Critical Falls: Why Remaining on the Ground After a Fall can be Dangerous, Whatever the Fall

As people age, it becomes increasingly difficult for them to rise after a fall. Healthy elderly adults require twice as long to stand up as younger patients. Those in institutions need three to four times as long to rise as healthy elderly adults, if they can actually do so.1 In another study, 25% of elderly adults were unable to rise from an accidental fall.2 It has been shown that reaching the age of 80 is a risk factor independently associated with inability to rise from the ground after a fall (adjusted relative risk (RR) = 1.6, 95% confidence interval (CI) = 1.2–2.1).3 This inability to rise from the ground after a fall is dangerous because of the length of time spent lying on the floor. This time depends on the individual's ability to rise after falling and on whether help is available.4 The risk of remaining for extended periods on the ground in elderly adults has been associated mainly with a major injury in individuals with reduced autonomy but also with body temperature above 37.5°C or potassium serum level <3.5 mmol/L.5 Finally, a fall often results from a traumatic functional disability that can explain the inability to rise, but not all of these cases are always related to a trauma itself. In addition to all of the consequences of the fall itself, prolonged immobilization on the ground will have many repercussions for poor prognosis for recovery. A systematic review and meta-analysis of early mortality related to inability to rise after a fall was conducted in elderly adults. A computer search strategy on MEDLINE using the Medical Subject Headings accidental falls and aged 80 and over identified 3,401 articles published from 1981 to 2011; 3,333 were excluded, leaving 68 articles concerning prospective studies about consequences and prognosis after falls in elderly adults, to which two references from a manual search were added to obtain 70 studies. Selecting studies with numerical data on mortality in groups lying or not lying on the ground for extended periods of time, four studies were included.3, 6-8 A meta-analysis was performed, and the odds ratios (ORs) and 95% CIs to assess mortality related to inability to rise after a fall were estimated for each study and overall. The Mantel–Haenszel fixed-effects method was used.9 Heterogeneity was assessed using the I² statistic.10 One study was excluded because of a different methodology that compromised the consistency of the results.7 The OR for the association between lying on the floor for a long time and mortality in all participants studied was 1.75 (95% CI = 1.15–2.67) (Figure 1). This result was moderately homogeneous (I² = 33%). The current study shows that lying on the floor for a long period after a fall nearly doubles the risk of death. Even a seemingly minor fall can be fatal if the person stays lying on the ground for a long time because of pressure ulcers, dehydration, hypothermia, rhabdomyolysis, or renal failure, all of these disorders being likely to compromise survival.6 It was possible to include only four studies out of 3,401 (<0.2%) because many articles concerned the consequences of traumatic falls-related injuries but not all type of falls. Published articles on the consequences or prognosis of falls far too often give results in which falls are categorized according to type (severe, repeated, injurious, or traumatic fall), population subgroups, or place of occurrence. This meta-analysis can help to define the association between early mortality and inability to rise after a fall, but multivariate analyses could have helped to estimate the real degree of connection. The strategy was limited and must be used as a complement to systematic review when studying consequences of falls, but it is too restrictive to focus only on traumatic falls in this case, because it is difficult to say whether it is the trauma itself that is responsible for the consequences or the inability to recover. The term “critical fall” is thus proposed to characterize a fall with an inability to retain upright posture, whatever the reason: trauma, feeling unwell, or lack of warning. Orienting the characterization of falls this way seems relevant for future studies, and being able to isolate this group of falls with severe consequences will allow the development of appropriate prevention strategies. Furthermore, early detection devices are crucial for the reduction of mortality in this type of fall. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: F. Bloch is responsible for the entire content of this paper. Sponsor's Role: None.