fulltext title banner


Falls

DEFINITION

  • Coming to rest inadvertently on the ground or at a lower level

  • Falls literature usually excludes falls associated with loss of consciousness (syncope).

BACKGROUND

  • One of the most common geriatric syndromes

  • Complications resulting from falls are the leading cause of death from injury in adults ≥65 years old.

  • 5%–10% of falls in older adults result in fracture or serious injury.

  • Causes are most often multifactorial.

  • Falls are associated with:

    • Increased use of medical services

    • Decline in functional status

    • Nursing home placement

SCREENING

  • All older adults should be asked annually about falls in the past year (previous falls are a strong risk factor for future falls).

  • Older adults with a single fall in the past 12 months should be evaluated for gait and balance problems.

  • Older adults with two or more falls in the past 12 months or with gait or balance abnormalities should undergo a multifactorial falls risk assessment (ie, thorough fall history and physical examination).

HISTORY OF PRESENT ILLNESS

  • Circumstances of fall

    • Symptoms at the time of the fall (lightheadedness, imbalance, dizziness)

    • Frequency of falls

    • Injuries

    • Activity at the time of the fall

    • Location of the fall

    • Potential contributing environmental factors (lighting, floor coverings, thresholds, furniture, etc)

  • Mobility difficulties

  • Use of assistive devices

  • Ability to perform activities of daily living

  • Exclude syncope or seizure

PAST MEDICAL HISTORY/ REVIEW OF SYSTEMS

Presence of conditions associated with falls or fall-related injuries:

  • Osteoarthritis

  • Osteoporosis

  • Vision loss

  • Motor weakness

  • Cognitive impairment

  • Depression

  • Delirium

  • Urinary incontinence

  • Cardiovascular disease

  • Cerebrovascular disease

  • Diabetes mellitus

  • Seizure disorder

  • Neurologic disorders (neuropathy, Parkinson disease, normal-pressure hydrocephalus)

  • Vertigo

  • Hypovitaminosis D

SOCIAL HISTORY

  • Alcohol intake

  • Social support and supervision

  • Consider possibility of abuse

MEDICATIONS

Thorough evaluation of medications that can contribute to falls (including over-the-counter medications):

  • Acetylcholinesterase inhibitors

  • Antiarrhythmics

  • Anticholinergics

  • Anticonvulsants

  • Antidepressants

  • Antihistamines

  • Antihypertensives

  • Antipsychotics

  • Benzodiazepines

  • Diuretics

  • Insulin and oral hypoglycemics

  • Narcotics

  • NSAIDs

  • Sedative hypnotics

  • Systemic glucocorticoids

PHYSICAL EXAMINATION

Comprehensive physical examination with focus on:

  • Orthostatic vitals (orthostatic hypotension = drop in systolic blood pressure ≥20 mmHg [or ≥20%] with or without symptoms, either immediately or within 3 min of rising from lying to standing)

  • Cognitive assessment

  • Eye examination if visual complaints

  • Cardiovascular examination, including heart rate and rhythm

  • Integrated musculoskeletal function test such as:

    • Timed Up and Go test (can be performed with or without timing); normal is <12 seconds

  • Neurologic evaluation, including reflexes, focal deficits, neuropathy, tremor, rigidity

  • Feet and footwear examination

DIAGNOSTIC TESTS

  • Based on results of history and physical, may consider:

    • Basic metabolic profile (dehydration, hypoglycemia)

    • Complete blood count (infection, anemia)

    • Vitamins D and B12 levels

    • Electrocardiography and echocardiography (for those with cardiac conditions believed to contribute to the maintenance of blood flow to the brain)

    • Neuroimaging (if head injury, new focal neurologic finding on exam, CNS process suspected)

    • Spinal imaging (in patients with abnormal gait, neuralgia examination, or lower-extremity spasticity or hyperreflexia) to exclude cervical spondylosis or lumbar stenosis

    • Bone densitometry (see AGS Geriatrics Evaluation & Management: Osteoporosis)

MANAGEMENT STRATEGIES (COMMUNITY-DWELLING OLDER ADULTS)

  • Resources to integrate fall reduction into clinical practice are available at https://www.cdc.gov/steadi/ materials.html.

  • Minimize medications.

    • Review medication profile and reduce number and dosage of all medications, as possible.

    • Monitor response to medications and to dosage changes.

  • Optimize treatment of underlying medical conditions that can contribute to falls.

  • Supplement vitamin D.

    • Ensure patient receives recommended dosage of vitamin D through sunlight, diet, or supplementation.

      • Age 51–70: vitamin D 600 IU/day

      • Age >70: vitamin D 800 IU/day

    • Exact mechanism is unknown; it is believed that vitamin D may reduce falls by increasing muscle strength and decreasing body sway; vitamin D supplementation also improves bone mineral density and reduces the risk of vertebral and nonvertebral fractures.

  • Treat vision impairment.

    • Insufficient evidence to recommend for or against inclusion of visual interventions

    • Initial cataract surgery decreases the rate of falls (subsequent surgeries have no effect on falls)

    • Avoid wearing multifocal lenses while walking, particularly up stairs

  • Manage postural hypotension.

    • Educate patient to sit for 2–3 minutes before transferring from lying to standing.

    • Educate patient to clench hands or pump ankles before standing or when feeling lightheaded.

    • Prescribe pressure stockings.

    • If appropriate, liberalize salt intake and optimize hydration.

    • If appropriate, add 1 cup of caffeinated coffee for postprandial hypotension (may interfere with sleep and potentially worsen incontinence).

    • Consider medications to increase blood pressure (contraindicated in severe hypertension, congestive heart failure, hypokalemia)

      • Midodrine 2.5–10 mg 3 times daily (4 hours apart)

      • Fludrocortisone 0.1 mg every 8–24 hours

  • Initiate an individually tailored exercise program.

    • Exercise programs incorporating more than one type of exercise (eg, gait training, balance, strengthening) are effective in reducing the rate of falls.

    • Tai Chi, which combines strengthening and balance measures, is effective in reducing the risk of falls.

  • Manage foot and footwear problems.

    • Recommend proper footwear (good fit, non-slip, low heel height, large surface contact area).

  • Manage heart rate and rhythm abnormalities.

    • Studies are inconclusive regarding reduction of fall rate among older adults with carotid sinus hypersensitivity treated with a pacemaker.

  • Refer to physical therapy for:

    • Comprehensive evaluation and rehabilitation of impaired gait, balance, or transfer skills

    • Evaluation for and training in use of assistive devices

    • Assistive device review for patients who have fallen while using devices

  • Recommend a home safety evaluation (often done by home health agency).

    • Potential environmental modifications

      • Improve home lighting

      • Remove or secure rugs and floor mats

      • Place electrical cords against the wall

      • Lower bed

      • Secure bathmats

      • Minimize clutter

      • Rearrange furniture

    • Potential medical equipment (may need to be purchased by patient): toilet riser, bedside commode, urinal, shower chair, grab bars, railings, fall alert buttons (call bell, bed alarm)

  • Consider need for increased assistance/supervision from caregivers.