Falls are a major hazard for persons with arthritis, especially postmenopausal women with osteoporosis, because of a fall’s major impact on morbidity and mortality. People with a rheumatic disease such as osteoporosis, osteoarthritis (OA), ankylosing spondylitis, rheumatoid arthritis (RA), and other types of inflammatory polyarthritis are among those at high risk for falls and, thus, for injury. Interference with mobility, flexibility, gait, and musculoskeletal strength are common effects of arthritis, creating susceptibility to falls. Lower limb arthritis has been identified as a significant predictor of falls.1
In an analysis of 16 studies on risk factors for falls in older adults, arthritis was identified as one of the most significant; other common factors identified included conditions as noted above that interfere with physical function (i.e., muscle weakness, gait deficit, and balance deficit).2 Those with arthritis affecting the lower limbs were found to have significantly more falls and falls with greater injury than those without arthritis over a 12-month period. A study focusing on rheumatoid arthritis found the greatest risk factors to be taking an antidepressant medication and self-reported impairment in lower limb function with difficulty in walking and rising.3 Another study of 316 women with inflammatory polyarthritis identified the risks (all at a confidence interval of 95%) of those who had fallen as a higher swollen joint count (of 10 joints), greater visual analogue pain intensity scores, higher Health Assessment Questionnaire (HAQ) total and individual domain scores, lower levels of outdoor activity, impaired vision, and impaired general health.4
Age as a Risk Factor
Advancing age is a common factor associated with the incidence of falls and the seriousness of resulting complications. About 35% to 40% of community-dwelling persons between the ages of 65 and 75 fall each year.2 In developed countries, 10% to 20% of older adults fall twice or more. Even though fewer than 5% of these falls result in fractures, the total number becomes significant.5
Age, in combination with rheumatic disease, becomes a major risk factor for falls.6 Although rheumatic disease affects persons of all ages, it is more prevalent in the older adult population.7 Two conditions that increase with age are osteoarthritis and osteoporosis. Both place the individual at increased risk for falls due to muscle weakness and stiffness of the hip and knee joints, resulting in unsteadiness. In the case of osteoporosis that is characterized by low bone density, the risk of fracture associated with falls increases.
Consequences of Falls
The costs of fracture are high, both in healthcare dollars and in quality of life, especially if the hip is fractured.8 The cost of osteoporosis-related fractures alone was estimated to be $19 billion in 2005.9 Other consequences of falls include lacerations, soft-tissue injuries, abrasions, inability to perform daily living activities for a period of time,10 activity avoidance, and fear of falling.11 These injuries may lead to hospitalization or a prolonged recovery period. Falls may be responsible for permanent, and often declining, changes in the person’s lifestyle. Injuries or fractures can lead to increased weakness and impaired mobility, making it impossible to resume activities that were possible before the fall.
Fear of Falling
Activities are not only limited by actual falls but also by the fear of falling. This fear increases with the number of falls experienced,11 though this fear is also common among nonfallers.12 Half of community-dwelling elders are fearful of falling. This percentage is somewhat higher (almost 60%) for patients with a diagnosis of RA; within this group, those who are fearful walk more slowly, have more comorbidities, and experience greater pain intensity than do those who are not.13 People who are afraid of falling may become debilitated by restricting their physical and social activities.14 It is important, therefore, to assess not only the fear of falling, but other risk factors as well. If individuals understand what their risk factors are, they can then take some positive steps to reduce them, thus increasing their confidence in performing activities.
Interference with mobility, flexibility, gait, and musculoskeletal strength are common effects of arthritis, creating susceptibility to falls.
What Rheumatology Practitioners Can Do
Assessment: Assessment is the first action that practitioners can take. Every community-dwelling person with arthritis should have a falls-related assessment to reduce the possibility of falling. Individual variations to include in such an assessment include age, comorbidities, history of falls, medications the person is taking, functional status, vision, and fear of falling. A Falls Risk Checklist can easily be kept as part of the patient’s record. A suggested checklist is provided in Figure 1 (see pg. 16). The items represent the most common risks exhibited by those who attended a falls clinic.15 The number of risks that might predict one’s likelihood of falling is unknown; but, obviously, a greater number of risks would make falling more probable. Any risks that are present, along with age and a diagnosis of arthritis, should be noted and addressed with the patient.