Even Level Ground Poses Fall Risk for Elderly

Report: Most who suffer brain injuries aren't on elevated surfaces

THURSDAY, April 3, 2003 (HealthDayNews) -- Elderly people are more likely to be hospitalized for traumatic brain injuries when they fall on level ground -- and not from elevated areas like stairs, chairs, or ladders.

Moreover, three out of five people over the age of 85 who are hospitalized for this type of injury end up being discharged to more structured care, either inpatient or outpatient, says a study appearing in the April 4 issue of Morbidity and Mortality Weekly Report, a publication from the U.S. Centers for Disease Control and Prevention (CDC).

Although the study looked only at California, many of these findings will play out with variations -- in other areas of the nation.

"Because we are one-eighth of the nation, normally the patterns that we see are going to be pretty close to the national pattern by dint of our size," says Roger Trent, co-author of the study and chief of the injury surveillance and epidemiology section at the California Department of Health Services in Sacramento.

Traumatic brain injury, which usually results when the head strikes some kind of object or surface, represents one of the worst kinds of survivable injury you can sustain, Trent says. Needless to say, the elderly are most at risk for falls in general, and therefore are at high risk for TBI as well.

According to the study, falls are the leading cause of hospitalizations due to traumatic brain injury (TBI) among people 65 and older and the second-leading cause of TBI-related hospitalizations overall.

Other experts caution, however, that TBI sustained during falls represent only a small part of the overall picture.

"The problem of falls in older adults is way, way bigger than TBI, which is significant," says Dr. Margaret-Mary Wilson, an assistant professor of geriatrics at Saint Louis University School of Medicine in Missouri. "If all we had to worry about was TBI complicating falls, then we would be worrying about far less falls."

"From the geriatric medicine point of view, we deal with fear, lack of confidence, recurrent falls, soft tissue injuries, and fractures -- and specifically hip fractures," Wilson adds. "By far, the greatest threats to morbidity and mortality would be fractures. If you take all older adults regardless of their state of health, should they break a hip, 25 percent of them will be dead in 12 months."

But fall-related TBI are a relatively unstudied group of injuries and they are extremely serious. "If you're that old and have a brain injury, your chances of having any kind of recovery are small," Trent says.

For this particular analysis, state health officials (along with representatives from the CDC) studied discharge data from California hospitals between 1996 and 1999.

During that time, 29,761 fall-related TBI hospitalizations were reported, of which 1,252, or 71 percent, were among those 65 and over. The hospitalizations rate increased with age and translated to 13.6 per 100,000 for those 64 and under, 41.8 per 100,000 for those 65 through 74, 104 per 100,000 for those 75 to 84, and 223 per 100,000 for those 85 and over.

Males were hospitalized more frequently than females, representing 59 percent of the total. The proportion decreased with age; while men accounted for 70 percent of hospitalizations among those under 65, that number dropped to 44 percent in the older age bracket.

Patterns of falls also differed by age group. In the under-65 crowd, only one-quarter of falls occurred at one level, while 60 percent of falls in those over 65 occurred at one level.

"As you get older, you don't climb around that much," Trent says. "People are cautious, but they do have to walk, and that's what happens. That's a very common pattern."

In the under-65 group, 86 percent were discharged from the hospital to self-care or unskilled care at home. The rest went to another facility or received skilled care at home. Among those 65 or over, 41 percent were discharged home.

There are a number of reasons why older people are more prone to falling. One is that many take medications -- including sedatives, anticonvulsants and antihypertensives -- that can cause dizziness and drowsiness. Many older adults also have impaired balance and decreased muscle strength. Finally, older adults are more likely to sustain severe head injuries when they fall because they are more frail.

"Old people are very fragile, and sometimes it doesn't take much," Trent says.

A self-perpetuating cycle is also at work in many seniors. Because they are more likely to fall on one level, "this exposes them to the risk of falling whenever they're ambulated," Wilson explains. "Young adults walking on a flat surface are almost certain we're not going to fall. With older adults, that certainty is removed."

That leads to a fear of falling which, in turn, leads many older adults to limit their physical activity.

"They lose muscle mass, the muscles become less efficient, the gait becomes more abnormal. This fear is actually putting them into a vicious cycle whereby they're even more likely to fall," Wilson says.

The good news is that many falls can be prevented. "We know that some of these falls can be prevented, for example, by screening medication use," Trent says. "Another strategy involves helping older people keep physically fit -- with exercise or tai chi or something like that -- that improves gait and balance."

More information

For more on exercising for seniors, visit Senior Health at the National Institutes of Health or strength training for senior adults from the Delaware Senior Olympics.

SOURCES: Roger Trent, Ph.D., chief, injury surveillance and epidemiology section, California Department of Health Services, Sacramento; Margaret Mary Wilson, M.D., assistant professor of geriatrics, Saint Louis University School of Medicine, St. Louis; April 4, 2003, Morbidity and Mortality Weekly Report
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