30% of older adults fall at least once per year, with 5% of falls resulting in fractures like hip fractures. Increased fall risk is associated with age, prior falls, use of multiple medications, visual impairments, gait disorders, and other factors. A study of over 3,000 older Dutch adults found that short-acting benzodiazepines are associated with increased fall risk, as are proton pump inhibitors though not to the extent of H2 blockers. Physical frailty and a history of falls are also predictive of future falls. Multifactorial fall prevention programs that address medical, behavioral and environmental risks have not consistently shown reductions in falls rates.

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Introduction
§ 30 % of all people 65 and older fall ≥ once/year
§ 15 % falls ≥ twice/year.
§ 10% leads to injuries
§ 5 % leads to fractures: 1-2% hip fracture
§ Big impact on quality of life.
§ 24% of 55 yr and over dies within a year following a hip fracture
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Increased fall risk
§ Risk factors:
§ Age
§ Dementia
§ Diminished visual acuity
§ Low body weight
§ Gait disorder
§ Prior fall
§ ≥ 4 generic drugs
§ Psychofarmacologicaly active drugs
§ Orthostatic hypotension
§ Interaction intrinsic/extrinsic factors
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Increased fall risk
§ Risk factors:
§ Age
§ Dementia
§ Diminished visual acuity
§ Low body weight
§ Gait disorder
§ Prior fall
§ ≥ 4 generic drugs
§ Psychofarmacologicaly active drugs
§ Orthostatic hypotension
§ Interaction intrinsic/extrinsic factors
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Longitudinal Aging Study Amsterdam
§ 1992: inclusion of 3107 participants 65 yr and
older in and around Zwolle, Oss and
Amsterdam
§ 1995/1996: medical interview of 1509
participants
§ Fall registration during 3 years
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Benzodiazepines
§ Screening-instrument (STOPP):
§ Especially avoid long-acting
benzodiazepines (half-life ≥ 24h) because
of increased fall risk.
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STOPP criteria
Gallagher et al, Age and Ageing 2008; 37: 673-9
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STOPP criteria
Gallagher et al, Age and Ageing 2008; 37: 673-9
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Benzodiazepines
§ Screening-instrument (STOPP):
§ Especially avoid long-acting
benzodiazepines (half-life ≥ 24h) because
of increased fall risk.
§ Hypothese:
§ Short-acting benzodiazepines (T1/2 ≤ 10h)
are also associated with an increased fall
risk.
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Benzodiazepines
§ Screening-instrument (STOPP):
§ Especially avoid long-acting
benzodiazepines (half-life ≥ 24h) because
of increased fall risk.
§ Hypothese:
§ Short-acting benzodiazepines (T1/2 ≤ 10h)
are also associated with an increased fall
risk.
§ Result:
§ Short-acting benzodiazepines are
associated with an increased fall risk.
De Vries, O.J. et al. Age and Ageing 2013;0:1-7
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Antacids
§ Literature:
§ Protonpump inhibitor use is associated with increased fracture
incidence.
§ Hypothesis:
§ PPI use is associated with more falls and fractures than other
antacids
§ Results:
§ PPI use is not associated with increased fall incidence
§ H2-blocker is associated with increased fall incidence.
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Frailty
§ Literature:
§ Physical frailty is associated with increased fall risk
§ Hypothesis:
§ Frailty according to LASA is also associated with increased fall
risk.
§ Result:
§ Frailty according to LASA is associated with increased fall risk.
§ Prior falls are at least as predictive.
De Vries O.J. et al. Osteoporosis International 2013; 24:2397-403
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Robinovitch S.N. et al. Lancet 2013;381:47-54
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Video capture of the circumstances of falls in elderly
people residing in long-term care: an observational study.
§ 227 falls of 130 persons
(mean age 78 yr, SD 10)
§ Activities during fall:
§ Walking forward 24%
§ Standing 13%
§ Sitting down 12%
§ Start walking 9%
§ Rising from a chair 9%
§ Cause of fall:
§ Weight shifting 41%
§ Trip or stumble 21%
§ Hit or bump 11%
§ Loss of support 11%
§ Collapse 11%
§ Slipping 3%
Robinovitch et al. Lancet 2013;381:47-54.
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http://www.thelancet/cms/attachment/2024445407/2044188965/mmc1.mp4
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CBO guideline (2004)
“Prevention of falls in older persons”
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The CBO fall guideline recommends:
§ Medication evaluation
§ Balance and strength training
§ Restore visual acuity
§ Safety in and around home
§ Estimate fracture risk
§ Consider evaluation of heart rhythm disorders
§ Possibly the highest risk reduction can be achieved in
high risk older persons.
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Multifactorial fall prevention study
§ Hypothesis:
§ Multifactorial analysis and intervention in older
persons with increased fall risk leads to prevention of
new falls.
§ Method:
§ 217 older persons in and around Amsterdam
§ Recent fall (ED or general practitioner)
§ Intervention and control group(106 vs 111)
§ 1 year fall follow-up (calendar)
§ After 1 year measurement of QoL, mobility and
mood.
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Multifactorial fall prevention study
§ Results:
§ No difference between intervention and control group in time to
first fall.
§ In both groups decrease of the number of falls.
§ No differences in secondary outcomes apart from mortality.
§ Discussion:
§ A lot of interventions in the control group.
§ Most potential participants refused: selection of the most
motivated.
§ The type of physical therapy possibly led to increased fall risk.
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Medication reduction fall prevention
§ Hypothesis:
§ Stopping or reducing fall-risk-increasing drugs in high
risk older persons leads to prevention of new falls.
§ Method:
§ 612 older persons in and around Rotterdam and
Amsterdam
§ Recent fall (ED)
§ Intervention and control group (319 vs 293)
§ 1 year registration of falls, GP and ED visits.
§ After 1 year measurement of QoL.
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Medication reduction fall prevention
§ Results:
§ No difference in time to 1st or 2nd fall nor in number of falls.
§ 40% of the FRIDs were necessary.
§ 36% of the medication reduction interventions failed.
§ Discussion:
§ ≥50% of the FRIDs were not discontinued; compliance,
dependence, necessity?
§ Possibly better effect with long-term physician-patient relation.
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Meta-analysis
§ Gillespie LD, et al. Interventions for preventing falls in
older people living in the community. Cochrane
Database Syst Rev. 2012
§ 159 trials with 79,193 community dwelling participants
§ Results:
§ Physical therapy or tai-chi: reduces both fall risk
and fall rate.
§ Multifactorial fall prevention: reduces only fall rate.
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Future
§ Studies of the relation between risk factors and
effectivity of different interventions.
§ Studies of more effective fall prevention: medication,
physical therapy, reduction of fear of falls, etc.
§ Clinically relevant and irrespective of dogmas
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