Falls Among the Elderly: A Brief Review

My previously independent 69-year-old grandmother, without prior medical issues, suffered a mechanical fall in her home, resulting in a diagnosis of a right hip fracture that required surgical intervention. Following this fall, she was extremely frightened about recurrent falls and avoided any ambulation. Her activity level gradually declined, leading to her confinement to bed until her death 20 years later. Despite being a very social person, she experienced social isolation after the fall. Due to the loss of independence, she increasingly depended on her family for assistance with all chores, eventually requiring the hiring of a full-time caregiver. This imposed a growing financial burden and social isolation on her family. This patient’s experience underscores the significant impact that falls can have on an individual’s mortality, morbidity, and their families.

Approximately a quarter of US residents aged 65 years or older report falling each year. These traumatic events often result in emergency department visits, decreased functionality in daily activities, and death.¹ Over the last decade and a half, the rate of deaths from falls in the elderly increased in the United States by an average of 3% per year.1 Though falls in the elderly have been discussed in the literature, the issue remains pervasive in various settings and persists as one of the leading causes of death among older adults. Nearly 10,000 deaths in older Americans are associated with falls annually.² Falls contribute significantly to the financial costs associated with elder health care, with patients experiencing prolonged hospital stays and management of associated injuries. SGIM physicians must recognize the risk factors associated with these events and implement protective measures to minimize the incidence and consequences of falls, both inside and outside of the hospital.

Falls are more prevalent among elderly females than males, occurring at a rate five times higher.³ The rates of falls and deaths from falls tended to be higher in white adults compared to other racial or ethnic groups.¹ In general, etiologies of falls may be separated into intrinsic and extrinsic causes.³ Intrinsic causes are more common and include dizziness, vertigo, lower extremity weakness, syncope, and stroke. The most frequent extrinsic causes include slipping, uneven floor surfaces, external forces, and insufficient lighting.^{2, 3} Reviewing medication history is integral in risk assessment, as numerous medication classes including hypnotics, anxiolytics, antihypertensives, corticosteroids, nonsteroidal anti-inflammatories, and anticholinergics may increase the risk of falls.² The causes of falls are commonly multifactorial.

Only a fraction of falls can be linked to a single identifiable cause. A history of falls is the single most significant association with an increased incidence of falls.³ Elderly patients contend with multiple underlying health conditions, are prescribed a variety of medications, and often manifest symptoms that coincide with their pre-existing ailments. These elements of the patient’s clinical profile should be evaluated in conjunction with the present history and the physical examination to delineate the etiology of falls.

As modern healthcare technology extends lifespans, the general population becomes older and the incidence of falls among elderly patients is on the rise. Prioritizing primary and secondary prevention remains paramount. The United States Preventative Services Task Force (USPSTF) 2023 recommendations included exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.⁴ For all adults aged 65 and older, the USPSTF recommended against vitamin D supplementation to prevent falls in 2018.⁴ The American Geriatrics Society recommends that all adults over 65 years old be screened annually for a history of falls or balance impairment.⁵ Comprehensive interventions encompass a spectrum of approaches, including targeted exercises—such as balance, strength, and gait training—adjustments to the home environment, and an evaluation of medications focusing on minimizing psychoactive drugs. To effectively diminish the risk of falls among the elderly, it is essential to meticulously consider other critical factors like foot problems, appropriate footwear, postural hypotension, vision impairments, and slippery surfaces. These interventions have demonstrated efficacy in reducing falls across various settings, spanning from community to hospital and nursing home environments.

In evaluating the appropriateness of these interventions for patients, SGIM clinicians should discuss the pros and cons with their patients through a shared decision-making process while considering factors such as co-morbidities and a history of previous falls. SGIM clinicians need to emphasize the importance of maintaining regular exercise routines, making home modifications to enhance safety, and adopting careful medication management to lower the risk of falls among older individuals. Looking back on our patient, a previously healthy and independent 69-year-old woman, she may have avoided the burden of physical dependence, social isolation, and being bed-bound after her fall through education about fall prevention, ensuring a safe home environment, and early introduction of physical therapy. Her family also suffered from the financial burden due to the expenditure on a full-time caregiver, along with social isolation. Falls can have a significant impact on our patients and their families, so vigilance and education about fall prevention among the elderly are paramount.