How to navigate getting older: frailty and falls

By Dr Ross Walker

Frailty and falls are significant concerns, particularly among older adults, as they significantly impact health outcomes and quality of life. Below the age of 70, you fall over, but over this age you “have a fall”. 

Frailty is characterised by a decrease in physiological reserve and increased vulnerability to stressors. This leads to a higher risk of adverse outcomes, including falls. Research has highlighted that frailty can be identified through various physical and clinical markers, such as:

• weakness
• slow walking speed, and
• low physical activity levels.

There is a very useful frail scale which goes by the acronym, strangely, FRAIL. For every “yes” answer, you score one point. If you answer yes to 3 or more questions, you’re considered frail. However, 1 to 2 yes answers are considered pre-frail.

FRAIL scale

1) Fatigue – are you tired most of the time?

2) Resistance – can you walk up a flight of stairs unaided or without stopping? Do you have difficulty getting out of a chair?

3) Ambulation – can you walk one block without any problems?

4) Illness – Do you have five or more illnesses? When you think about this answer it may be as simple as high blood pressure, obesity, diabetes, osteoporosis and arthritis. These are five illnesses, and this gives you one point.

5)  Loss of weight – Have you lost more than 5% of your body weight unintentionally over the past six months?

Bone density

It is fact that from age 30 we lose muscle mass and bone mass. This is especially so for people who are inactive where you can lose 3 to 5% of bone and muscle mass per decade. This accelerates over age 65. At age 30 we have maximum bone strength and especially after menopause, women for five years the rate of bone loss can be as much as 2 to 3% per year and then 1 % per year, thereafter. Typically, a female loses 53% of their peak bone mass by age 80.

Fall risk

A recent study published in the journal BMC Geriatrics examined a simple but effective method of assessing fall risk in older adults. Falls remain a significant health concern for older adults, being the second leading cause of injury-related deaths for individuals aged 65 and above, as reported by the World Health Organization (WHO). These incidents can severely impact quality of life, even without serious injuries.

I recommend that older adults undergo annual balance and mobility assessments during routine health visits, regardless of their overall health status. These tests are critical for early intervention and risk management.

This study involving 153 participants aged 60 to 89 demonstrating an improved model for assessing fall risk. This research indicates that current testing protocols may not effectively predict future falls, even in those with seemingly good balance and mobility.

The Modified Balance Test requires individuals to maintain four standing positions for 30 seconds each to evaluate balance. The balance test is simple and only requires an older person to remain in each of the four positions:

1. Parallel feet [bipedal], with one foot slightly in front of the other [semi-tandem],
2. with one foot in front of the other [tandem],
3. and balanced on left foot [unipedal].
4. and balanced on right foot [unipedal].

The study of 153 volunteers showed that the assessment can be much more effective if the individual can remain in at least two of the most challenging positions (preferably tandem and unipedal) for 30 seconds each.

Study findings

The study found that for every extra second [of the 30 seconds] that the older person was able to stay in the tandem or unipedal position, the chance of falling over the next six months decreased by 5%. This makes it possible to predict the risk of falling over a six-month period, which is important because the test can be done in the clinic, quickly and without the need for equipment.

Implementing improved assessments can lead to timely interventions that may prevent falls, preserving mobility and independence in aging populations.

This comprehensive study underscores the need for regular assessment and potential adjustments in care practices for older adults to mitigate fall risks effectively.

How falls can affect overall health

Falls, often a consequence of frailty, pose a major risk for severe injuries, such as fractures and head trauma, which can lead to hospitalisation and long-term disability. Approximately one in three older adults experiences a fall each year, emphasising the urgent need for preventive measures. The interplay between frailty and falls is complex, as frail individuals may have diminished strength, balance, and coordination, compounding their fall risk.

Effective interventions are crucial to address these interconnected issues. Comprehensive fall prevention strategies may include physical therapy to improve strength and balance, environmental modifications to reduce hazards in the home, medication reviews to minimise side effects that can contribute to falls, and education for patients and caregivers about fall risks. 

Additionally, screening for frailty in primary care settings can help identify at-risk individuals, allowing for early interventions tailored to their specific needs.

Creating awareness of frailty and falls

Furthermore, promoting a culture of awareness regarding frailty and falls within healthcare settings is essential. Healthcare providers should receive ongoing training to recognise frailty and understand its implications for fall risk management. Through multidisciplinary approaches, including physiotherapists, occupational therapists, and geriatricians, it is possible to implement personalised care plans that enhance mobility, independence, and overall well-being.

In conclusion, addressing frailty and falls requires a comprehensive and proactive approach. This approach includes focusing on prevention, early identification, and effective management strategies to improve health outcomes for older adults.