Worldwide, around 37.3 million falls are recorded every year. They are responsible for 684,000 deaths per year, 80% of which occur in low and middle-income countries [1] . Prevalence increases with age. It has been established that a third of people aged 65 and over and half of those aged 85 and over fall at least once a year, with 50% of them falling repeatedly [2] . Falls are therefore a major public health problem. In Senegal, the prevalence of falls varies between 9.26% and 26.6% in elderly subjects [3] [4] .

Falls are a major cause of morbidity and mortality in this often frail population. In addition to their traumatic consequences (10% to 15%) [5] , falls are responsible for frequent non-traumatic complications (metabolic, psychological and psychomotor) that may be life-threatening or functionally compromising [6] . In geriatric medicine, a fall can be a non-specific presentation of several acute pathologies (pneumonia, urinary tract infection or myocardial infarction) and is also a factor that can decompensate pre-existing co-morbidities, creating a vicious circle that is often deleterious [7] . Around a quarter (25%) of elderly people admitted for falls die within a year, compared with 6% of those admitted for other reasons [8] . Falls are also a major socio-economic burden. In the United States, the global annual cost of falls was estimated at around $40 billion in 2018 [9] .

In Senegal, two previous studies have been carried out on falls in the general population and geriatrics [3] [4] . These studies provided an overview of some of the risk factors of falls found in the Senegalese elderly population, as well as some of the mechanical and social complications of falls. However, the data were collected at a distance from the falls and did not provide information on the patient's state of health at the time of their falls. We therefore proposed to carry out this study with the main objective of updating our knowledge on falls in elderly trauma patients in Senegal by integrating geriatric dimensions.

The prevalence of falls found in our series (13.69%) is corroborated by several data in the literature. In a 2016 study of fall injuries in the general population at IPGH, Dieng et al. [4] found a prevalence of 9.26% of elderly people among fallers. In Japan, a survey of elderly people found an almost similar prevalence of 16.5% [10] . However, our prevalence is much lower that found in the literature from Africa and developed countries. In England, for example, a prevalence of 52% was found in a geriatric population [11] , and 24.98% in elderly people in India [12] . A study conducted at the Ouakam Geriatrics and Gerontology Center (Dakar) in 2016 on falls in geriatrics by Gbehi et al. [3] identified a double prevalence (26.67%). This difference could be explained, on the one hand, by the framework of this study where the population received was exclusively geriatric and, on the other hand, by the frequency of non-traumatic complications (decompensations of comorbidities, post-fall syndrome, rhabdomyolysis, etc.) indicating a referral to a geriatric medical unit. This difference in prevalence could therefore be explained by the variability in study frameworks and methodology.

In our series, the mean age was 73 +/− 8.43 years, which is higher than that found by Gbehi et al. [3] with a mean age of 69.39 +/− 7.45 years. However, in developed countries, the average age is generally higher. In 2016, the ChuPADom study evaluating the profiles of French elderly patients aged 65 and over who suffered an accidental fall at home resulting in a fall found an average age of 84.5 +/− 7.9 years [13] . In the Netherlands, a study of a geriatric population found an average age of 80 +/− 8 years [14] .

A clear predominance of women was found in our patients, in agreement with most of the data in the literature [15] [16] , which identified the female sex as a risk factor for falls in the geriatric population. The study by Gbehi et al. [3] found the same predominance of women, but in smaller proportions (61.43%). However, a few studies disagree with our findings. In India, Pitchai et al. [12] conducted a study in 2019 assessing falls in a cohort of 2049 people aged 60 or over, and found a predominance of men (53.83%). Other authors found no significant differences between men and women [17] . Our finding could be explained by the configuration of the Senegalese population, with a female predominance in people aged over 60 [18] . In addition, postmenopausal osteogenic deficiency favors the occurrence of traumatic complications (fractures+++) due to osteoporosis [19] , indicating a referral to trauma emergencies department.

In our study, the majority of falls occurred during the day (68%). This diurnal predominance is corroborated by several studies. In the United States and Tunisia, 62% and 82.5% respectively of falls occurred during the day [11] [20] . The ChuPADom study found a lower frequency of 62.9% [13] .

The majority of patients fell at home (82%), more frequently in the bedroom (30%), the courtyard or common room (28%) and the toilet (14%). The study by Gbehi et al. [3] identified lower proportions (64.29%). A study in New Zealand on falls among the elderly found the dining room (27.4%) and bedroom (21.4%) to be the most frequently involved areas [21] , while Pitchai et al. found the toilets (50.75%), halls (18.21%) and in the bedroom and kitchen (11.94%) to be the most frequently involved areas [12] . Furthermore, a Norwegian study of a population of elderly women found that falls predominated outside the home (57.5%) [22] . This finding could be explained by the greater frequency of natural daytime activities for this age group, and also by the high frequency of environmental risk factors, as evidenced by the frequency of obstacles on the ground (27%) and wet or slippery surfaces (19%) in our series.

The main mechanisms of falls in our patients were tripping (32%), slipping (28%) and loss of balance (26%). These results are relatively similar to those of Gbehi et al. [3] , who found floor obstacles (35.49%), wet floors (16.13%) and loss of balance (21.81%) to be the main mechanisms of falls. According to several authors, the elderly fall more often from a height than from high places or stairs [13] [17] .

In our series, most patients (86%) had risen from the ground within 30 minutes of the fall with help (77%) and without help (9%). The vast majority of our patients lived with their family, which meant that they were not necessarily far from any relative to help them get up quickly. Only three patients (3%) had spent more than 1 hour on the floor. It has been established that time spent on the floor in excess of an hour exposes patients to metabolic complications (dehydration, rhabdomyolysis, acute renal failure, etc.), bedsores and inhalation pneumonitis. These complications increase the morbidity and mortality associated with falls.

The geriatric syndromes found in our patients were mainly pre-fragility (32%), followed by frailty (22%), risk of malnutrition (24%), malnutrition (15%) and mental confusion (9%). In the ChuPADom cohort, pre-fragility and frailty were found in 42.7% and 45.3% of patients respectively [13] . This difference with our study may be explained by the higher average age in this study (84.5 years vs. 73 years in ours). The prevalence of frailty increases with advancing age, and frailty increases the risk of falling [19] . A survey carried out in the homes of elderly people in Dakar found a prevalence of undernutrition of 2.4% and a risk of undernutrition of 39.76%, with a significant association between a risk of falling of 30.30% in cases of risk of undernutrition compared with 4.16% when nutritional status was normal [23] . Undernutrition is accompanied by sarcopenia and the consequent reduction in the adipose pannicle, which increases the risk of falls and fractures. Mental confusion in the elderly corresponds to a cerebral disorder caused by physical, psychological or emotional stress. It is associated with increased mortality, more frequent institutionalization and an increase in the number of falls [24] .

In our series, the main factor predisposing to falls was visual impairment (56%), followed by a history of falls (36%) and isolation at home (35%). The studies by Gbehi et al. [3] and ChuPADom [13] found visual problems to be more prevalent, accounting for 83.3% and 91.9% of falls in the elderly respectively. Pitchai et al. [12] found that 23.01% of elderly people suffering a fall had visual problems. Aging is accompanied by a deterioration in the various sensory functions, particularly vision, which plays an essential role in the mechanisms for maintaining posture and balance. What’s more, the prevalence of eye diseases (cataracts, glaucoma, age-related macular degeneration, etc.) increases with age. A third of our patients (36%) reported at least one fall in the current year, which is about the same as the series by Tinetti et al. [16] in the United States (30% of patients) and less than Pitchai et al. [12] , who found a history of falls in almost half their patients.

The factors precipitating falls were mainly environmental (62%), in particular the presence of obstacles on the ground (27%) and slippery surfaces (19%). Floor obstacles accounted for 20% of the causes of falls in the study by Campbell et al. [21] . Gbehi et al. [3] identified floor obstacles as the main precipitating factor (35.49%), followed by slippery surfaces (16.13%) and stairs (8.07%). Clutter in the living environment of elderly people is often blamed for falls in other series [21] . Furniture (chairs, stools, beds, etc.) and irregular stones and paving stones were the main factors found in our study.

The main complications found in our patients were traumatic, dominated by fractures (86%) and soft tissue contusions (10%). A Moroccan study in 2019 found a prevalence of 66% of fractures in elderly patients who had fallen [25] . However, our results differ from those found in the literature. In the United States, Phelan et al. [26] mainly noted bruises (70%), followed by sprains (16%) and fractures (14%). A French study of everyday accidents found that post-fall complications were dominated by fractures (41%), followed by contusions and concussions (30%) and wounds (19%) [27] . This predominance of fractures in our series can be explained by our study setting, which is a national reference trauma department for the management of severe trauma. Less severe trauma was probably treated in peripheral health facilities. On the other hand, the predominance of women in our study population is also incriminated as being responsible for bone demineralization under the influence of post-menopausal estrogen deficiency and advanced age [19] .

Drug treatment was almost systematic (98%), mainly analgesics (98%) and Enoxaparin in preventive doses (69%). Heparin therapy to prevent thromboembolic complications using low molecular weight heparin is recommended by several learned societies for patients with severe lower limb trauma requiring prolonged immobilization [28] . Pain management is an essential but often complex stage in the management of trauma in the elderly. When poorly managed, pain can lead to acute mental confusion, regressive syndromes with withdrawal, anorexia or depression [29] . Conversely, excessive analgesia exposes elderly patients to impaired alertness, depression of the upper respiratory centers and an increased risk of falls.

In our series, surgery was indicated for 58% of patients, but only 33% of patients were able to have surgery in the department, with an average waiting time for surgery of 25.36 +/− 19 days (extremes of 7 and 87 days). We did not find such long waiting times in the literature. In elderly patients, the time to surgery has a prognostic value. Surgery delayed beyond 48 hours exposes elderly patients to frequent intra and post-operative complications (acute mental confusion, pressure sores, inhalation pneumonitis, thromboembolic accidents, etc.) and increases the risk of death [30] . In our context, this is a scheduled surgery that responds to organizational (availability of the operating theatre and staff) and financial (availability of osteosynthesis equipment and payment of surgery costs) imperatives. Further studies on the pre and post-operative state of these patients would give us a better understanding of the consequences of these long delays on the health of elderly Senegalese. In addition, studies have shown the benefit of an ortho-geriatric organization, of whatever type, in improving the prognosis in the management of fractures of the upper end of the femur in the elderly [29] [31] . In fact, multidisciplinary management (emergency physicians, anesthetists, orthopedists, geriatricians, etc.) can reduce the rate of complications, mortality, length of hospitalization and healthcare costs, while improving post-operative functional prognosis [29] [32] .

However, our study had limitations due to selection and information bias. Because of the way emergency departments were organized for triage, elderly patients with falls due to fainting or loss of consciousness were referred to the medical emergency department, and those with head trauma were referred to neurosurgeons. Only those consulting for pain following a fall and with normal consciousness were referred to orthopedic surgeons. In addition, the working and reception conditions sometimes made it impossible to assess and interview patients and their relatives, which greatly reduced the size of our sample.

Falls in the elderly are a frequent occurrence in trauma emergencies, with etiological factors that are often multiple and interrelated, leading to significant morbidity. They are associated with a relatively long delay in consultation and surgical intervention, which can have negative consequences on the autonomy of the elderly in the medium and long term. Raising awareness among at-risk populations, free surgical devices such as prostheses through government initiatives, and the establishment of an ortho-geriatric network would enable prevention and optimized management in the short and long term.

The authors declare no conflicts of interest regarding the publication of this paper.

Bâ, M., Sall, A., Tienin, B.P., Djajheté, R., Diouf, S.N., Bâ, D. and Coumé, M. (2023) Assessment of Falls among the Elderly in the Emergency Department of the Idrissa Pouye General Hospital in Dakar, Senegal: A Cohort of 100 Cases. Journal of Biosciences and Medicines, 11, 12-26. https://doi.org/10.4236/jbm.2023.1112002