Slips and Falls on the Slippery Slope

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 anti-inflammatory 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.³It 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)
• 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.

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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