Falls are common in the elderly. A Fall is
defined as a person coming to rest on the ground or another
lower level. The “Elderly” has been defined as those above the
age of 65, whereas the United Nations has defined age above 60
as “Older Population” or “Old Age”.
In the community the incidence of falls in the elderly
approximately is 30 – 40% whereas in Nursing homes it is
approximately 50 – 60% [1]. Falls are the primary cause
of accidental death in the elderly and several factors are
identified for the same. Evidence based investigations have
proved that falls are preventable if proper action is taken in
time [2]. Also applying preventive measures in the vulnerable
population impacts public health. Almost 50% of the falls are
recurrent.
Factors causing falls
These can be classified into three main categories [1]:
1. Intrinsic Factors – Age related morbidities,
drugs etc.,
2. Extrinsic Factors – Environmental hazards like uneven
surface, slippery surface, new home, unsafe stairways,
slippery bath, mats, carpets etc.
3. Situational Factors – Related to activities like walking
while talking on the phone, being distracted during
multitasking, failing to notice a step or curb, or rushing
to the bathroom at night, rushing to answer the phone, poor
lighting etc.
Risk Factors for a Fall
Several risk factors which can cause a fall in the elderly
[2]:
1. History of previous falls
2. Balance impairment
3. Decreased muscle strength
4. Visual Impairment
5. Poly pharmacy when more than 4 drugs are given or when
Psychotropic drugs given,
6. Gait impairment and walking difficulty
7. Dizziness/Depression
8. Orthostatic Hypotension
9. Age over 80 years
10. Female sex
11. Incontinence of Urine or stools leading to hurrying to
the toilet
12. Cognitive impairment
13. Arthritis
14. Diabetes mellitus especially with Neuropathy – Autonomic
or Peripheral
15. Any acute or chronic pain
Cardiac Causes of Syncope in the Elderly
Some important intrinsic causes of falls in the elderly are:
1. Cardiac Causes
2. Neurological causes like TIA, Stroke, Parkinson’s
disease, Vertigo.
3. Neurally mediated causes like Orthostatic Hypotension,
Carotid Sinus Syncope, Vasovagal syncope (Rare in the
elderly, more in the young)
4. Dehydration
5. Drugs
6. Frailty
The Main Cardiac Causes are [3]:
• Increase in structural heart hisease and cardiac
conduction defects are more common in older age.
• One out of three causes of syncope are cardiac
• These are mostly arrhythmias – brady and Tachyarrhythmias
of which bradyarrhythmia predominates.
Common arrhythmias encountered in the elderly are:
* Atrial Fibrillation
* Supraventricular Tachycardias
* Ventricular Tachycardia
* Complete Heart Block
*Sick Sinus Syndrome
• Valvular causes like severe aortic stenosis and mitral
valve disease are also not uncommon and may be a cause of
syncope in the elderly.
• Other structural causes are hypertrophic obstructive
cardiomyopathy, cardiac failure and dilated cardiomyopathy.
Clinical and ECG features suggesting Arrhythmic Syncope are
listed below [3]:
* Syncope during exertion
* Palpitations associated with syncope
* Family history of sudden cardiac death
* Non-sustained ventricular tachycardia
* Bifascicular block in ECG
* Sinus bradycardia with HR < 50 bpm
* Pre-excitation in the ECG
* Prolonged or short Q-T interval
* Brugada pattern in the ECG
The following investigations reveal the cause of cardiac
syncope [3]:
1. ECG – A routine 12-lead ECG is often helpful in
diagnosing some conditions like Pre-excitation, Brugada
pattern, Ischemic heart disease, Chamber hypertrophy and
Arrhythmias.
2. Echocardiography is useful in the diagnosis of structural
heart diseases which may be the cause of cardiac syncope.
3. Ambulatory BP monitoring will record the fluctuation in
the blood pressure which may occur during the day and can
diagnose the periods of low blood pressure which may lead to
the syncope.
4. Cardiac monitoring – A 24-hour Holter monitoring, or an
external loop recorder will be helpful in diagnosing
transient arrhythmias causing the syncope.
5. Electrophysiological studies may have to be
undertaken for the diagnosis of arrhythmias and may also be
used to treat tachyarrhythmias by ablation.
6. Investigation for co-morbidities - Anemia and
Electrolyte abnormalities, especially Hyponatremia which are
common causes, and other metabolic disorders too may be
diagnosed by blood examination.
The treatment of cardiac causes will depend on the etiology.
1. Anti-arrhythmic therapy with appropriate
anti-arrhythmic drugs will be needed in many arrhythmias.
2. Electrophysiological studies and ablation may have to be
done both for the diagnosis and treatment of
tachyarrhythmias.
3. Device implantation like pacemaker in cases of
bradyarrhythmias will be necessary in those with slow
persistent heart rates.
4. Surgical or endovascular treatment for valve lesions like
aortic valve stenosis.
5. Management of cardiac failure with the guideline based
therapy will go a long way in reducing hospitalization and
improving the quality of life of the patient.
Orthostatic hypotension
Approximately 5 – 25% of normal elderly population may have
orthostatic fall of blood pressure at some time. It is
diagnosed when after three minutes of standing, the systolic
blood pressure falls by 20 mm Hg and/or the diastolic blood
pressure falls by 10 mm Hg [4].
Risk factors for orthostatic hypotension are:
1. Autonomic dysfunction often occurs in long
standing diabetes or as a stand-alone entity rarely. Proper
investigations will indicate the diagnosis.
2. Hypovolemic orthostatic hypotension often caused by
dehydration occurs not uncommonly in the elderly, especially
who live alone and do not consume adequate fluids.
3. Low cardiac output also cause orthostatic fall of blood
pressure leading to falls.
4. Parkinsonism is a not so uncommon may cause falls from
associated autonomic changes causing orthostatic
hypotension, difficulty in locomotion and the drugs
prescribed for its treatment.
5. Metabolic and endocrine disorders like diabetes,
hypothyroidism, addison’s disease etc., must be considered.
6. Medications - often antihypertensives,
antidepressants, sedatives, antipsychotics and neuroleptics
prescribed to the elderly may be the cause of falls due to
orthostatic fall of blood pressure.
Dehydration in the elderly [1]
Dehydration is very common in elderly patients due to many
reasons. Even if it’s not hot outside dehydration may occur
and is often unrecognized. The elderly do not drink enough
water due to many reasons. Also, elderly persons have less
thirst signals compared to the young. They often forget to
drink water or fluids often due to memory problems. Problems
with mobility and living in nursing homes is associated with
an increase in incidence of dehydration. The elderly may have
swallowing difficulties which impairs their ability to swallow
liquids. Acute illnesses like fever, vomiting or diarrhea may
acutely cause dehydration leading to a low blood pressure and
consequent falls. A hot and humid weather outside may also
contribute to rapid dehydration in the elderly, coupled with
inadequate intake. The elderly may be prescribed diuretic
drugs as part of their treatment which can also lead to
dehydration.
The main signs of dehydration in the elderly are dry mouth and
skin, sunken eyes, dark colored urine, low systolic blood
pressure, less frequent urination, sinus tachycardia and often
urinary incontinence.
Dehydration presents often as weakness and the low systolic
blood pressure can provoke falls in the elderly. Also, when
the dehydration is severe and longstanding, it can result in
acute kidney failure. Constipation is another symptom and may
even end up in impaction of feces in the rectum. Dehydration
causing hemoconcentration may lead to renal calculi. Urinary
infection in the elderly is also a consequence of dehydration.
Lab Diagnosis
Elevated urea, creatinine and plasma osmolality are noted.
Serum sodium levels are often abnormal with either
hyponatremia or even hypernatremia rarely. The urine on
examination shows low urine sodium concentration.
A proper assessment of the fluid status of the individual can
be made by measuring the inferior vena cava diameter in the
abdomen with an ultrasound or cardiac probe. A collapsed
inferior vena cava suggests dehydration.
Prevention of dehydration in the elderly
Elderly persons must be encouraged to drink at least 1.8 liter
of fluids per day.
It is better to consume it in small quantities frequently as
they cannot drink large quantities of fluid. The beverage
offered should also be appealing to them. In case of
difficulty in holding the glass or cup, a drinking straw may
be provided. They should be encouraged to visit the toilet at
fixed intervals to prevent incontinence and precipitancy of
micturition. It is also useful to offer drinks on schedule to
ensure adequate intake of fluids. Problems of incontinence, if
present should be addressed appropriately [1].
History taking and Screening after a Fall in the elderly
[2]
A detailed history as to the circumstances of the fall and the
medications that the person has been taking is helpful in
preventing future falls in the individual.
A detailed assessment of gait, assessment of sensorimotor
functions, vision and hearing also should be done to find out
if any of these are impaired leading to the fall. Orthostatic
recording of blood pressure is important. Other additional
causes like cognitive impairment should be investigated. A
detailed review of the person’s footwear and gait
appropriateness should be investigated.
Carotid sinus hypersensitivity is another not so uncommon
condition and should be looked for in the supine position.
Vitamin D supplementation in a dose of 800 i.u/day has been
recommended as a measure to reduce the incidence of falls.
The person should be introduced to an exercise regimen
gradually with strength and gait training. Any psychotropic
drugs should be gradually withdrawn.
Vision must be tested and if possible, a single-lens glasses
should be prescribed as bifocal lenses may be associated with
increased tendency to falls. Wherever appropriate, cataract
surgery should be advised.
The environment also should be investigated – use of Anti-slip
shoes, anti-skid flooring in bathrooms, use of a walking stick
or walker etc., should be appropriately advised.
The prevention of falls should be through a multicomponent
intervention program designed separately for each elderly
individual.
Simple tips to prevent falls in the elderly [5]
A regular check-up with their family physician or any other
doctor will be helpful in making early diagnosis of any
condition in the elderly that could lead to falls. Medications
and their dosage also could be adjusted if the individual has
a regular follow up with his physician.
An elderly individual should also be encouraged to keep moving
and perform light exercises. Regular physical activity
prevents falls to a great extent. Gentle exercises such as
walking, Tai-chi, swimming etc., are good exercises that could
be recommended. Exercise increases strength, co-ordination,
balance and flexibility.
Footwear should be sensible, meaning that it should be
anti-skid and prevent falls. Proper footwear also reduces
joint pains. Any home hazards that could pose a threat should
be removed or set right. The living space of the individual
should be properly lit up. Whenever needed, assist devices
like walking sticks, walkers or grab bars in the toilets
should be provided to prevent falls and injury.
Frailty [6]
It is a complex biological process with decreased
physiological reserve and vulnerability to stressors [6]. It
is more common in women and is an important cause contributing
to falls in the elderly. Frailty increases with advancing age.
There are five important variables in frailty, any three of
those, if present predict increased chances of morbidity and
mortality. They are:
Unintentional weight loss
Self-reported exhaustion
Low energy expenditure
Slow gait speed
Weak grip strength.
References
1. Rubenstein LZ. MSD Manual: Medical Topics.
2. Tareef Al-aama. Can. Fam Physician 57 (7) 2011,
771-776
3. O’Brien H, Kenny RA, European Cardiology Review 9 (1) 2014,
28-36.
4. Rubenstein LZ, Josephson KR. Clin. Geriatr.Med 18: 2002,
1410158.
5. Fall Prevention – Simple tips to prevent falls: Healthy
Aging – Mayo Clinic Staff.
6. Solbiat IM, Sheldon R, Steifer C. Managing syncope in
Elderly: The not so simple faint in Aging Patients. Canadian
Journal of Cardiology 32: 2016, 1124–1131.