Injuries in the
elderly
Francesco Mattace Raso
Head Geriatric Medicine
Department of Internal Medicine
Injuries in the
elderly
Francesco Mattace Raso
Head Geriatric Medicine
Department of Internal Medicine
Falls and injuries: The challenge
 3.000.000 cases per year
 5.3000.000.000 Euro/year
Persons at risk
●Young adults
●Elderly
●Sporters
Falls and injuries in the elderly
A Big Issue?
Falls in community dwelling
incidence in 65+
 2001  600.000 fallers community dwelling
 2009
 800,000 fallers community dwelling
Falls in community dwelling
 30% falls 1x Year
 15% falls ≥2x Year
Consequences of Falls (st)
10%
Severe injuries (1-2% hip #)
3-5%
Other fractures
5%
Less severe
Consequences of Falls (lt)
 1- year Mortality 20%
 1/3 decreased function/ mobility (nursing homes)
 Psychosocial problems (fear of falling, isolation)
Arch Intern Med. 2010;170(10):905-911. doi:10.1001/archinternmed.2010.106
Table Title:
Hartholt et al Arch Int Med 2010
Arch Intern Med. 2010;170(10):905-911. doi:10.1001/archinternmed.2010.106
Table Title:
Hartholt et al Arch Int Med 2010
Arch Intern Med. 2010;170(10):905-911. doi:10.1001/archinternmed.2010.106
Table Title:
Hartholt et al Arch Int Med 2010
Older patients= longer LOS
Hartholt et al Arch Int Med 2010
8
2300
Circumstances surrounding injurious falls
Boye et al Injury 2014
Injuries following a fall
Boye et al Injury 2014
Circumstances leading to all injurious falls
Boye et al Injury 2014
Circumstances surrounding falls leading to brain injury
Boye et al Injury 2014
Circumstances surrounding falls leading to a hip #
Boye et al Injury 2014
Risk Factors for Falls
Risk Factors for Falls
Risk Factors for Falls
Different patterns
In young persons mostly accidents (sport, transport)
In old subjects mostly heterogeneous
Young adults
Older persons
 (Usually no) Comorbidities
 Comorbidities
 (Usually no) Polipharmacy
 Polipharmacy
 (Usually not) Frail
 Frail
 (Usually no) Cognitive disorders
 Cognitive disorders
 Rehab
 (Challenging) Rehab
Risk Factors for Falls
intrinsic
extrinsic
Intrinsic
Extrinsic
 Previous fall
 Obstacles (in the dark)
 Medical conditions
 Requires
 Cognitive decline
 Environmental changes
 Physical functioning
 Drugs
 Strength, balance
 Sensory declines
Decreased strength in the elderly
 Decreased muscle mass
 Decreased sVitamine D
 White matter lesions
 Changes in peripheral nerves function
Changes in the Population pyramids
Pathology that occurs with Age
Prevalence of selected chronic conditions, expressed in percentages, as a function
of age for the US population (2002-2003 dataset). Source: National Center for Health
Statistics, Data Warehouse on Trends in Health and Aging.
Sarcopenia
• Degenerative loss of skeletal
muscle mass
• 1% loss per year after the age of 25
• It can be differentiated from
cachexia in that cachexia includes
malaise and is secondary to an
underlying pathosis (such as cancer),
whereas sarcopenia may occur in
healthy people and does not
necessarily include malaise
Sarcopenia
• Simple circumference
measurement does not provide
enough data to determine whether
or not an individual is suffering
from severe sarcopenia
• Extreme muscle loss is often a
result of both diminishing
anabolic signals, such as growth
hormone and testosterone, and
promotion of catabolic signals,
such as pro-inflammatory markers
CHANGES IN MUSCLE MASS
CHANGES IN STRENGTH WITH AGING
Sarcopenia, so what?
High
risk of falls!!
Osteoporosis
Osteoporosis
 Silent Killer
 1/ 3 of the women aged 50+
72 yrs woman
0.2 mm
Osteoporosis
High
risk of
fractures!!
Medications’ use increases the
risk of falls
Medications, falls and fractures
van Voast Moncada Am Fam Physician. 2011
Fall- risk increasing drugs
Boye’et al, submitted
Psychotropic drug and
physical performance
Boye’et al, submitted
Title slide
How to do it?
A1 Het is aangetoond dat interventies die
spierkrachtversterkende oefeningen en
evenwichtsoefeningen bevatten, die specifiek aangepast
zijn aan het individuele niveau van de ouderen, een
absolute reductie in het aantal vallen en het aantal
valincidenten met letsel geven.
Robertson JAGS 2002
A2 Er zijn aanwijzingen dat in multifactoriele interventies
kracht- en evenwichtstraining bij thuiswonende ouderen
van 70 jaar en ouder als afzonderlijke interventie een
valreductie van 7% tot gevolg heeft.
Day BMJ 2002
Summary
Summary
Summary
Fall prevention: does any?
Fall prevention: does any?
 159 trials with 79,193 participants
 Most trials compared intervention prevention vs no intervention or
an intervention not expected to reduce falls.
 The most common interventions tested were exercise as a single
intervention (59 trials) and multifactorial programmes (40 trials)
Interventions
 Overall, vitamin D did not reduce the risk of falling (RR 0.96, 95% CI
0.89 to 1.03; 13 trials; n=26,747).
 Pacemakers did not reduce falls in people with carotid sinus
hypersensitivity
 No effect for cognitive behavioural interventions and the risk of falling
(RR 1.11, 95% CI 0.80 to 1.54; 2 trials; n=350).
Interventions
 Multiple-component group exercise significantly reduced risk of
falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; n=5333)
 Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57
to 0.87; 6 trials; n=1625).
 Exercise interventions reduced the risk of a fall-related fracture (RR
0.34, 95% CI 0.18 to 0.63; 6 trials; n= 810).
 Home safety assessment and modification interventions were
effective in reducing risk of falling (RR 0.88, 95% CI 0.80 to 0.96; 7
trials; n=4051).
Film 1
Film 2
When are you old?
Will you still need me, will you
still feed me, when I’m 64?
The Beatles, “When I’m Sixty-Four”
Is this person old?
Is this person old?
Several Intoxications
Comfortably numb state of mild
apparent confusion
Healthy aging
Will we be able to prevent falls and injuries?
Prediction is
very difficult,
especially about
the future
(Niels Bohr, Nobel Prize Physics)
Conclusions
 Falls and injuries are common in the elderly
 Patterns of falls and injuries differ in young and old
 Falls and injuries have severe consequences in the
elderly
Difficult questions?
f.mattaceraso@erasmusmc.nl