Falls in older people are a geriatric syndrome, the main clinical symptom of which is the case when a person over 60 years old inadvertently suddenly finds himself on the floor or ground. Concomitant symptoms depend on the existing background diseases. Diagnosis of the causes of the syndrome is carried out using laboratory tests, radiography, ECG, Holter monitoring, neuroimaging. Therapy includes drug correction of background pathology, the appointment of vitamin D preparations, an individual exercise therapy program, and, if necessary, psychotherapy.
ICD 10
W00-W19 Falls
General information
Falls in older people are the leading gerontological problem affecting the prognosis and quality of life of patients. This syndrome does not include cases that have arisen due to the effects of mechanical factors (for example, shock), epiprime, loss of consciousness, sudden paralysis. According to research, among people over 65 years of age, 33% indicate the presence of falls in the anamnesis, half of them have such cases more than once a year. In the elderly, falls are the main cause of injuries and come out on top among the causes of death from injuries.
Causes
The main etiological factors are irreversible age-related changes in the body and environmental conditions. Psychological characteristics of the elderly also play a significant role. The combination of several etiofactors increases the probability of a fall. All etiological causes are divided into 2 groups: internal and external. The first are due to the physical and mental state of a person. These include:
- Age-associated changes. Age-related visual, hearing, and motor disorders contribute to the occurrence of the syndrome. Changes in the nervous system lead to a reduced reaction rate, a decrease in mindfulness.
- Diseases of organs and systems. On the part of the central nervous system, this is Parkinson’s disease, cerebral circulatory disorders, degenerative processes. Among other diseases, falls can provoke: anemia, myocardial infarction, arrhythmias, spinal deformities, diarrhea.
- Psychoemotional disorders. Anxiety, depression, fear of falling lead to a restless state, irrational behavior that increases the chances of falling. A favorable background for the occurrence of pathology is nervous exhaustion.
- Iatrogenic causes. Increased tendency to falls may be associated with immobilization of limbs, polypragmasia. The appointment of sedatives, tranquilizers entails inhibition of reactions, drowsiness, inattention, increasing the likelihood of falling.
- Behavioral factors. They include the presence of bad habits, lack of sufficient physical activity. Uncontrolled self-administration of a large number of medications changes the state of the body in the direction of increasing the risk of falling.
External etiofactors affect a person from the outside. They are caused by the environment, various social reasons. Among the external factors , the following are distinguished:
- Environmental. The environment surrounding an elderly person can provoke a loss of balance. For example, uneven asphalt, holes on the sidewalk, stairs that are too high or narrow. For the elderly, it is difficult to move in poor or too bright lighting, on a slippery surface.
- Social. Isolation of the elderly from society, living alone lead to a lack of support and assistance in landscaping, medical care. Economic problems entail reduced nutrition, which can cause asthenia.
Pathogenesis
The fall occurs due to the inability to maintain balance when the center of gravity is shifted. The work of the vestibular and musculoskeletal system prevents this. Normally, the retention of the body position occurs due to the tension of the muscles of the lower extremities, a step reaction or support on surrounding objects.
After the age of 30, there is a gradual decrease in the number of muscle fibers and muscle strength, which leads to muscle weakness in the elderly. Sarcopenia develops, more pronounced in relation to fast muscle fibers. The mobility of the ligamentous apparatus decreases, the volume of movements in the joints. As a result, the possibility of a quick muscle reaction to maintain balance suffers.
In the step reaction in the elderly, a short step forward is accompanied by an additional step to the side. Small steps cause one foot to touch the other. Such a change in the step pattern leads to frequent falls on the side with the risk of injury to the hip joint and fracture of the femoral neck.
Classification
Currently, the syndrome of falling in the elderly is classified on the basis of 2 criteria: by causal factor and by the presence of injury. Etiopathogenetic classification is necessary for the statistics of causes with the subsequent implementation of preventive measures. According to it, the fall is divided into:
- Random. It is connected with environmental reasons. Includes stumbling over obstacles, underestimating the location of surrounding objects. One of the reasons is the darkening of the room.
- Predictable. It is associated with the physiological state of the patient. The probability of falling is higher in patients with dizziness, muscle weakness, parkinsonism, cognitive impairment.
- The unpredictable. The patient falls due to an unpredictably arisen pathological condition. Unpredictable causes are infarction, stroke, hypoglycemic episode, syncopal condition.
The classification of the syndrome according to the emerging traumatic complications and their severity is of clinical importance. It is necessary to determine the further tactics of the patient’s management. There are 2 main groups:
- Falls without injury. They are not accompanied by visible damage and complaints. In some cases, radiography, tomography, and other instrumental studies are necessary to exclude damage.
- Falls with injury. Include cases that lead to injury to the victim. The mild degree is characterized by the presence of bruises and abrasions, the average degree is characterized by the appearance of sprains, wounds that need to be stitched. Severe fractures, traumatic brain injuries, and damage to internal organs are considered.
Symptoms
The clinical symptoms depend on the premorbid background and the severity of the injuries. Complaints of walking uncertainty, instability, dizziness, weakness in the legs are characteristic. Arbitrary movements are slowed down, there is a shortening of the step length, a shuffling gait is possible. The frequency of falls, the circumstances under which they occur, are different. Elderly patients with mnestic disorders may not remember that they fell. Such an incident is evidenced by the fear of falling, which they still have.
Repeated falls in an elderly patient usually have a similar pattern characteristic of him. With orthostatic hypotension, atonic attack, arrhythmias, the patient literally “collapses” to the floor. In Parkinsonism, loss of balance occurs when the body position changes, after fading. Weakness of the foot muscles, spastic muscular hypertonus of the feet are characterized by an incontinence of balance after stumbling. In the case of senile dementia, psychoemotional disorders, a clear pattern is not traced.
Complications
Falls in older people in 10-15% of cases lead to serious injury. Possible damage to tendons and ligaments, fractures of the lower leg, thigh, upper limb, ribs. Due to the violation of the step pattern, hip fractures occur most often. Given the slowness of regenerative processes in old age, fracture consolidation is difficult and not always successful. When hitting the head, concussion, brain contusion, and the formation of a subdural hematoma are possible. Severe cerebral trauma can cause death.
Diagnostics
Identification of patients at risk is carried out by interviewing when applying on an outpatient basis, during hospitalization. The diagnosis is established by two criteria: the presence of the fact of a fall in an elderly person, the exclusion of the connection of the incident with epileptic paroxysm, shock, loss of consciousness. A wide examination is shown to identify internal etiofactors with a view to their subsequent correction. Diagnostic measures include:
- Neurological examination. In the neurological status, attention is paid to a decrease in muscle strength, shaky gait, instability in the Romberg pose, cognitive deviations. In practical neurology, tests are additionally used: getting up from a chair, standing on one leg, standing in the “tandem” pose.
- Laboratory diagnostics. A general blood test is recommended to determine the level of hemoglobin, a urine test. The functional state of the kidneys is assessed by creatinine level, glomerular filtration rate. A study of thyroid hormones is prescribed.
- Cardiological examination. Includes measurement of pressure, heart rate, mandatory ECG. Holter monitoring is used in the diagnosis of arrhythmias. If there are indications, it is recommended to consult a cardiologist.
- Bone radiography. It is carried out if a fracture is suspected in order to assess the condition of the musculoskeletal system. If more detailed visualization is required, a CT scan of the hip joint and spine is recommended.
- Ultrasound of the vessels of the head and neck. It is prescribed to assess cerebrovascular hemodynamics, violations of which act as triggers of falls in older people. If necessary, the study is supplemented by angiography.
- MRI of the brain. It is recommended for assessing the state of cerebral structures, identifying atrophic and degenerative changes. It is used during differential diagnostics with volumetric formations.
Differential diagnosis
Falls in older people should be differentiated from intracranial neoplasms. The latter manifest general cerebral symptoms, which is also possible in old age. Differential diagnosis is carried out by the presence of focal symptoms (paresis, sensory disorders, speech disorders), visualization of the neoplasm on cerebral CT / MRI.
Treatment
Motor activity is recommended for patients, according to their functional capabilities. An important point is the observance of a full-fledged diet, with the use of food rich in protein, trace elements, vitamins. Therapy is carried out in a complex with the use of all possible methods. In case of arrhythmia, the question of the expediency of installing an electrocardiostimulator is considered. The basic elements of treatment are:
- Drug therapy. It is aimed at correcting the identified concomitant diseases that act as individual triggers. Special attention is paid to the exclusion of polypragmasia. With vitamin D deficiency, its additional intake is indicated.
- Physical therapy. A set of exercises is individually selected to strengthen the muscles of the extremities, train the vestibular apparatus, improve coordination of movements. Daily classes are recommended.
- Psychotherapy. Cognitive behavioral, psychoanalytic techniques help elderly patients overcome the fear of falling. Special cognitive training contributes to the improvement of mindfulness and mnestic functions.
Prognosis and prevention
The lack of qualified medical care leads to repeated episodes of incontinence of body position in the elderly, injuries, severe complications with loss of autonomy. The results of treatment depend on age, degree of functional activity, concomitant pathology. The mortality associated with falls in the age group of 65 years is about 50 per 100 thousand and is steadily increasing with age.
Primary prevention of falls in older people includes an active lifestyle, a full diet, regular gymnastics, timely treatment of emerging diseases. Secondary prevention is carried out by creating safe conditions in the place of residence (selection of stable furniture, installation of handrails, correction of lighting), selection of comfortable shoes, wearing special orthoses, individually selected insoles.