Falls, a community care perspective

Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study

OBJECTIVES

We investigated prospectively the relationships among falls, physical balance, and standing and supine blood pressure (BP) in elderly persons.

BACKGROUND

Falls occur often and adversely affect the activities of daily living in the elderly; however, their relationship to BP has not been clarified thoroughly.

METHODS

A total of 266 community-dwelling elderly persons age 65 years or over (123 men and 143 women, mean age of 76 years) were selected from among residents of Coop City, Bronx, New York. Balance was evaluated at baseline using computerized dynamic posturography (DPG). During a one-year follow-up, we collected information on subsequent falls on a monthly basis by postcard and telephone follow-up.

RESULTS

One or more falls occurred in 60 subjects (22%) during the one-year follow-up. Women fell more frequently than men (28% vs. 16%, p < 0.03), and fallers were younger than nonfallers. Fallers (n = 60) had lower systolic BP (SBP) levels when compared with nonfallers (n = 206) (128 +/- 17 vs. 137 +/- 22 mm Hg for standing, p < 0.006; 137 +/- 16 vs. 144 +/- 22 mm Hg for lying, p < 0.02), whereas diastolic BP was not related to falls. Falls occurred 2.8 times more often in the lower BP subgroup (<140 mm Hg for standing SBP) than in the higher BP subgroup (> or =140 mm Hg, p < 0.0003), and gender-related differences were observed (p = 0.006): 3.4 times for women (p < 0.0001) versus 1.9 times for men (p = 0.30). Loss of balance, as detected by DPG, did not predict future falls and was also not associated with baseline BP levels. Multiple logistic regression analysis demonstrated that female gender (relative risk [RR] = 2.1, p = 0.02), history of falls (RR = 2.5, p = 0.008) and lower standing SBP level (RR = 0.78 for 10 mm Hg increase, p = 0.005) were independent predictors of falls during one year of follow-up.

CONCLUSIONS

Lower standing SBP, even within normotensive ranges, was an independent predictor of falls in the community-dwelling elderly. Elderly women with a history of falls and with lower SBP levels should have more attention paid to the prevention of falls and related accidents.

Epidemiology of adulthood injuries: a quickly changing injury profile in Finland

Although developed societies have undergone many profound changes during recent decades, including urbanization, increased traffic and aging of the populations, epidemiologic information on secular trends in profiles of injuries is limited. We investigated such trends in Finland by selecting from the National Hospital Discharge Register all Finns aged 15 years or more who required hospital treatment because of an unintentional injury during 1971-1995. The injury incidences were expressed as the number of patients per 100,000 individuals per year. In Finnish men, road traffic accidents and falls, the two leading causes of injury, produced equal numbers of injuries in 1971 (4935 and 4957), but thereafter the role of the traffic accidents gradually decreased (3512 injuries with unadjusted and age-adjusted incidences of 177 and 183 in 1995) and that of falls clearly increased (13,218 injuries with unadjusted and age-adjusted incidences of 664 and 635 in 1995). Changes in the other injury categories of men were less drastic. In Finnish women, falling was the most common cause of injury in 1971 (5051 injuries), after which its role increased sharply, to 17,250 injuries in 1995 (unadjusted and age-adjusted incidences of 804 and 698, respectively). In 1971, road traffic produced 2369 injuries in women, after which this number somewhat decreased (2160 injuries with unadjusted and age-adjusted incidences of 101 and 101 in 1995). The role of all the other injury categories was small in Finnish women during 1971-1995. We conclude that a quick change in the overall profile of injuries occurred in Finland in 1971-1995, a change in which falls replaced road traffic accidents as the major cause of a serious injury. This epidemiologic change will give a new challenge for injury prevention in the new millennium.

Closed pelvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards

OBJECTIVE

To investigate the characteristics and outcomes of older patients with pelvic fracture admitted to medical and geriatric wards.

METHODS

All patients admitted to medical and geriatric wards with a pelvic fracture over a four year period were identified using the hospital clinical coding database. Data were collected from casenotes, hospital and Family Health Services Authority databases. Where available, pelvic radiographs were graded according to the Singh index.

RESULTS

The casenotes of 148 patients (126 women) were studied; 83% (n=123) of patients suffered a pelvic fracture in low energy trauma. Mean (SD) length of hospital stay was 21.3 (17.6) days. Single breaks of the pubic rami accounted for 47.2% (n=68) of all fractures. Inpatient mortality was 7.6% and at one year was 27%. There was a marked adverse effect on the mobility of survivors with all patients using at least a walking stick at discharge and 51.1% (n=70) needing assistance for mobility. Although 70.9% (n=83) of patients admitted from home (or warden aided accommodation) were able to return there, 84.3% (n=70) of them required extra community support. Rates of institutionalisation rose from 20.9% (n=31) at admission to 35.8% (49/137) of survivors at discharge. Altogether 93% (n=107) of 115 patients, in whom adequate quality pelvic radiographs were available, were assigned a Singh index grade of 4 or less indicating the presence of osteoporosis.

CONCLUSIONS

Pelvic fractures are often the result of low energy trauma. They are associated with appreciable inpatient and considerable one year mortality. They also have marked negative effects on mobility in the short term. They result in increased levels of dependency in terms of higher levels of community support and rates of institutionalisation. On the evidence of Singh index grading, pelvic fractures are associated with low bone density.

Accidental falls and related fractures in 65-74 year olds: a retrospective study of 332 patients

We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.

Psychotropic drugs and falls: new evidence pertaining to serotonin reuptake inhibitors

Falls are a significant cause of fatal and nonfatal injuries in older persons. Risk factors include previous falls, several disease states, and certain drugs such as tricyclic antidepressants and antihypertensives. We conducted a MEDLINE search from January 1966-March 1999 to identify studies and review articles on the association of neuroleptics, benzodiazepines, and antidepressants with fall risk in older people. The focus was on the risk associated with serotonin reuptake inhibitors, biologic plausibility, and limitations of these studies. It was thought that the agents did not increase the risk of falls, although recent evidence suggests that this is not the case.

Impact of gait problems and falls on functioning in independent living persons of 55 years and over: a community survey

In a cross-sectional, population-based study among community-dwelling persons of 55 years and over the incidence of falls, risk indicators for falls, specifically age, and the impact of gait problems, falls and other risk factors on functioning was determined. A randomly age-stratified sample (n = 655) was taken from all independent living persons of 55 years and over (n = 2269) and registered in a primary health care centre. They received a mail questionnaire concerning demographic data, history of falls and injuries due to falls, physical and mental health status, gait problems, functional status, including social activities. The response rate was 62% (n = 405). Of the subjects aged 55 years and of those aged 65 years and over, 25% and 31% respectively fell at least once in the previous year. Half of the people reporting falls fell more than once. Serious injury occurred in 9% of the fallers, with 4% fractures. There is a significant association between falling and age and, even more clearly, between gait problems and age. The main risk factors of single and recurrent falls were female gender, physical health status and gait problems. Logistic regression analysis reveals that the main determinants of falling in general are gait problems and female gender and, of recurrent falling female gender, physical complaints and gait problems. Falls have some negative effect on functioning, i.e. mobility range and social activities, but this is overshadowed by mental status indicators and gait problems.