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IAURENCE Z. RUBENSTEIN
Difculties with ambulation and the related phenomenon of falling
are among the most common and serious problems facing elders-
causing considerable mortality, morbidity, reduced functioning,
and premature nursing home admissions. Impaired gait and balance
rank among the most important causes for falls, and are also com~
mon consequences of falls. These disorders are generally the result
of multiple and diverse etiologies, and health care providers must
use careful and thorough diagnostic approaches to identify the
most likely causes, contributing factors, and associated comorbid~
ity-many of which conditions respond successfully to treatment.
DESCRIPTION OF THE PROBLEM
Epidemiologic Considerations
Both the incidence of falls and the severity of fall-related.complication rise
steadily after entering the sixth decade. Accidents are
the fth leading cause of death in elders, and falls constitute two
thirds of these accidental deaths. About three fourths of deaths
due to falls in the United States occur in the 13 percent of the
Population age 65 years and over. Fall incidence varies among settings and
populations. The low-
est rates are reported among community-living, generally healthy
elders, about a third of whom will fall each year, with an overall
rate of about 0.6 falls per person annually. Most of these falls result

Falls constitute two thirds ot

occidental deoths of elders.
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lnjury susceptibility in elders
makes even o relatively mild
fall dongerous.

In no Serious injury, but in a given year, about 5 percent of these

community fallers experience a fracture or need hospitalization, a
Proportion much higher than among younger fallers. lncidence
rates in nursing homes and hospitals are almost three times the
community rates (1.5 falls per bed annually). and complication
rates are also considerably higher (10 percent to 25 percent of
institutional falls result in fracture, laceration, or need for hospital
care). Thus, an important issue concerning falls in elders is not
simply the high incidence, because children and athletes have even
higher fall incidences, but rather a combination of a high incidence
together with a high susceptibility to injury.

This injury susceptibility in elders results from a high prevalence of comorbid

diseases (e.g., osteoporosis) and age-related decline (e.g., slowed reexes),
which make even a relatively mild fall particularly dangerous. Fear of falling and
the post fall aruriety syndrome result in loss of selfcondence and self-imposed
functional limitations among both community-dwelling and nursing
home residents who fall. Falls and instability are a leading precipitating cause of
nursing home admissions. Recent national data indicate that falls were the
largest single cause of restricted activity
days among elders. Other national data indicate that fall related injuries recently
accounted for 6 percent of all medical expenditures for persons age 65 years and
older.

The related problems of gait and balance disorders are also extremely prevalent
among elders and can have similarly profound impacts on physical health,
quality of life, and capacity for independent living. Detectable gait abnormalities
affect 20 percent to 40 percent of people age 65 years and older, and about half
of these people have a grossly abnormal gait. Gait problems are even more
common in older subgroups, affecting 40 percent to 50 percent of those over age
85 years. ln a large study of community dwelling persons age 75 and older, 10
percent needed assistance to walk across a room, 20 percent were unable to
climb a ight of stairs without help, and 40 percent were unable to walk half a
mile. As will be shown, gait and balance disorders are among the most
highly predictive risk factors for falling.

Couses ol Fcills and Disordered Goit

A number of predictable changes of normal aging adversely affect gait and
balance. These include stiffening of connective tissue, loss of muscle mass,
slowing of nerve conduction, decreasing visual
acuity, and impaired proprioception. These directly result in decreased joint
range of motion, reduced nitiscle strength, prolonged reaction time, impaired
depth perception, and increased postural sway. Consequently, with aging, gait
becomes slower, with a shortened step length, decreased cadence, and wider
base of support.feet are not picked up as high and are more prone to tripping.
Slowed reaction time makes it less likely for an elder to stop a fall once a trip,
slip, or other sudden displacement has occurred.

In addition to these age-related changes, specic conditions and disease

processes contribute to pathologic gait. These factors are outlined in Table 23-1
and include pain, joint immobility, muscle
weakness, spasticity, sensory decits, and impaired central processing. For
example, arthritis, present in over half of all elders, interferes with normal joint
mobility through both pain and deformity of the joint. Muscle weakness, often the
result of disuse, is also endemic in elders and results in decreases in step height,
stride length, gait speed, and stability. Disorders of the central nervous system,
such as stroke and parkinsonism, cause a variety of abnormalities affecting gait,
including weakness, sensory impaimient, decreased proprioception, spasticity,
and tremor. lt has also been shown that mobility deteriorates as the number of
chronic conditions increase. Other risk factors associated with declines in
mobility in large studies include increasing age, low income, smoking, obesity,
and low physical activity levels. A careful assessment outlined as follows, should
enable the health care provider to establish the existence of a mobility problem,
identify the major age-related or disease process(es) involved, and detect other
associated risk factors, which will enable formulation of a comprehensive
therapeutic plan.
pain Bone and joint abnormalities
Arthritis
Injury Contractures
Leg injury or shortening
Weakness
Deconditioning
Myopatliy and neuropathy
Pulmonary and cardiovascular
problems
Loss of muscle mass
Sensory impairment
Stroke
Spinal cord l6i0n
Peripheral ncuropiIl1Y
Proprioceptive imPa"m"
Visual impairment
Connective tissue stiffening
Impaired central processing
Dementia
Stroke
Normal pressure hydrocephalus
Parkinsons disease .
Age-related slowing V
Spasticity
Stroke
Spinal cord lesion
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- CHAPTER 23
cAU5E MEAN (PeRci2N'r), RANGE
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Accident and environment-related 31 -
Gait and balance disorders or weakness l7 -
Diuiness and vertigo 13
Drop attack 9
Confusion 5
Postural hypotension 3 -
Visual disorder 2 't '
Syncope 0-3 _
Other specied causes 15 "
Unknown "
"Mean percent calculated from the 3,628 reported falls.
Ranges indicate the percentage reported in each of the 12 studies.
This category includes: arthritis, acute illness, drugs. alcohol. Palm ePiP5Y- and
falling from bed.
(Adapted, with permission, from Rubenstein LZ. falls. In: Yoshikawa TT, Cobbs
EL, Brummel-Smith K, eds. Ambulatory Gt?rlt1!!!C Care. St. Louis: Mosby-Year
Book, lnc.; 1993:296304.)

Table 23-2 lists the major precipitating causes bf falls and their relative
frequencies based on published studies. The relative importance of causes differs
depending on the population studied. For example, frail, high-risk populations
have increased rates of medical-related falls and also a higher incidence of falls
of all types than do healthier populations. Overall, accidents, gait and balance
disorders, and the nonspecic symptom of dizziness are the three most frequent
causes of falls.

Accidents, generally involving some environmental hazard, pre iggually reported

as the most common cause of falls and account or percent to 50 percent in most
studies. In reality however most of the falls. attributed to accidents stem from
the interaction between an environmental hazard (e.g., an irregular oor a wet
surface) and increased susceptibility to these hazards because Of the effect of
aging or disease. Age-associated changes in gait and Posture Control, along with
impairments in vision hearing and memory tend to impair an elders ability to
avoid hazards and recover from a trip or stumble. Unfortunately, the homes of
such susceptible elders are commonly lled with avoidable environmental
hazards, such as trow rugs, dim lighting, trailing electrical cords, unsafe stairs
and accumulated clutter
The Secgmd nfccumulated clutter (see Chapters 9, 14, 15, 21).

The second most common cause of falls in the board category

of gait problems and weakness. As discribe earlier, gait problem are common
and can be caused by many factors. Muscle weakness is also extremely common
among elders., much of it stemming from disease and inactivity rather than
aging per se. Studies report the prevalence of easily detected leg weakness
ranging from about 50 percent among community-dwelling elders to over 80
percent among nursing home residents. Common causes of weakness includ
deconditioning, stroke, parkinsonism, skeletal abnormalities, arthntis.
myopathies, neuropathies, and cardiorespiratory disorders. in addition to age-
related muscle loss.

The sensation of dizziness is a very common complaint of elders who fall.

Because the symptom is subjective and can reect a number of different causes
and mechanisms, a careful history is required. True vertigo, a sensation of
rotational movement, can indicate a disorder of the vestibular apparatus (e.g.,
benign positional vertigo, acute labyrinthitis, or Menieres disease). Symptoms
describedas imbalance on walking often reect a gait disorder. Many patients
descnbe a vague light-lieadedness that can reect cardiovascular problems,
hyperventilation, orthostatie hypotension, drug side effects, anxiety, or
depression. Another common cause of dizziness or unsteadiness is a combination
of visual loss and peripheral neuropathy, which must be sought on physical
examination.

Drop attacks are sudden falls associated with abrupt leg weak-
ness without loss of consciousness or dizziness, sometimes precipi-
tated by sudden change in head position. This syndrome has been
attributed to transient vertebrobasilar insufciency, although it is
probably caused by more diverse pathophysiologie mechanisms.
The leg weakness is usually transient but can persist for hours.
Recent studies, employing stricter diagnostic criteria, are nding
this to be a much less common cause for falls thanearlier reported.
Confusion and cognitive impairment are often associated with
falls and can rellect an underlying systemic or metabolic process
causing both the confusion and the fall (e.g., electrolyte imbalance,
fever). Dementia can cause an increase in falls by impairing judg-
ment, visuospatial perception, and ability to orient oneself geo-
graphically. Dementia-related wandering activities are also often
associated with falls. -
Orthostatic hypotension, most often dened as a consistent
drop of 20 mm Hg or greater in systolic blood pressure after stand-
ing from a supine position, has a 5 percent to 25 percent prevalence
among normal elders living at home. It is even more common
among persons with certain predisposing factors, such as autonomic
dysfunction (often related to age, diabetes, or central nervous sys-
tem damage), hypovolemia, low cardiac output, parkinsonism, met-
abolic and endocrine disorders, and medications (particularly seda-
tives, antihypertensives, and antidepressants). The orthostatie drop
may be more pronounced on arising in the morning, since the
baroreceptor response is diminished after prolonged recumbency,
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as well as after meals (post-prandial hypotension).t_Fortunately,

most people with orthostatic hypotension adjust to the phenom.
non and are able to avoid falling, which is why it is a less common
cause of falls than its high prevalence might suggest.
Syncope is a serious but less commonly reported cause of falls.
It is, however, much more common than the mean gure listed in
Table 23-2 because several of the falls studies specically excluded
patients with syncope. Syncope, dened as a sudden loss of con-
sciousness with spontaneous recovery, usually results from de-
creased cerebral blood ow or occasionally, from metabolic causes
such as hypoglycemia or hypoxia. Among elders, its H105! frequent
causes are cardiac arrhythmias (especially ventricular tachycardia
and sick sinus syndrome), orthostatic hypotension, situational re-
ex syndromes (e.g., micturition syncope, Valsalva maneuver), and
the very common syncope of unclear etiologyf l_.ess common
causes of syncope are vasodepressorvasovagal reactions, transient
ischemic attacks, and seizures. A history of syncope can be difcult
to obtain because many elders do not remember exactly what
occurred during the fall, and they may confuse drop attacks or
diuiness for syncope.
Other specic causes of falls include visual problems, disorders
of the central nervous system, drug side effects, aild alcohol intake.
Diseases of the central nervous system (e.g., cerebrovascular dis-
ease, normal pressure hydrocephalus, and parkinsonism) often re-
sult in falls by causing dizziness, ortliostatic hypotension, and gait
disorders. Drugs frequently have side effects that result in impair-
ment of mentation, circulatory integrity, body stability, and gait.
Especially strong relationships between falls and drugs have been
noted for psychotropic agents (e.g., sedatives, hypnotics, anxiolyt-
ics, and antidepressants) as well as with total number of medications
taken. Similar, but less consistent, risks have been associated with
antihypertensives, diuretics, vasodilators, and beta blockers. Alco-
hol use is an under~reported but common problem among the
elderly population. Elders should be specically questioned about
this, since alcohol can be an oc/:ult cause of instability, falls, and
serious injury. Other less common causes of falls include seizures,
anemia, hypothyroidism, unstable joints, foot problems, and severe
osteoporosis with spontaneous fracture.-5-5
Risk Fcictors
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