Falls

Author: Kathleen Pace Murphy, PhD MS, GNP-BC; Jennifer Larson, MSE; and Sharon Ostwald, PhD, RN

Key Points

An estimated one in three adults, aged 65 years or older, falls each year (CDC, 2013).

Fall rates increase exponentially with age; older adults, age 80 years or older, have a 50% chance of falling each year (de Negreiros Carbral et al, 2013).

Falls are the leading cause of death due to injury in the elderly (CDC, 2013).

The most important risk factor for falling is a history of falls, so health care providers need to ask about falls at every visit!

Adults age 75 and older who fall are 4 to 5 times more likely than their 65-74 year old age cohort to be admitted to a long term care facility for a year or longer following a fall (Stevens & Dellinger, 2002).

Exercise is an effective intervention for falls. Older adults should exercise regularly focusing on increasing core and leg strength, as well as improving balance (CDC, 2013). Tai Chi exercise programs are very effective in meeting these exercise goals.

Interprofessional team work is critical to successful fall protection. Geriatric best practices include preventing polypharmacy, ophthalmology consults to assess for diminishing vision (cataracts) and to update glass prescriptions, dietary consults to insure adequate food intake including calcium and vitamin D, osteoporosis diagnostic work-ups when clinically indicated, physical therapy consults to assess gait and balance dysfunction and provide an exercise therapeutic plan, and interprofessional team home visits to conduct home safety evaluations (Gillespse et al, 2012).

 

Overview

Falls are defined as an unintentional lowering to rest from a higher to a lower position, not due to loss of consciousness or violent impact (Kellogg International Work Group on the Prevention of Falls by the Elderly, 1987). Falls often go unrecognized by health care professionals because they are not routinely evaluated while taking a patient’s history or during a physical exam (unless there is frank injury).

Many patients do not admit to falling for fear of losing their independence.

The incidence of falls varies with age. Persons aged 65 to 79 years living at home have a fall incidence of 30-40%. Persons aged 80 years and older living at home have an increased fall incidence of 50%.

Complications resulting from falls are the leading cause of death from injury in men and women aged 65 and older.

Many factors that contribute to fall risk in older adults. The World Health Organization Europe (2004) has characterized risks into two broad categories, intrinsic and extrinsic risk factors for falls.

Intrinsic risk factors include a history of falls, age, gender, medical conditions, impaired mobility and gait, sedentary behavior, psychological status, nutritional deficiencies, impaired cognition, visual impairments and foot problems.

Many older adults have multiple comorbidities including neurological, cardiovascular, metabolic, urinary, musculoskeletal, and psychological disorders that may increase their risk of falls. In addition, medications to treat these conditions may produce side effects that further impair their physical or psychological status.

Extrinsic risk factors for falls include environmental hazards such as uneven surfaces, poor lighting, and unstable or inappropriately placed furnishings, inappropriate assistive devices, ill- fitting clothing and footwear that lacks support.

 

Assessment

Falls are multifactorial in nature. Health care providers should always ask patients, aged 65 and older, if they have fallen recently or have a history of falling. If the patient admits to a recent fall, query for specific circumstances surrounding the fall. Inquire about gait and balance dysfunction. A medication review is critical for both prescribed and over the counter medications. Ask your patient about current medical co-morbidities such as cardiovascular disease, musculoskeletal diseases (i.e. arthritis, osteoporosis) and genitourinary (i.e. urinary tract infection, BPH). 

For those that have had a fall or a near fall, obtain a functional history. CATASTROPHE (Sloan, 1997) is a mnemonic for a complete functional history. 

C Caregiver and housing 

A Alcohol (including withdrawal) 

T Treatment (i.e. medications) 

A Affect (depression or lack of initiative) 

S Syncope (any episodes of fainting) 

T Teetering (dizziness) 

R Recent illness 

O Ocular problems 

P Pain with mobility

H Hearing (necessary to avoid hazards) 

E Environmental hazards 


Observing your patient’s gait while entering the room, sitting on the exam table or in the chair, and their ability to move around your examination room will provide a tremendous amount of information. Physical examination should include a detailed assessment of the neurological and musculoskeletal system (gait, balance, ability to ambulate, lower extremity range of motion, muscle strength, assessment of extrapyramidal and cerebellar function). The cardiovascular system should be assessed including orthostatic blood pressure readings and heart rate/rhythm. Vision should be examined for reduced visual acuity (i.e. cataracts). The patient’s feet should be inspected as well as their footwear. 

The American Geriatrics Society recommends conducting a fall risk assessment during routine primary care visits. High risk groups should have a more intensive assessment including the Timed Get Up and Go screening test.

 

Intervention

Multifactorial and interprofessional interventions are the best approach to fall prevention. Recommendations include:
  1. Exercise has been shown to reduce fall rates and the risk of falling. Exercise can include individual balance, gait training, aerobic and strength exercises, group exercises (Tai Chi) and home based exercise programs designed by a professional.
  2. Interprofessional home safety evaluations for environmental risk for falls with specific recommendations to correct hazards.
  3. Treatment of medical co-morbidities that would increase the elder’s risk factors for falls (i.e. orthostatic hypotension secondary to cardiovascular disease and treatment; visual impairment related to cataracts; podiatry consults for foot problems).
  4. Medication Reviews with the goal of reducing polypharmacy and medications that can increase fall risks (i.e. 4 or more medications, psychotropic medications, hypnotics)
  5. Nutritional assessment especially undernutrition (i.e. low BMI)
  6. Educate the older adult and their family members regarding risk factors and the interventions to reduce both environmental and physical risk factors.

 

References

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49,664. 

Center for Disease Control and Prevention (2013). Falls among older adults: An overview. Accessed on September 9, 2013 at http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls/html. 

Chang, J.T., Morton, S.C., Rubenstein, L.Z., et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medical Journal, 328, 680. 

De Negreiros Cabral, K, Perracini, M.R., Soares, A.T. et al. (2013). Effectiveness of a multifactorial fall prevention program in community-dwelling older people when compared to usual care: study protocol for a randomized controlled trial. BMC Geriatrics 13(27) 2-9/ http://www.biomedcentral.com/1471-2318/13/27. 

Gillespie, LD, Robertson MC, Gillespie W.J. et al. (2009). Interventions for preventing falls in older people living in the community. Cochrane Database Systematic Review, 2, CD007146. 

Graafmans, W.C., Ooms, M.E., Hofstee, H.M., et al. (1996). Falls in the elderly: A prospective study of risk factors and risk profiles. American Journal of Epidemiology, 143, 1129. 

Kellogg International Work Group on the Prevention of Falls by the Elderly (1987). The Prevention of Falls in Later Life. Danish Medical Bulletin, 41, 297-308. 

Podsiadlo, D., & Richardson, S. (1991). The timed "Up & Go:" A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39,142. 

Stevens, J.A. & Dellinger, A.M. (2002). Motor vehicle and fall related deaths among older Americans 199-1998; sex, race and ethnic disparities. Injury Prevention, 8, 272-275. 

Summary of the Updated American Geriatric Society/British Geriatrics Society clinical practice guidelines for prevention of falls in older persons: Summary of the Updated American Geriatrics Society/Britissh Geriatrics Society clinical practice guideline for prevention of falls in older persons (2011). Journal of American Geriatric Society, 59(1), 148-157. 

Tinetti, M.E. (2003). Preventing falls in elderly patients. New England Journal of Medicine, 348(1), 42-49. 

U.S. Census Bureau: An older and more diverse population by mid-century (2008). Book an Older and More Diverse Population by Mid-Century Retrieved from http://www.census.gov/newsroom/releases/archives/population/cb08-123.html 

World Health Organization Europe. (2004). “What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls?” Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0018/74700/E82552.pdf