literature review on falls in the elderly

• Academic Literature Review
• Open access
• Published: 13 November 2013

Physical consequences of falls in the elderly: a literature review from 1995 to 2010

• Miguel Terroso 1 , 2 ,
• Natacha Rosa 2 ,
• Antonio Torres Marques 2 &
• Ricardo Simoes 1 , 3 , 4  

European Review of Aging and Physical Activity volume  11 ,  pages 51–59 ( 2014 ) Cite this article

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In the last decade, population ageing has been registered as a global phenomenon. A relation exists between falling and ageing, since falling frequency increases significantly with age. In fact, one in three older adult falls annually. Although ageing is generically associated with decrease and degeneration of psychological and physical functions, it is still not common for the correct identification of risk factors to lead to a clinical prognosis of the elder being in risk of falling. Therefore, the goal of this review article is to identify, categorise and analyse typical ageing and fall factors mentioned in the literature as well as to quantify the number of times they were referenced. The research considered hundreds of publications, but analysis was then restricted to the 87 most pertinent articles written in English and published in journals or scientific magazines between 1995 and 2010. We concluded that falls among older adults can be characterised by the following: anatomic characteristics and physiological consequences of ageing; the pathologies that induce falls, which can be neurological, musculoskeletal, cardiovascular and other diseases; causes and risk factors of falls that can be behavioural, biological, environmental or socio-economic; type of physical consequences of falls, including fractures, bruises, injuries or other physical consequences; and strategies to prevent, mitigate or rehabilitate, which can be of a physical, environmental or behavioural nature.

Introduction

Elderly are currently considered the fastest growing age group worldwide [ 13 ]. In the last decades, the number of elderly people in the world has been consistently and proportionally increasing. In 1996, there were a total of 323 million people in the world aged above 65 years [ 49 ]. That number increased in 2010 to 440 million [ 13 ] and is forecasted to be 1,555 million by 2050 [ 49 ].

The physical changes inherent to ageing can reduce autonomy and functional independence, which may directly or indirectly lead to falls. Falls are coded as E880–E888 in the International Classification of Disease-9 (ICD-9) and as W00–W19 in ICD-10, being commonly defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects” [ 84 ]. About one third of the population over 65 suffers at least one indoor fall every year [ 33 , 47 ], and about half of the population in this age group who is institutionalised fall each year [ 33 ]. Among the elderly, falls are one of the main causes of injuries, physical incapacity and even death. Each year, around 37.3 million falls among elderly will require health care, and about 424,000 lead to death of the faller [ 19 ].

It is thus obvious that the problem of falls among the elderly population has epidemiological levels with a global incidence and dimension. Therefore, the following question was posed: What are the physical consequences of falls in the elderly population?

In order to answer this question, a quantitative review was conducted. This paper aims at identifying, categorising and analysing the typical ageing and fall factors mentioned in the literature as well as quantifying the number of times these factors were referenced. This study considered the incidence of the anatomic characteristics and physiological consequences of ageing, the pathologies that power falls, causes and risk factors for falls, physical consequences of falls and strategies to prevent, mitigate and rehabilitate.

This work is focused on providing an overview of the published literature to researchers, academics and practitioners, who deal with this issue; it does not cover the entire research area of elderly population falls.

Materials and methods

The research was limited to peer-reviewed articles, written in English and published in scientific journals or magazines between the years 1995 and 2010. The research was restricted to the following databases: PubMed , Access Medicine , Science Direct , Oxford Journals and Taylor & Francis Online . Additionally, a manual search was carried out for the other publishers in the areas already mentioned, such as McGraw-Hill and BioMed Central as well as publications edited by organisations that focus the problem of falls in the elderly people, such as the National Center for Injury Prevention and Control and the World Health Organization .

The keywords used, as title and/or abstract and/or keywords of the articles, either for searching scientific publications databases or for manual search in other online publications, were the following: “physical consequences of falls”, “senior population and falls”, “falls pathologies”, “anatomy of ageing”, “causes of falls” and “risk factors”.

After the search, the titles and abstracts were analysed in order to eliminate duplicates and publications with topics that did not meet the purpose of this review work. The remaining publications were thoroughly read and analysed, and all references to the topics addressed in the review article were identified and quantified.

Search results

A total of 87 publications were selected and analysed, from which 81 were journal publications from scientific database and 6 were articles published in book chapters or specialty reports obtained from the manual search. The publications came from 25 different countries in the world and represent all continents with the exception of Africa. The strongest geographic incidence, with about 82 % of the total publications was identified in two continents: North America and Europe. South America and Asia represent 18 % of the total publications. Publications from Turkey, Israel and Iran were considered as being from the Asian continent.

Ageing pathologies that potentiate falls

Falls are events that depend on multiple factors and can be related to the presence of pathologies. The pathologies inherent to the process of ageing, which may lead to fall in the elderly population, are numerous and diverse. Therefore, four categories were considered: neurological, musculoskeletal, cardiovascular and other pathologies (see Table  1 ). The neurologic and musculoskeletal pathologies were the most referenced in the analysed literature. The cardiovascular pathologies also had a considerable incidence of references, although small when compared with the former. Table  1 shows the references in the literature for each pathology type and the number of times they were referenced (in percentage).

In the selected literature, the neurological diseases, such as stroke (13.7 %), dementia (10.3 %), vestibular disorders/balance (10.3 %) and Parkinson (9.1 %), are the most referenced ageing pathologies as propitiating falls in the elderly population.

In terms of musculoskeletal pathologies, osteoporosis was the pathology with a higher incidence of references (16 %), followed by loss of muscle density (9.1 %) and arthritis (6.8 %). Problems in the lower extremities and joint deformities were also diseases common in the falling elderly, but with a lower incidence of references (3.4 and 2.2 %, respectively).

Cardiovascular diseases, such as orthostatic hypotension (6.8 %), arrhythmias (3.4 %) and syncope (3.4 %), are also common pathologies due to the ageing process and may also lead to falls.

In the “other pathologies” category, the following typical pathologies of ageing that can lead to falls were identified: diabetes and depression (4.5 %), pneumonia and lung infections (2.2 %) and sleep disorders (1.1 %).

The causes and risk factors of falls

Table  2 identifies multiple causes and risk factors of falls in the elderly population as well as the respective incidence in the reviewed literature. The causes and risk factors of falls are very diverse, and several of these factors can occur simultaneously. Due to that diversity, the causes and risk factors of falls were grouped in four categories, analogous to those adopted by the World Health Organization, in WHO Global Report on Falls Prevention in Older Age [ 84 ]:

Behavioural , characteristics of human actions, emotions or daily choices;

Biological , individual's characteristics pertinent to the human body;

Environmental , interactions between the individual's physical condition and the surrounding environment;

Socio-economic , related to the individual's social and economic situation.

The results of this analysis are shown in Table  2 . The behaviour causes and risk factors most referenced in the reviewed literature were overdose of medication (with 32.1 %) and the fear of falling—without having ever fallen before or after the first fall (29.8 and 22.9 %, respectively). The reduction in physical activity (16 %), carrying out activities of daily living (11.4 %) and alcohol consumption (10.3 %) are located in the intermediate incidence group. In the smallest incident group, the following were identified: slip (6.8 %), fainting (4.5 %) as well as smoking and an inappropriate use of footwear (both with 3.4 %).

Concerning the biological causes and risk factors , highest incidence was on a lack of balance during gait (33.3 %), musculoskeletal and sensory degradation (26.4 %), functional dependence in the mobility (25.2 %), cognitive impairment (24.1 %), age (19.5 %) and sex (18.3 %) with higher incidence in females. The decrease in bone density and lack of vision (with 14.9 % each), chronic diseases (13.7 %), depression (12.6 %), occurrence of dizziness and vertigo (11.4 %) and decrease of index bone mass (10.3 %), which weakens the ability to absorb and dissipate impact forces, were intermediate incidence factors. Finally, urinary incontinence, orthostatic hypotension, pain, soft tissue changes, hearing problems and body weight, with between 3.4 and 4.5 % incidence, were identified as causes and behaviour risk factors with least references in the reviewed literature.

With respect to the environmental causes and risk factors , unsafe domestic (17.2 %) and outdoors (16 %) environments were found to have the highest incidence. Falls from hospital beds, mobility aids (for example walkers) and the collision against objects were referenced only one to two times.

Last, the socio-economic causes and risk factors of falls included limited access to health and social services (2.2 %), low income and low educational level (2.2 %) and lack of social interactions (1.1 %). This category had the lowest number of references in the literature, when compared with the other categories of causes and risk factors.

If a profile is established for a senior individual with a high risk of falling based simultaneously on the causes and risk factors more referenced on the four categories, the overall risk of falling and consequent injury gravity for that individual can be expected to be very high.

Physical consequences of falls and physiological effects

Falls among the elderly are associated with a large diversity and heterogeneity of undesired physical consequences, which can be more or less severe. Four main categories were considered for the physical consequences: fractures, bruises, injuries and “other” physical consequences. A fifth category was also defined, focused on the physiological effects associated to the physical consequences of falls.

The results concerning the physical consequences and the physiological effects of falls are shown in Table  3 . It was observed that fractures (as consequences of falls) can occur in almost every region in the body. However, the hip fracture and undifferentiated bone fractures are the most referenced in the literature, with 37.9 and 27.5 % incidence, respectively.

The head bruises due to falls, with 10.3 % incidence, were the more referred physical consequence in the bruises category.

For the injuries category, the incidence of references in the literature is more homogeneous than in other categories. The most referenced injuries are soft tissues and the upper extremities, respectively with 6.8 and 5.7 % incidence. Injuries on the elbows are the ones that had the least incidence, namely 2.2 %.

For other consequences , lacerations with 8 % and dislocations with 5.7 % incidence were the most referenced in the literature. This category also included sprains, hematomas and pain, but these were identified in the literature to a smaller extent.

The physiological effects of elderly falls were also identified. The two effects with higher incidence of references were death and morbidity, with 21.8 %, and functional decline, with 20.6 %. Other still significant effects were inactivity, with 14.9 %, functional dependence and loss of autonomy, with 13.7 %, and depression, with 10.3 % incidence.

This analysis reveals a possible cause–effect relation between the different physiological effects. For example, depression can lead to higher functional dependence; in the same way, inactivity can lead to functional decline. On the other hand, the state of physical incapacity and functional dependence as a result of a fall can retract the ability to participate in everyday life activities and increase the chance of depression. These interrelations between causes will be further explored in future work.

Interventions for prevention, rehabilitation and minimization of falls

Many actions, strategies and mechanisms can—and have been—employed for the prevention, minimization and rehabilitation aspects of elderly falls. The different interventions can be categorised into three groups: the first group consists of physical interventions, the second of environmental interventions, and the third with behavioural interventions. For each of those, one can correspond them to the three stages associated with falls: the moment before the fall (interventions to prevent falls), the time during the fall (interventions to minimise the consequences of falls) and the moment after the fall (interventions related with the rehabilitation of the consequences of falls).

The different interventions, related to falls, as well as the respective percentage of references incidence are indicated in Table  4 . For each type of intervention (physical, environmental and behavioural), Table  4 also shows at which stage of the fall event they can be applied (prevention, minimization and rehabilitation). Note that these stages are not mutually exclusive.

The physical interventions are those that represented the highest incidence: most notably, adjustment of medication with 18.3 % incidence, hip protection coating systems with 17.2 % incidence and the use of strengthening nutrition programmes with 11.4 % incidence.

The environmental interventions were those that exhibited the lowest incidence and were essentially limited to changes in the home and public environments to reduce the risk of fall, with 11.4 % incidence. Note also that the other intervention “removal of obstacles in the household” is directly related to the former.

Finally, in the behavioural interventions, the highest incidence, of 21.8 %, was found for carrying out activities and exercise. The use of rehabilitation methods based on gait training and management of risk factors of multiple falls, with an incidence of 14.9 and 10.3 %, respectively, were also relevant types of behavioural interventions.

Concluding remarks

In this review article, we have quantitatively characterised relevant research efforts on this issue of great social relevant over the last decade and a half, by identifying the incidence of articles concerning the anatomic characteristics and physiological consequences of ageing, the pathologies that propitiate falls, the causes and risk factors for falls, the physical consequences of falls and the strategies to prevent, minimise or rehabilitate.

This study will be useful both for those who want to identify key research issues and those who study ageing from the perspective of social sciences. In the future, repeating this study for the period of 2011–2025 will provide a historical time frame for analysis and comparison.

In subsequent work, we aim to study the economic impact of falls, from the individual and societal perspectives.

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Acknowledgments

We acknowledge the Foundation for Science and Technology (FCT), Lisbon, through the 3º Quadro Comunitario de Apoio, the POCTI and FEDER programmes, project PEst-C/CTM/LA0025/2013, and FCT scholarship SFRH/PROTEC/67465/2010. Partial support has been provided by project PT21, no. 13848, co-financed by the European Community Fund through COMPETE Programa Operacional Factores de Competitividade. The financial sponsors played no role in the design, execution, analysis and interpretation of data or writing of the study.

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Miguel Terroso & Ricardo Simoes

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Miguel Terroso, Natacha Rosa & Antonio Torres Marques

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Terroso, M., Rosa, N., Torres Marques, A. et al. Physical consequences of falls in the elderly: a literature review from 1995 to 2010. Eur Rev Aging Phys Act 11 , 51–59 (2014). https://doi.org/10.1007/s11556-013-0134-8

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SYSTEMATIC REVIEW article

The risk of falls among the aging population: a systematic review and meta-analysis.

• Department of Geriatrics, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China

Aim: This study aims to clarify the risk factors for falls to prevent severe consequences in older adults.

Methods: We searched the PubMed, Web of Science, Embase, and Google Scholar databases using the terms “risk factors” OR “predicting factors” OR “predictor” AND “fall” OR “drop” to identify all relevant studies and compare their results. The study participants were divided into two groups, the “fall group” and the “control group”, and differences in demographic characteristics, lifestyles, and comorbidities were compared.

Results: We included 34 articles in the analysis and analyzed 22 factors. Older age, lower education level, polypharmacy, malnutrition, living alone, living in an urban area, smoking, and alcohol consumption increased the risk of falls in the aging population. Additionally, comorbidities such as cardiac disease, hypertension, diabetes, stroke, frailty, previous history of falls, depression, Parkinson's disease, and pain increased the risk of falls.

Conclusion: Demographic characteristics, comorbidities, and lifestyle factors can influence the risk of falls and should be taken into consideration.

Introduction

By 2050, people older than 65 years are estimated to account for 16% of the population ( 1 ). Falls are a major public health problem, as approximately 28–35% of individuals aged ≥ 65 years experience falls each year. As the aging population increases, more individuals will be at risk of falling ( 2 ).Among older people, physical falls are events that adversely affect health and lead to disability and mortality ( 3 , 4 ). Moreover, fall-associated economic burdens are substantial and continue to increase worldwide ( 4 , 5 ). Even non-injury falls are associated with negative impacts, such as anxiety, depression, and decreased mobility, which greatly affect the quality of life (QOL) and aging trajectory. The most harmful consequences of injurious falls are hip fracture and brain damage ( 4 ). Research on the risk of falling has become increasingly important to maintain the health of older individuals ( 2 ).Early screening for the risk of fall that takes risk factors into account is needed. Many retrospective, cross-sectional, and longitudinal studies have examined fall prevalence, fall-related consequences, and risk factors for falls in older individuals. However, even though some reviews have addressed these topics ( 6 , 7 ), a high-quality systematic review has yet to be conducted. Therefore, in this study, we aimed to investigate the association between lifestyle factors and fall risk in aging adults to promote the development of effective fall prevention strategies.

Guidelines and ethical review

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in this systematic review. As this study was a review, no ethical approval was necessary.

Search strategy and data extraction

We hypothesized that demographic characteristics, lifestyle factors, and comorbidities would influence the risk of falls in the aging population. We chose these risk factors on the basis of records in the literature. After searching and carefully reading the literature, we found that the above factors had the most related studies and received the most attention. Therefore, we compared these factors between fall and non-fall groups. We searched for potentially relevant articles published in English before January 2022 during the initial search process. The terms searched in the PubMed, Web of Science, Embase, and Google Scholar databases were as follows: “risk factors” OR “predicting factors” OR “predictor” AND “fall” OR “drop”. Since Boolean operators do not work on Google Scholar, we used search terms like “risk factors for fall” and “predicting factors for fall” on Google Scholar. Two authors independently screened all the abstracts and citations of all studies identified with the search strategy to determine eligible studies. Data were independently extracted by two of the authors using a standardized Excel file. Studies were considered eligible if they included two groups and aging individuals (≥65 years old) with or without falls, and presented data on the baseline lifestyle characteristics and comorbidities of the participants. The exclusion criteria were as follows: duplicate publications, reviews, studies on unrelated topics, studies with different variables, and studies with different group criteria. The search process consisted of 2 steps, the initial search with short keywords and then detailed search with detailed search strategy (present in Supplementary File 1 ). The description of the detailed search strategy for each part of the PICO research question is provided in Supplementary File 1 , which is amended for other databases using database-specific subject headings, where available, and keywords in both titles and abstracts. The extracted data included baseline characteristics, lifestyle habits, comorbidities, and occurrence of falls. All the included data were subsequently entered in RevMan 5.1.4.

Comparisons

In our meta-analysis, we compared 22 factors between the two groups (the fall group and the control [no falls] group). The factors included age, body mass index (BMI), education level, polypharmacy, sex, relationship status (living alone), residential location (rural), (mal)nutrition, smoking status, alcohol consumption, and comorbidities including cardiac disease, hypertension, diabetes, stroke, depression, Parkinson's disease, pain, vision impairment, frailty, previous history of falls, and cognitive impairment.

Quality assessment

The quality of the included studies was assessed by two authors according to the Cochrane Collaboration Reviewer's Handbook and the Quality of Reporting of Meta-analysis guidelines ( 40 , 41 ).

Data analysis

The data were analyzed using RevMan 5.1.4. Continuous outcomes are presented as weighted mean differences (MDs) with 95% confidence intervals (CIs). Dichotomous data are presented as relative risks (RRs) with 95% CIs. A meta-analysis was performed using fixed-effect or random-effects models as appropriate. Specifically, the fixed-effects models were used when no significant heterogeneity was present, and the random-effects models were used when heterogeneity was present. Statistical heterogeneity among the trials was evaluated by the I 2 test, with significance set at P < 0.05.

Description of the included studies

A total of 14,144 reports were initially identified from the databases. After screening for duplicate publications, reviews, and irrelevant records based on the titles and abstracts, 13,139 reports were excluded from the study. After screening the full texts, 422 articles with different baseline data, 432 articles with different results criteria, and 117 articles with different group classifications were excluded. Thus, we eventually included 34 articles in the final analysis ( 8 – 32 , 34 – 39 , 42 – 44 ). The conditions of these studies and the clinical details of the participants are presented in Table 1 . A flow chart of the literature search is shown in Figure 1 .

Table 1 . Details of included papers.

Figure 1 . Flowchart of the literature review process and exclusion criteria.

Characteristics and lifestyles of people with/without falls

First, we compared aging adults in terms of age, BMI, education level, polypharmacy, malnutrition, sex (female), living alone, living in a rural area, smoking status, and alcohol consumption ( Figures 2A – L ). Older age (MD 1.87; 95% CI 1.14–2.6; p < 0.00001, Figure 2A ), number of drugs used (MD.36; 95% CI.19–0.52; p < 0.0001, Figure 2E ), and polypharmacy (RR 1.06; 95% CI 1.03–1.09; p = 0.0002, Figure 2F ) were associated with increased incidence of falls. Malnutrition (RR 1.4; 95% CI 1.19–1.64; p < 0.0001, Figure 2G ), living alone (RR 1.39; 95% CI 1.29–1.5; p < 0.00001, Figure 2I ), living in a rural area (RR 1.09; 95% CI 1.02–1.16; p = 0.006, Figure 2J ), smoking (RR 1.17; 95% CI 1.05–1.3; p = 0.004, Figure 2K ), and alcohol consumption (RR 1.18; 95% CI 1.09–1.28; p < 0.001, Figure 2L ) were risk factors for falls. Education level (MD −0.29; 95% CI −0.73–0.16; p = 0.21, Figure 2C ) had no impact on risk of falls, but completion of the mandatory level of education (RR 0.93; 95% CI 0.89–0.97; p = 0.006, Figure 2D ) decreased the risk of falls. BMI (MD −0.22; 95% CI −0.48–0.05; p = 0.11, Figure 2B ) and sex (RR 1.02; 95% CI 1–1.04; p = 0.13, Figure 2H ) did not affect risk of falls.

Figure 2 . (A–L) Forest plots of the impacts of patient characteristics and lifestyle factors on the risk of falls.

Comorbidities in people with or without falls

Eleven comorbidities were compared between people with and without falls: cardiac disease, hypertension, diabetes, stroke, vision dysfunction, frailty, fall history, cognitive impairment, depression, Parkinson's disease, and pain ( Figures 3A – L ). Even though these comorbidities may alter the rate of frailty among elderly individuals (RR 1.1; 95% CI 1.05–1.15; p < 0.0001, Figure 3A ), not all of the comorbidities mentioned above necessarily influence falls. For instance, diabetes (RR 1.08; 95% CI 0.87–1.34; p = 0.49, Figure 3D ), stroke (RR 1.55; 95% CI 0.72–3.35; p = 0.26, Figure 3E ), vision dysfunction (RR 1.24; 95% CI 0.91–1.69; p = 0.17, Figure 3F ), and cognitive impairment (RR 1.11; 95% CI 0.88–1.39; p =0.37, Figure 3I ) did not significantly differ between the two groups. In contrast, heart disease (RR 1.14; 95% CI 1.09–1.19; p < 0.00001, Figure 3B ), hypertension (RR 1.08; 95% CI 1.03–1.12; p = 0.0004, Figure 3C , frailty (RR 1.35; 95% CI 1.25–1.45; p < 0.00001, Figure 3G ), fall history (RR 1.53; 95% CI 1.44–1.62; p < 0.00001, Figure 3H ), depression (RR 4.34; 95% CI 4.02–4.68; p < 0.00001, Figure 3K ), Parkinson's disease (RR 3.05; 95% CI 1.84–5.05; p < 0.0001, Figure 3K ), and pain (RR 1.22; 95% CI 1.11–1.34; p < 0.0001, Figure 3L ) were associated with increased risk of falls among the aging population.

Figure 3 . (A–L) Forest plots of the impacts of comorbidities on the risk of falls.

In older adults, falls impose major health, economic, and societal burdens ( 16 ). Falls are the leading cause of injury in the elderly population ( 36 ). A serious fall could result in decreased independence and reduced QOL ( 36 ). Hip fracture, in particular, is a serious and devastating consequence of falling in older individuals ( 36 ). Moreover, Makino et al. reported that fall history is the most influential predictor of future falls ( 25 ). According to recent research, fall history increases the current risk of falls. Some research has also proposed that fear of falling is significantly associated with falls. Usually, fear of falling arises from a fall history ( 45 ). Patil R et al. suggested that fear of falling may increase even after a non-injurious fall. Subsequently, older adults may enter into a negative cycle in which they reduce their activity, leading to reduction in functionality ( 45 ). To avoid this negative cycle, we recommend early prevention of falls in elderly adults. Fear of falling was also independently associated with presence of knee pain, with a significant relationship observed between fear of falling and moderate to severe knee pain but not mild knee pain ( 14 ). Pain is a frequently mentioned factor, but only a few studies have prospectively collected data on fall occurrence in relation to knee pain or the lack of association between knee pain and fall occurrence during long-term follow-up. Furthermore, fear of falling may exacerbate depression. Our present results demonstrated that depression can also impact the risk of falls. As most falls result from loss of balance while walking and poor balance is the leading risk factor for falls, people tend to focus on the importance of mobility in the risk of falls ( 46 ). This explains the lack of sufficient predictive factors in older adults at risk of one or more falls. Additionally, social factors can increase the psychological burden on elderly individuals and reduce self-care capability, a factor with strong influences ( 47 ) on the risk of falls as well as the incidence rates of many diseases. Thus, the identification of risk factors for falls will provide important guidance for the care of elderly individuals.

Older age, polypharmacy, malnutrition, frailty, smoking, and alcohol consumption significantly increased the risk of falls; these factors also reflect decline in physical condition. Moreover, chronic illnesses are very common in older adults, and cardiac disease, hypertension, diabetes, stroke, and Parkinson's disease are associated with falls. Older adults residing in urban areas had a higher risk of falling than those residing in rural areas ( 27 ). This difference may be explained by traffic, which can impede medical treatment. Residency in suburban areas has certain advantages; for instance, it is easier to engage in physical exercises, such as walking, in suburban and rural areas than in urban areas. Physical exercise helps to reduce the risk of falls in adults and improves lower limb strength in older people ( 27 , 47 ). Moreover, living in a rural area is associated with less pollution exposure; this factor is particularly important in developing countries because pollution may cause comorbidities. However, only a few articles have focused on this topic. We plan to explore this topic further in the future once a larger number of relevant reports have been published. Sex has been identified as a risk factor for falls among older adults ( 37 ), but in our study, women did not have a higher risk of falling than men. While women experience a higher rate of frailty than men ( 37 ), men are more likely to exhibit harmful lifestyle habits, such as smoking and consuming alcohol; therefore, sex differences in the risk of falling merit further study. Another risk factor in our study is living alone, which increases the risk of depressive symptoms and the impacts of falls.

A major strength of this study is that we analyzed data from several large-scale, well-characterized cohorts and systematically summarized the risk factors for falls in the elderly population. These findings can inform healthcare in the elderly population. Biswas et al. explored the risk factors for falls among older adults in India ( 6 ); however, their study focused on only the Indian population and thus exhibited geographic and ethnic limitations. Xie et al. examined risk factors for the development of fear of falling, but fear of falling was only one of the risk factors for falls; we suggest that it is more meaningful to identify the risk factors for falls. Our meta-analysis also has some limitations. For example, we did not categorize the participants according to whether they lived in the community or in nursing homes, which is a major factor associated with the risk of falls.

We demonstrated that (1) older age, polypharmacy, malnutrition, single status, living in a rural area, smoking, and alcohol consumption significantly increased the risk of falls in elderly adults. In contrast, higher education level was protective against falls. Additionally, we found that (2) individuals with cardiac disease, hypertension, frailty, previous history of falls, depression, Parkinson's disease, and pain had a higher risk of falls than individuals without such comorbidities.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding authors.

Author contributions

Data acquisition and drafting of the manuscript: QX, XO, and JL. Conception and design of the study: JL. Analysis and/or interpretation of data: QX and XO. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.902599/full#supplementary-material

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Keywords: age, malnutrition, fall, meta-analysis, rural

Citation: Xu Q, Ou X and Li J (2022) The risk of falls among the aging population: A systematic review and meta-analysis. Front. Public Health 10:902599. doi: 10.3389/fpubh.2022.902599

Received: 23 March 2022; Accepted: 20 September 2022; Published: 17 October 2022.

Reviewed by:

Copyright © 2022 Xu, Ou and Li. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jinfeng Li, xuebai_1314@126.com

† These authors share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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• Published: 23 April 2018

Ageing vision and falls: a review

• Liana Nafisa Saftari 1 &
• Oh-Sang Kwon 1  

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Falls are the leading cause of accidental injury and death among older adults. One of three adults over the age of 65 years falls annually. As the size of elderly population increases, falls become a major concern for public health and there is a pressing need to understand the causes of falls thoroughly.

Main body of the abstract

While it is well documented that visual functions such as visual acuity, contrast sensitivity, and stereo acuity are correlated with fall risks, little attention has been paid to the relationship between falls and the ability of the visual system to perceive motion in the environment. The omission of visual motion perception in the literature is a critical gap because it is an essential function in maintaining balance. In the present article, we first review existing studies regarding visual risk factors for falls and the effect of ageing vision on falls. We then present a group of phenomena such as vection and sensory reweighting that provide information on how visual motion signals are used to maintain balance.

We suggest that the current list of visual risk factors for falls should be elaborated by taking into account the relationship between visual motion perception and balance control.

Falls are the second leading cause of accidental deaths after road traffic accidents worldwide. It is estimated that 646,000 people die from falls worldwide [ 1 ]. According to the WHO global report published in 2007 [ 1 ], 28–35% of people aged > 65 years old fall each year and this prevalence increases to 32–42% for people > 70 years old.

The increase in fall risk in the elderly is unavoidable because physical, sensory, and cognitive functions deteriorate with age. Numerous studies have reported various factors related to fall risks [ 2 , 3 ] in an attempt to clarify the causes of falls and to propose methods of fall prevention [ 3 , 4 ]. The ability of balance and gait control [ 5 ], musculoskeletal functions [ 6 , 7 ], cardiovascular functions [ 8 , 9 , 10 ], vestibular functions [ 11 , 12 ], somatosensory functions [ 13 , 14 ] and visual functions [ 4 , 15 , 16 ] have been suggested to be the major factors responsible for the increase in fall risks in older adults.

As demonstrated in the classical study by Lee and Aronson [ 17 ], in which young stationary observers fell in response to the visual motion of a whole scene, visual information plays a critical role in balance control. Given that visual functions deteriorate with age, it is not surprising that many studies have found correlations between the ageing of visual functions and falls in elderly people [ 4 , 15 , 16 ]. However, the majority of the existing studies focused on the correlations between fall risks and performance in simple visual detection or discrimination tasks such as visual acuity, contrast sensitivity, and stereo-acuity [ 18 , 19 , 20 , 21 , 22 , 23 ]. Consequently, the list of visual risk factors for falls in the literature often does not include the ability of visual motion perception as a significant contributor to fall risk [ 20 , 24 , 25 , 26 , 27 ]. It is a critical omission, because it has been well documented since the seminal study by Lee and Aronson [ 17 ] that balance control is strongly influenced by visual motion signals [ 17 ].

We will first review the characteristic changes in vision as a result of ageing, and we will review the relationship between visual functions and fall risk in older adults. We will then discuss the mechanism by which visual motion signals are directly used in balance control by reviewing phenomena such as vection and sensory reweighting. Finally, we will introduce three relevant phenomena that could elaborate our understanding of how visual functions are related to fall risk.

Visual functions and falls

Visual function unavoidably deteriorate with age, and the deterioration of visual function in turn increases fall risk [ 15 , 20 , 28 , 29 ]. In this section, we will first provide an overview of anatomical and functional changes in the visual system in the elderly and will then review the studies that examined whether and how specific deficits in visual functions are correlated with fall risks. Both the effects of ageing on visual functions and the relationship between the visual functions and fall risk are summarized in Table  1 . Notably, although numerous studies have reported a significant correlation between diverse visual declines and falls, the correlation between the ability of processing visual motion signal and fall risk has not been reported. It is an important gap in the literature because visual motion signals induce an automatic reaction of the balance control system. We will discuss the relationship between visual motion perception and balance control further in the next section.

Ageing vision

The decline in many visual functions in older adults can be directly attributed to anatomical changes of the eyeball. The anatomical changes reduce the quality of sensory inputs to higher-level visual processing and, as a result, visual functions deteriorate. However, some functional declines cannot be fully explained by anatomical changes. Declines of computational efficiency and compensatory heuristics in the higher-level visual processes are responsible for those functional changes. In this section, we will review anatomical changes of eyeball first and functional declines of vision in general.

Anatomical changes

Ageing is accompanied by structural changes to the eyeball. The weight and cross-sectional area of the lens in the eye change throughout the lifespan. As we age, the lens that is responsible for the change of focal distance of the eyes, allowing it to focus on objects at various distances by changing its shape, becomes heavier and thicker and loses its elasticity. The resistance of the lens to external force exponentially increases with age resulting in presbyopia, a condition characterized by a decreased ability to focus on near objects [ 30 ]. Changes due to ageing also can be observed in the ciliary muscle, a smooth muscle surrounding the lens that changes the shape of the lens during accommodation for viewing objects at various distances. The diameter of the ciliary muscle in the relaxed accommodation condition negatively correlates with age [ 31 ].

It has been well documented that the aberrations of the eye increase with age, which causes the deterioration of spatial vision [ 32 ]. To determine the main factor of the age-related increase in the aberrations, Artal et al. [ 33 ] measured the aberrations in both the corneal surface and the complete eye in subjects across a range of age groups. The results indicated that aberrations of the cornea increased with age, although the size of the increase was too small to explain the total aberrations of the eye. The main difference between young and older subjects was the coupling between corneal and internal aberrations. In the eyes of younger subjects, the corneal aberrations were compensated by the internal aberrations, which made the total aberration smaller than the corneal aberrations. In the eyes of older subjects, the total aberrations were larger than corneal aberrations, indicating no sign of a compensation mechanism.

Anatomical changes of the eyeball due to ageing cause a reduction in the quality of visual inputs to the central nervous system and contribute to the decrease of visual function performance. For example, ocular aberrations in older eyes result in a decrease in modular transfer function (MTF), which transfers object resolution and contrast to a retinal image. This poor quality retinal image contributes to the decrease in contrast sensitivity [ 34 ]. However, anatomical deterioration may not completely explain the decrease in contrast sensitivity, as neural mechanisms have also been reported to contribute to the decrease in contrast sensitivity with age [ 35 ].

Functional changes

The majority of visual functions decline with age. In the 1990s, a large-scale project, termed the Salisbury Eye Evaluation project, was conducted to examine visual ageing [ 36 ]. In the study [ 36 ], the visual performance of 2520 older adults aged 65 to 84 years old was examined in various visual tasks. Visual acuity, contrast sensitivity, glare sensitivity, and visual field size were found to decline linearly with age.

Haegerstrom-Portnoy et al. [ 37 ] measured spatial vision, high- and low-contrast acuity, contrast sensitivity, disability glare, glare recovery, color vision, stereopsis, and visual fields to understand the effect of ageing on visual functions. The results from 900 subjects aged 58 and 102 years old indicated that the high-contrast acuity was relatively well maintained until the age of 65 to 70 years old, and began to decline above the age of 70. Meanwhile, all the other visual functions declined with age. Notably, the authors found that a single exponential function well fits the data representing the changes in spatial vision across the range of ages. Betts et al. [ 38 ] measured contrast sensitivity under a range of external noise levels. The contrast threshold in older adults was significantly higher than in younger adults when the external noise level was low; however, it was comparable when the external noise level was high. This result suggests that lower contrast sensitivity observed in older subjects was mainly due to the higher level of the internal noise rather than the deteriorated ability to filter out external noise. Sloane et al. [ 35 ] measured contrast sensitivities as a function of luminance levels across four spatial frequencies. In general, the contrast sensitivity was lower in older adults than in young adults. However, more importantly, the size of the differences was significantly larger in the low luminance levels compared to the high luminance levels, which suggests that the optical mechanisms cannot fully account for the decline in the contrast sensitivity in older adults. In an additional experiment, the effect of temporal flickering on contrast sensitivity with age was measured by presenting a target grating that flickered at 7.5 Hz. The results revealed that flickering affects contrast sensitivity differently across age groups, which again suggests that the age-related decline in spatial vision was partially due to the changes in neural processing rather than purely optical.

Bian and Andersen [ 39 ] examined how ageing affects one’s judgment of egocentric distance. Egocentric distance is the perceived distance between an observer and a location in the 3D world. The results indicated that younger observers had a tendency to underestimate the egocentric distance, while older observers did not. One possible explanation for this result is that older observers have accumulated more knowledge regarding egocentric distance in real-world scenes and consciously or unconsciously use this knowledge to correct the estimation bias. The role of past experience in egocentric distance judgment was also examined in a study that compared egocentric distance judgments between athletes and non-athletes [ 40 ].

Motion perception is another visual function that is affected by ageing. Snowden and Kavanagh [ 41 ] studied how the ability to motion perception changes with age. The low-speed threshold was higher for older adults compared to young adults across wide spatial frequency levels (0.5 to 4 cycles/degree), and the speed discrimination threshold (i.e. the minimum speed differences of two stimuli to be distinguished) at a range of speeds (0.1°/s to 10°/s) was also higher for older adults. The coherence threshold (i.e. the minimum percentage of coherently moving dots to reliably detect motion directions), for the random dot kinematograms stimulus, was higher for older adults when the stimulus speed was relatively low (< 2°/s). However, the coherence thresholds for high-speed random dot kinematograms were almost identical for older and young adults. Their results suggested that deficits in motion perception could not be fully accounted for by contrast sensitivity or visual acuity. Betts et al. [ 42 ] found that for high-contrast large-size motion stimuli, older adults exhibited higher sensitivity than young adults. This counter-intuitive finding could reflect the centre-surround antagonism of neurons in middle temporal area [ 43 ]. Motion signals from the peripheral receptive field effectively suppressed the signals from the central receptive field in young adults, whereas the suppression effect was diminished in older adults, resulting in higher sensitivity for large high-contrast stimuli. As listed above, the effect of ageing on the ability of motion perception varies widely across the different stimuli and tasks. This inconsistency demonstrates the complex mechanisms involved in motion perception.

Correlation between the decline in visual functions and fall risk

The decline in the visual functions of older adults impairs gait and balance control, and consequently increases fall risk [ 4 , 15 , 16 ]. A large-scale survey study, termed the Blue Mountain Eye Study, examined the relationship between visual functions and fall risk in 3299 older adults [ 20 ]. The study found that visual acuity, contrast sensitivity, glare sensitivity, and visual field size were significantly correlated with fall risk. Eye diseases such as a cataracts and glaucoma were associated with falls. The study also confirmed that age, sex, psychotropic drug use, and history of stroke are associated with the number of falls. In this section, we will discuss in detail the effect of a specific visual function on fall risk.

Visual acuity and fall risk

Reduced visual acuity is the most common visual impairment across age, gender, and ethnicity [ 44 , 45 ]. As described in the previous section, the flexibility of the lens enables the eye to focus on near and far object, and the lens loses its flexibility and becomes harder with age. This causes many older adults to suffer from presbyopia (the inability to focus on near objects). And thus requires them to wear bifocal lenses. The bottom section of the bifocal lens allows wearer to focus in near distance while the upper section allows them to focus in a far distance. Wearing bifocal lenses may impair other visual functions, such as depth perception and contrast sensitivity, and cause falls [ 46 ].

Although some studies did not identify a significant relationship between visual acuity and fall risk [ 21 , 47 , 48 , 49 ], the majority of studies have reported that older adults with low visual acuity have a higher risk of falls [ 28 , 50 , 51 , 52 , 53 , 124 ]. The reason behind these inconsistent outcomes is unclear. However, it may be worth noting that different visual acuity tests were used in different studies. In the studies that report a significant relationship between visual acuity and fall risks, the Bailey-Lovie chart [ 28 ], Landolt ring chart [ 51 ], Snellen chart [ 50 , 124 ], low/high contrast letter chart [ 52 ], and face recognition test [ 53 ] were used. In the studies that did not report a significant relationship between visual acuity and fall risk, the Parinaud chart [ 47 ], Monoyer chart [ 47 ], LogMAR chart [ 21 , 49 ], and the Early Treatment of Diabetic Retinopathy Study (ETDRS) scale [ 48 ] were used.

Visual acuity is also related to the vestibular contribution in controlling postural balance. Willis et al. [ 22 ] analysed the data from a large-scale survey of 4590 adults aged 40 years old and above and reported that the percentage of failure in maintaining balance was higher in individuals with uncorrected refractive errors even when visual and proprioceptive sensory inputs were not available (i.e. only vestibular signals were available). The authors suggested that the deteriorated visual inputs might weaken the efficacy of the vestibulo-ocular reflex, which is related to the efficacy of postural balance control by vestibular inputs.

Contrast sensitivity and fall risk

Contrast sensitivity in visual functions is the ability to discriminate between two luminance levels in a static image. Low contrast sensitivity, even with relatively high visual acuity, makes detecting hazardous objects in the environment more difficult, particularly at night [ 54 ]. Many studies have reported correlations between contrast sensitivity and fall risks. Contrast sensitivity function and the Melbourne Edge Test [ 55 ] are often used to measure contrast sensitivity. Contrast sensitivity function represents contrast thresholds for sine wave gratings across a range of spatial frequencies. Contrast sensitivity function not only related to the past occurrences of falls [ 20 ] but also predicted future occurrence of falls [ 19 ]. In studies focusing on gait and balance in the elderly, the most common contrast sensitivity measure is the Melbourne Edge Test [ 23 , 56 , 57 ]. In the Melbourne Edge Test, participants report the orientation of a line defined by the contrast between two abutted surfaces. Then, minimum contrast for edge detection is measured. Several studies using the Melbourne Edge Test found that low contrast sensitivity is associated with the occurrence of falls in the past [ 58 ] and the follow-up period of the test [ 52 ]. Furthermore, the contrast sensitivity correlates with performances in physical tasks, which is related to fall risk, such as the stand-to-sit task [ 14 ] and the choice stepping reaction time task [ 58 ].

Depth perception/stereoacuity and fall risk

Depth perception allows us to accurately construct spatial relationships between objects and ourselves, which helps us to navigate our movement in the environment [ 52 , 59 ]. Depth information can be acquired by various cues that are often classified as monocular or binocular depth cues. Monocular depth cues, which include motion parallax, accommodation, blurring, and perspective cues, can be observed with one eye, whereas binocular depth cues, which include stereopsis and convergence, require both eyes. Stereoacuity tests are designed to measure the minimum difference between the images in the left and right eyes that can induce depth perception. The Howard-Dolman test and the Frisby Stereo test are commonly used to measure stereoacuity.

Lord and Dayhew [ 52 ] reported that performance in the Howard-Dolman test and the Frisby Stereo test was more strongly correlated with the occurrence of multiple falls in older adults than visual acuity, contrast sensitivity, and the size of the visual field. Poor stereoacuity was also associated with an increase in hip fractures [ 60 ], which is a common injury caused by falls [ 61 ]. Stereoacuity requires good quality of visual images from both eyes. Mono-vision condition in which one eye wears a contact lens for distance vision and the other eye wears a contact lens for near vision reduce stereoacuity and walking speed compared to both eyes having full distance vision correction [ 62 ]. And in another study, higher fall rates were found in subjects with high visual acuity in one eye and moderate or low visual acuity in the other eye [ 52 ]. The presence of a common factor in these two studies suggests that stereoacuity is related to fall risk.

Visual field and fall risks

Several studies have reported that the size of the visual field is strongly correlated with fall risk [ 15 , 16 , 20 , 63 , 64 ]. After re-examining the Salisbury Eye Evaluation data, Freeman et al. [ 63 ] found that visual field impairment was associated with self-reported fall occurrence. In another study, severe binocular visual field loss was associated with frequent falls during a 1-year follow-up period [ 16 ].

Different regions of the visual field have different effects on postural sway. A higher rate of falls was reported to be associated with the inferior region of the visual field, but not the superior region [ 65 ]; this result underlines the fact that, when dealing with the real-world environment, we depend more on the inferior region of our visual field. The risk of falls was associated with both central and peripheral visual fields [ 66 ]. Moderate to severe impairment in central vision was found to increase the risk of falls by 2.4-fold. While peripheral vision loss was found to increase the risk of falls by 1.4-fold. Straube et al. [ 67 ] also found that postural sway was less with central visual inputs than peripheral visual inputs when the sizes of visual field were the same. However, when they adjusted the size of the visual field in a way that the area of primary visual cortex representing the visual fields similar, there was no difference between central and peripheral vision in postural control. Based on this result, Straube et al. suggest that the contribution of visual stimuli to postural control is determined by the number of neurons in the primary visual cortex that are stimulated by the size of the visual field.

Visual motion perception and balancing

Postural balance control is strongly affected by visual motion signals, because visual motion signals provide direct information regarding head movements [ 17 , 68 ]. Considering this strong relation between visual motion perception and postural balance control, one may expect that deterioration in visual motion perception can cause a major deficit in balance control and increase the risk of falls. However, to the best of our knowledge, there have been no studies examining the correlation between visual motion perception ability and the risk of falls.

In this section, we will review studies investigating the mechanism by which visual motion signals generate reactive body movements. These studies can be classified into two topics: (1) studies related to vection and (2) studies related to sensory re-weighing, both of which will be discussed in detail.

Vection and postural control

Vection is a sensation of illusory self-motion that occurs when an observer is exposed to a visual motion signal. It clearly demonstrates that perception of visual motion signals is directly related to postural balance control. Vection has been reported to occur in various directions: anterior-posterior direction/depth motion [ 69 ], left-right direction/circular motion [ 70 ], and clockwise-counterclockwise direction/roll motion [ 71 ].

The magnitude of vection can be manipulated by several factors. Brandt et al. [ 70 ] tested the effect of visual field size on vection using a circular vection stimulus that is produced by placing the subject inside a rotating drum with black and white vertical gratings. When the motion stimulus covers the entire visual field or the peripheral visual field without central vision, subjects reported the sensation of self-motion with a perceived speed that matched the speed of stimulus motion. However, when the motion stimulus only covered the central 30° without peripheral vision, subjects reported no sensation of self-motion. The results suggested that the motion signal in peripheral vision is critical to the perception of circular vection. The effect of the visual field size was also found in roll vection. Allison et al. [ 71 ] examined sensation of self-rotating motion (i.e. roll vection) in a tumbling room, in which subject sat in a stationary chair observing a furnished room rotating about the body roll axis. The rotation speed of the tumbling room and the degree of the visual field affected the magnitude of roll vection. When full-field view was allowed, the majority of the subjects reported a complete 360° body rotation. The percentage of subjects experiencing 360° roll vection decreased as the degree of visual field decreased.

Predictably, presenting stationary objects along with vection stimuli can diminish the magnitude of vection. A more important finding was that the effect of stationary objects on vection depends on the relative distance of between stationary objects and moving stimulus. Stationary objects presented closer to subjects than moving stimuli do not affect the magnitude of vection, whereas stationary objects presented further away than moving stimuli markedly reduced the magnitude of vection [ 72 , 125 ]. The inhibitory effect of stationary objects was consistently found in forward/backwards vection [ 73 ]. This result is practical, because closer stationary objects can be perceived to move together with subjects, such as the interior of a moving car.

Vection and postural control are highly correlated as can be demonstrated by the fact that optic flow that generates vection [ 69 ] can also induce postural sway of an observer [ 74 , 75 ]. In addition, the magnitude of vection is correlated with the size of the postural sway in various directions [ 76 , 77 , 78 ]. In depth vection direction, the magnitude of vection is positively correlated with postural sway. Postural body sway was measured while optic flow from random dot patterns was presented to participants [ 76 ]. Similarly, postural sway was also larger when the magnitude of the perceived roll vection direction was higher [ 78 ]. Recently, it was reported that dependence on vision in postural control predicts the strength of vection [ 79 ]. In detail, the dependence on vision in controlling upright posture was measured by subjects’ postural sway ratio in opened and closed eyes conditions. The magnitude of perceived vection was assessed by subjective rating given by subjects to vection stimuli that were introduced immediately after the postural control test.

The vection and postural sway correlation can be stimulated by direct visual motion and also by illusory visual motion caused by the motion after effect (MAE) [ 80 ]. The postural sway of participants was measured while being stimulated by the MAE. MAE stimulation began with adaptation to left or right motion of a random pixel array. This was followed by a black screen and test pattern which consisted of three conditions: a static random pixel array (expected to produce longer MAE), a dynamic random pixel array in which each pixel was randomly assigned to bright or dark every 16.7 ms (expected to produce shorter MAE), and a blank screen (expected to produce no MAE). MAE was perceived to be significantly longer in the static condition compared to the dynamic condition. Furthermore, postural sway was found to be larger in the static condition than in the dynamic condition.

With age, perceived vection declines but postural sway rate increases. In a study conducted by Haibach et al., postural sway was recorded in two age groups, young adults and older adults, with stimulation in the form of a virtual reality moving room. They were also asked to rate the perceived vection. The results revealed that older adults experienced smaller vection than young adults, but exhibited larger postural sway. The lower rate of perceived vection in older adults suggests that a reduction in proprioceptive feedback due to ageing may contribute to a larger postural sway [ 81 ].

Considering that visual motion stimulation is important in vection and postural control, in-depth investigation of visual cue components in this visual motion stimulation will be fruitful in aiding our understanding of fall risk with ageing vision.

Sensory reweighting

In order to effectively estimate and control the state of body posture, the balance control system should integrate sensory inputs from proprioceptive, vestibular, and visual systems [ 82 , 83 ]. There has been an interesting line of research suggesting that the degree by which the balance control system relies on each sensory input is not hard-wired, but adaptively changes. The phenomenon, which is termed sensory reweighting, suggests that the balance control system will rely on one sensory signal over the other as the sensory environment changes.

Sensory reweighting is observed in various contexts. Ageing alters the relative accuracy of sensory signals, and, consequently, older adults rely more on vision to control postural balance than on vestibular or proprioceptive signals [ 81 ]. Loss of vestibular function affects the way patients respond to the visual signals to control posture. Peterka [ 83 ] measured the size of postural sway as a function of the magnitude of visual signals. As the amplitude of the visual signal increased, normal subjects’ decreased gain to visual inputs was demonstrative of adaptive sensory reweighting. However, patients with vestibular loss exhibited a constant gain regardless of the magnitude of visual inputs.

Sensory reweighting can be classified as inter- or intra-modality reweighting. Inter-modality reweighting indicates a change in the gain of a sensory modality due to the magnitude change of motion signal of the same sensory modality [ 82 , 84 , 85 ]. Intra-modality reweighting refers to a change in the gain of a sensory modality due to the magnitude change of motion signal from a different sensory modality [ 84 , 85 ].

An example of intra-modality reweighting was observed in an experiment conducted by Polastri et al. [ 85 ]. When an observer was surrounded by visual motion stimulation of constant frequency and standing on a platform that increased the sway amplitude, postural sway decreased relative to the platform. Another example of intra-modality reweighting is demonstrated when a randomly fluctuating visual motion stimulus was presented for 60 s and was introduced before presenting the main visual motion stimulus to observers [ 82 ]. The magnitude of sensory sway in response to the main visual motion stimulus was reduced. This result indicates that the postural control system re-adjusts the reliance on sensory modalities in response to the previous experience in an identical context.

Inter-modality reweighting was also demonstrated in the same study conducted by Polastri et al. [ 85 ]. When postural sway relative to the platform was decreased by an increase in the platform amplitude, postural sway relative to the visual stimulus increased as a result. Another example can be demonstrated by varied visual motion stimulation and constant touch motion stimulation amplitudes being introduced to observers simultaneously. Increased visual motion stimulation amplitude did not significantly affect the gain from sensory touch. However, when the condition was reversed (i.e. the amplitude of touch motion stimuli was varied and visual motion stimuli amplitude was set to constant), the increased amplitude of touch motion stimuli significantly affected vision sensory gain [ 84 ].

Sensory reweighting is slower in older adults when balance is being maintained. Hay et al. [ 86 ] investigated the mechanism by which older and young adults maintain their postural balance when the availability of visual and proprioceptive information was manipulated. When the proprioceptive inputs were perturbed by means of tendon vibration, both elderly and young adults exhibited a marked decrease of stability. A clear distinction between older and young adults was found when the perturbed proprioceptive inputs were reinserted. Young adults were able to rapidly integrate available information to control balance, whereas older adults were unable to utilize the reinserted sensory signals. These findings suggest that elderly adults are slower in adjusting weights on sensory modalities in response to their availability. A recent study also supports this result as, unlike young adults, older adults lose the ability to select stimulation such as galvanic vestibular stimulation (GVS) in order to reduce postural instability when perturbation of ankle and vision was introduced [ 87 ]. In a recent neuroimaging study on balance control, activity in the brains of older adults was distributed across several locations when somatosensory and visual information was absent, while in young adults the temporal-parietal region was more active, suggesting that in older adults sensory re-weighting demands more attention [ 88 ].

It is known that sensory reweighting is important in balance control and that ageing affects this ability even in healthy adults [ 89 ]. However, despite of older adults’ responses are generally poorer than young adults’ in a condition where sensory conflicts were presented, 1-h exposure to sensory conflict induced by virtual environment exhibits a better adaptation in older adults’ muscle response. Muscle response delay is shorter in first 10 trials compared to last 10 trials suggesting the possibility of postural balance improvement using sensory reweighting in older adults [ 90 ]. These results indicate that knowledge of the mechanism underlying sensory reweighting in older adults may become a stepping stone in understanding falls and in the development of prevention strategies.

Future research directions

As reviewed above, diverse visual motion stimuli have been extensively used to study their influence on postural balance control. We suggest that a systematic examination of individual differences in processing visual motion signals will widen our perspective on the visual risk factors for falls. However, evaluating individual differences in visual motion perception is not a simple matter, because the ability of visual motion perception has diverse aspects. Thus, simple measurement of the detection threshold to motion stimulus cannot provide a proper index of individual differences in visual motion perception. An approach that takes into account diverse aspects of visual motion processing is required. Here, we propose three well-known phenomena related to motion perception and postural balance control, which could potentially indicate novel directions for research.

Spatial suppression in motion perception

In the “ Visual motion perception and balancing ” section, we discussed the notion that the effect of ageing on the sensitivity to motion signals depends on the properties of the motion stimulus. The sensitivity to a small, low-contrast motion stimulus deteriorated with age, but the sensitivity to a large, high-contrast motion stimulus improves [ 42 ]. In other words, older adults are better at detecting the direction of a large, high-contrast motion stimulus than young adults. It was suggested that the relatively poor performance of young adults in the task was caused by strong centre-surround antagonism in visual motion perception. Centre-surround antagonism in visual motion perception refers to the fact that the firing rate of motion-sensitive neurons in the MT (middle temporal area in the brain) decreases when the surrounding area of the receptive field is stimulated [ 91 ]. Thus, the sensitivity to the motion stimulus declines as the stimulus size becomes larger [ 43 , 92 ].

It is possible that the sensitivity to a small, low-contrast motion stimulus and the sensitivity to a large, high-contrast motion stimulus, which reflect the magnitude of spatial suppression, are related to the fall risks in older adults in a completely different manner. Further investigation of this theory will clarify our understanding of the relationship between visual motion perception and fall risk.

Theories of multisensory integration

Balance control involves several sensory modalities, including visual motion perception. In order to use the multi-modal sensory signals efficiently, the system should be able to integrate visual, vestibular, and somatosensory signals properly. Therefore, understanding the principles by which our balance control system integrates multisensory information is critical to understand human balance control and fall risk. However, as far as we are aware, the ability to integrate multisensory signals has not been discussed in the context of fall risk factors.

There are two well-supported theories of multisensory cue integration that might contribute to the understanding of balance control and fall risk. The first theory states that humans integrate multi-sensory signals in a statistically optimal manner [ 93 ]. Statistical optimality of cue integration implies that the perceptual system depends more on sensory signals with low uncertainty than sensory signals with high uncertainty. For example, it is expected that the balance control system relies more on the visual stimuli when the stimulus is clearly presented (e.g. during the daytime) than when the visual stimulus is unclear (e.g. at night). It is largely unknown how the uncertainty of sensory signals affects the sensory integration in balance control.

The second theory is known as the causal inference model of multisensory cue integration [ 94 ]. According to the theory, temporal and spatial distances between multisensory signals determine the degree of perceptual integration. When sensory signals from different modalities are spatially and temporally distant, the perceptual system processes the signals independently, and when sensory signals from different modalities are spatially and temporally close, the perceptual system integrates the signals. By applying the two general theories of multisensory integration to understand human balance control, we could better understand why and how the balance control system reacts to diverse patterns of visual, vestibular, and somatosensory signals. Among visual inputs, visual motion signals are highly correlated with the vestibular and somatosensory signals. Thus, multisensory integration is particularly important in understanding how visual motion signals are related to balance control and fall risk.

Older adults who are prone to falls have a tendency to over-integrate multisensory signals [ 95 , 96 ]. This is demonstrated in the sound-induced flash illusion, in which the number of concurrently presented sounds affects the perceived number of flashes. Subjects perceive two visual flashes when one visual flash and two consecutive auditory stimuli are briefly presented. In general, the delay between visual and auditory stimuli diminishes the effect. However, the older adults who are prone to falls report the illusion even when the delay between visual and auditory stimuli is relatively long. This result suggests that the risk of falls may be associated with the inability to infer the causes of multisensory signals [ 95 ].

Understanding the mechanism of multisensory integration in postural control is important in studying fall risk and developing prevention strategies. In a recent study, balance training intervention successfully improved postural balance control in healthy and fall-prone older adults, and the improvement was demonstrated to correlate with multisensory processing efficiency [ 97 ].

Cognitive load and balance control

Many studies have examined the effect of cognitive load on postural control [ 98 , 99 , 100 , 101 , 102 , 103 ]. Cognitive spatial processing and postural balance control may rely on the same neural mechanics. When participants performed spatial and non-spatial memory tasks in sitting and standing positions in the Romberg test, a significantly higher number of errors were observed in the spatial memory task in the standing position compared to the sitting position. However, in the non-spatial memory task, the number of errors was not significantly different in the standing and sitting positions [ 104 ]. Postural sway was also affected by a secondary cognitive task [ 105 ]. Young and older adults without a history of falls exhibited significantly larger postural sway in a sentence completion task. However, older adults with a history of falls exhibited significantly larger postural sway in both the sentence completion and perceptual matching tasks. Moreover, the study also found that the surface condition (fixed vs swaying) had no significant effect in either age groups. The results suggested that the task of postural control shared cognitive resources with other cognitive tasks and that fall risk in older adults was related to a lack of cognitive resources. Similar results were also observed when cognitive task was demanding attention [ 106 ]. Participants were instructed to verbally classify an auditory tone as being high or low during several conditions of balance tasks: a combination of two ground conditions, sway and fixed, and three visual conditions, open, closed, and visual motion. In healthy older adults, postural balance control was affected when visual and somatosensory information was removed simultaneously. However, in balance-impaired older adults, the auditory task affected postural balance control in all sensory conditions. In contrast, Swan et al. [ 103 ] demonstrated that adding cognitive load decreased postural sway. In their study, subjects were required to stand still while performing cognitive tasks under different visual (open vs closed eye) and ground (fixed vs swaying pedal) conditions. Cognition tasks were spatial or non-spatial memory tasks. Surprisingly, the results indicated that in the closed-eyes/swayed-ground condition, which was the most difficult condition, cognitive tasks reduced the postural sway. This effect only appeared in the older adults group. Using the same memory task as one of the secondary tasks, Bergamin et al. [ 107 ] also observed improvement in postural stability in older adults by adding visuospatial tasks while maintaining balance. Recently, a cognitive task was also reported to decrease postural sway in young adults [ 108 , 109 ]. Diverting attention from postural control decreases postural sway during the continuous cognitive task but not during the irregular cognitive task [ 108 ]. The continuous cognitive task in this study consisted of mentally counting and summing a series of three-digit numbers and mentally performing a series of simple mathematical equations. The irregular cognitive task consisted of verbally responding to random auditory stimuli and distinguishing high-pitched beeps from low-pitched beeps by verbally responding only to the high-pitched beeps [ 108 ]. In line with the findings of the studies mentioned above [ 103 , 107 , 108 , 109 ], it has been shown that postural sway is smaller when subjects focus attention on a cognitive task compared to when subjects focus attention on postural control itself. In the study, participants were asked to silently count numbers in the cognitive task condition, and participants were asked to minimize movement of the hips in the postural control condition [ 110 ].

Although inconsistent findings regarding the effect of cognitive load on balance control necessitate further investigation, it seems clear that maintaining posture requires significant cognitive resources. We suggest that one of the main reasons for the sizable effect of cognitive load on balance control is that visual motion processing requires cognitive resources. The motion signal detected from a retinal image is an ambiguous signal. Retinal motion can represent movements of the head, eye, or objects in the world, and identifying the causes of retinal motion signals in sufficiently short duration would require sizable cognitive resources. Indeed, it has been demonstrated that the ability to detect briefly presented visual motion signals is a good indicator of IQ [ 111 ]. We suggest that further research on the relationship between cognitive load, visual motion perception, and fall risks may reveal one of the key factors responsible for the falls in older adults.

Numerous studies have been conducted to identify relevant factors that contribute to the high risk of falls. It has been demonstrated that the deteriorations of diverse perceptual, cognitive, and muscular functions are correlated with fall risk. However, the majority of research regarding fall risk has focused on the simple correlation between the risk factors and the frequency of falls and did not attempt to provide clear mechanistic explanations regarding why and how those factors are related to falls. On the other hand, there are rich theory-oriented studies that examine how the balance control system is affected by sensory and cognitive processing. Researches on vection, sensory reweighting, spatial suppression in visual motion perception, multi-sensory integration, and effect of cognitive load on balance control are representative examples.

Considering that falls occur when one loses the control of balance, it is worth noting that the results of balance control studies have not been exploited in studies focusing on risk factors for falls. The lack of communication between the two fields is demonstrated by the fact that the ability of visual motion perception, which directly affects balance control, has not been studied as a key risk factor for falls. We believe that efforts to integrate knowledge from theory-oriented balance control studies and knowledge from application-oriented fall risk studies will be fruitful and help us to prevent falls more efficiently.

Abbreviations

Three dimensional

Early Treatment of Diabetic Retinopathy Study

Galvanic vestibular stimulation

Intelligence quotient

Motion after effects

Middle temporal

Modular transfer function

World Health Organization

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Saftari, L.N., Kwon, OS. Ageing vision and falls: a review. J Physiol Anthropol 37 , 11 (2018). https://doi.org/10.1186/s40101-018-0170-1

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• Indu Chawla 1  

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To ensure healthy lives and promoting well-being for all in the society at all ages is one of the goals of United Nations. Specially, health of elderly people plays an important factor in productivity and prosperity of any country. According to reports, there will be over two billion elderly people worldwide by 2050. Most of elderly people live independently and need some system to protect them from any kind of fall. As old people are highly susceptible to fall due to weak body structure as well as some external conditions, researchers from academia and industries are developing fall detections systems (FDS) or devices to prevent them from fall. Hence, this paper majorly aims to review the papers on fall detection systems (FDS) to protect elderly people from any kind of fall. Papers selected for this study spans from 2017- 2023. FDS will be helpful to sustain the health of elderly persons. In view of strengthening research in this domain, this study gives an integrated and a critical review of work done in this area for both wearable, non-wearable systems and hybrid systems with research directions as the advent of new technologies like deep learning, computer vision, Internet of Things (IoT) and big data may improve the existing approaches/systems.

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Purwar, A., Chawla, I. A systematic review on fall detection systems for elderly healthcare. Multimed Tools Appl 83 , 43277–43302 (2024). https://doi.org/10.1007/s11042-023-17190-z

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Received : 25 December 2022

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DOI : https://doi.org/10.1007/s11042-023-17190-z

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Prevention of falls in the elderly--a review

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• 1 Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics and Clinical Sciences, Skåne University Hospital, Lund University, 205-02 Malmö, Sweden. [email protected]
• PMID: 23296743
• DOI: 10.1007/s00198-012-2256-7

The proportion of elderly in the society increases and fall frequency increases with advancing age. Many falls result in fractures and also soft tissue injuries, longstanding pain, functional impairment, reduced quality of life, increased mortality, and excess in healthcare costs. Due to the magnitude of these negative effects, a variety of single- and multicomponent fall-preventive intervention programs has been initiated.This review identifies programs that, in randomized controlled trials (RCTs), have been shown with fall-reductive effects.The most effective strategies in community-dwelling elderly include regular physical training with program that includes several different training modalities. Modification of the overall or patient-specific risk factor profile in home hazard modification program has been proven to decrease fall risk in community-living elderly. The elderly in the community benefit also from wearing antislip shoe devices when walking in icy conditions, from adjustment of psychotropic medication, and from structured modification of multipharmacy. If vitamin D levels in blood are low, supplementation is beneficial as is the first eye cataract surgery and pacemaker implantation in patients with cardioinhibitory carotid sinus hypersensitivity. In addition to modification of specific risk factors, generalized and individualized multifactorial preventive programs, all including some sort of physical training, have been found to decrease the fall risk. In summary, there is now strong evidence in the literature that structured fall-preventive programs in the elderly, especially in high-risk groups, are beneficial in reducing both the number of fallers and the number of falls in community.

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• Health Services for the Aged
• Hip Fractures / epidemiology
• Hip Fractures / etiology
• Hip Fractures / prevention & control
• Osteoporotic Fractures / epidemiology
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Polypharmacy and Falls in the Elderly: A Literature Review

Tania hammond.

1 Lower Eyre Health Services, Cummins and Districts Memorial Hospital, Australia

Anne Wilson

2 School of Medicine, University of New South Wales, Flinders University of South Australia, Bedford Park, Australia

Medications are taken to ease, control or cure ailments. They are effective and safe if used correctly. In the elderly, disorders that occur as a result of ageing, frequently require treatment, resulting in increased use of medications. Polypharmacy is common among the elderly and although it can be therapeutic in nature, is linked to adverse events such as falls.

Evidence Acquisition:

A review of the literature was conducted. English articles in Cinahl, Medline and Healthsource (2000-2012) were searched for links between polypharmacy and falls in older adults aged 65 years old and over. Articles not meeting the age criterion were excluded.

Search terms included falls, polypharmacy, medications, multiple medications, medicines, elderly, aged. A total of 120 articles were retrieved from the Literature search.

Sixteen articles were included in the literature review. Four literature reviews, three observational prospective cohort, three cross-sectional, three case-control, one longitudinal study and two retrospective cohort studies were examined. Many studies were able to demonstrate a link between the number of medications taken and risk of falls however the potential for bias resulting from confounding by indication was high due to study design in many cases.

Conclusions:

Polypharmacy as an independent variable has been linked to falls in older people, however there appears to be a stronger link between falls and the type of medications taken (e.g. medications known to increase risk of falls), rather than polypharmacy on its own. Polypharmacy can sometimes be therapeutic and it may be more beneficial to consider terms such as ‘inappropriate prescribing’ or potentially inappropriate medications’ when considering the effects of medication on falls in older adults. Polypharmacy in older people is often viewed in a negative light due to the increased risk of adverse events, including falls. This article examined current knowledge on the characteristics that define polypharmacy, its effect on falls in elderly people and provided recommendations for future research. Further research utilizing prospective and intervention studies are needed to clarify the causal relationship between polypharmacy, comorbidities and fall risk.

In any two-week period, nine out of ten elderly Australians take at least one medication ( 1 ). The presence of co-morbidities, age-related physiological changes and an ageing population means that older people are frequently prescribed a high number of medications, often referred to as polypharmacy ( 2 ).

Polypharmacy is linked to increased risk of adverse drug events in older people due to increased risk of drug interactions, lack of adherence to medication regimes, susceptibility of older people to side effects of medications, and physical changes related to ageing causing difficulties in taking medications as intended ( 2 , 3 ).

In Australia, adverse drug events are responsible for more than 30% of unplanned admissions to hospital in elderly people 75 years and over ( 4 ). Also, repeated admissions related to adverse drug events have increased at a much greater rate than ‘first-time’ admissions for adverse drug events ( 5 ).

One adverse event that can be related to medications and polypharmacy in the elderly is falls. Falls are known to be a serious health problem for older people ( 6 , 7 ). As the percentage of elderly adults in the Australian population grows, falls in this group have come to the forefront as a serious and growing health concern. Approximately 30% of community-dwelling older people fall each year and the consequences of these falls can be catastrophic, resulting in loss of quality of life, fear of falling, depression and general lack of self-confidence.

Medications are often associated with an increased risk of falls and it is generally accepted that the risk of falls increases with the number of medications taken, with those taking four or more medications at greater risk of falling ( 8 - 12 ). Furthermore, the type of medications or specific medications ingested has been shown to significantly influence the fall risk ( 7 ).

Despite an abundance of literature on the subject, there is no universally accepted definition of polypharmacy. It is defined in the literature as the use of a number of medications taken at the same time, the number of medications varies from 2 to 5 or more, depending on the study ( 8 , 10 ). Some definitions include over the counter and complementary medications, while others consider prescription medications only ( 8 , 10 ). Some studies use a list of characteristics to define polypharmacy, regardless of the number of medications taken; for example unnecessary or excessive use of medications ( 13 ). Brager and Sloand ( 2 ) define polypharmacy as the use of two or more medications with the following characteristics:

• To treat the same condition
• Of the same chemical class
• With the same or similar pharmacologic actions to treat different conditions

The authors highlight that polypharmacy should not always be considered in a negative light, and is sometimes an appropriate and therapeutic treatment strategy. Brager & Sloand ( 2 ) consider different types of polypharmacy and believe ‘irrational polypharmacy’ to be the type that can have detrimental effects on older people.

Some authors do not use the term polypharmacy at all, instead opting for terms such as ‘inappropriate prescribing’ or ‘potentially inappropriate medications’ to explain the phenomenon of polypharmacy and how it affects older people ( 3 , 14 ).

Falls in the elderly population are recognized as a leading cause of mortality and morbidity with increased hospitalizations and drain on health systems. This paper reports on published literature examining polypharmacy as a risk factor for falls in the elderly and provides information on how to address the gaps in knowledge.

The purpose of this literature review was to establish published theoretical viewpoints on polypharmacy as a risk factor for falls in the elderly and produce an overview on the subject.

2. Evidence Acquisition

Medline, CINAHL and HEALTHSOURCE databases were searched for original English articles published between January 2000 and September 2012. Search terms included falls, polypharmacy, medications, multiple medications, medicines, elderly, aged.

Cochrane Library reference lists and retrieved articles reference lists were examined for articles not already retrieved. A total of 120 articles were retrieved from the Literature search.

Abstracts of the original 120 articles found through the literature search were read. The following criteria were used to exclude articles:

• Sample aged below 65 years of age (or a mean age of less than 65 years)
• Sample did not include community-dwelling older adults
• Studies/articles relating to specific classes of medications
• Studies/articles that did not clearly demonstrate a link between polypharmacy and falls in older adults
• Articles that discussed falls risk factors, but did not include medications or polypharmacy

Twenty-four articles remained after sorting, based on the above criteria. Eight Of these 24 articles were excluded as they were information-based articles only, not literature reviews or reports of research studies.

The remaining 16 articles were included in this literature review ( Table 1 ).

Of the reviewed sixteen articles there were four literature reviews, three observations of prospective cohorts, three cross-sectional, three case-control, one longitudinal study and two retrospective cohort studies. Sample sizes in relevant studies ranged from 118 ( 15 ) to almost 18,000 ( 14 ).

The most common definition of polypharmacy used in the studies was ‘the use of four or more medications’ ( 12 , 16 - 18 ). Despite making references to polypharmacy, five studies did not include a definition. However, polypharmacy was not the primary theme of these studies ( 9 , 11 , 19 , 20 ). All but two papers identified links between polypharmacy and falls. Some studies cited links between increased falls and an increase in the number of medications used per day ( 12 , 15 , 17 , 20 ). Other studies concluded that increased falls risk is associated with the type of medication used rather than the number of medications used, although the likelihood of being prescribed a medication that is known to cause falls increases with the number of medications taken ( 11 , 17 , 19 ). One study identified that elderly people taking one or more anticholinergic or sedatives had almost doubled the risk of having a fall over a year compared with people taking less than one of either drugs ( 7 ).

French et al. ( 9 ) and Kelly et al. ( 19 ) used case-control methods to study the relationship between medications and hip fractures and medications and falls, respectively. Case-controls are more accurately able to identify causality between medications and falls as they consider medications taken leading up to, and at the time of the fall. Other study design methods do not allow for this consideration.

Veehoff, Jong & Hajjar-Ruskamp (2000), attempted to find a workable definition of polypharmacy and the implications of the phenomenon in general practice, however they were unable to draw many conclusions due to the lack of quality literature available at the time.

4. Conclusion

The review of the literature showed that because there is no universally accepted definition of polypharmacy it is not always considered a risk to the elderly’s well-being. Although there is a large amount of literature available from studies conducted on the subject but, they were not always rigorous, utilizing weak study designs.

Significantly, the review identified links between polypharmacy, and increased falls that was associated either with the type of medications taken or, as in some situations, were linked with an increase in the number of medications used ( 21 ) per day. The association of fall risk with comorbidities and medications was confirmed ( 6 ). Unfortunately, falls in the elderly can result in hip fractures and subsequent sequelae to reduced quality of life or longevity.

Prior to 2000, polypharmacy was generally considered an independent risk factor for falls in the elderly, however more recent evidence suggests that polypharmacy alone is unlikely to be the risk factor ( 12 , 18 ). The association between increased falls risk and polypharmacy appears to be much stronger when the older person is taking at least one medication that is known to cause falls ( 7 , 12 , 18 ). Such medications may almost double the risk of having a fall.

A more appropriate way of looking at the effects of polypharmacy on falls in older adults appears to be ‘inappropriate prescribing’ rather than the number of medications taken. This takes into consideration the types of medications prescribed, reasons for prescreption, things to consider when commencing certain types of medication, potential effects on the older person and reasons for omission of certain types of medications ( 2 ).

Considering polypharmacy as purely the number of medications taken by an older person can be limiting and adherence issues may not be considered. Studies have shown that polypharmacy can lead to omissions by older people due to the complex nature of their medication regime, which in turn can cause adverse effects. A missed medication can cause hospitalization due to adverse drug events just as much as a medication that has been ingested ( 5 ).

Most studies retrieved were observational epidemiological studies, in particular prospective or cross-sectional. The potential for bias in these types of studies, as a result of confounding by indication, is quite high. Interventional and prospective studies designed for the elderly population are needed to determine strategies and guidelines to reduce falls.

This review points out that further research is required to fully understand the phenomenon of polypharmacy and its effect on older people, not only in relation to falls but other adverse effects. A common understanding of what is considered to be polypharmacy is essential and should include characteristics other than simply the number of medications taken. Through the review, the authors have identified that a universal definition would aid research, improve clinical practice by the development of standardized guidelines and address potential risks to the elderly population. Further research utilizing prospective and intervention studies are needed to clarify the causal relationship between polypharmacy, comorbidities and fall risk.

Acknowledgments

The author declares no acknowledgment.

Implication for health policy/practice/research/medical education: Falls affect approximately one third of older people. Falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death and reduce quality of life. Fortunately, falls are a public health problem that is largely preventable. The link between multiple medicine use and falls in the elderly is often discussed but not widely investigated, partly because older people do not always discuss their falls with their health care provider. To reduce the risk of falls, health professionals need to understand the causative factors and learn to be anticipatory when conducting assessments. As people age their use of medications generally increase, therefore research into the adverse effects of medication use on the mortality of older individuals is needed for increased understanding.

Please cite this paper as: Hammond T, Wilson A. Polypharmacy and Falls in the Elderly: A Literature Review. Nurs Midwifery Stud. 2013;1(4):171-5.

Author's contribution: Tania Hammond conducted the study under the guidance of Anne Wilson. Tania Hammond wrote the manuscript. Anne Wilson directed, edited, revised and submitted the manuscript.

Financial Disclosure: Tania Hammond conducted the study under the guidance of Anne Wilson. Tania Hammond wrote the manuscript. Anne Wilson directed, edited, revised and submitted the manuscript.

Funding/Support: No financial assistance was provided for this study.