance and gait impairments. In addition to significantly about the effectiveness of interventions to prevent falls and
greater time to the first fall (P = .05), there was a trend fall injuries in older persons living in the c~mmunity.’~
toward fewer injuries requiring medical treatment in the
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