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Falls in Older Adults

General Information

General InformationGeneral Information

Incidence/Prevalence

  • 28%-35% of adults ≥ 65 years old are reported to fall each year worldwide, with more falls reported with increasing age4
  • incidence/prevalence in United States
  • incidence/prevalence in Australia
    • Study Summary
      in Australia, 17% of emergency department visits in patients ≥ 70 years old are due to falls
      Details
      studySummary
      • based on retrospective cohort study Cohort Study
      • 18,902 adults aged ≥ 70 years presenting to emergency department in Sydney, Australia, were evaluated for cause of presentation to ED
      • 3,220 adults (17%) presented to ED due to fall, of whom
        • 35.4% ≥ 1 ED visits within past 12 months
        • 20.3% ≥ 1 hospital admissions within past 12 months
        • 42.7% hospitalized after ED visit
        • 9.5% became first-time resident of long-term care facility after hospitalization
      • PubMed21965178Emergency medicine journal : EMJ20120901Emerg Med J299742742 Reference - 21965178Emerg Med J 2012 Sep;29(9):742
  • incidence/prevalence in Asia
  • Study Summary
    fall rates 14.7%-34% (median 18%) per year in older adults in Asia
    Details
    studySummary
    • based on systematic review of observational studiesSystematic Review
    • systematic review of 21 studies conducted in China, Hong Kong, Macao, Singapore, and Taiwan evaluating prevalence of falls in community-dwelling adults ≥ 60 years old
    • all studies had inclusion criteria limiting population to samples with ≥ 75% adults of Chinese ethnicity
    • in 4 prospective cohort studies, 60%-75% of adults who reported a fall also reported a fall-related injury
      • most fall-related injuries reported to be minor (swollen joints, bruises, abrasions)
      • approximately 10% of fall-related injuries reported to be major, with fractures in 6%-8% of all injuries
    • PubMed21361880Journal of the American Geriatrics Society20110301J Am Geriatr Soc593536536 Reference - 21361880J Am Geriatr Soc 2011 Mar;59(3):536
  • incidence/prevalence in residential facilities or nursing homes
    • more than 50% of adults aged ≥ 65 years living in residential facilities or nursing homes are reported to experience ≥ 1 fall each year (mnh16310556paph18936472pa9h18936472pbyh18936472pafh18936472pbeh18936472phch18936472pnyh18936472pnxh18936472pbth18936472ppbh18936472pcxh18936472pmdc16310556pLancet 2005 Nov 26;366(9500):1885)
    • Study Summary
      8.7% of older adults admitted to geriatric service reported to have fallen during hospitalization
      Details
      studySummary
      • based on prospective cohort study Cohort Study
      • 2,945 adults (mean age 83 years, 62% female) admitted to acute geriatric medicine service in hospital in Sydney, Australia were evaluated for falls
      • 94% of adults admitted from the emergency department
      • most admitted to hospital based on targeting criteria that included delirium, deconditioning, functional impairment, gait abnormalities, fall, multiple diagnoses, polypharmacy, or malnutrition
      • median length of hospitalization of 11 days
      • 257 adults (8.7%) had a fall, of whom
        • 33 adults (12.8%) had 2 falls, 13 (5.1%) had 3 falls, and 7 (2.7%) had ≥ 4 falls
        • 66 adults (25.7%) had fall-related injuries, including 5 severe injuries (2 hip fractures and 1 fracture each of ankle, wrist, or vertebra)
      • Clinical interventions in aging201501Clin Interv Aging1016371637Reference - Clin Interv Aging 2015;10:1637full-text

Complications

  • in older adults, falls are reported to be the leading cause of injury, injury-related disability, and injury-related death4
  • about 40%-60% of falls in older adults reported to result in injuries
  • potential long-term consequences of fall reported to include4
    • hip fracture
      • 95% of hip fractures in older people are reported to be due to falls
      • 20% of older patients with hip fracture reported to die within 1 year
      • see Hip fracture for additional information
    • traumatic brain injury (See Concussion and mild traumatic brain injury or Moderate to severe traumatic brain injury for additional information)
    • nursing home admission
      • 95% of patients with hip fracture are subsequently admitted to nursing home
      • about 40% of nursing home admissions are reported to be related to falls
  • other negative consequences that may be associated with fall, fall-related injury, or fear of falling include4
    • reduced physical activity and subsequent deconditioning
    • impairment in daily activities due to functional decline
    • social isolation and reduced quality of life
    • depression
    • increased risk of subsequent falls
    • fall-related death (see Prognosis - fatality for information concerning mortality and falls in older adults)
  • Study Summary
    falls are a frequent cause of acute traumatic spinal cord injury among older adults
    Details
    studySummary
  • Study Summary
    use of long-term anticoagulation associated with increased risk of intracranial hemorrhage after fall
    Details
    studySummary
    • based on retrospective cohort study Cohort Study
    • 47,717 adults ≥ 65 years old hospitalized due to a fall in 2004 identified in New York, United States database
    • 3.1% patients were on long-term anticoagulation
    • 5.2% patients had intracranial hemorrhage
    • comparing patients on long-term anticoagulation vs. patients without long-term anticoagulation
      • traumatic intracranial hemorrhage after fall in 8% vs. 5.3% (p < 0.0001, NNH 37)
      • mortality among patients with traumatic intracranial hemorrhage 21.9% vs. 15.2% (p = 0.04)
      • no significant difference in overall mortality
    • PubMed18073595The Journal of trauma20070901J Trauma633519519 Reference - 18073595J Trauma 2007 Sep;63(3):519
    • DynaMed Commentary

      Despite increased risk of intracranial hemorrhage, guideline groups typically do not recommend withholding anticoagulation due to risk of falls, as benefits are still judged to outweigh risks (BMJ 2014 Jun 19;348:g3655).

Prognosis

  • adults ≥ 65 years old who experience a fall are reported to have 66% likelihood of falling again within 12 months4
  • Study Summary
    of adults ≥ 60 years old who called emergency services for falls in suburban area of United States during 2007-2016, 29.2% made ≥ 2 fall-related calls
    Details
    studySummary
    • based on retrospective analysis of emergency medical services database Cohort Study
    • 37,324 emergency calls ("911") during 2007-2016 in suburban community in United States were analyzed
    • 4,084 calls were fall-related and were made by 2,343 community-dwelling adults ≥ 60 years old (mean age 81 years)
      • 62% of calls resulted in transport for higher care
      • 29.2% made ≥ 2 fall-related calls
    • transport in 21% of adults with ≥ 5 fall-related calls vs. 75% of first-time callers (p < 0.001)
    • of 1,723 calls with subsequent call, median time to next call was 2.7 months
    • PubMed30019749Journal of the American Geriatrics Society20180901J Am Geriatr Soc66917371737 Reference - 30019749J Am Geriatr Soc 2018 Sep;66(9):1737
  • Study Summary
    increasing age, male sex, and lower postoperative hemoglobin associated with returning to hospital for older adults discharged from hospital following fragility fracture
    Details
    studySummary
    • based on systematic review of observational studies Systematic Review
    • systematic review of 35 observational studies (mostly retrospective and prospective cohort studies) evaluating correlates of re-presentation to hospital in older adults (mean age ≥ 65 years old) discharged from hospital after fragility fracture
    • 11 studies classified as high-quality included in best evidence synthesis
    • factors positively associated with hospital re-presentation in best evidence synthesis of 11 high-quality studies
      • increasing age (1 of 11 studies)
      • male sex (1 of 11 studies)
      • lower postoperative hemoglobin level (1 of 11 studies)
      • higher cumulative illness rating score at index admission (1 of 11 studies)
      • comorbidities including impaired perception, renal insufficiency, asthma, and chronic liver disease (in 5 studies)
    • PubMed27615745BMC medicine20160912BMC Med141136136 Reference - mnh27615745paph118086279pa9h118086279pafh118086279pcxh118086279pmdc27615745pBMC Med 2016 Sep 12;14(1):136
  • Study Summary
    functional trajectory after a serious fall appears highly correlated with prefall functional trajectory in community-dwelling adults ≥ 70 years old
    Details
    studySummary
    • based on prospective cohort study Cohort Study
    • 754 community-dwelling adults ≥ 70 years old and initially not disabled in basic activities of daily living assessed for prefall functional trajectory (no, mild, moderate, progressive, or severe disability) and followed for 12 years
    • 4 postfall functional trajectories (rapid, gradual, little, and no recovery) identified in 130 adults with subsequent serious fall injury (62 with hip fracture and 68 with other injury from fall resulting in hospitalization)
    • among patients with serious fall injury
      • rapid recovery observed only in persons with no or mild prefall functional disability
      • substantive recovery (rapid or gradual recovery) highly unlikely in patients with prefall progressive or severe disability
      • postfall trajectories worse for hip fractures than for other serious injuries
    • PubMed23958741JAMA internal medicine20131028JAMA Intern Med1731917801780 Reference - mdc23958741pJAMA Intern Med 2013 Oct 28;173(19):1780full-text, editorial can be found in mdc23959545pJAMA Intern Med 2013 Oct 28;173(19):1786
  • rates of fatalities from falls in older adults
    • 2016 fatality data of adults ≥ 65 years old from United States Centers for Disease Control and Prevention (CDC)
    • Study Summary
      reported age-adjusted rate of fatality due to fall is 53.7 per 100,000 people ≥ 65 years old in United States in 2011
      Details
      studySummary
      • based on cross-sectional surveys from National Health and Nutrition Examination Surveys (NHANES) from 2005 to 2013 Cross-Sectional Study
      • age-adjusted fatality rate due to falls in adults ≥ 65 years old increased from 2005 to 2011; rates were
        • 42.3 per 100,000 people in 2005
        • 53.7 per 100,000 people in 2011
      • in 2011, there were 22,901 deaths due to unintentional injury from a fall in adults ≥ 65 years old
      • PubMed2535667320141031MMWR Suppl63433 Reference - 25356673MMWR Suppl 2014 Oct 31;63(4):3
    • Study Summary
      12.4% of deaths among adult nursing home residents in Australia may be due to falls
      Details
      studySummary
      • based on retrospective cohort study Cohort Study
      • 21,672 adult nursing home residents in Australia (median age 88 years for women and 86 years for men) who died between 2000 and 2013 were evaluated for cause of death
      • 3,298 deaths (15.2%) were due to external causes (premature, typically injury-related, and potentially preventable deaths), of which 2,679 deaths (81.5%) were due to falls
      • fall-related injuries accounted for 12.4% of all deaths
      • The Medical journal of Australia20170605Med J Aust20610442442Reference - Med J Aust 2017 Jun 5;206(10):442
    • Study Summary
      deaths due to accidental falls in adults aged ≥ 65 years in Spain increased between 2000 and 2015
      Details
      studySummary
      • based on population-based retrospective cohort study Cohort Study
      • 30,893 deaths due to accidental falls in Spain between 2000 and 2015 were identified using population data by Spanish National Statistics Institute
      • 23,502 accidental fall deaths (76.1%) occurred in adults ≥ 65 years old
      • adjusted mortality rates due to falls among adults ≥ 65 years old increased between 2000 and 2015
        • in 2000
          • 16.3 per 100,000 person-years in all adults
          • 20.6 per 100,000 person-years in men
          • 13.8 per 100,000 person-years in women
        • in 2015
          • 24.6 per 100,000 person-years in all adults
          • 30.1 per 100,000 person-years in men
          • 20.8 per 100,000 person-years in women
      • BMC geriatrics20171128BMC Geriatr171276276Reference - BMC Geriatr 2017 Nov 28;17(1):276full-text
    • Study Summary
      fatalities from falls increased in adults ≥ 65 years old between 1993 and 2003, but rate of hospitalizations for hip fractures decreased
      Details
      studySummary
      • Cohort Study based on cohort study
      • overall rate of fatal falls increased from 1993 to 2003
        • based on annual mortality data in United States
        • age-adjusted fatality rate from falls increased significantly, with higher rates in men
        • rate increased in men from 31.8 per 100,000 persons in 1993 to 46.2 per 100,000 persons in 2003 (45.3% rate increase, p < 0.01)
        • rate increased in women from 19.5 per 100,000 persons in 1993 to 31.1 per 100,000 persons in 2003 (59.5% increase, p < 0.01)
        • rates increased in all ethnic populations for men and women, except for black men
      • rate of hospitalizations for hip fractures decreased between 1993 and 2003
        • based on data from National Hospital Discharge Survey (NHDS)
        • overall age-adjusted hospitalization rate decreased from 917.6 per 100,000 persons in 1993 to 775.7 per 100,000 persons in 2003 (15.5% decrease, p = 0.001)
        • annual rate of hospitalization higher in women than men
      • PubMed17108890MMWR. Morbidity and mortality weekly reportMMWR Morb Mortal Wkly Rep2006111755451221-41221Reference - MMWR Morb Mortal Wkly Rep 2006 Nov 17;55(45):1221full-text, correction can be found in MMWR Morb Mortal Wkly Rep 2006 Dec 8;55(48):1303

References

General references used

  1. Thurman DJ, Stevens JA, Rao JK. Practice parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 Feb 5;70(6):473-9, reaffirmed 2016 Jan 23, commentary can be found in Neurology 2009 Jan 27;72(4):382
  2. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011 Jan;59(1):148-57
  3. Avin KG, Hanke TA, Kirk-Sanchez N, et al. Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015 Jun;95(6):815-34full-text
  4. Vieira ER, Palmer RC, Chaves PH. Prevention of falls in older people living in the community. BMJ. 2016 Apr 28;353:i1419, commentary can be found in BMJ 2016 Jun 1;353:i3005

Recommendation grading systems used

  • Academy of Geriatric Physical Therapy (AGPT) uses a synthesis of grading systems including National Institute for Health and Care Excellence (NICE) and American Geriatrics Society/British Geriatrics Society (AGS/BGS)
    • levels of evidence
      • Level I
        • NICE - evidence from meta-analysis of randomized controlled trial (RCT) or ≥ 1 RCT
        • AGS/BGS - ≥ 1 properly conducted RCT
      • Level II
        • NICE - evidence from ≥ 1 controlled trial without randomization or ≥ 1 other type of quasi-experimental study
        • AGS/BGS
          • Level II-1 - well-designed controlled trial without randomization
          • Level II-2 - well-designed cohort study or case-control analytic study, preferably from > 1 source
          • Level II-3 - multiple time series evidence with or without intervention, dramatic results of uncontrolled experiment
      • Level III
        • NICE - evidence from nonexperimental studies, such as comparative studies, correlation studies, and case-control studies
        • AGS/BGS - opinion of respected authorities, descriptive studies, case reports, and expert committees
      • Level IV
        • NICE - evidence from expert committee reports of opinions and clinical experience of respected authorities
        • AGS/BGS - not applicable
    • grades of recommendation
      • Grade A - strong recommendation based on level I or level II evidence, and benefits substantially outweigh harms
      • Grade B - recommendation based on level I or level II evidence, and benefits outweigh harms
      • Grade C - recommendation based on level III evidence or extrapolation from level I or II evidence, and benefits outweigh harms
        • some recommendations based on level III evidence are labeled as strong because benefits of recommendation far outweigh associated harms
    • Reference - AGPT of the APTA clinical guidance statement on management of falls in community-dwelling older adults (mnh25573760paph103091104pa9h103091104pbyh103091104pafh103091104pbeh103091104pbmh103091104przh109799207pc8h109799207ps3h103091104phch103091104pnyh103091104pnxh103091104pnhh103091104pcxh103091104prss103091104pmdc25573760pPhys Ther 2015 Jun;95(6):815full-text)
  • American Geriatrics Society (AGS) Beers Criteria grading system for recommendations
    • strength of recommendation
      • Strong - benefits clearly outweigh harms, adverse events, and risks, or harms, adverse events, and risks clearly outweigh benefits
      • Weak - benefits may not outweigh harms, adverse events, and risks
    • quality of evidence
      • High - evidence includes consistent results from well-designed, well-conducted studies with directly applicable results; further research unlikely to change confidence in estimate of effect
      • Moderate - evidence from RCTs with important limitations or from well-designed nonrandomized controlled trials, cohort studies, or case-control studies; further research will probably have important effect on confidence in estimate of effect and may change the estimate
      • Low - evidence from observational studies; further research is very likely to have important effect on confidence in estimate of effect and will probably change the estimate
    • Reference - AGS 2019 updated Beers Criteria for potentially inappropriate medication use in older adults (J Am Geriatr Soc 2019 Apr;67(4):674)
  • American Geriatric Society/British Geriatric Society (AGS/BGS) guideline grading system
    • Grade A - strong recommendation that clinicians provide intervention to eligible patients (good evidence found that intervention improves health outcomes and conclusion is that benefits substantially outweigh harm)
    • Grade B - recommendation that clinicians provide this intervention to eligible patients (at least fair evidence found that intervention improves health outcomes and conclusion is that benefits outweigh harm)
    • Grade C - no recommendation for or against routine provision of intervention is made (at least fair evidence found that intervention can improve health outcomes, but balance of benefits and harms too close to justify general recommendation)
    • Grade D - recommendation is made against routinely providing intervention to asymptomatic patients (at least fair evidence found that intervention is ineffective or that harm outweighs benefits)
    • Grade I - evidence insufficient to recommend for or against routinely providing intervention (evidence that intervention is lacking, or of poor quality, or conflicting, and balance of benefits and harms cannot be determined)
    • Reference - AGS/BGS clinical practice guideline on prevention of falls in older persons (21226685J Am Geriatr Soc 2011 Jan;59(1):148)
  • American Academy of Neurology (AAN) grading system for recommendations
    • levels of evidence
      • Level A - established as effective, ineffective, or harmful (or established as useful/predictive or not useful/predictive) for given condition in specified population
        • requires at least 2 consistent Class I studies
        • in exceptional cases, 1 convincing Class I study may suffice for an "A" recommendation if all criteria met and magnitude of effect is large (relative rate improved outcome > 5 and lower limit of confidence interval > 2)
      • Level B - probably effective, ineffective, or harmful (or probably useful/predictive or not useful/predictive) for given condition in specified population (requires at least 1 Class I study or at least 2 consistent Class II studies)
      • Level C - possibly effective, ineffective, or harmful (or possibly useful/predictive or not useful/predictive) for given condition in specified population (requires at least 1 Class II study or at least 2 consistent Class III studies)
      • Level U - data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven (studies not meeting criteria for Class I-III)
    • classifications of evidence for prognostic interventions
      • Class I study
        • prospective study of broad spectrum of persons who may be at risk for developing outcome (such as target disease, work status)
        • measures predictive ability using independent gold standard for case definition
        • predictor measured in evaluation masked to clinical presentation and outcome measured in evaluation that masked to presence of predictor
        • all patients have predictor and outcome variables measured
      • Class II study
        • prospective study of narrow spectrum of persons at risk for having condition, or by retrospective study of broad spectrum of persons with condition compared to broad spectrum of controls
        • study measures predictive ability using acceptable independent gold standard for case definition
        • outcome, if not objective, determined by someone other than person who measured predictor
      • Class III study
        • evidence provided by retrospective study where either persons with condition or controls are of a narrow spectrum
        • measures predictive ability using acceptable independent gold standard for case definition
        • outcome, if not objective, determined by someone other than person who measured predictor
      • Class IV study - any design where the predictor is not applied in an independent evaluation OR evidence provided by expert opinion or case series without controls
    • Reference - AAN practice parameter on assessing patients for risk of falls (18250292Neurology 2008 Feb 5;70(6):473), reaffirmed 2016 Jan 23, commentary can be found in 19171841Neurology 2009 Jan 27;72(4):382
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade Definitions

Synthesized Recommendation Grading System for DynaMed Content

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    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
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Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115430, Falls in Older Adults; [updated 2018 Dec 05, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115430. Registration and login required.

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