Fall Prevention in the Elderly

Aka: Fall Prevention in the Elderly, Fall Prevention, Fall Prevention Education, Fall Risk Factors, Fall Risk

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II. Epidemiology

  1. Falls occur yearly in >25-30% of age over 65 years in community (and two thirds of those over age 80)
    1. Falls in the elderly are associated with injury in 14% of cases
    2. Results in 7 million injuries, and 2.8 million emergency department visits per year
    3. Each fall increases the risk of future falls by 2-6 fold, and a harbinger of more serious falls
  2. Serious injury (Fractures, Traumatic Brain Injury) occurs in >20% of falls in older adults
    1. Most common serious injuries are Hip Fractures, spine injuries and closed head injuries
    2. Intracranial Hemorrhage occurs in up to 15% of older patients with fall regardless of Anticoagulant use
    3. Falls are the leading cause of fatal and nonfatal injury in those over age 65 years
    4. One year mortality after Hip Fracture in the elderly is as high as 20-30%
    5. Falls in older patients result in 27,000 deaths per year
  3. Most falls occur in and around the patient's home
    1. Typically ground level falls from standing, chairs or bed
    2. Fear of falling, may result in social isolation and functional decline
  4. Falls from standing height are typically due to many factors
    1. Syncope related fall is only one of several potential causes
    2. Non-syncopal falls ("mechanical falls") are often due to a collection of deficits (see risk factors below)

III. Risk Factors: Strongest modifiable risk factors for falls

  1. Environmental hazards (most common, e.g. poor lighting, throw rugs)
    1. See Fall Prevention with Home Adaptation
  2. Lower extremity Muscle Weakness and decreased Muscle tone
  3. Dehydration risks
  4. Altered gait or balance
    1. Parkinsonism
    2. Peripheral Neuropathy
    3. Dizziness or Vertigo
    4. Syncope
    5. Postural Hypotension
  5. Medication use (especially more than 4 medications)
    1. See Polypharmacy
    2. See Medications to Avoid in Older Adults (Beer's List, STOPP)
    3. Anticholinergics
      1. Antihistamines
      2. Skeletal Muscle Relaxants
      3. Muscarinic Antagonists for Urge Incontinence
    4. Cardiovascular medications
      1. Class IA Antiarrhythmics
      2. Digoxin
      3. Diuretics
      4. Beta Blockers
      5. Nitrates
      6. Presynaptic Adrenergic Release Inhibitor (e.g. Clonidine)
      7. Postsynaptic Alpha Adrenergic Antagonist (e.g. Terazosin)
    5. Neurologic and psychiatric medications
      1. Anticonvulsants
      2. Antiparkinsonism medications
      3. Antipsychotics
      4. Tricyclic Antidepressants
      5. Benzodiazepines (and Z-Drugs)
    6. Miscellaneous medications
      1. Opioids
      2. Laxatives

IV. Risk Factors: Other, less modifiable risk factors for falls

  1. Age over 80 years old
  2. Female gender
  3. History of prior falls or Fractures
  4. Hospital discharge in the last month
  5. History of Cerebrovascular Accident or transient ischemia attack
  6. Decreased Visual Acuity
  7. Arthritis
  8. Dementia, Delirium or Altered Level of Consciousness
  9. Major Depression
  10. Alcohol Abuse
  11. Diabetes Mellitus (esp. Hypoglycemia)
  12. Vitamin D Deficiency
  13. Nocturia or Urinary Incontinence
  14. Cardiovascular disease (CHF, Hypertension, Cardiac Arrhythmias)

V. History

  1. Screening questions (positive if any questions are positive)
    1. Did you fall in the last year?
      1. How many times did you fall?
      2. Were you injured?
    2. Do you feel unsteady when standing or walking?
    3. Are you worried about falling?
  2. Positive screening
    1. Positive screening should also prompt additional testing (e.g. Get Up and Go Test, Orthostasis)
    2. Detailed questions
      1. Medications predisposing to falls (see above, and e.g. Beers List)
      2. Assistive Device use
      3. Footwear (Prefer flat, Rubber soled shoes)

VI. Exam: Fall Risk

  1. Perform annually for those over age 65 years
    1. Screen at Welcome to Medicare Physical
    2. Evaluate gait, strength and balance
    3. Includes Fall Risk History (see above)
  2. Vital Signs
    1. Orthostatic Blood Pressure and pulse
    2. Visual Acuity
    3. Hearing Test (consider)
  3. Cardiovascular exam
    1. Arrhythmias (consider EKG)
  4. Neurologic Exam
    1. Assess coordination and balance
    2. Grip strength and proximal arm strength
    3. Lower extremity Muscle Strength
    4. Proprioception and vibration sense
    5. Consider Mental Status Exam (e.g. SLUMS Exam)
  5. Functional Testing
    1. Get Up and Go Test
    2. 30 Second Chair Stand
    3. Four stage balance test
  6. Miscellaneous exam
    1. Visual Acuity
    2. Joint exam
    3. Feet and shoe exam
      1. Prefer flat, Rubber soled shoes

VII. Evaluation: Fall Risk

  1. See Acute Fall Management in the Elderly
  2. Step 1: Obtain history as above
    1. Positive history for falls, unsteadiness or concerns
      1. Go to Step 2
    2. Negative history for falls, unsteadiness or concerns
      1. Go to Step 3
  3. Step 2: Perform gait, strength and balance testing (e.g. See functional testing above)
    1. Positive exam for gait, strength or balance problem
      1. 0-1 fall in the last year, and no injury: Go to Step 4
      2. 1-2 or more falls in the last year or fall with injury: Go to Step 5
    2. Negative exam for gait, strength or balance problem
      1. Go to Step 3
  4. Step 3: Low Risk Management
    1. Educate on Fall Prevention
    2. Osteoporosis Prevention (Vitamin D Supplementation, Calcium Supplementation)
    3. Consider community Exercise program or Fall Prevention program
  5. Step 4: Moderate Risk Management
    1. Includes low risk interventions as above (education, Osteoporosis Prevention, community programs)
    2. Review and modify medications
    3. Consider physical therapy for improvement of gait, strength and balance
  6. Step 5: High Risk Management
    1. Review "Stay Independent" publication (see below)
      1. https://www.cdc.gov/steadi/pdf/stay_independent_brochure-a.pdf
    2. Includes low risk and moderate risk interventions as above
    3. Complete fall history and full examination as above
    4. Hypotension evaluation and management
    5. Manage foot problems
    6. Optimize Vision
    7. Fall Prevention with Home Adaptation
    8. Reassess in 30 days
      1. Fall Risk reduction plan compliance and barriers
      2. Exercise program as able

VIII. Management

  1. See Acute Fall Management in the Elderly
  2. See Evaluation protocol above
  3. Treat falls as a sentinel event
    1. Falls should not be considered a normal part of aging
    2. Patients should present for acute evaluation after a fall
      1. Even older patients with a normal GCS of 15 and not on Anticoagulants may have Intracranial Bleeding
      2. Even older patients without NEXUS Criteria, may still have Cervical Spine Injury
  4. Consider Syncope evaluation
    1. Evaluate for Carotid Sinus Hypersensitivity (a risk for recurrent unexplained falls)
      1. Management with cardiac Pacemaker placement
    2. Non-syncopal falls ("mechanical falls") require as thorough an approach as for syncopal falls
      1. Identify and treat reversible contributing factors
      2. Evaluate for Dehydration, Electrolyte abnormality, Arrhythmia and infections
      3. Evaluate for Postural Hypotension, Vision Loss, vestibular abnormalities, Muscle tone loss, Polypharmacy
  5. Use this to prompt team evaluation
    1. Fall safety and home safety evaluation
    2. Evaluate for Osteoporosis
    3. Hearing and sight evaluation
    4. Review medications (see Polypharmacy)
    5. Discuss Advanced Directives

IX. Prevention: Assistive Devices

  1. Wear flat, Rubber soled shoes
  2. Use ambulatory aid as needed (cane or walker)
  3. Consider Hip Protection Device
  4. Consider occupational therapy and physical therapy Consultation
  5. References
    1. Heidrich (2003) AAFP Board Review, Seattle
    2. Kannus (2000) N Engl J Med 343:1506-13 [PubMed]

X. Prevention: Education

  1. Stand slowly and stand near support for 1-2 minutes or until equilibrated
  2. Proper lifting technique
    1. No stooping; bend knees and keep back straight

XI. Prevention: Optimize Comorbid Conditions

  1. Vitamin D Replacement 800 to 1000 IU/day or 20-25 mcg/day (esp. if Vitamin D Deficiency)
    1. May reduce Fall Risk
  2. Consider DEXA Scan for Osteoporosis if not done recently
  3. Assess medications that may increase Fall Risk
    1. Focus on medications causing Orthostatic Hypotension, Dizziness, sedation, Hypoglycemia
    2. Assess number/type of medications
      1. See Polypharmacy
    3. Review patient's medication list against medications that increase Fall Risk (also see above)
      1. See Medications to Avoid in Older Adults (Beer's List, STOPP)
      2. Reevaluate Opioids, Antipsychotics, Benzodiazepines and Sedatives
        1. Benzodiazepines are high risk of falls and Hip Fracture (esp. in first 2 weeks of starting)
        2. Wagner (2004) Arch Intern Med 164:1567-72 [PubMed]
      3. Reevaluate Antihypertensives for Orthostatic Hypotension (e.g. Beta Blockers)
      4. Reevaluate diabetes medications for Hypoglycemia (e.g. Sulfonylureas, Insulin)
      5. Avoid first-generation Antihistamines (e.g. Diphenhydramine)
    4. Obtain levels on medications with toxicity risk (e.g. Digoxin, anticonvulsants)
  4. Check Visual Acuity
    1. Vision <20/60 is a risk for falls
    2. Encourage single lens glasses over multifocal glasses for outdoor activities, walking, stairs
      1. Haran (2010) BMJ 340:c2265 [PubMed]
    3. Check for Cataracts
      1. Minimize delay between Cataract replacement
      2. Fall Risk increases after the first Cataract replacement and decreases after the second
      3. Meuleners (2014) Age Ageing 43(3): 341-6 [PubMed]
    4. Assess for depth Perception
    5. Refer to ophthalmology as needed
  5. Blood Pressure
    1. Orthostatic Blood Pressure and pulse
    2. Control systolic Hypertension (but avoid overzealous lowering of Blood Pressure)
      1. Systolic Hypertension affects balance and Fall Risk
      2. Hausdorff (2003) Am J Cardiol 91:643-5 [PubMed]
  6. Foot Care
    1. Prefer flat, Rubber soled shoes
    2. Consider podiatry Consultation
      1. Spink (2011) BMJ 342:d3411 [PubMed]

XII. Prevention: Modify home environment and Activities

  1. See Fall Prevention with Home Adaptation
  2. Consult physical therapy
    1. Reduces fall-related return ED visits by 30% at 30 and 60 days
    2. Evaluate and manage mobility concerns
    3. Make use of Assistive Devices where able

XIII. Prevention: Regular Exercise

  1. See Exercise in the Elderly
  2. Goal Exercise for 30 minutes, 4-5 times per week
  3. Walking Program
  4. Exercise classes twice weekly reduces Fall Risk
    1. Day (2002) BMJ 325:128-31 [PubMed]
    2. Lord (2003) J Am Geriatr Soc 51:1685-92 [PubMed]
  5. Encourage balance-type activities
    1. See Geriatric Balance Training
    2. Dance
    3. Tai-chi
      1. Does not appear to decrease Fall Risk
      2. Wolf (2003) J Am Geriatr Soc 51:1693-701 [PubMed]

XIV. Resources

  1. CDC Home and Recreational Safety - Falls in Older Adults
    1. https://www.cdc.gov/homeandrecreationalsafety/falls/index.html
  2. Stay Independent Bronchure (CDC)
    1. https://www.cdc.gov/steadi/pdf/stay_independent_brochure-a.pdf

XV. References

  1. (2017) Presc lett 24(4): 21
  2. Beck-Esmay and Shenvi in Herbert (2020) EM:Rap 20(7): 5-6
  3. Coulter (2024) Am Fam Physician 109(5): 447-56 [PubMed]
  4. Moncada (2017) Am Fam Physician 96(4): 240-7 [PubMed]
  5. Rao (2005) Am Fam Physician 72:81-94 [PubMed]
  6. Tinetti (2003) N Engl J Med 348:42-9 [PubMed]
  7. Van Voast Moncada (2011) Am Fam Physician 84(11): 1267-76 [PubMed]

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