Articles: Medical Topics
Slips and Falls on the Slippery Slope
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 The
risk of falls increases as adults age. More than one third
of adults over the age of 75 fall each year. Among the frail
elderly who reside in nursing homes, the fall rates are
two to three times higher, with experts identifying the
fall rate as 1.6 falls per year per nursing home bed. [1-
2] The incidence of injurious falls will increase as
the population ages.
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What
puts elderly people at such high risk for falls? Factors
associated with both normal aging and disease create risks.
Elders frequently lose muscle mass and the ability to regain
balance when faced with obstacles. Sensory deficits such
as visual impairment associated with aging contribute to
the risks. Diseases and conditions that increase the risk
of falls include diabetic peripheral neuropathy, arthritis,
atherosclerosis, brain bleeds, postural hypotension (drop
of blood pressure when standing up), Parkinson’s disease,
and strokes (which impair judgment), among others. The side
effects of medications are implicated in falls, with prime
offenders being sedatives, anti-seizure, cardiac, antidepressants,
and antiinflammatory medications. [1] Often falls are caused
by the interaction of several factors. A hazardous environment
containing uneven pavement, ice, spills, improperly installed
or absent handrails, poorly lit stairs, lack of contrast
between stairs and the floor, and other factors creates
the catalyst for the fall. A fall may occur from a lying,
sitting, or standing position. An analysis of 12 large studies
found that the most common factor associated with falls
was an accident or environmental hazard. [3] It is a hallmark
of weakness, illness and social isolation if the injured
person remains on the ground or floor for more than one
hour after a fall. [1]
A recent
summary of 16 studies defined the most common risk factors
for falls, listed here in the order of most frequent to
least frequent: leg weakness, history of falls, gait deficit,
balance deficit, use of an assistive device, visual deficit,
arthritis, impaired ability to perform activities of daily
living, depression, cognitive impairment, and age greater
than 80. Leg weakness increased the risk of falling by more
than four times. The risk factors for injurious falls are
the same factors for falls in general, with the addition
of being female, the presence of at least two chronic conditions,
and having low body mass. [2, 3] An easy way to keep in
mind all of the major factors that contribute to a fall
is to remember the ten S’s:
Structure
(anatomy, arthritis, range of motion), Stride (the person’s
step length, gait, or shuffle), Speed (of walking), Sepsis
(presence of infection), Strength (arms and legs), Sway
(ability to maintain balance and posture), Surface (on which
the person fell, including a wet environment, uneven flooring,
pavement, or ground, slippery floors, obstacles such as
throw rugs, extension cords, and clutter), Shoes (heels,
slippery or tacky soles, shoe fit), Sensorium (delirium,
depression, dementia, medications with drug interactions,
multiple medications, and fear of falling), and Sight (visual
acuity, cataracts, or glaucoma.) [2]
Ninety
percent of falls in adults result in no or non-serious injuries
[1] and therefore should not result in a claim if damages
are the prime criteria for screening a claim. The more serious
injuries—fractures of the arms or legs, spine, or
skull or the development of a brain bleed—are usually
the cases that come to the attention of attorneys.
Operative
treatment of fractures carries its own set of potential
complications including reactions to anesthesia, nerve damage,
postoperative blood clots or fat emboli, hemorrhaging, nerve
injury, and infection. Fractured hips have their own specific
risks, including heterotopic ossification, failure of hardware,
leg length discrepancy, among others. Although experts on
falls disagree on the exact percentage of individuals who
die in the year following a fall, up to 36% will not survive.
[4] A fall causing a fractured hip may be the factor that
starts a chain of events leading to immobility, pressure
sores, pneumonia, and then death. Twenty to 30% of people
who sustain a hip fracture die within a year of the fracture.
[3] The fear of falling again typically causes the elderly
to restrict their physical and social activities, leading
to isolation and depression. For many individuals, a fall
may precipitate an admission to a nursing home, filled with
its own environmental hazards.
Implications
for attorneys:
1. Question the plaintiff about the events that
occurred right before a fall, keeping in mind that the most
common risk factor for falls is leg weakness. A collapse
of the legs could have nothing to do with the environment
in which the fall occurred.
2. Develop a list of questions specific to falls cases,
include the ten S’s and risk factors associated with
falls. Use the list to interview/depose the plaintiff.
3. Recognize that there is an up to one in three chance
that the plaintiff will not survive for more than a year
after a fall. Schedule depositions with this in mind.
4. Consider the full range of damages that may be attributable
to the changes that result from a fall, including debility,
immobility, skin breakdown, pneumonia, blood clots, social
isolation, fear of falling again, and so on.
5. Keep fit, maintain weight control and participate in
endurance exercises to reduce your own risk of injurious
falls as you age.
Useful
Fall-related Terms
Bipedal - standing on two feet
Dizziness - a sensation of disorientation
in relationship to body position
Dynamic balance - balance when moving,
such as when walking
Heterotopic ossification - the soft tissues
around the hip become ossified (hard)
Static balance - balance when sitting or
standing still
Syncope - partial or complete loss of consciousness,
fainting
Unipedal - standing on one foot
Vertigo - spinning sensation
References
1. Matsumura, B. and Ambrose, A, “Balance in the elderly”,
Clinics in Geriatric Medicine, 22, 2006, 395-412.
2.
Komara, F. “The slippery slope: reducing fall risk
in older adults”, Primary Care: Clinics in Office
Practice, 32 (3), September 2005.
3. Rubenstein,
L. and Josephson, K., “Falls and their prevention
in elderly people: what does the evidence show?” Medical
Clinics of North America, 90 (5) September 2006.
4. Watters,
C. and Moran, W. “Hip fractures—a joint effort”,
Orthopaedic Nursing, 25 (3), May/June 2006, 157-165
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