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FALL PREVENTION AND FALLS

DEFINITION

An event whereby an individual unexpectedly comes to rest on the ground or another lower level without known loss of consciousness (AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons, 2010). Excludes falls from major intrinsic event (eg, seizure, stroke, syncope), which should be evaluated and managed.

ETIOLOGY

Typically multifactorial. Composed of intrinsic (eg, poor balance, weakness, chronic illness, visual or cognitive impairment), extrinsic (eg, polypharmacy), and environmental (eg, poor lighting, no safety equipment, loose carpets) factors. Commonly a nonspecific sign for one of many acute illnesses in older adults.

RISK FACTORS

Table 57. Risk Factors and Medications Associated with Falls
Risk Factor OR for all fallers (those who fell at least once during follow-up) OR for recurrent fallers (those who fell at least twice during follow-up)
Falls
Hx of falls
2.8
3.5
Fear of falling
1.6
2.5
Pain
Number of chronic musculoskeletal pain sites 5.3 ND
Pain (yes/no) 2.2 2.0
Severe foot pain
1.4
3.5
Moderate foot pain
1.2
1.8
Medical Conditions
Parkinson disease
2.7
2.8
Rheumatic disease
1.5
1.6
Urinary incontinence
1.4
1.7
Arthritis
1.4
ND
Depression/Anxiety
1.3
ND
Comorbidity
1.2
1.5
Activity/Balance
Balance limits activities
2.4
ND
Homebound
2.4
ND
Walking aid use
2.2
3.1
Gait deficit
2.1
2.2
Many problems moving around
1.8
ND
Sensory
Vertigo
1.8
2.3
Visual deficit, particularly unilateral visual loss
1.4
1.6
Hearing impairment
1.2
1.5
Cognitive/Psychiatric
Depression
1.6
1.9
Poor self-rated health
1.5
1.8
Cognitive impairment
1.4
1.6
Other Risk Factors that Have Not Been Studied
Impaired ADLs, higher pain severity
ND
ND
Pain interference with activities
ND
ND
Medications Associated with Falls
Two or more CNS-active agents (Avoid ≥3 CNS-active agentsBC)
2.4
ND
NSAIDs 2.2 1.1
Non-TCA/non-SSRI (SNRIBC)
2.0
2.91
TCA (AvoidBC)/SSRI
1.4
1.51
BenzodiazepinesBC
1.4
1.4
Polypharmacy (≥4 medications) 1.8 ND
Other sedatives (AvoidBC), hypnotics
1.7
ND
Opioids 1.0 1.0
Anticonvulsants (AvoidBC,2) 1.6 2.8
Antipsychotics (AvoidBC) 1.4 1.7
Antiarrhythmics (Class 1A) 1.6 ND
Antihypertensives 1.2 ND
Loop diuretics 1.4 ND
Other Medications Associated with Falls
Skeletal muscle relaxants (AvoidBC), systemic glucocorticoids
OR = Odds ratio; ND = no data on OR or unable to calculate
1 In a study of frail older women
2 Avoid unless safer alternatives are not available; avoid except if seizure disorder.BC

SCREENING

Fall risk screening is an important 1st step in fall prevention, but must be followed by a thorough assessment and the development of a plan that tailors person-centered interventions to address identified risk factors. Fall risk screening or assessment is a quality measure included in the CMS MACRA and Medicare Annual Wellness Visit.

Tool kits available to guide screening, assessment, and tailored intervention:

Screen for fall risk as part of routine primary healthcare visit (at least annually). Risk of falling significantly increases as the number of risk factors increases. Falling is more frequent in ambulatory residents in long-term care and in acute care settings.

  • Use a fall risk screening tool to identify risk factors (see below)
  • Complete Stay Independent brochure: a 12-question tool to identify risk
  • Ask 3 questions to determine risk (yes to any question)
    • Feel unsteady when standing or walking?
    • Worries about falling?
    • Has fallen in past year? (If yes, ask “How many times?” and ”Were you injured?”)
  • Screen for fall risk in nursing home (Morse Fall Scale, www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3h.html).
  • Screen for fall risk in acute care settings and rehabilitation wards (Hendrich II Fall Risk Model, consultgeri.org/try-this/general-assessment/issue-8).
  • Recommend prevention strategies to prevent future risk
    • Use CDC STEADI toolkit to screen and educate community-dwelling older adults to increase short- and long-term behavior change to reduce fall risk.

ASSESSMENT

  • Assess for modifiable risk factors and fall hx.
  • See Figure 5 for recommended assessment strategies. USPSTF does not recommend multifactorial assessment, although small benefit (6% reduction in fall risk; 11% when risk factors managed).
  • USPSTF recommends a small number of risk factors for falls in older adults: age, hx of falls, and impairments in mobility, gait, and balance. Use assessments of gait and mobility, such as the Timed Up & Go (TUG) test.
  • Assess for risk factors (Table 57) using a multidisciplinary approach, including PT and OT if problems with gait, balance, or lower extremity strength are identified.
  • Assess fear of falling using 7-item Falls Efficacy Scale-International (FES-I). Measures levels of concern about falling during physical and social activities on a 1- to 4-point Likert scale. sites.manchester.ac.uk/fes-i/

Gait, Balance and Mobility Assessment

  • Functional gait: observe patient rising from chair, walking (stride length, base of gait, velocity, symmetry), turning, sitting (Timed Up and Go Test)
  • Balance: semi-tandem, and full-tandem stance; Functional Reach test; Berg Balance Scale (especially retrieve object from floor); Short Physical Performance Battery (SPPB)

Figure 5. Assessment and Prevention of Falls

  • Cognition: assess frontal-lobe cognitive function (eg, CLOCK or MiniCog) to identify impaired executive function and judgment that can impact fall risk.
  • Mobility: observe patient’s use and fit of assistive device (eg, cane, walker) or personal assistance, extent of ambulation, restraint use, footwear evaluation.
    • Cane fitting: top of the cane should be at the top of the greater trochanter or at the break of the wrist when patient stands with arms at side; when the patient holds the cane, there is approximately a 15-degree bend at the elbow. Canes are most often used to improve balance but can also be used to reduce weight-bearing on the opposite leg.
    • Walker fitting: walkers are prescribed when a cane does not offer sufficient stability. Front-wheeled walkers allow a more natural gait and are easier for cognitively impaired patients to use. Four-wheeled rolling walkers (ie, rollators) have the advantage for a smoother faster gait, but require more coordination because of the brakes; however, they are good for outside walking because the larger wheels move more easily over sidewalks.
  • Identify medications that increase fall risk (Beers Criteria)
  • Complete environmental assessment, including home safety, and mitigate identified hazards
  • Measure orthostatic BP
  • Check visual acuity, Snellen eye test
  • Assess feet and footwear
  • Assess calcium and vitamin D intake (see Osteoporosis chapter)
  • Identify comorbidities that contribute to falls

PREVENTION

See Figure 5 for recommended prevention strategies.
Recommendations below are primarily based on studies of community-dwelling older adults with limited evidence from RCTs regarding single or multifactorial interventions in the long-term care setting and in cognitively impaired patients.
  • Use multifactorial strategies for lowering fall risk by targeting risk factors (Table 58).
    • Consider balance of benefits and harms of identified interventions, based on circumstances of prior falls, comorbid medical conditions, and patient values, in providing comprehensive intervention.
    • Multiple component interventions are most effective across care settings ( risk 21% [USPSTF 2018]).
    • No evidence for hip protectors and medication review in long-term care facilities.
  • Evidence-based programs advocated by the CDC and/or Administration for Community Living. Exercise: Tai Chi: Moving for Better Balance (or similar tai chi classes), Otago Exercise Program, Stay Safe, Stay Active. Multifactorial evidence-based educational programs: Stepping On, Prevention Of Falls in the Elderly Trial (PROFET), A Matter of Balance. Additional evidence-based programs at cdc.gov/homeandrecreationalsafety/Falls/compendium.html and community resources. Exercise videos for Otago home-based exercise available at med.unc.edu/aging/cgec/exercise-program/videos and for Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE).
  • Additional CDC recommendations for visually impaired (eg, VIP trial home safety program) and for specific situations such as walking on ice and snow (eg, Yaktrax Walker). See cdc.gov/HomeandRecreationalSafety/Falls/compendium.html
  • See Prevention or Musculoskeletal Disorders for details on exercise.

INTERVENTION TO REDUCE RISK FACTORS

  • Establish patient and provider goals for reducing fall risk to avoid falls
  • Develop tailored tx plan including recommended interventions as appropriate to fall risk
Table 58. Strategies for Lowering Falls

Factors

Suggested Interventions (Outcome Reduction1)

General Risk
Offer: exercise program to include exercises that address balance and stability, plus resistance (strength), flexibility, and endurance
  • medical assessment before starting
  • tailor to individual capabilities; consider strengths, weaknesses, and injury risk
  • initiate with caution in those with limited mobility not accustomed to physical activity
  • progress slowly, appropriate to ability and competence
  • maintain regular, comfortable, yet challenging plan
  • provide environment that builds self-efficacy
  • prescribed by qualified healthcare provider
  • regular review and progression
↓ risk 13% [USPSTF 2018]
↓ risk 15%; ↓ rate 29% [Cochrane]
Tai Chi: ↓ risk 29%, ↓ rate 22% [Cochrane]
Aerobic + strength + balance 2–3×/wk (↓ risk 12%)
Education and information, CBT intervention to decrease fear of falling and activity avoidance (limited evidence [Cochrane])
Manage pain and anxiety to reduce fear of falling
Medication-related Factors (Consider deprescribing [See Appropriate Prescribing])
Use of benzodiazepines, sedative-hypnotics, antidepressants, or antipsychotics
Consider agents with less risk of falls
Avoid if hx of falls or fracture. BC
Taper and D/C medications, as possible
Address sleep problems with nonpharmacologic interventions (see Sleep Disorders)
Educate regarding appropriate use of medications and monitoring for AEs
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
(Withdrawal of antipsychotics; no ↓ risk; ↓ rate 66% [Cochrane])
Monitor response to medications and to dosage changes
Mobility-related Factors
Environmental hazards (eg, improper bed height, cluttered walking surfaces, lack of railings, poor lighting)
Refer to OT
Improve lighting, especially at night
Remove floor barriers (eg, loose carpeting)
Replace existing furniture with safer furniture (eg, correct height of beds/chairs, more stable)
Install support structures, especially in bathroom (eg, railings, grab bars, elevated toilet seats)
Use nonslip bathmats
(↓ risk 12%; ↓ rate 19%; more effective delivered by OT [Cochrane])
Impaired gait, balance, or transfer skills
Provide exercise program resources (eg, NIA Exercise Booklet, Otago resources) or refer to local senior exercise program (↓ risk of fall 17%; ↓ risk of injurious falls 49%)
Refer to PT for comprehensive evaluation and rehabilitation
Refer to PT or OT for gait training, transfer skills, use of assistive devices, balancing, strengthening and resistance training, and evaluation for appropriate footwear
Refer to podiatrist for evaluation and management of foot or ankle issues that affect mobility and balance
Impaired leg or arm strength or range of motion, or proprioception Refer to PT or OT
Medical Factors
Parkinson disease, osteoarthritis, depressive symptoms, impaired cognition, carotid sinus hypersensitivity, other conditions associated with increased falls
Optimize medical tx
Monitor for disease progression and impact on mobility and impairments
Address issues related to anxiety and impulsiveness, which may increase fall risk
Determine need for assistive devices
Use bedside commode if frequent nighttime urination cannot be managed by other methods
Cardiac pacing in patients with carotid sinus hypersensitivity who experience falls due to syncope
(↓ rate 27%, but not risk [Cochrane])
Postural hypotension: drop in SBP ≥20 mmHg (or ≥20%) with or without symptoms, within 3 min of rising from lying to standing See orthostatic postural hypotension
Visual (see Eye Disorders)
Refer to ophthalmologist for evaluation and management of vision-related issues
Cataract extraction (1st eye cataract removal, rate ↓ 34%, but not 2nd eye)
Avoid wearing multifocal lenses while walking, particularly up stairs
1 risk of falls = # people falling; rate of falling = # falls per person

EVALUATION OF FALL

Diagnose and treat underlying cause. Exclude acute illness or underlying systemic or metabolic process (eg, infection, electrolyte imbalance) as indicated by hx, exam, and lab studies. Determine if fall is syncopal or nonsyncopal (see Syncope). Evaluate impact of cognition.

History
  • Circumstances of fall (eg, activity at time of fall, location, time, footwear at time of fall,
    lighting)
  • Associated symptoms (eg, lightheadedness, vertigo, syncope, weakness, confusion,palpitations, joint pain, joint stability, feelings of pitching [common in Parkinson disease], foot pain, ankle instability)
  • Relevant comorbid conditions (eg, prior stroke, parkinsonism, cardiac disease, DM, seizure disorder, depression, anxiety, hyperplastic anemia, sensory deficit, osteoarthritis, osteoporosis, hyperthyroidism, glucocorticoid excess, GI or chronic renal disease, myeloma)
  • Medication review, including OTC medications and alcohol use; note recent changes in medications

Physical Exam

Look for:
  • Vital signs: postural pulse and BP lying and 3 min after standing, temperature
  • Head and neck: visual impairment (especially poor acuity, reduced contrast sensitivity, decreased visual fields, cataracts), motion-induced nystagmus (Dix-Hallpike test), bruit, nystagmus
  • Musculoskeletal: arthritic changes, motion or joint limitations (especially lower extremity joint function), postural instability, skeletal deformities, podiatric problems, muscle strength
  • Neurologic: slower reflexes, altered proprioception, altered mental status (focus on frontal-lobe impairment and impact on making poor choices), focal deficits, peripheral neuropathy, gait or balance disorders, hip flexor weakness, instability, tremor, rigidity
  • Cardiovascular: heart arrhythmias, cardiac valve dysfunction (peripheral vascular changes, pedal pulses)


Diagnostic Tests

  • Lab tests for people at risk include CBC, serum electrolytes, BUN, Cr, glucose, B12, thyroid function
  • Bone densitometry in all women aged >65 except those on osteoporosis tx or those who have osteopenic fragility fractures. Although bone density is not a risk factor for falls, it does affect serious fall-related outcomes (See Osteoporosis).
  • Cardiac workup if symptoms of syncope or presyncope (Syncope Evaluation)
  • Imaging: neuroimaging if head injury or new, focal neurologic findings on exam or if a CNS process is suspected; spinal imaging to exclude cervical spondylosis or lumbar stenosis in patients with abnormal gait, neurologic examination, or lower extremity spasticity or hyperreflexia

Management