Introduction

Falls are a common and serious problem in older adults (OA), representing an important cause of disability.1,2 These are defined as involuntary events in which an individual ends up on the ground, or at a lower level, due to reasons other than an intrinsically event, such as a cerebrovascular accident.1,2 In OA, falls are associated with increased morbidity and mortality, reduced functionality and quality of life, as well as higher healthcare costs.1,2 In fact, between 20% and 30% of OA who experience a fall suffer moderate to severe injuries, including hips, wrist, arm or ankle fractures, and craniocerebral trauma.3,4

According to a systematic review and meta-analysis published in 2022, the worldwide prevalence of falls among OA level is 26.5%, with the highest prevalence reported in Oceania (34.4%) and America (27.9%).2 In United States, falls are the leading cause of injuries among adults aged ≥65 years. Moreover, one of four OA reports experiencing a fall, representing a 14 million falls annually.5,6 Furthermore, nearly one million of hospitalization occur each year in the United States due to fall-related injuries in this population.3 According to the National Survey of Health, Well-being and Ageing conducted in Colombia in 2015, 31.9% of the 23,694 OA included in the study had experienced falls, with a higher frequency observed among women.7

Although the concept of Long Lie has not been standardized, several studies have used this term to describe remaining on the ground for at least one hour after a fall, generally because the individual was unable to stand up independently.8-14 However, this definition has some limitations, as it is difficult to accurately determine the duration of time spent on the ground after a fall, since this information is usually based on self-report. Additionally, health consequences associated with prolonged time on the ground may occur even before one hour has elapsed.8

OA who remain on the ground for a prolonged period after a fall may present short- and long-term physical, metabolic, and psychological complications. These may include laboratory abnormalities, hypothermia, dehydration, rhabdomyolysis, sepsis, infections, injuries and multiple lesions, as well as fear of falling and limitations in performing activities of daily living.8,15

The following article presents the case of an OA who developed multiple health complications after remaining on the ground for a prolonged period (approximately one hour) following a fall.

Case presentation

An 84 years-old woman was admitted to the emergency department of a tertiary care hospital in Cali, Colombia. She had experienced a fall while leaving the bathroom; however, at the time of the accident, she was alone. The patient remained on the ground for approximately one hour before receiving assistance from three people to help her stand up.

On physical examination at admission, the following findings were reported: pain in the left wrist (Visual Analogue Scale [VAS]: 8/10) and left hip (VAS: 9/10), functional limitation, deformity of the left forearm, and a shortening with external rotation of the lower extremity. In addition, a grade I pressure ulcer was observed in sacral region. Regarding vital signs, blood pressure was 160/70mmHg and hearth rate was 110lpm. Also, the patient was alert and orientated, without signs of respiratory distress or fever.

On the other hand, the patient had the following pre-existing conditions: osteoarthritis and obesity (diagnosed 11 years earlier), a pelvis fracture, and an extensor tendon injury of the wrist resulting from a fall 4 years prior to the current event, as well as a total left hip replacement due to a fragility fracture 3 years earlier. As part of the evaluation at admission, radiographs of the left hip and left forearm were obtained, revealing a periprosthetic fracture of the left hip and transverse metaphyseal fractures of the distal radius and ulna with dorsal displacement (Figure 1). Based on the clinical and imaging findings, as well as the patient’s age, she was hospitalized for comprehensive management.

Figure 1. Radiographies were taken just after the patient was admitted to the emergency department. A. Radiography of the left forearm showing fractures of the radius and ulna. B. Radiography of the hip showing a periprosthetic fracture of the left hip.

Source: Images obtained during the clinical management of the patient.

Shortly after admission, a Comprehensive Geriatric Assessment (CGA) was performed as part of the orthogeriatric evaluation. Functional assessment mild dependence in activities of daily living (Barthel Index: 95 points) and total dependence in instrumental daily activities (Lawron and Brody scale: 0 points). On the other hand, neuropsychological assessment showed a positive screening for neurocognitive disorder (Mini-Mental State Examination: 23 points) and a negative screening for depressive symptoms (Cornell Scale: 6 points). Social assessment identified a high risk of institutionalization. Based on the geriatric assessment, the patient was diagnosed with secondary disability to fall-related injuries, multimorbidity, total edentulism, malnutrition, osteoporosis and sarcopenia.

Laboratory tests at admission showed mild leukocytosis (13 790/µL), moderate normocytic normochromic anemia (hemoglobin: 9.6 g/dL; mean corpuscular volume: 89.4fL), and an elevated blood urea nitrogen (BUN)/to creatinine ratio (28.75), without evidence of active sediment on urinalysis. In addition, due to the prolonged time remained on the ground after the fall, creatine-phosphokinase (CPK) levels were assessed and found to be markedly elevated (5 926U/L) (Table 1).

At admission, a comprehensive medical approach was initiated, including intravenous crystalloids hydration (Sodium Chloride 0.9%) to treat dehydration, Acute Kidney Injury (AKI) and rhabdomyolysis, while ensuring achievement of the target diuresis goal (1ml/kg/hour). Additionally, pain management was initiated with hydromorphone (0.2mg intravenously line [IV] every 4 hours, with dose titration according to clinical response) and acetaminophen (1gr every 8 hours). Unfractionated heparin (5,000IU every 12 hours) was prescribed for thromboembolic prophylaxis, omeprazole (40mg every 24 hours) for gastroprotection, and a hydrocolloid dressing for the pressure ulcer. Renal function progressively improved, with normalization of BUN and creatinine levels by the fourth day of hospitalization (Table 1).

On the fifth day of hospitalization, the patient underwent left hip prothesis replacement and closed reduction of radius and ulna fractures. Following the surgical procedure, she developed acute anemia, requiring a transfusion of 2 units of packed red blood cells. During the immediate postoperative period, the patient began mobilization with protected weight-bearing using a walking frame; however, immobilization of the left forearm with plaster cast caused difficulties with ambulation.

On the sixth day of hospitalization, the patient reported dysuria and urinary frequency, consequently, a urine culture was obtained to evaluate for the presence of a Urinary Tract Infection (UTI), and empirical treatment with a fourth-generation cephalosporin was initiated (1gr of cefepime IV every 12 hours). On the seventh day, the urine culture revelated susceptible Escherichia coli; therefore, cefepime was suspended and treatment with ampicillin/sulbactam was initiated (3gr every 8 hours for 5 days). Subsequently, on the ninth day, CPK levels had normalized (Table 1).

Table 1. Creatine-phosphokinase, creatinine, and blood urea nitrogen levels during hospitalization.

Hospitalization day	CPK test (Normal value: 30 -135U/L)	Creatinine test (Normal value: 0.7-1.3mg/dl)	Blood urea nitrogen test (Normal value: 6-20mg/dl)
Day 1	5,926	1.92	55.2
Day 3	1,190	1.15	28.7
Day 5	607	0.84	21
Day 7	511	0.72	11.9
Day 9	117	0.58	7.6

CPK: Creatine-phosphokinase.

Source: Own elaboration.

Finally, the patient presented a favorable clinical progress and, for that reason, she was discharged at the eleventh day of hospitalization with the following recommendations: analgesic management (1gr of acetaminophen every 8 hours), pharmacological treatment for osteoporosis (60mg of denosumab every 6 months), home-based physical rehabilitation, use of an assistive device for ambulation, a nutritional recovery plan and follow-up appointments with the geriatric care team, including nutrition and physiatry services. In addition, recommendations for fall prevention at home were provided, including the use of an assistive device for ambulation, improvement of household lighting, and non-slip mats in the bathroom and on stairs.

Discussion

OA are at increased risk of falls due to the physiological changes associated with aging, such as reduced processing of sensory information (vision, proprioception, etc.), gait alteration, decreased muscle strength, multimorbidity risk and, consequently greater medication use.1 According to literature review, risk factors for falls in OA include: age over 80 years, female sex, widowhood or being single, reduced muscle strength and balance, history of previous falls, use of ≥3 medications, functional impairment, need for a walking aid, arthritis, urinary incontinence, cognitive impairment, diabetes, depression, among others.1,15 In addition, environmental factors such as poor lighting, uneven surfaces, and slippery floors have been associated with and increased risk to falls.1 In the present case, the patient was an 84 year old woman with a history of previous falls who presented functional decline, malnutrition, cognitive impairment, obesity, osteoporosis, osteoarthritis, and sarcopenia. Furthermore, several environmental and social risk factors were identified: slippery floors, absence of grab bars in the bathroom, and living alone.

It has been documented that individuals who remain on the floor for a prolonged period after a fall may develop complications such as hypothermia, skin lesions, rhabdomyolysis, dehydration, AKI, severe injuries, pneumonia, UTI, and sepsis. These complications increase the likelihood of hospitalization, functional limitations, and even death.8,9,15,16 In the present case, the patient sustained fractures of the hip, radius and ulna and also developed dehydration, a pressure ulcer, rhabdomyolysis, UTI and AKI.

Rhabdomyolysis is one of the most severe complications in OA after a fall associated with prolonged time on the floor.8 This condition occurs because muscle injury leads to disruption of musculoskeletal integrity, resulting in the release of intracellular muscles components, such as myoglobin, Creatine Kinase (CK), aldolase, lactate dehydrogenase, and electrolytes, into the bloodstream and extracellular space, which is associated with increased morbidity and mortality.17 Besides, patients with rhabdomyolysis present elevated CK levels and may be asymptomatic or develop electrolyte disturbances, AKI, disseminated intravascular coagulation, and other life-threatening conditions.17 In consequence, treatment includes rehydration (starting with intravenous fluids, preferably initiated within the first 6 hours after the muscle injury), discontinuation of medications associated with rhabdomyolysis and, in some cases, admission to the intensive care unit with administration of mannitol and/or sodium bicarbonate.18 In the present case, the patient developed rhabdomyolysis with marked elevation of CPK levels (5,926 U/L on the first day of hospitalization) and AKI. Therefore, crystalloids fluids administrated within the first 6 hours after muscle injury, achieving normalization of CPK levels by the ninth day of hospitalization.

Although, there are no evidence-based clinical practice guidelines specifically addressing the medical management of OA who remain on the floor for a prolonged period after a fall, an integral and multidisciplinary approach is recommended.16 Initially, when an OA is found on the floor, this situation should be considered potentially life-threatening and capable of significantly worsening the patient’s clinical condition.16 Therefore, during the acute phase, treatment should focus on clinical stabilization and management of complications associated with prolonged time on the floor (hypothermia, skin injuries, rhabdomyolysis, dehydration, infections and AKI).16 In the present case, the patient received comprehensive medical management that included a CGA (covering functional, cognitive, nutritional, and social domains) as well as appropriate treatment of fractures and associated complications (use of hydrocolloid dressing for the pressure ulcer, IV hydration, and antibiotic therapy), which contributed to a favorable clinical outcome.

Furthermore, it is important to mention that falls may generate a significant psychological impact in OA, particularly fear of falling, which has been reported in 20-85% of OA. Fear of falling is characterized by anxiety related to the unpredictability of falls and concern about vulnerability.19 This emotional state may lead to reduced participation in daily activities, especially among OA with a history of previous falls or gait disorders.19 Consequently, these effects may significantly impair mobility and participation in activities that promote their physical and emotional well-being.19

In OA, implementation of fall-prevention strategies at home is highly relevant. These strategies include patient education, training in techniques for safely standing up after a fall, use of assistive technologies (e.g. fall detection sensors), and promotion of social support systems.16 In the present case, the patient was considered at high risk of developing fear of falling because of her previous fall, consequently, at hospital discharge, the following recommendations were provided to prevent future falls: a nutritional recovery plan, home-based physical rehabilitation, use of an assistive device for ambulation, improvements in household lighting, and installation of non-slip surfaces in the bathroom and on stairs.

Conclusion

Prolonged time on the floor after a fall constitutes a factor that significantly increases the risk of medical complications in OA, including dehydration, rhabdomyolysis, AKI, infections and pressure ulcers. Findings of this case report support that these complications may occur even when the time spent on the floor is close to one hour, emphasizing the need for a targeted and systematic assessment to promptly identify the consequences of falls associated with a prolonged time on the floor in this population.

Moreover, the present case demonstrates the positive impact of implementing a multidisciplinary medical approach combining CGA, orthopedic evaluation, and treatment of medical complications associated with both, the fall and prolonged time on the floor. The favorable clinical evolution observed in our patient reinforces the importance of stablishing management protocols that include: early hydration, close monitoring of renal function, and skin care; as well as, interventions aimed at rehabilitation and fall prevention, with the goal of improving clinical outcomes and preserving functionality in this population.

Informed consent

The patient singed an informed consent authorizing the use of her anonymous data and clinical images to elaborate and publish the present case report.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

None stated by the authors.

Use of Artificial Intelligence

None stated by the authors.

References

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