How do you unintentionally accelerate aging

Fall in old age and its consequences

A fall can be a decisive event, especially for an elderly person, which initiates the beginning of a downward spiral, at the end of which there is a risk to independent living. A fall can not only break your bones, but also lose confidence in your own motor skills. This leads to avoidance behavior with a progressive loss of further skills. In order to be able to effectively prevent this downward spiral, the identification of endangered patients and target-oriented prevention are crucial in order to contain existing risk factors.

Ms. H., 83 years old, previously lived independently in a small terraced house on the outskirts of a small town. For a long time, however, she has been feeling increasingly insecure on her feet. When you get up quickly or turn from the stove to the refrigerator, she suddenly becomes dizzy. She has already fallen several times at home, but apart from a graze and a bruise on her buttocks, she has not sustained any further injuries. The family doctor has not yet been consulted, "since nothing bad has happened". Ms. H. withdraws increasingly and is clearly dejected. She rarely leaves the house. Fearful of falling again, Ms. H. avoids the stairs to the first floor, where the bedroom is, instead she prefers to sleep on the couch in the living room. Ms. H. unintentionally accelerates the age-related muscle breakdown with her behavior and the restriction of the range of motion reduces her general functional level even further. Nutrition also suffers from restricted mobility. As the nearest shopping facility is around 800 m away, purchases can only rarely be made. A neighbor would be willing to go shopping for Ms. H., but she is uncomfortable asking for it. So she mainly feeds on sachet soups, since she is no longer very hungry due to the reduced exercise. The rooms that were once so well cared for are increasingly neglected due to the restricted mobility. When a niece who lives away from home comes to visit, she is appalled by the "dismantling" and the neglected condition of the house and urges Ms. H. to move to a retirement home.

The general practitioner is very often confronted with falls in geriatric patients in daily practice. By definition, geriatric patients are characterized by multimorbidity and older age (mostly over 70 years of age). The calendar age should not necessarily be seen as having priority over multimorbidity. In the case of those over 80 years of age, it is assumed per se that they are more vulnerable to complications and are more likely to become chronic with the risk of loss of autonomy.

In Germany, around 4 - 5 million senior citizens fall each year. Around a third of people over 65 who live independently fall once a year, among those over 80 the proportion rises to over 50% [24, 25, 28]. A large proportion of patients even fall several times. In institutionalized patients, the number of patients who fall is even higher [23]. In about half of all cases, a fall is without physical injury. In 30 - 40% there are minor injuries such as hematomas [25, 28]. Serious injuries occur in 5 - 10% of those who have fallen. Older women have a higher risk of falling injuries than men of the same age [16].

5% of seniors suffer fractures after a fall [25, 28]. The "worst-case scenario" in old age is the common femoral neck fracture, 90% of which are due to falls. For Germany that is around 120,000 fractures per year [4]. The consequences of injuries, such as pain or immobilization (for example with a cast), lead to a reduction in the functionality of the patient. 40% of the patients who had to go to an emergency room because of a fall still complain of restricted activity after two months [12].

Half of the elderly who develop a femoral neck fracture after a fall can no longer cope with five steps after one year, can no longer sit or stand up independently on the toilet or take shorter walks [19]. For 20% of those affected, this has the consequence that they cannot stay in their own four walls and have to move to a retirement home with permanent care [4]. A problem for the general practitioner to recognize a patient at risk of falling is the word "fall" in German-speaking countries. Everyone understands a different event by this word [8].

Fear of falling

The importance of the psychosocial consequences of a fall is increasingly being considered [28]. A reduction in physical activity can be a direct consequence of falls, e.g. B. be caused by pain when walking, but also by fear of falling (English: Fear of Falling) [5]. The data on the incidence of fear of falling vary in the literature between 20 and 50% [3, 20, 21]. Interestingly, a fall does not necessarily have to trigger the fear of falling. Older people without a history of falling also develop fear of falling [30].

Fear of falling often leads to a downward spiral of avoidance, loss of self-confidence, a reduction in everyday activity and further muscle degradation. Ultimately, this also increases the risk of falling. It is not uncommon for this development to end with social withdrawal and loss of independence [7, 26]. It has been shown that people who suffer from fear of falling are more likely to develop depression [14].

Risk factors

Although many falls are multifactorial, large epidemiological studies have identified risk factors that relate either to the individual himself (intrinsic risk factors), the environment (extrinsic risk factors) or to the task or situation (behavior and risk). It is hardly surprising that weakness in the lower extremities (leg strength) is associated with a four-fold increased risk of falling [26]. A fall in the last twelve months increases the risk of falling three times [2], walking aids per se by two and a half times. Patients with cognitive impairments fall almost twice as often. As an example of extrinsic tripping hazards, sliding carpets or bed rugs are mentioned, which are involved in 20 to 45% of all falls [26]. Behavior in certain situations or complex tasks can also significantly increase the risk of falling. It could be shown that the gait pattern changes after a fall. Fear of further falls also seems to be an independent risk factor for further falls [6]. The risk of falling also accumulates with the number of risk factors. While the risk of falling is 27% with none or one risk factor, it increases to 72% with four or more risk factors [28].

Screening and Assessment

The guideline of the American and British Geriatrics Societies suggests a very simple, easy-to-implement algorithm in which every patient over 65 years of age should undergo a simple screening consisting of three questions (Fig. 1) [22]. Only when a question is answered with "yes" should the patient be classified as a "high-risk patient" and an assessment should be carried out using a standardized test. Otherwise the screening should be repeated annually.

The Federal Initiative for Fall Prevention recommends the Short Physical Performance Battery (SPPB), as this test battery can also map slight changes well and can be carried out quickly [9]. The SPPB measures strength as well as balance and gait speed [13]. It includes these three areas:

  • the habitual walking pace over 4 m (normal: 0.6 - 0.8 m / sec)
  • the chair rise test (normal: 11-15 sec)
  • the ability to balance in the closed and semi-tandem position (normal: 10 sec or <10 sec).

In addition to the assessment, a detailed medical history and physical examination should be carried out. In doing so, a targeted search is made for factors that favor falls and possible resources are also recorded [10].

With an increased risk of falling, the multidimensionality must be taken into account and cognitive areas as well as fear of falling and environmental influences must be recorded (see above). In particular, the influence of cognitive abilities on motor control in maintaining balance - also known as the dual-task paradigm - can be easily assessed in the general practitioner's practice by talking to the patient while accompanying him from the waiting room to the examination room [18]. The dual-task paradigm can also be captured with other assessment methods (walking and listing animal names). It is particularly sensitive when it comes to the early detection of motor restrictions that cannot be detected in "motor only" assessment [1].

intervention

If appropriate risk factors have been identified, they should be addressed in a targeted manner. A multifactorial approach is recommended in the guideline (Fig. 2). The exhaustion of resources, e.g. B. social support, patient information, etc. With regard to local offers for age-appropriate training programs, fall prevention strategies and an increase in sensitivity to fall triggers in the home environment, as well as the targeted improvement of motor skills, form the basis for avoiding future falls.

Strength and balance can be improved in both group and individual therapies and has proven to be very effective [27]. It should be noted that the training should be progressive and challenging and take place at least twice a week. There are numerous programs for this, such as B. the OTAGO program. Corresponding courses are z. B. offered by the German Gymnastics Federation in cooperation with the Federal Initiative for Fall Prevention (BIS).

In addition, pharmacotherapy should be optimized with a view to avoiding or reducing drugs that promote falls, such as benzodiazepines and neuroleptics [15, 17]. The combination of antihypertensive drugs with diuretics and accompanying desiccosis can cause postural hypotension. In addition to adjusting the pharmaceuticals, care should be taken to ensure adequate hydration, and support stockings should be prescribed if necessary. In particularly pronounced cases, drug therapy must also be considered. A meta-analysis showed no positive effect in terms of reducing the risk of falls or the fall rate for general administration of vitamin D to senior citizens living independently [11]. However, a supplementation of vitamin D (800 IU / day) if a deficit is suspected and if there is an increased risk of falling is generally recommended before initiating an intervention.

The installation of handholds as well as the removal of tripping hazards in the home environment and an optimization of the lighting can reduce the risk of falling, especially for people at high risk of falling [11]. Changing footwear to stable shoes with non-slip soles is also effective. In the case of falls due to underlying cardiovascular diseases such as brady or tachyarrhythmias, a hypersensitive carotid sinus or a vasovagal syndrome, the patient should be referred to a cardiologist or to the clinic for further diagnosis and therapy. The implantation of a pacemaker can help avoid future falls if there is an existing indication. Whether the detection of a visual impairment through an assessment and an individual intervention leads to a reduction in the risk of falling is still a matter of controversy. However, cataract surgery can make sense. be.


1. Al-Yahya E, Dawes H, Smith L et al. (2011) Cognitive motor interference while walking: a systematic review and meta-analysis. Neurosci Biobehav Rev 35: 715-728
2. Anonymous (2001) Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 49: 664-672
3. Austin N, Devine A, Dick I, et al. (2007) Fear of falling in older women: a longitudinal study of incidence, persistence, and predictors. J Am Geriatr Soc 55: 1598-1603
4. Becker C, Blessing-Kapelke U (2011) [Recommended guidelines for physical exercise to prevent falls in elderly people living at home]. Z Gerontol Geriatr 44: 121-128
5. Chu LW, Chiu AY, Chi I (2006) Impact of falls on the balance, gait, and activities of daily living functioning in community-dwelling Chinese older adults. J Gerontol A Biol Sci Med Sci 61: 399-404
6. Delbaere K, Sturnieks DL, Crombez G et al. (2009) Concern about falls elicits changes in gait parameters in conditions of postural threat in older people. J Gerontol A Biol Sci Med Sci 64: 237-242
7. Freiberger E SD (2010) Fall prevention in old age - basics and modules for planning courses. . Deutscher Ärzte Verlag, Cologne
8. Freiberger E, Vreede P (2011) If recall-limitations of the most used inclusion criteria. European Review of Aging and Physical Activity: 1-4
9. Freiberger E. DVP, Schoene D., Rydwik, E., Mueller V., Frändin K., Hopman-Rock M. (2012) Performance-based physical function in older community-dwelling persons: a systematic review of instruments. Age and Aging
10. Ganz D, Bao Y, Shekelle P et al. (2007) Will my patient fall? JAMA 297: 77-86
11. Gillespie LD, Robertson MC, Gillespie WJ et al. (2012) Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 9: CD007146
12. Grisso JA, Schwarz DF, Wolfson V et al. (1992) The impact of falls in an inner-city elderly African-American population. J Am Geriatr Soc 40: 673-678
13. Guralnik JM, Simonsick EM, Ferrucci L et al. (1994) A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 49: M85-94
14. Jefferis BJ, Iliffe S, Kendrick D et al. (2014) How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men? BMC Geriatric 14: 114
15. Landi F, Onder G, Cesari M et al. (2005) Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. J Gerontol A Biol Sci Med Sci 60: 622-626
16. Lehtola S, Koistinen P, Luukinen H Falls and injurious falls late in home-dwelling life. Archives of Gerontology and Geriatrics In Press, Corrected Proof
17. Leipzig RM, Cumming RG, Tinetti ME (1999) Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 47: 30-39
18. Lundin-Olsson L, Nyberg L, Gustafson Y (1997) "Stops walking when talking" as a predictor of falls in elderly people. Lancet 349: 617
19. Magaziner J, Hawkes W, Hebel JR, et al. (2000) Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci 55: M498-507
20. Mendes Da Costa E, Pepersack T, Godin I, et al. (2012) Fear of falling and associated activity restriction in older people. results of a cross-sectional study conducted in a Belgian town. Arch Public Health 70: 1
21. Murphy SL, Williams CS, Gill TM (2002) Characteristics associated with fear of falling and activity restriction in community-living older persons. J Am Geriatr Soc 50: 516-520
22nd Panel on Prevention of Falls in Older Persons AGS, British Geriatrics S (2011) Summary of the Updated American Geriatrics Society / British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 59: 148-157
23. Rapp K, Becker C, Cameron ID et al. (2012) Epidemiology of falls in residential aged care: analysis of more than 70,000 falls from residents of bavarian nursing homes. J Am Med Dir Assoc 13: 187 e181-186
24. Rubenstein L, Solomon Dh., Roth Cp., Young Rt., Shekelle Pg., Chang Jt., Maclean Ch., Kamberg Cj., Saliba Dw., Enger Ns (2004) Detection and management of falls and instability in vulnerable elders by community physicians. JAGS 52: 1527-1731
25. Rubenstein LZ (2006) Falls in older people: epidemiology, risk factors and strategies for prevention. Age Aging 35 Suppl 2: ii37-ii41
26. Rubenstein LZ, Josephson KR (2006) Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am 90: 807-824
27. Sherrington C, Tiedemann, A., Fairhall, N., Close, J. C., Lord, S. R. (2011) Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales public health bulletin 22: 78-83
28. Tinetti ME, Speechley M, Ginter SF (1988) Risk factors for falls among elderly persons living in the community. N Engl J Med 319: 1701-1707
29. Tinetti ME, Williams CS (1998) The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci 53: M112-119
30. Zijlstra GA, Van Haastregt JC, Van Eijk JT et al. (2007) Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age Aging 36: 304-309




Clinic for General Internal Medicine and Geriatrics
Brothers of Mercy Hospital

Institute for Biomedicine of Aging
University of Erlangen-Nuremberg

Conflicts of Interest: The authors have not declared any.

More articles on similar topics