To evaluate the incidence of unexplained falls in elderly patients affected by fall-related fractures admitted to orthopaedic wards, we recruited 246 consecutive patients older than 65 (mean age
Falls in older people are a major public health concern in terms of morbidity, mortality, and health and social services costs [
Falls are the leading cause of injury-related visits to emergency department in the United States. Trauma is the fifth leading cause of death in people starting from 65 years, and falls are responsible for 70% of accidental death in people starting from 75 years.
More than a third of older adults falls each year [
Data regarding fall types in patients admitted to orthopaedic wards because of fall-related injury are lacking: the UFO study (Unexplained Falls in Older Patients) was made to assess the incidence and the clinical characteristics of unexplained falls in this specific group of elderly subjects affected by fall-related fractures.
We defined four different types of falls: “accidental” (fall explained by a definite accidental cause), “medical” (fall caused directly by a specific medical disease, e.g., hypoglycemia, drugs, drop and attack, transient ischemic attack, myocardial infarction, arrhythmic drugs, orthostatic hypotension), “dementia-related” (fall in a patient with previous diagnosis of moderate-severe dementia), and “unexplained” (nonaccidental falls, not related to a clear medical or drug-induced cause, where no apparent cause has been found) [
All enrolled patients were starting from 65 years and consecutively admitted to orthopaedic wards because of fall-related injury, without any exclusion criteria.
All patients (or relatives if the patient had diagnosis of dementia) gave informed written consent.
Centers involved in the study (the appendix) designated and instructed a trained investigator who used to manage falls and syncope to run the study.
All subjects were asked to complete their clinical history, with a specific questionnaire about fall characteristics, pharmacologic anamnesis considering all drugs taken in the last month, clinical and neurological examination, routine blood chemistry tests, and 12-lead ECG.
Moreover, we performed a multidimensional geriatric evaluation including Mini Mental State Examination-(MMSE) [
Data analysis was performed using SPSS, 14th version (SPSS, Chicago, IL, USA). The
246 patients (mean age
Clinical characteristics of the studied sample are shown in Table
Clinical characteristics.
All |
65–79 years |
≥80 years |
| |
---|---|---|---|---|
Age |
|
|
|
0.0001 |
Sex (males, %) | 17.9 | 21.5 | 16.2 | 0.306 |
Number of drugs |
|
|
|
0.569 |
Use of more than 4 drugs (%) | 43.5 | 43.0 | 43.7 | 0.612 |
CIRS |
|
|
|
0.432 |
Lost BADL |
|
|
|
0.0003 |
Lost IADL |
|
|
|
0.001 |
MMSE |
|
|
|
0.003 |
GDS |
|
|
|
0.03 |
BMI (Kg/m2) |
|
|
|
0.01 |
Blood glucose (mg/dL) |
|
|
|
0.280 |
Hemoglobin (g/dL) |
|
|
|
0.0004 |
Creatinine (mg/dL) |
|
|
|
0.179 |
Data are expressed as mean ± standard deviation; CIRS: Cumulative Illness Rating Scale; BADL: basal activities of daily living; IADL: instrumental activities of daily living; MMSE: Mini-Mental State Examination; GDS: Geriatric Depression Scale; BMI: body mass index.
Patients older than 80 years were more likely to be self-dependent and obtained lower MMSE scores; they were more likely to show depressive symptoms, and they had lower values of BMI. No differences were found in the two groups in terms of biochemical values, except for hemoglobin that was significantly lower in older subjects. 17 patients (8.1%) had syncope as a cause of fall. According to the anamnestic features of the event, older patients had a lower tendency to remember the fall (Table
Clinical history.
All |
65–79 years |
≥80 years |
| |
---|---|---|---|---|
Remember the event | 78.9 | 92.2 | 72.3 | 0.002 |
Witness presence | 39.4 | 45.3 | 36.6 | 0.244 |
Syncope | 8.1 | 7.4 | 8.3 | 0.967 |
Fractures | 92.6 | 90.0 | 93.9 | 0.300 |
Prodromes | 17.9 | 17.7 | 18.0 | 0.568 |
Data regarding drugs taken in the last 30 days are shown in Table
Drugs taken in the previous month.
All |
65–79 years |
≥80 years |
| |
---|---|---|---|---|
Antihypertensives (%) | 60.1 | 56.7 | 62.9 | 0.416 |
Antiplatelet agents (%) | 35.3 | 26.7 | 39.5 | 0.087 |
Anticoagulants (%) | 9.2 | 15.0 | 6.4 | 0.060 |
Central nervous system drugs (%) | 47.5 | 40.9 | 50.8 | 0.208 |
Ace inhibitors/AT2 antagonists (%) | 38.0 | 38.3 | 37.9 | 0.955 |
Calcium-channel blockers (%) | 16.8 | 18.3 | 16.1 | 0.708 |
Diuretics | 34.2 | 21.6 | 40.3 | 0.02 |
Beta-blockers | 13.1 | 11.7 | 13.8 | 0.685 |
Alpha-blockers | 5.4 | 6.7 | 4.8 | 0.608 |
Other, |
79.3 | 80.0 | 79.0 | 0.897 |
The different fall types are described in Table
Different fall types (suggestive diagnosis).
All |
65–79 years ( |
≥80 years |
| |
---|---|---|---|---|
Accidental (%) | 99 (40.2) | 38 (48.1) | 61 (36.5) | 0.02 |
Medical (%) | 25 (10.2) | 7 (8.9) | 18 (10.8) | 0.323 |
Dementia-related (%) | 31 (12.6) | 5 (6.3) | 26 (15.6) | 0.02 |
Unexplained (%) | 91 (37.0) | 29 (36.7) | 62 (37.1) | 0.475 |
Data are expressed as number (percentage).
Younger patients had a higher number of falls documented as accidental (48.1% versus 36.5%,
Clinical characteristics of patients with different fall types are shown in Table
Clinical patient features with different fall types.
Accidental ( |
Medical ( |
Dementia-related ( |
Unexplained ( |
|
---|---|---|---|---|
Age (years) |
|
|
|
|
Sex (males, %) | 14.1 | 24.0 | 9.7 | 23.1 |
Number of falls |
|
|
|
|
Number of drugs |
|
|
|
|
More than 4 drugs (%) |
|
|
|
|
CIRS |
|
|
|
|
Lost BADL |
|
|
|
|
Lost IADL |
|
|
|
|
MMSE |
|
|
|
|
GDS |
|
|
|
|
BMI (Kg/m2) |
|
|
|
|
Blood glucose (mg/dL) |
|
|
|
|
Hemoglobin (g/dL) |
|
|
|
|
Creatinine (mg/dL) |
|
|
|
|
Data are expressed as mean ± standard error or %; CIRS: Cumulative Illness Rating Scale; BADL: basal activities of daily living; IADL: instrumental activities of daily living; MMSE: Mini-Mental State Examination; GDS: Geriatric Depression Scale; BMI: body mass index.
Patients with falls related to medical causes reached higher levels of comorbidity than patients with accidental falls (CIRS score:
Patients with unexplained falls lost a higher number of IADL with respect to patients with accidental falls (lost IADL:
No differences were found between the four groups as far as the use of different classes of drugs is concerned.
History in different syncope types is illustrated in Figure
History in different syncope types.
We drew four multivariate models (logistic regression, method backward stepwise) separately, considering the four fall types as independent variables. We considered in the models the variables that were significantly different between the four groups at the univariate analysis. No predictive factor was found for medical and dementia-related falls. Younger age, low GDS values, and no syncopal spells were independent accidental falls predictors (Table
Multivariate analysis: types of fall predictors.
OR | 95.0% CI |
| |
---|---|---|---|
(A) Independent factor: accidental fall | |||
Age | 0.66 | 0.45–0.98 | 0.05 |
GDS | 0.63 | 0.45–0.89 | 0.01 |
Syncopal spells (anamnestic) | 0.59 | 0.43–0.83 | 0.005 |
| |||
(B) Independent factor: unexplained fall | |||
GDS | 1.49 | 1.06–2.09 | 0.029 |
Syncopal spells (anamnestic) | 1.49 | 1.04–2.12 | 0.036 |
GDS: Geriatric Depression Scale.
According to our knowledge, there is no study about causes of falls leading an old patient to an orthopaedic ward in Italy. Our study demonstrates that these patients are very old and frail because of severe comorbidity and polytherapy. The percentage of patients affected by dementia is quite high (12.6%). The majority of our patients were admitted to hospital because of hip fracture. Hip fractures are very common, and their incidence was not reduced in the last ten years [
Our study found a high number of patients with unexplained falls (37%), when the study of Kenny et al. found a significantly lower number of unexplained falls (15%). This difference is explained by the fact that they also considered younger patients (older than 50) admitted to an emergency department, and not to an orthopaedic ward [
A number of different strategies and interventions for each case are effective, but population-based strategies have not yet been evaluated, particularly in frail old patients, admitted to orthopaedic wards. Multidisciplinary, multifactorial intervention programmes inclusive of risk-factor assessment, screening, cause identification by means of diagnostic flow charts, and appropriate intervention proved to be effective [
In our “faller” cohort, as shown in Table
Our study demonstrates the need to study deeply and correctly patients with falls at the very beginning of the story (e.g., when they are admitted to the orthopaedic ward because of the fall). Unfortunately, at the moment, this is very difficult to achieve because of cultural and organizational problems. Future studies may be conducted to evaluate the correct strategy for patients with unexplained falls, probably in a postacute setting such as a rehabilitation unit.
One limitation to this study is the observational design and the absence of an active “prevention and treatment time.” In the literature it is well known that the presence of a team applying comprehensive geriatric assessment and rehabilitation, including prevention, detection, and treatment of fall risk factors, can successfully prevent inpatient falls and injuries, even in those with dementia [
In conclusion, all these data demonstrate that patients admitted to orthopaedic wards after a fall-related injury are frail and affected by severe comorbidity and that unexplained falls are frequent in these patients. These results underline the absolutely relevant role of geriatric evaluation and intervention in older patients admitted to orthopaedic wards. Further studies are necessary to evaluate the impact of diagnostic protocol in patients with unexplained falls.
Florence, Syncope Unit, Department of Geriatric Cardiology, University of Florence and Azienda Ospedaliero Universitaria Careggi. Investigators: Andrea Ungar, Annalisa Landi, Alice Maraviglia, Niccolò Marchionni, Giulio Masotti, Alessandro Morrione, and Martina Rafanelli. Modena, Chair of Geriatrics, University of Modena and Reggio Emilia: Chiara Mussi, and Gianfranco Salvioli. Trento, Division of Geriatrics, Santa Chiara Hospital: Gabriele Noro, and Gianni Tava. Reggio Emilia, Division of Geriatrics, Santa Maria Nuova Hospital: Loredana Ghirelli. Naples, Department of Geriatrics, Federico II University: Pasquale Abete, Vincenzo Del Villano, Gianluigi Galizia, and Franco Rengo. Grosseto, Division of Geriatrics, Walter De Alfieri, Fabio Riello. Chiavari, Department of Geriatrics, Paolo Cavagnaro.
This paper is done on behalf of the Italian Group of Syncope in the Elderly of the Italian Society of Gerontology (GIS Group).