Fall Prevention – Risk Factors – Part II

          What are the most common risk factors for falling?

Lists of risk factors for falling often differ depending on the type of specialist performing the evaluation or the type of evaluation performed.  One thing that nearly everyone agrees on, the more risk factors present, the higher the chance of falling.  This is more eloquently stated by Tinetti  et al (1988) who listed several risk factors associated with falling (discussed in later studies below) and noted that “The risk of falling increased linearly with the number of risk factors.”  Gary Jacobson and Devin McCaslin (2008) in developing an audiology based “Risk of Falls” clinic at Vanderbit University, list the following risk factors: history of falls, impaired cognitive function, impaired reaction time, depression, postural (orthostatic) hypotension, impaired somatosenses (proprioception and vibration sense), impaired postural stability, impaired vestibular system function, and impaired vision. Rubenstein (2006), a geriatrician, summarized several studies and provided a list of “Important individual risk factors”, as well as a list of “Causes of falls in elderly adults”, seen below:

Important Individual Risk Factors: Weakness, Balance deficit, Gait deficit, Visual deficit, Mobility Limitation, Cognitive impairment, Impaired functional status, Postural hypotension.

Causes of fall in elderly adults: Accident/environment related, Gait/Balance disorders or weakness, Dizziness/vertigo, Drop attack, Confusion, Postural Hypotension, Visual disorders, Syncope, Other specified causes (including arthritis, acute illness, drugs, alcohol, pain, epilepsy and falling from bed), Unknown.

A 2001 joint clinical practice guideline endorsed by the American Geriatrics Society (AGS), the British Geriatrics Society (BGS) and the American Academy of Orthopedic Surgeons (AAOS) includes a list of “most common risk factors”: Muscle weakness, History of falls, Gait deficit, Balance deficit, Use of assistive device, Visual deficit, Arthritis, Impaired Activities of Daily Living (ADL), Depression, Cognitive impairment, Age>80 years.

The American Academy of Neurology has issued an “Evidence Based Guideline for Assessing Patients in a Neurology Practice for Risk of Falls”, and provides this list of Neurological and General risk factors:

Neurological risk factors: Stroke, Dementia, Gait or Mobility problems, Parkinsonism, Peripheral neuropathy, Use of assistive device, Lower extremity weakness, Sensori-motor loss.

General risk factors: Age > 65 years, Vision deficit, Arthritis, Depression, Polypharmacy, Use of cane or walker, Restricted ALDs. 

Others have developed lists of risk factors delineated by various criterion: Definite versus possible, intrinsic versus extrinsic versus environmental, modifiable versus non-modifiable. So, while you can see that there is considerable overlap on these lists, there is also the matter of varied perspectives and examination techniques.

 What are the chances that an older person at risk for falling has one or more risk factors?

It is rare that a patient presenting to a falls clinic will suffer from only one listed risk factor. More frequently a patient will be found to show signs of multiple risk factors. Each, in isolation, may not be of sufficient severity to cause a fall. When multiple factors are involved simultaneously, the patient’s risk of falling increases. For example, a patient with peripheral neuropathy (numbness) of the lower extremities may be reasonably secure in most situations. If they also suffer from orthostatic hypotension (a drop in blood pressure on rising), they may experience greater than expected unsteadiness when they first stand up. In this situation, they are experiencing transient, postural lightheadedness, while at the same time they do not have reliable tactile feedback from the legs to help them stabilize. This can put the patient at increased risk for falling when rising from the sitting or supine position. 

Jacobson and McCaslin (2009) found that the majority of patients assessed in a falls risk clinic had multiple risk factors: “Only 2% had a single risk factor, 10% had two risk factors, 8% had three risk factors, 33% had four risk factors, 18% had five risk factors, 18% had six risk factors, 11% had seven risk factors.”  As noted at the beginning of this post, the more risk factors present, the higher the likelihood of a fall.

 Why is there so much disagreement regarding the best way to minimize the risk of falling?  We will discuss that next week.

 References:

 American Geriatrics Society, British Geriatrics Society, and AmericanAcademyof Orthopaedic Surgeons Panel on Falls Prevention. (2001). Guideline for the prevention of falls in older persons. JAGS, 49, 664-672.

 Jacobson, G. & McCaslin, D. (2008). Assessment of falls risk in the elderly. In: Jacobson, G. & Shepard, N. (Eds.), Balance Function Assessment and Management (pp. 585-612).San Diego: Plural Publishing, Inc.

Rubenstein, L. (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Aging, 35(S2), 37-41.

 Tinetti, M., Speechley, M., & Ginter, S. (1988). Risk factors for falls among elderly persons living in the community. New Eng Jour Med, 319(26), 1701-1707

 

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.