II. Epidemiology
- Falls occur in >25-30% of age over 65 years in community each year
- Results in 7 million injuries, and 2.8 million emergency department visits per year
- Each fall increases the risk of future falls by 2-6 fold, and a harbinger of more serious falls
- Serious injury (Fractures, Traumatic Brain Injury) occurs in >20% of falls in older adults
- Leading cause of fatal and nonfatal injury in those over age 65 years
- Results in 27,000 deaths per year
- Most falls occur in and around the patient's home
- Fear of falling, may result in social isolation and functional decline
III. Risk Factors: Strongest modifiable risk factors for falls
- Environmental hazards (most common)
- Lower extremity Muscle Weakness
- Altered gait or balance
- Medication use (especially more than 4 medications)
- See Polypharmacy
- See Medications to Avoid in Older Adults (Beer's List, STOPP)
- Cardiovascular medications
- Class IA Antiarrhythmics
- Digoxin
- Diuretics
- Antihypertensives
- Neurologic and psychiatric medications
- Anticonvulsants
- Antiparkinsonism medications
- Antipsychotics
- Tricyclic Antidepressants
- Benzodiazepines (and other sedatives and hypnotics)
- Miscellaneous medications
IV. Risk Factors: Other, less modifiable risk factors for falls
- Age over 80 years old
- Female gender
- History of prior falls or Fractures
- Hospital discharge in the last month
- History of Cerebrovascular Accident or transient ischemia attack
- Decreased visual acquity
- Arthritis
- Dementia, Delirium or Altered Level of Consciousness
- Major Depression
- Alcohol Abuse
- Diabetes Mellitus
- Vitamin D Deficiency
- Nocturia or Urinary Incontinence
- Cardiovascular disease (CHF, Hypertension, cardiac arrhythmias)
V. History
- Screening questions
- Did you fall in the last year?
- How many times did you fall?
- Were you injured?
- Do you feel unsteady when standing or walking?
- Are you worried about falling?
- Did you fall in the last year?
- Detailed questions (when screening positive)
- Medications predisposing to falls (see above, and e.g. Beers List)
- Assistive Device use
VI. Exam: Fall risk
- Perform annually for those over age 65 years
- Screen at Welcome to Medicare Physical
- Evaluate gait, strength and balance
- Includes Fall Risk History (see above)
- Get Up and Go Test
- Cardiovascular exam
- Postural Hypotension
- Arrhythmias
- Carotid Bruits
-
Neurologic Exam
- Assess coordination and balance
- Lower extremity Muscle Strength
- Proprioception and vibration sense
- Consider Mental Status Exam (e.g. SLUMS Exam)
- Miscellaneous exam
- Visual Acuity
- Joint exam
- Feet and shoe exam
- Prefer flat, Rubber soled shoes
VII. Labs: Consider as part of acute fall evaluation
- Urinalysis
- Complete Blood Count
- Thyroid Function Tests
- Basic Metabolic Panel including Renal Function tests
- Serum Vitamin B12
- Vitamin D level
VIII. Diagnostics
- Electrocardiogram
- Echocardiogram
- Brain Imaging (CT Head, MRI Brain, MRA Brain and Neck)
IX. Evaluation
- Step 1: Obtain history as above
- Positive history for falls, unsteadiness or concerns
- Go to Step 2
- Negative history for falls, unsteadiness or concerns
- Go to Step 3
- Positive history for falls, unsteadiness or concerns
- Step 2: Perform gait, strength and balance testing (e.g. Get Up and Go Test)
- Positive exam for gait, strength or balance problem
- 0-1 fall in the last year, and no injury: Go to Step 4
- 1-2 or more falls in the last year or fall with injury: Go to Step 5
- Negative exam for gait, strength or balance problem
- Go to Step 3
- Positive exam for gait, strength or balance problem
- Step 3: Low Risk Management
- Educate on Fall Prevention
- Osteoporosis Prevention (Vitamin D supplementation, Calcium Supplementation)
- Consider community Exercise program or Fall Prevention program
- Step 4: Moderate Risk Management
- Includes low risk interventions as above (education, Osteoporosis Prevention, community programs)
- Review and modify medications
- Consider physical therapy for improvement of gait, strength and balance
- Step 5: High Risk Management
- Review "Stay Independent" publication (see below)
- Includes low risk and moderate risk interventions as above
- Complete fall history and full examination as above
- Hypotension evaluation and management
- Manage foot problems
- Optimize vision
- Fall Prevention with Home Adaptation
- Reassess in 30 days
- Fall risk reduction plan compliance and barriers
- Exercise program as able
X. Management: Falls - General Approach
- See Evaluation protocol above
- Treat falls as a sentinel event
- Falls should not be considered a normal part of aging
- Consider Syncope evaluation
- Evaluate for Carotid Sinus Hypersensitivity (a risk for recurrent unexplained falls)
- Management with cardiac Pacemaker placement
- Evaluate for Carotid Sinus Hypersensitivity (a risk for recurrent unexplained falls)
- Use this to prompt team evaluation
- Fall safety and home safety evaluation
- Evaluate for Osteoporosis
- Hearing and sight evaluation
- Review medications (see Polypharmacy)
- Discuss Advanced Directives
XI. Prevention: Assistive Devices
- Wear flat, Rubber soled shoes
- Use ambulatory aid as needed (cane or walker)
- Consider Hip Protection Device
- References
- Heidrich (2003) AAFP Board Review, Seattle
- Kannus (2000) N Engl J Med 343:1506-13 [PubMed]
XII. Prevention: Education
- Stand slowly and stand near support for 1-2 minutes or until equilibrated
- Proper lifting technique
- No stooping; bend knees and keep back straight
XIII. Prevention: Optimize Comorbid Conditions
-
Vitamin D Replacement 800 to 1000 IU/day or 20-25 mcg/day (esp. if Vitamin D Deficiency)
- May reduce fall risk
- Consider DEXA Scan for Osteoporosis if not done recently
- Assess medications that may increase fall risk
- Focus on medications causing Orthostatic Hypotension, Dizziness, sedation, Hypoglycemia
- Assess number/type of medications
- See Polypharmacy
- Review patient's medication list against medications that increase fall risk (also see above)
- See Medications to Avoid in Older Adults (Beer's List, STOPP)
- Reevaluate Opioids, Antipsychotics, Benzodiazepines and sedatives
- Benzodiazepines are high risk of falls and Hip Fracture (esp. in first 2 weeks of starting)
- Wagner (2004) Arch Intern Med 164:1567-72 [PubMed]
- Reevaluate antihypertensives for Orthostatic Hypotension (e.g. Beta Blockers)
- Reevaluate diabetes medications for Hypoglycemia (e.g. Sulfonylureas, Insulin)
- Avoid first-generation Antihistamines (e.g. Diphenhydramine)
- Obtain levels on medications with toxicity risk (e.g. Digoxin, anticonvulsants)
- Check Visual Acuity
- Vision <20/60 is a risk for falls
- Encourage single lens glasses over multifocal glasses for outdoor activities, walking, stairs
- Check for Cataracts
- Minimize delay between Cataract replacement
- Fall risk increases after the first Cataract replacement and decreases after the second
- Meuleners (2014) Age Ageing 43(3): 341-6 [PubMed]
- Assess for depth perception
- Refer to ophthalmology as needed
-
Blood Pressure
- Orthostatic Blood Pressure and pulse
- Control systolic Hypertension (but avoid overzealous lowering of Blood Pressure)
- Systolic Hypertension affects balance and fall risk
- Hausdorff (2003) Am J Cardiol 91:643-5 [PubMed]
-
Foot Care
- Prefer flat, Rubber soled shoes
- Consider podiatry Consultation
XIV. Prevention: Modify home environment
XV. Prevention: Regular Exercise
- Goal Exercise for 30 minutes, 4-5 times per week
- Walking Program
- Exercise classes twice weekly reduces fall risk
- Encourage balance-type activities
- Dance
- Tai-chi
- Does not appear to decrease fall risk
- Wolf (2003) J Am Geriatr Soc 51:1693-701 [PubMed]
XVI. Resources
- CDC Home and Recreational Safety - Falls in Older Adults
- Stay Independent Bronchure (CDC)
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Related Studies
Concepts | Finding (T033) |
SnomedCT | 298344006 |
English | elderly falling, elderly falls, fall elderly, fall geriatrics, falls geriatrics, elderly fall, falls geriatric, Elderly fall, Geriatric fall, Elderly fall (finding) |
Spanish | caída de un anciano (hallazgo), caída de un anciano |