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FALLS

KEY POINTS

  • Falls are not only common events that threaten the independence of older adults, but also the leading cause of death from injury in this age group.

  • Falls are generally multifactorial in origin, with complex interactions among intrinsic risk factors (age-related declines, chronic disease, medications), challenges to postural control (environment, changing position, routine activities), and mediating factors (risk-taking behaviors, situational hazards, acute illness).

  • Older adults with even a single fall should have a gait and balance evaluation.

  • For older adults with two or more falls in the past 12 months, or with gait or balance abnormalities, a multifactorial falls risk assessment should be pursued.

  • Important components of a fall history include the activity of the patient at the time of the fall, the occurrence of prodromal symptoms (lightheadedness, imbalance, and dizziness), and the location of the fall.

  • Interventions shown to be effective in reducing falls include medication review, exercise programs that include muscle strengthening and balance training, vitamin D supplementation, use of appropriate footwear, and multifactorial interventions including home hazards assessment for those at high risk of falls.

A fall is one of the most common events threatening the independence of older adults. A fall is considered to have occurred when a person comes to rest inadvertently on the ground or lower level. Most of the literature on falls in older adults does not include falls associated with loss of consciousness (eg, syncope, seizure) or with overwhelming trauma, because most falls are not associated with syncope or trauma.

PREVALENCE AND MORBIDITY

Every second of every day, an older person in the United States will fall. According to a CDC report, one of three adults ≥65 years old reports falling in the previous year. The incidence of falls is more frequent with advancing age and among nursing-home residents, such that one-half of individuals >80 years old or nursing-home residents will fall each year. Among those with a history of a fall in the previous year, the annual incidence of falls is close to 60%. Almost one-third of those who fall need to restrict their activities for a day as a result of the fall or need medical attention related to the fall. Most falls result in minor soft-tissue injury, whereas 5%–10% of falls result in fracture or a more serious soft-tissue injury or head trauma. Women and nursing-home residents are more likely to experience a nonfatal fall-related injury than men. Even among those who do not experience physical injury, falls are associated with subsequent declines in functional status, greater likelihood of nursing-home placement, increased use of medical services, and development of a fear of falling. Of those older adults who fall, only half are able to get up without help, thus experiencing the “long lie.” Long lies are associated with lasting declines in functional status. Fall-related injuries are not a common cause of death in older adults; however, complications resulting from falls are the leading cause of death from injury in adults ≥65 years old. The death rate attributable to falls increases with age, with white men ≥85 years old having the highest death rate (>180 deaths per 100,000 population).

The true cost of falls in healthcare dollars is difficult to ascertain. Because many falls result in injury, use of emergency department facilities among those who fall is common. In 2014, 2.8 million nonfatal falls were treated in emergency rooms, with 27% of these visits resulting in hospitalization. Thus, the direct cost of medical visits for falls and services/therapies for fall-related injuries is substantial. Indirect costs from fall-related injuries, such as hip fractures, can also be considerable.

CAUSES AND RISK FACTORS

Falls, incontinence, delirium, and other geriatric syndromes result from the accumulated effects of multiple impairments. In older adults, falls rarely have a single cause. Rather, there is often a complex interaction among intrinsic risk factors (age-related physiologic changes, chronic disease, medications), challenges to postural control (environment, changing positions, routine activities), and mediating factors (risk-taking behaviors, acute illness, or situational hazards, such as unfamiliar staff or high patient-to-staff ratios in hospitals and long-term care facilities).

In multiple prospective cohort studies, several risk factors have been consistently associated with falls, including older age, cognitive impairment, female gender, past fall history, arthritis, foot disorders, balance problems, hypovitaminosis D, psychotropic medication use, pain, Parkinson disease, and stroke (SOE=B). These studies differed significantly in the types of risk factors evaluated, the types of population studied (eg, past fall history was sometimes an entry criterion), and the outcome (one fall, two or more falls, rate of falls, injurious falls). The differences in risk factors found across the studies highlight the multifactorial nature of falls and suggest the importance of unique mediating factors unaccounted for in these studies. In general, the risk of falling increases with the number of risk factors, although as many as 10% of falls occur in individuals with no identifiable risk factor for falls. Also, risk factors for indoor and outdoor falls differ: indoor falls tend to occur among older, frail adults with mobility disorders, whereas outdoor falls occur in younger, healthier persons.

Successful prevention of falls begins with knowledge of the age-related changes that increase the risk of falls. With aging, there are declines in the visual, proprioceptive, and vestibular systems. For example, visual changes with aging include reduced visual acuity, depth perception, contrast sensitivity, and dark adaptation. The proprioceptive system loses sensitivity in the legs. The vestibular system has a loss of labyrinthine hair cells, vestibular ganglion cells, and nerve fibers.

Despite these age-related changes in sensory systems, quantifying the age-related changes in postural control that are independent of disease is difficult. When postural stability is tested in young and older people with no apparent musculoskeletal or neurologic impairment, there are measurable age-related differences in sway with perturbations of stance, such as changing the support surface, changing body position, changing the visual input, or moving the support surface horizontally or rotationally. This occurs because these perturbations of stance stress the redundancy of the sensory systems in their ability to maintain postural control. This is borne out by the observation that gait speed deteriorates when individuals are presented with a dual task (“walking while talking”). In addition, there may be other age-related changes in the CNS that affect postural control, including the loss of neurons and dendrites, and the depletion of neurotransmitters, such as dopamine, within the basal ganglia.

Some of the most striking postural control differences between young and old people relate to the order or grouping of muscle activation patterns: in response to perturbations of the support surface, older adults tend to activate the proximal muscles, such as the quadriceps, before the more distal muscles, such as the tibialis anterior. This strategy may not be an efficient way to maintain postural stability. Similarly, in older adults, there may be greater co-contraction of antagonistic muscles, and the onset of the muscle activation and associated joint torque may be delayed. Finally, the ability to recover balance after a postural disturbance may be compromised by an age-related decline in the ability to rapidly develop joint torque by using muscles of the leg. All these mechanisms potentially impair maintenance of upright posture.

Another important physiologic contributor to the maintenance of upright posture is regulation of systemic blood pressure. With advancing age, baroreflex sensitivity declines, which manifests as an inability to increase heart rate in response to common stresses (such as changing posture, eating a meal, or suffering an acute illness) and results in subsequent hypotension. Because many older adults have a resting cerebral perfusion that is compromised by vascular disease, even slight reductions in blood pressure can result in cerebral ischemic symptoms and subsequent falls. Finally, with aging, the amount of total body water is reduced, which places older adults at increased risk of dehydration with acute illness, diuretic use, or hot weather. Because basal and stimulated renin and aldosterone levels progressively decrease with aging, dehydrating stresses can lead to orthostatic hypotension and falls.

A number of age-related chronic conditions deserve special mention because of their association with fall risk. Parkinson disease increases the risk of falls through several mechanisms, including the rigidity of leg musculature, the inability to correct sway trajectory because of the slowness in beginning movement, hypotensive effects of medication, and in some cases, cognitive impairment. Strokes can result in an increased risk of falls secondary to visuospatial defects, impaired peripheral sensation, cerebellar dysfunction, muscle weakness, and residual dizziness. Knee osteoarthritis can affect mobility, the ability to step over objects and maneuver, and balance due to a tendency to avoid complete weight bearing on a painful joint. Chronic pain has been associated with an increased risk of falls possibly due to changes in gait and muscle strength or because pain can act as a cognitive distractor.

One of the most modifiable risk factors for falls that has been repeatedly demonstrated in observational studies is medication use (Table 1). Individual classes of psychotropic medications, such as the benzodiazepines, other sedatives, antidepressants, and antipsychotic medications, have been associated with an increased risk of falls and hip fracture. There appears to be no difference in the risk of falling with the use of older antidepressants or antipsychotics compared with the newer SSRIs or atypical antipsychotics. Similarly, there is no protection with respect to risk of falls and fracture by choosing a nonbenzodiazepine hypnotic (“Z-drug”) to treat insomnia versus using a benzodiazepine. As might be expected, the risk of falls increases in older adults taking more than one psychotropic medication, and among older adults taking more than 3 or 4 medications of any type.

Table 1—Medication Classes Associated with an Increased Risk of Falls in Older Adults

α-blockers
Amiodarone
Antidepressants (SSRIs, TCAs, others)
First-generation antihistamines or anticholinergic drugs
Other antihypertensives
Antimuscarinic incontinence agents
Antipsychotics, first- and second-generation
Benzodiazepines
Non-benzodiazepine hypnotics
Dementia medications, acetylcholinesterase inhibitors*
Insulin
Opioids
Muscle relaxants
Parkinson drugs

* Associated with increased risk of syncope

Other classes of medications affect falls risk as well. Conflicting data exist with respect to the role of antihypertensive medications and falls risk, but these medications likely increase falls risk in persons with a history of falls. Given their favorable effect on bone density, long-term use of thiazides is associated with a decreased risk of hip and pelvic fracture than use of other antihypertensives. Meta-analyses have demonstrated an increased risk of falls among those taking digoxin, diuretics, type 1A antiarrhythmic agents, and NSAIDs. Acetylcholinesterase inhibitors, which are used to treat dementia, have been associated with an increased risk of syncope. Diabetic medications can also be associated with falls risk during periods of hypoglycemia.

Older adults may be particularly vulnerable to falls in the days to weeks after a new medication is started or the dosage of an existing medication is increased. An increased risk of falling has been observed after a new prescription or dosage increase of a non-SSRI antidepressant, benzodiazepine, antihypertensive, or diuretic medication. Older adults are more vulnerable to hip fractures after a new prescription for a nonbenzodiazepine hypnotic, diuretic, or antihypertensive medication. Providers should alert older patients and their caregivers to the increased risk of falls after a new prescription of these medications in an effort to avoid injury.

The relative importance of environmental and mediating factors on the risk of falling has not been well quantified. Most intervention studies have focused on improving the risk-factor profile of the individual or have combined individual interventions with environmental manipulation, making it difficult to isolate the contributions of the environmental factors. Nevertheless, attention to safety hazards in the home environment appears to be worthwhile in those at high risk of falls.

CLINICAL GUIDELINES

The CDC has published an Algorithm for Falls Risk Assessment and Interventions (Figure 1) For older adults presenting with a fall, or an adult who is worried about falling or feels unsteady while standing or walking, it is recommended that gait, strength, and balance be evaluated. Further, if the older adult has had two or more falls, or a fall with injury, a multifactorial falls risk assessment should be pursued.

Figure 1—Fall Risk Screening, Assessment, and Intervention

EDITORIAL NOTE: Recent Systematic reviews of vitamin D and calcium supplementation in community-dwelling older adults do not support routine use in persons who are not frail, at high risk of falls, or who have normal 25(OH)D serum concentrations.
SOURCE: Centers for Disease Control and Prevention. STEADI: Stopping Elderly Accidents Deaths and Injuries.

For older adults who have no history of falling, providers should still ask about falls and use traditional geriatric assessment to target major risk factors. For a summary of the recommendations of the expert panel on falls prevention assembled by the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS), see http://bit.ly/2rJPkM3.

DIAGNOSTIC APPROACH

History and Physical Examination

Many falls never come to clinical attention for a variety of reasons: the patient may never mention the event, there is no injury at the time of the fall, the clinician may neglect to ask the patient about a history of falls, or the patient or clinician may make the invalid assumption that falls are an inevitable part of the aging process. The treatment of injuries resulting from falls commonly fails to include an investigation of the cause of the fall.

In the clinical evaluation of noninstitutionalized older adults who are not being seen specifically as the result of a fall, it is still important to include an assessment of fall risk in the history and physical examination. The most important point in the history is asking whether there has been a previous fall, because this is a strong risk factor for future falls. Older adults presenting with a single fall 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; evaluation of recurrent indoor falls is most likely to uncover multiple risk factors.

For patients presenting with a fall, important components of the history include the activity at the time of the fall, the occurrence of prodromal symptoms (lightheadedness, imbalance, dizziness), and the location and time of the fall. Loss of consciousness is rare, but it should raise important considerations, such as orthostatic hypotension or cardiac or neurologic disease.

Information on previous falls should be collected to identify patterns that may help determine strategies to reduce future falls. A complete medication history should focus on newly added medications or recent dosage changes, as well as the use of antihypertensives, diuretics, and psychotropic medications because of their association with falls and their common use in older adults.

In addition to inquiring about the circumstances surrounding the fall, the clinician should attempt to identify any potential contributing environmental factors. Information on lighting, floor coverings, door thresholds, railings, and furniture can add important clues. Footwear can also be an important factor (Figure 2). In one small study that evaluated the effect of various shoe types on balance in older men, shoes with thin, hard soles produced the best results, even though they were perceived as less comfortable than thick, soft, mid-soled shoes, such as running shoes. In another nested case control study of men and women, athletic shoes were associated with the lowest risk of falls, and shoes with increased heel height and decreased surface area between the sole and the floor were associated with a higher risk of falls.

Figure 2—Characteristics of shoes recommended for older adults

When performing a physical examination on an older adult with a fall, the provider should focus on risk factors, including gait assessment. Probably the most important part of the physical examination is an assessment of integrated musculoskeletal function, which can be accomplished by performing one or more of the following tests of postural stability. The most commonly used test of integrated strength and balance is the Up and Go test, which can be performed with or without timing. It consists of observation of an individual standing up from a chair, walking across a room (about 3 meters), turning around, walking back, and sitting down without using the arms. This test can grade muscle weakness, balance problems, and gait abnormalities using a scale of 1–5, with 5 indicating severe abnormalities. The need to use arms to stand may indicate hip extensor weakness. This test may be timed, with inability to complete the test within 12 seconds suggesting an increased risk of falls. The 30-second chair stand is another integrative test of balance and strength. Patients are asked to cross their arms over their chest while seated in a chair. It should be noted if the patient needs to use his or her arms to arise from the chair. The provider records how many times the patient can fully stand and sit in 30 seconds. For patients 75–79 years old, <11 stands in men and <10 stands in women is considered abnormal and represents an increased fall risk. The 4-stage balance test is a third integrative test whereby patients are asked to stand for at least 10 seconds in the following positions: feet adjacent, semitandem stance, tandem stance, and on one foot. Patients unable to perform the semi-tandem test for 10 seconds are at increased risk of falling. The functional reach test, Berg Balance Test, and Performance-Oriented Mobility Assessment are infrequently used in clinical settings, but they are used in research studies as other integrated measures of neuromuscular support. Impaired performance on these tests has been demonstrated to predict falls in older adults.

A number of screening tools for risk of falls have been developed for use in the acute hospital setting, including the Morse Fall Scale and the St. Thomas’s Risk Assessment Tool (STRATIFY). The Morse Fall Scale, one of the more commonly used scales, comprises 6 items: history of falling in the past 3 months, presence of any secondary diagnosis, use of an ambulatory aid, receipt of intravenous therapy, abnormal gait, and impaired mental status. Scores range from 0 to 125, with higher numbers indicating a greater risk of falls. A cutpoint of >45 is often used to identify patients at high risk of falls.

Although these screening tools perform relatively well in predicting falls, a systematic review and meta-analysis of prospective studies suggests that they are comparable with nursing clinical judgment when predicting falls in the hospital setting. Screening tools are likely to be even less useful in the nursing-home setting, where most residents have multiple risk factors for falls. For this reason, all nursing-home residents that can transfer or ambulate should be considered at high risk of falls, prompting a consideration of modifiable, individual risk factors.

Laboratory and Diagnostic Tests

There is no standard diagnostic evaluation of a person with a history of falls or a high risk of falling. Laboratory tests for hemoglobin, BUN, creatinine, or glucose concentrations can help to exclude anemia, dehydration, or hyperglycemia with hyperosmolar dehydration as the cause of falling. There is no proven value of routinely performing Holter monitoring of individuals who have fallen. Because data demonstrate that carotid sinus hypersensitivity contributes to falls and even hip fracture, some have advocated performing carotid sinus massage with continuous heart rate and phasic blood pressure measurement in older adults with unexplained falls. Similarly, the decision to perform echocardiography, brain imaging, or radiographic studies of the spine should be driven by the findings of the history and physical examination. Echocardiography should be reserved for those with cardiac conditions believed to contribute to the maintenance of blood flow to the brain. Spine radiographs or MRI can be useful in patients with gait disorders, abnormalities on neurologic examination, leg spasticity, or hyperreflexia to exclude cervical spondylosis or lumbar stenosis as a cause of falls.

TREATMENT AND PREVENTION

The evaluation and management of falls in older adults may differ according to the clinical setting. For example, in the home, the fall may be reported by the patient or family, or in response to clinician query. In the hospital or nursing home, staff may directly witness a fall, or find the patient on the floor. For evidence-based approaches to the management of falls, see Table 2.

Table 2—Evidence-Based Interventions for Lowering Fall Risk by Site of Care

Home

Muscle strengthening or balance training prescribed by clinician (SOE=A)

Tai Chi (SOE=B)

Home-hazard assessment prescribed for those with history of falls (SOE=A)

Multidisciplinary, multifactorial health and environmental risk-factor screening or intervention for: (SOE=A)

  • unselected community-dwelling older adults
  • older adults with a history of falling
  • older adults selected because of known risk factors

Withdrawal of psychotropic medications (SOE=B)

Vitamin D supplementation at ≥800 IU/d in persons with vitamin D deficiency (SOE=A)

First cataract surgery, when indicated (SOE=B)

Hospital

Many risk assessments have reasonable sensitivity and specificity to be of potential value in targeting high-risk patients. Multifactorial interventions that target an individual’s greatest risk factors for falls, including a plan that uses health information technology, has been effective in reducing falls (SOE=B).

Nursing Home

No proven interventions have been reported other than vitamin D supplementation.

Reasonable to assume all nursing-home residents are at high risk of falls and to target resident’s most important individual risk factors, using an interprofessional team (SOE=C).

Vitamin D supplementation at ≥1,000 IU/d for residents independent in transfers at risk of falls (SOE=A)

Exercise programs may reduce risk of falls (SOE=C).

NOTE: MDS = minimum data set

Multiple studies of preventive interventions have been conducted, including programs to improve strength or balance, educational programs, optimization of medications, and environmental modifications in homes or institutions. Some interventions have targeted single risk factors; others have attempted to address multiple factors by either targeting patient-specific risk factors (multifactorial intervention) or by offering the interventions to an entire population (multicomponent intervention).

A Cochrane collaboration systematic review of interventions to reduce the incidence of falling in older adults has been performed. Because of the large numbers of fall intervention trials and because interventions may be more effective in certain settings, systematic reviews of fall prevention interventions were divided into 2 groups: those among community-dwelling adults and those among institutionalized adults. The 2012 update of the Cochrane systematic review of fall interventions among community-dwelling adults included 159 individual trials. The results of this review demonstrated that the following falls prevention interventions are likely to be beneficial in the community setting: medication review; home hazards assessment by health care professionals in older adults at high risk of falling; Tai Chi; multiple-component interventions (strength, balance, or gait training) or home-based exercises; vitamin D supplementation in patients with vitamin D deficiency; an antislip shoe device to be worn in icy conditions; pacemaker placement in patients with carotid sinus hypersensitivity; first cataract surgery; and multifactorial, multidisciplinary interventions.

In 2011, the AGS and the BGS updated clinical practice guidelines for the prevention of falls in older adults. These guidelines advocate for interventions tailored to major falls risk factors, coupled with an appropriate exercise program. All older adults in the community at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered but not as sole components of the program. Interventions should include an education component tailored to the individual’s cognitive ability and language. The interventions most commonly identified and that are considered to be efficacious in preventing falls in community dwellers include the following:

  • Modify the home environment: When included as part of a multifactorial intervention, home environment assessments with environmental modification performed by a health care professional reduced the risk of falling among older adults who have fallen or are at high risk of falling because of visual impairment (2 trials; 491 participants; relative risk [RR] 0.56; CI 95%, 0.42–0.76) (SOE=A). Home environment assessment and intervention performed by a health care professional should be included in a multifactorial assessment and intervention for older adults who have fallen or who have risk factors for falling.

  • Discontinue or minimize psychoactive medications: In one study of 93 community-dwelling adults, a gradual taper of psychotropic medications was associated with a decreased rate of falls (relative hazard 0.34; CI 95%, 0.16–0.74) (SOE=B).

  • Discontinue or minimize other medications: A prescribing modification program for primary care physicians that included a medication review checklist, education and feedback from a pharmacist, and financial incentives significantly reduced the risk of falling (1 cluster randomized trial; 20 providers and 849 participants; RR 0.61; 95% 0.41–0.91) (SOE=B). There was no effect of medication reviews led by pharmacy on the risk of falls (2 trials; 445 participants; RR 1.03; CI 95%, 0.81–1.31). Multifactorial interventions that have been successful in preventing falls often include a review of medications.

  • Manage postural hypotension: The sensation of dizziness is strongly associated with an increased risk of falls; thus, assessment and treatment of postural hypotension should be included as components of multifactorial interventions to prevent falls in older adults. Achieving better control of systolic blood pressure has been associated with a decrease in postural changes in blood pressure. It is unclear whether this might also translate into a decreased risk of falls. Although no trial to date has addressed whether a single intervention to reduce orthostasis results in decreased falls, multifactorial interventions that include fluid optimization, medication review and reduction, and behavioral changes have shown a modest effect in reducing the risk of falls among community-dwelling adults (SOE=C).

  • Manage foot problems and footwear: One trial comparing multifaceted podiatry intervention including foot and ankle exercises with standard care in people with disabling foot pain significantly reduced the rate of falls (305 participants; relative attributable risk (RAR) 0.64; CI 95%, 0.45-0.91) but not the risk of falls (SOE=B). Footwear associated with higher heels and decreased surface area has been associated with an increased risk of falls (SOE=C). Clinicians should advise their patients to wear walking shoes with high contact surface area. Although nonslip soles are generally recommended, they should be avoided in those with a shuffling gait. In older adults with disabling foot pain, falls may be reduced by a multifaceted intervention, including customized insoles, attention to shoe wear, foot and ankle exercises, and falls prevention education.

  • Prescribe exercise, particularly balance, strength, and gait training: The 2012 Cochrane review of fall interventions included 59 trials that tested the efficacy of exercise as an isolated intervention to prevent falls in the community setting. Exercise classes incorporating more than one type of exercise (eg, gait training, balance, strengthening) were effective in reducing the risk of falls (22 trials; 5,333 participants; RR 0.85; CI 95%, 0.76–0.96) (SOE=A). Multiple-component home-based exercise was also effective in reducing the risk of falls (6 trials; 714 participants; RR 0.78; CI 95%, 0.64–0.94). In a separate meta-analysis, home-based and group exercises reduced the rate of injurious falls in community dwellers (10 trials; 2,922 participants; RAR 0.63; CI 95%, 0.51–0.77) (SOE=A). Tai Chi, which combines both strengthening and balance measures, is effective in reducing the risk of falls among community-dwelling adults (6 trials; 1,625 participants; RR 0.71; CI 95%, 0.57–0.87) (SOE=A).

The AGS/BGS recommendations state “Exercise programs should consider the functional status and comorbidities of the older person, and they should be prescribed by qualified health professionals or fitness instructors, whenever possible. The exercise program should include regular review, progression and adjustment of the exercise prescription as appropriate.” For homebound older adults, programs such as the Otago Exercise Program that include in-home physical therapy and requires fewer one-on-one sessions over the course of a year, have been shown to reduce the rate of falls (SOE=A).

  • Treat vision impairment: There is insufficient evidence to recommend for or against the inclusion of vision interventions within multifactorial fall prevention interventions. However, first cataract surgery results in a decreased rate of falls (1 trial; 306 participants; RR 0.66; CI 95%, 0.45–0.95) (SOE=B). Second cataract surgery showed no benefit in reducing the rate of falls or number of fallers. Although routine eye screening with correction of visual defects is considered good medical practice, one trial with an intervention to treat vision problems resulted in a significant increase in the risk of falls (616 participants; RR 1.54; CI 95%, 1.24–1.91). In another trial of 597 participants, regular wearers of multifocal glasses who routinely participated in outdoor activities experienced a reduced rate of falls when given single lens glasses (SOE=B). However, there was a significant increase in outside falls in intervention group participants who infrequently participated in outside activity. The AGS/BGS recommends cautioning older adults with multifocal lenses to be more attentive to falling while walking, particularly on stairs (SOE=C).

  • Manage heart rate and rhythm abnormalities: One trial demonstrated a reduction in the rate of falls among older adults with carotid sinus hypersensitivity treated with a pacemaker (175 participants; weighted mean difference –5.20; CI 95%, −9.40 to −1.00) (SOE=B). In contrast, a small randomized cross-over trial of 34 participants with carotid sinus hypersensitivity and a history of falls found no benefit in preventing falls when their pacemaker was switched to the on mode as compared with the off mode (RR of falling when pacemaker was off: 0.82, CI 95%, 0.62–1.10) (SOE=B).

Additionally, several multifactorial interventions in which participants received more than one intervention targeting their major risk factors were effective in reducing the rate of falls (19 trials; 9,503 participants; RR 0.76; CI 95%, 0.67–0.86) (SOE=A). Because these trials were conducted in different populations and used different interventions, it is unclear which combinations of interventions are the most effective.

The health professional or team conducting the fall risk assessment should directly implement interventions or assure that the interventions are carried out by other qualified health care professionals. It is also reasonable to educate cognitively intact older adults at risk of falls on home hazards, proper footwear choices, and the importance of regular exercise. In one trial of 1,206 hospitalized older adults, intensive falls education as provided by a physiotherapist in combination with written and video materials on falls reduced the risk of falls as compared with usual care in cognitively intact persons (RR 0.51; CI 95%, 0.28–0.94) (SOE=B). However, results from a meta-analysis do not demonstrate that education reduces falls risk or fall-related injuries (4 trials; 2,555 participants; RR 0.88; CI 95%, 0.75–1.03). Thus, education alone should not be provided as a single intervention to prevent falls.

A number of interventions have not been effective for fall prevention, including group-delivered exercise interventions (SOE=B), nutritional supplementation (SOE=C), isolated modification of home hazards (SOE=B), cognitive-behavioral approach (SOE=B), and hormone therapy (SOE=C). Fall prevention programs in nursing-home settings have been largely unsuccessful in reducing the number of fallers, although they may reduce the number of recurrent fallers. Interventions that include medication reduction show some promise in preventing falls in this setting (SOE=B). Multifactorial interventions were successful in reducing falls in the hospital setting and, when delivered by an interprofessional team, were successful in reducing falls in the nursing-home setting. Among 8 trials of exercise in the acute hospital and rehabilitation settings, there was no clear effect of exercise on the risk of falls (1,887 participants; RR 1.07; CI 95%, 0.94–1.23). A multicenter randomized controlled trial of more than 10,000 acutely hospitalized adults found that a fall prevention tool kit using individual patient characteristics as ascertained from health information technology reduced the absolute rate of falls by 1.16 falls/1,000 bed days (CI 95%, 0.17–2.16). Vitamin D supplementation has been demonstrated in the nursing-home setting to reduce the rate of falls (5 trials; 4,603 participants; RAR 0.63; CI 95%, 0.46–0.86) but not the risk of falling (6 trials; 5,186 participants; RR 0.99; CI 95%, 0.90–1.08) (SOE=A).

The AGS/BGS makes the following recommendations regarding interventions to prevent falls in the nursing-home setting: Multifactorial/multicomponent interventions should be considered in long-term care to reduce falls. Exercise programs should be considered to reduce falls in older adults living in long-term care settings with caution regarding risk of injury in frail persons. Limited data exist on falls prevention in the assisted-living setting. These individuals often resemble nursing-home residents, and thus, it is reasonable to approach falls prevention in the assisted-living setting using a similar multidomain approach.

A practical approach for clinicians who are treating older adults, including nursing-home residents, at risk of falls targets risk factors in 3 major domains: medications, mobility, and medical conditions (Table 3).

Table 3—Preventing Falls: Selected Risk Factors and Suggested Interventions
Factors
Suggested Interventions
General Risk
Offer exercise program to include combination of resistance (strength) training, gait, balance, and coordination training:
  • tailor to individual capabilities
  • start with low intensity and graduate slowly in those with limited mobility not accustomed to physical activity
  • prescribed by qualified health care provider
  • regular review and progression

Education and information, cognitive-behavioral intervention to decrease fear of falling and activity avoidance

Recommend daily supplementation of vitamin D3 (1,000 IU) to older adults wtih vitamin D deficiency and to those residing in long-term care facilities. After supplementation, vitamin D levels may be appropriate for select patients at risk of vitamin D deficiency with the goal of achieving a 25-hydroxy vitamin D level of 30 ng/mL.

Medication-Related Factors
Use of benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antihypertensive medications
Consider whether medication is really needed.

If medication is needed, reduce dosage as possible.
Address sleep problems with nonpharmacologic interventions.
Educate regarding appropriate use of medications and monitoring for adverse events.
Recent change in dosage or number of prescription medications, or use of ≥4 prescription medications, or use of other medications associated with fall risk
Review medication profile and reduce number and dosage of all medications, as possible.
Counsel patients at risk of falls with new prescription or dosage increase.
Monitor response to medication changes.
Mobility-Related Factors
Presence of environmental hazards (eg, improper bed height, cluttered walking surfaces, lack of railings, poor lighting)
Improve lighting, especially at night.
Remove floor hazards (eg, loose carpeting in home or carpeted flooring in nursing home).
Replace existing furniture with safer furniture (eg, correct height, more stable).
Install support structures, especially in bathroom (eg, railings, grab bars, elevated toilet seats).
Use nonslip bath mats.
Impaired gait, balance, or transfer skills
Refer to physical therapy for comprehensive evaluation, rehabilitation, and training in use of assistive devices.
Provide gait training.
Prescribe balance and strengthening exercises.
If able to perform tandem stance, refer for Tai Chi, dance, or yoga.
Provide training in transfer skills.
Prescribe appropriate assistive devices.
Recommend appropriate footwear (eg, good fit, nonslip, low heel height, large surface contact area).
Impaired leg or arm strength or range of motion, or proprioception
Strengthening exercises (eg, use of resistive rubber bands, putty)
Resistance training 2–3 times/week, 3 sets of 10 repetitions with full range of motion, then increase resistance
Tai Chi
Refer to physical therapy or occupational therapy
Medical Factors
Parkinson disease, osteoarthritis, depressive symptoms, impaired cognition, carotid sinus hypersensitivity, other conditions associated with increased falls
Optimize medical therapy.
Monitor for disease progression and impact on mobility and impairments.
Determine need for assistive devices.
Use bedside commode if frequent nighttime urination.
Cardiac pacing in patients with carotid sinus hypersensitivity who experience falls due to syncope
Postural hypotension:
Review medications potentially contributing and adjust dosing or switch to less hypotensive agents; avoid vasodilators and diuretics if possible.
Educate on activities to decrease effect (eg, slow rising, ankle pumps, hand clenching, elevation of head of bed) and to slow rising from recumbent or seated position, grab bars by toilet and bath.
Prescribe pressure stockings (eg, Jobst).
Optimize hydration.
Liberalize salt intake, if appropriate.
Recommend caffeinated coffee (1 cup) or caffeine 100 mg with meals for postprandial hypotension.
Consider medication to increase blood pressure (if hypertension, heart failure, and hypokalemia not serious):
  • midodrine 2.5–10 mg given 3 times/day 4 hr apart
  • fludrocortisone 0.1 mg q8–24h
Visual impairment
Cataract extraction (first but not second cataract removal found to reduce falls, but second cataract extraction still useful for improvement in vision)
Increase awareness and vigilance when wearing multifocal lenses while walking, particularly up stairs.
SOURCE: Adapted with permission from Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips, 20th ed. New York: American Geriatrics Society; 2018:124–125.

Considerations for Recurrent Fallers

A small number of older adults will fall repeatedly despite interventions. These patients generally have non-modifiable risk factors that place them at particularly high risk, including Parkinson disease and dementia. For these patients, every attempt should be made to reduce modifiable risk factors, including reducing medications associated with falls, treating pain, and assessing environmental hazards. As with all fallers, it is important to get a history of the events surrounding the fall to exclude syncope, seizures, and other less common medical conditions. These patients frequently seek medical attention as a result of the falls, and often times medical providers suggest moving to a nursing home or environment with more intense supervision. Patients who are able to understand the risks and alternatives and express their choice to remain independent have the right to do so. In these instances, a direct discussion of goals of care with or without a palliative care consult may be helpful (SOE=C).

RESOURCES

Francis-Coad J, Etherton-Beer C, Bulsara C, et al. Evaluating the impact of a falls prevention community of practice in a residential aged care setting: a realist approach. BMC Health Serv Res. 2018;18:21.

Guirguis-Blake JM, Michael YL, Perdue LA, et al. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force, JAMA. 2018;319(16):1705‒1716.

Vlaeyen E, Coussement J, Leysens G, et al. Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials. J Am Geriatr Soc. 2015;63(2):211‒221.