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Editorial: A Fall Is a Major Event in the Life of an Older Person

^a Division of Geriatric Medicine, Saint Louis University School of Medicine, and Geriatric Research, Education, and Clinical Center, VA Medical Center, St. Louis, Missouri

John E. Morley, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104 E-mail: jgeronmed{at}slu.edu.

FALLING is a common occurrence. Many of us trip and fall as we go about our daily lives. However, in an older person, a fall can have disastrous consequences. Falls are a major cause of death in older persons ⁽¹⁾. Falls are the key event in the pathogenesis of hip fracture ⁽²⁾. Hip fractures are associated with a marked decline in functional status in the year following their occurrence ⁽³⁾⁽⁴⁾. Persons who fall often develop fear of falling ⁽⁵⁾, which leads to isolation and depression ^(6)(7)(8). Fear of falling is strongly associated with impaired instrumental activities of daily living ⁽⁸⁾. Falling is not only an important marker of frailty ^(9)(10)(11), but frequent falls can play a role in accelerating the downward spiral in a frail older person ⁽¹²⁾. In California, the mean cost of hospitalization following a fall was $17,086 ⁽¹³⁾.

Fallers are often more functional than nonfallers when compared within similar levels of performance. Thus, in the New Mexico Aging Process Study, it was the highly active older individuals who had the most falls ⁽¹⁴⁾. In a nursing home study, among wheelchair-bound persons, it was those who had a higher functional level who were more likely to fall ⁽¹⁵⁾. Pavol and colleagues ⁽¹⁶⁾ demonstrated that, in healthy elderly persons, walking rapidly was the most important reason that an older person fell following an induced trip. Other factors associated with falling after a trip were moving the body's center of gravity forward and weakness in back and knee extensor muscles.

In this issue of the Journal, Fletcher and Hirdes ⁽¹⁷⁾ in a large study of elders receiving community-based services reported that 27% of them fell once and 10% more than once. In their study, factors associated with falling included being male, having an impaired gait, being frail, and having environmental hazards in the house. In addition, persons with poor self-rated health were more likely to fall. Pavol and colleagues ⁽¹⁸⁾, also in this issue, found that older persons and repeated fallers are more likely to fall when a slip is induced. However, they found that with repeated exposure to a perturbation, older adults can learn to recover and not fall.

Impaired balance represents a major cause of falls ^(19)(20). Simple tests such as the unipedal stance, tandem walk, and the get-up-and-go test are good predictors of impaired balance and the propensity to fall ^(21)(22). Functional reach appears to be a poor test to identify fallers ⁽²³⁾, although a multidirectional reach test that includes sideways and backwards reaches appears to be a more promising tool for determining stability limits ⁽²⁴⁾. This is in keeping with the study of Rogers and colleagues ⁽²⁵⁾, which demonstrated that older fallers have a greater sideways body motion toward the stepping side. In addition, fallers tend to lift off earlier and have a longer step duration. Lord and Fitzpatrick ⁽²⁶⁾ have developed the choice stepping reaction time (CSRT) as a composite measure of fall risk. The CSRT is a significant independent predictor of falls risk. It consists of stepping onto one of four panels that are illuminated in random order.

The factors regulating balance are multifactorial as previously elucidated by Woollacott in the Journal ⁽²⁷⁾. These include alterations in cerebral function, such as a decrease in neuronal endrites and beta-adrenergic input ⁽²⁸⁾, proprioceptive input ⁽²⁹⁾, and quadriceps strength ^(30)(31)(32). Brauer and colleagues ⁽³³⁾ found that recovery of balance was cognitively demanding. Their research demonstrated that an elderly person had more difficulty maintaining balance when required to perform a second task at the same time. Thus, cognitively impaired persons are less likely to be able to maintain balance when they experience a trip. A number of studies have demonstrated that balance and resistance exercises can improve balance and reduce falls ^(34)(35)(36). Tai Chi, the ancient Chinese exercise form, appears to be particularly useful for improving balance ⁽³⁷⁾. Interestingly, weighted vest exercise, which improves bone mineral density ⁽³⁸⁾, also improves lateral stability, lower body muscular strength, and muscular power ⁽³⁹⁾.

Diabetes mellitus is an important cause of falls and injurious falls in older persons ^(40)(41)(42). Even very old persons with diabetes have worse neuromuscular performance than do those without diabetes ⁽⁴³⁾. In addition, persons with diabetes mellitus are more likely to have cognitive impairment ⁽⁴⁴⁾. Foot abnormalities are common in persons with diabetes, and foot abnormalities are a cause of falls ⁽⁴⁵⁾. There is a need for research into balance function in older diabetics and approaches to reverse this problem.

Loss of muscle mass, or sarcopenia, represents a major contributor to the pathogenesis of falls ^(46)(47). Following hip fracture, muscle mass and strength are strong predictors of mobility recovery ⁽⁴⁸⁾. Resistance exercises are the best available method to reverse sarcopenia ^(34)(49)(50). However, there is increasing interest in the ability of anabolic hormones to increase lean muscle mass. Testosterone replacement, in particular, has been shown to increase lean muscle mass and improve strength in older hypogonadal men ^{(51)(52)(53)(54)}. Testosterone also increases bone mineral density, thus decreasing the propensity to develop a hip fracture ^(55)(56). Low bioavailable testosterone levels are correlated with declining functional status ⁽⁵⁷⁾. Growth hormone also increases lean muscle mass but does not appear to increase strength ^(58)(59). A recent study in the Journal has shown synergetic effects of testosterone and growth hormone on enhancing muscle strength and bone mineral density ^(60)(61). Testosterone has also been shown to increase muscle mass and bone mineral density in older women ^(62)(63). There is a need for studies examining the effect of testosterone in frail older men and women.

Poor nutritional status is an important contributor to sarcopenia and falls ^(64)(65). Aggressive nutritional treatment plays a role in improving muscle strength and preventing falls ⁽⁶⁶⁾. Vitamin D replacement increases strength and decreases hip fractures ⁽⁶⁷⁾. Polypharmacy remains an important cause of falls ^(68)(69). Selective serotonin reuptake inhibitors have been associated with an increase in falls and hip fracture ⁽⁷⁰⁾. The mechanism by which they do this is uncertain but may be associated with the hyponatremia that these drugs can produce ⁽⁷¹⁾. Antidepressants such as amitryptilene are particularly likely to produce falls. Draganich and colleagues ⁽⁷²⁾ showed that amitryptilene, but neither paroxetine nor desipramine, slowed the ability of older subjects to cross obstacles. The potential effect of antidepressants to produce falls should not, however, lead to nontreatment of depressed older persons, as aggressive treatment of depression in home-bound individuals results in decreased hospitalizations ⁽⁷³⁾.

Falls are often associated with dizziness and less often with syncope ⁽⁷⁴⁾. While it is rare that the work-up of a single episode of syncope is productive, persons with multiple episodes and/or cardiovascular defects on the history or physical examination often are found to have cardiovascular disease that is amenable to treatment ⁽⁷⁵⁾. Postprandial hypotension (PPH) occurs following the ingestion of a carbohydrate meal ^(76)(77). PPH is thought to be related to release of a vasodilatory peptide such as calcitonin gene-related peptide ⁽⁷⁸⁾. PPH is present in approximately a quarter of all persons who fall ⁽⁷⁹⁾. PPH is more common in persons with Parkinson's disease ⁽⁸⁰⁾ and diabetes mellitus ⁽⁷⁹⁾. Orthostatic hypotension remains an important cause of falling in older persons and is extremely common ⁽⁸¹⁾. Standing and lying blood pressures should be obtained in all older persons who fall. Orthostasis is more common in the morning, so it should be checked between 7 AM and 10 AM.

Other recent falls studies have highlighted the high rate of falling in older persons with sleep disturbances ⁽⁸²⁾ and visual risk factors ⁽⁸³⁾. Persons with poor functional mobility have been shown to be at increased risk for falls ⁽⁸⁴⁾. In an older person with new onset falls, delirium should be excluded as a diagnosis ⁽⁸⁵⁾. While geriatricians should no longer need to be reminded, the use of physical restraints in older persons in hospitals and even in nursing homes remains far too common. It is clear that physical restraints are dangerous, have little or no function, and should be avoided at all costs ^(86)(87). Using appropriate continuous quality improvement methods ^(88)(89) and education ⁽⁹⁰⁾, physical restraint use can be markedly reduced with a decrease in injurious falls. The Life Care Subacute Care Unit associated with Saint Louis University has been restraint free from its inception, without any excess of falls or fractures ⁽⁹¹⁾. Side-rails are also becoming recognized as an important cause of bed-related falls and injuries ⁽⁹²⁾.

Numerous fall risk assessment tools are available, and one of these should be routinely utilized in persons at high risk for falling ⁽⁹³⁾. Yates and Dunnagan ⁽⁹⁴⁾ showed that a simple home-based fall risk reduction program in older adults living in the community was highly effective. Recently, a number of other fall-risk prevention programs have been equally effective ^(95)(96)(97). Interventional programs have also reduced fall risk in nursing homes ⁽⁹⁸⁾. Given the weight of evidence-based data, it is no longer appropriate that physicians fail to recognize older persons at fall risk and place them in a fall-risk reduction education program. Guidelines for the prevention of falls in older persons have been developed by the American Geriatrics Society ⁽⁹⁹⁾. In addition, all persons at risk for falls should be evaluated for osteoporosis and receive at a minimum calcium and vitamin D. Studies have shown that osteoporosis is poorly treated in older persons, even following a hip fracture ⁽¹⁰⁰⁾.

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