Endogenous Risk Factors

The prevalence of falls has risen over the last decade. In people above 75 years of age, falls are most often related to factors typically associated with aging, such as loss of strength, changes in visual acuity, decreases in reflexes, and a general loss of flexibility. Over the age of 85, multiple medications may become more of a risk factor associated with falls. Fear of falls, leading to the limitation of activities, may actually contribute to an increased risk of falls in older adults.

Cardiovascular and neuromuscular

Bone issues

Cognitive and psychiatric conditions

Medicare side effects

Falls can be caused by a variety of different factors, but this can be simplified by examining internal or endogenous, (inside the body) and external or exogenous (or outside the body) factors that affect balance. Endogenous factors include vascular, bone, neuromuscular, and other problems. Exogenous factors include environmental hazards, need for the use of assistive devices and appliances, and medications that alter perception and balance. Your printed table describes several categories of risk factors.

Older patients with neurologic disorders may be most at risk. Also contributing to this risk are the routine use of medications that act on the central nervous system (CNS) or the use of four or more non-CNS acting medications. Examples of additional risk factors include wheelchairs that have been improperly fitted or maintained, poor transfer techniques, and generally suboptimal care.

A review of 18 studies related to the prediction of falls suggested that risks for falls were most closely associated with impaired gait or balance. Less consistent predictors included the domains of visual impairment, medications, limitations in activities of daily living, and cognitive impairment. Though orthostatic hypotension has been associated with falls, reviews have suggested that they did not adequately predict falls once controlled for other variables.[2] Because gait changes are significant predictors of falls, assessment of stride-to-stride variability was suggested to have the closest association with falls.[3] Interestingly, increased stride width is used by some patients in an effort to stabilize balance. However, this appeared to be associated with both falling and fear of falling and actually have a detrimental effect on stability.

Intermittent episodes of falling, delirium from multiple system impairments, and urinary incontinence can all lead to a general functional decline and further increase risk for falls. These “geriatric syndromes” create a downward spiral that can lower quality of life and lead to serious injury and/or death.

Exogenous Risk Factors 

A review of 22 studies about falls in medical literature suggested that psychotropic drugs, such as antidepressants, antipsychotics, and benzodiazepines, were most associated with falls in older people.[4] A retrospective review that looked at fall data from three nursing homes showed 419 falls for 158 patients over a period of two years. In these residents there was a 3.4 fold increase in the risk of falls within 1-3 days of any central nervous system medication changes when compared to 7-9 days prior to the medication change, after adjustments for other risk factors, including previous falls, balance, and dementia.[5]

Medications: type and changes

Appliances and devices

Environmental hazards

Others

Other exogenous risk factors may include ill-fitting or improperly used appliances and devices and environmental hazards.
 

[2] Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall?  JAMA. 2007;297(1):77-86.

[3] Maki BE. Gait changes in older adults: predictors of falls or indicators of fear. J Am Geriatr Soc. 1997;45(3):313-320.

[4] Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci. 2007;62(10):1172-1181.

[5] Sorock GS, Quigley P, Rutledge M, Taylor J, Luo S, Foulis P, Bellantoni M, Baker SP, Varadhan R, Wang, MC. Psychotropic medication changes and the short-term risk of falls in nursing home residents: a case=crossover study. Am Public Health Assn Scientific Session, November 2007. 2047.0 Abstract 157696. Available at: http://apha.confex.com/apha/135am/techprogram/paper_157696.htm.