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Geriatrics - Falls - Fast Facts | NEJM Resident 360

Falls are common in older adults and the risk increases with age. Falls are associated with morbidity and mortality but the consequences of falls are not limited to the patient. Falls have huge societal implications. On average, more than 200 older adults per hour are evaluated at an emergency department for fall-related injuries. Falls from a standing height account for more than 95% of hip fractures in adults older than 70 years; one in four elderly people with hip fracture die within 1 year after fracture.

Falls are the leading cause of traumatic brain injuries and falls or fall injuries increase the risk of nursing home placement. Further, the fear of falling in older adults with or without a prior fall has a significant negative effect on overall quality of life, often leading to activity restriction, disability, and loss of independence. Taken together, falls represent a multifactorial process that integrates multiple domains of health including mind, mobility, medications, and multicomplexity.

(Source: Important Facts about Falls. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control 2017.)

In this section, we will review:

• Risk Factors for Falls in Older Adults

• Screening for Fall Risk

• Assessment of Falls

• Interventions to Prevent Falls

Risk Factors for Falls in Older Adults

While falls and fall-related injuries increase with age, most older adults who are at risk of falling — or who have fallen — have multiple risk factors. These risk factors can be categorized as intrinsic or extrinsic:

Risk Factors for Falls

Intrinsic Factors	Extrinsic Factors
Advanced age	Lack of stair handrails
Previous falls	Poor stair design
Muscle weakness	Lack of bathroom grab bars
Gait and balance problems	Dim lighting or glare
Poor vision	Obstacles and tripping hazards
Postural hypotension	Slippery or uneven surfaces
Fear of falling	Medications
Chronic conditions
(including arthritis, stroke,
incontinence, diabetes,
Parkinson’s disease,
dementia)	Improper use of assistive device

(Reference: Risk Factors for Falls. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control 2017.)

Often a fall is triggered by an acute event such as an environmental hazard, delirium, or a medication change. The strongest and most consistent risk factor for falls, across studies and in different populations, is a history of a fall.

Screening for Fall Risk

Among the many tools for screening older people for falls, only a few have been validated in prospective studies. Older people and their caregivers should be asked about history of falls and difficulties with gait or balance on an annual basis.

• The Timed Up-and-Go Test, a useful fall-risk screening tool, evaluates postural stability (view video demonstration here). When a patient takes 12 or more seconds to complete the test, the screening result is considered positive for increased fall risk.

• The STEADI algorithm (Stopping Elderly Accidents, Deaths & Injuries), a risk-stratification tool developed by the Centers for Disease Control and Prevention (CDC), details each step of fall-risk screening and assessment — and guides intervention according to a person’s risk level.

• Other available screening tools, appropriate for particular clinical settings, include those for hospitals (STRATIFY), nursing home and residency care (including STRATIFY, FRAT, Hendrick Fall Risk Model, Morse Fall Scale).

Assessment of Falls in Older Adults

Fall assessment aims to identify factors that increase an older person’s risk for falling — and to identify interventions that may prevent falls. After patients screen positive for falling or gait/balance impairment, they should be assessed for fall risk factors, with particular attention to factors that are modifiable. Asking the patient and his or her caregiver(s) about the patient’s symptoms around the time of a recent fall is an important part of fall assessment. In addition, a careful review of medications is needed to identify drug adverse effects. For example, a patient who fell while going to the bathroom after starting a new prescription for a diuretic should be asked about postural dizziness and incontinence to assess whether the new medication contributed to the fall.

Although most falls occur in the absence of an acute medical illness, the following acute diagnoses may be considered if the history is suggestive:

• dizziness around the time of the fall: consider vestibular dysfunction, hypoglycemia, drug adverse effect(s)

• palpitations: arrhythmias

• asymmetric weakness or slurring of speech: cerebrovascular disease

• incontinence or tongue biting: seizures

• sudden rise from a lying to a sitting position: orthostatic hypotension

Physical examination after a fall should consider orthostatic changes to vital signs, focal neurological signs (foot neuropathy), gait assessment, lower extremity joint examination for osteoarthritis, hearing loss, visual deficits, and cognitive dysfunction.

Laboratory evaluation is not required for fall evaluation. However, if a clinician suspects that an underlying medical problem might have caused a patient to fall, the following next steps may be considered:

• complete blood count and metabolic panel to assess for acute illness, anemia

• electrocardiogram in people with suspected acute coronary syndrome

• electroencephalogram in people with suspected seizures

• brain imaging for suspected stroke, hematomas

The following algorithm from the CDC’s Injury Center, endorsed by the American Geriatric Society, outlines assessment of falls in older persons.

(Source: Algorithm for Fall Risk Screening, Assessment, and Intervention. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.)

Interventions to Prevent Falls

The American and British Geriatrics Societies’ Guideline for Prevention of Falls in Older Persons offers the following recommendations:

• Discontinue or reduce medications, including various psychotropic medications, that have known associations with falls.

• For community-dwelling older people, a multipart intervention should include an exercise component that focuses on balance, gait, and strength training (e.g., tai chi or an individualized physical therapy program).

• Assess visual acuity; expedite cataract surgery when older patients require the intervention.

• Manage pain in lower extremity joints.

• Consider assessment of hearing.

• Recommend appropriate footwear that reduces fall risk: low heel height and greater surface-contact area.

• Screening of the home environment should include removal of hazards, improvement in lighting, and installation of safety devices such as handrails on stairs.

• Overall, vitamin D supplementation does not appear to reduce fall risk but may be effective in people who have lower vitamin D levels before treatment. Supplementation with 800 international units (IUs) of vitamin D is recommended for institutionalized older adults or frail older adults who are at increased risk for falling.

  • This recommendation is based on studies in nursing home residents who have demonstrated reduced risks for falls and for fracture with vitamin D supplementation.

• Screen patients who have already fallen for osteoporosis.

• Consider a fall alert system in patients who are at high risk for falling and are cognitively able to use such an alert system.

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