FALLS

OBJECTIVES

Be able to describe:
• The importance of falls in older people
• How to assess and prevent falls in an older
person
 TOPICS COVERED

• Incidence and Morbidity

• Risk Factors
• Clinical Guidelines for Preventing Falls
• Diagnostic Approach to Falls
• Treatment and Prevention of Falls
 FALLS

• Definition: coming to rest inadvertently on

the ground or at a lower level
• One of the most common events threatening
the independence of older adults
• Most falls are not associated with syncope or
trauma
• Falls literature usually excludes falls
associated with loss of consciousness for this
reason
 EPIDEMIOLOGY OF FALLS

• 1 in 3 adults ≥ 65 years reports falling each

year
• One-half of those > 80 years
• One-half of nursing-home residents
• Nearly 60% of those with history of falls
• Complications of falls are the leading cause of
death from injury in people aged ≥65 years
 MORBIDITY AND MORTALITY

• 5%–10% of falls by older adults result in

fracture or more serious soft-tissue injury or
head trauma
• The death rate attributable to falls increases
with age
• Mortality highest in white men aged ≥85:
>180 deaths/100,000 population
 SEQUELAE OF FALLS

• Associated with:
 Decline in functional status
 Nursing home placement
 Increased use of medical services
 Fear of falling
• Half of those who fall are unable to get up without help
(“long lie”)
• A “long lie” predicts lasting decline in functional status
 COSTS OF FALLS

• Increased emergency department visits

• More hospitalizations

• Indirect costs from fall-related injuries such as

hip fractures are substantial
 CAUSES OF FALLS IN
OLDER ADULTS

• Rarely due to a single cause

• May be due to the accumulated effect of multiple

impairments (similar to other geriatric syndromes)
• Complex interaction of:
Intrinsic factors (eg, chronic disease)
Challenges to postural control (eg, changing position)
Mediating factors (eg, risk taking, situational hazards)
 INTRINSIC RISK FACTORS

• Older age
• Cognitive impairment • Balance problems
• Female gender • Psychotropic medication
use
• Past history of a fall
• Pain
• Leg weakness or gait
problems • Parkinson’s disease

• Foot disorders • Stroke

• Arthritis
The risk of falling increases with the number of risk factors
 INTRINSIC RISK FACTORS

• Age-related decline
 Changes in visual function
 Proprioceptive system, vestibular system
 Regulation of systolic blood pressure
 Reduced total body water, risk of dehydration with
stressors

• Chronic disease
 Parkinson’s disease
 Strokes
 Osteoarthritis, chronic pain
• Medication use
 MEDICATION USE

• Specific classes, for example:

 Benzodiazepines
 Other sedatives
 Antidepressants
 Antipsychotic drugs
 Cardiac medications
 Hypoglycemic agents

• Recent medication dosage adjustments

• Total number of medications

 CLINICAL GUIDELINES

• Ask all older adults about falls in past year

• Single fall: check for balance or gait disturbance

• Recurrent falls or gait or balance disturbance:

 Pursue a multifactorial falls risk assessment
 For a summary of the recommendations of the expert panel on
falls prevention assembled by AGS and BGS, see
www.americangeriatrics.org
 COMPONENTS OF A FALL HISTORY

• History of falls • Lighting

• Activity at time of fall(s) • Floor coverings
• Prodromal symptoms • Railings
• Location and time of • Furniture
fall(s)
• Door thresholds
• Medication history
(new, dose changes, • Footwear
high-risk meds)
FEATURES OF SAFE FOOTWEAR
 PHYSICAL EXAMINATION

• The most important part includes an assessment of

integrated musculoskeletal function

Up and Go test (with or without timing)

Chair stand

4-Stage balance test

Berg Balance Test

Performance-Oriented Mobility Assessment (POMA)

Functional reach test

 LABORATORY AND
DIAGNOSTIC TESTING

• Tests and procedures should be guided by the history

& physical exam: echocardiography, brain imaging,
radiographic studies of spine
• Hemoglobin, BUN, creatinine, glucose: can exclude
anemia, dehydration, or hyperglycemia
• Holter monitoring: no proven value for routine
evaluation
• Carotid sinus massage with continuous heart rate and
BP monitoring is advocated by some for pts with
unexplained falls: can uncover carotid sinus
hypersensitivity
 TREATMENT

• In the nursing-home setting, vitamin D

supplementation has been shown to decrease
falls risk.
• Multifactorial/multicomponent interventions
should be considered in this setting
• Hip protectors have not been consistently
shown to reduce hip fractures in community
dwelling or institutionalized older adults, and
most of the commercially available products
have never been used in clinical trials
 AGS/BGS FALLS PREVENTION
GUIDELINES

• Most commonly identified interventions to

prevent falls in community dwelling elders:
 Prescribe exercise, particularly balance, strength,
and gait training
 Discontinue or minimize psychoactive and other
medications
 Manage postural hypotension
 Manage foot problems and footwear
 Supplement vitamin D
 Treat vision impairment
 Manage heart rate and rhythm abnormalities
 Modify the home environment
 SUMMARY

• Falls by older adults are common and usually

multifactorial
• Falls are associated with functional decline

• Screening and targeted preventive interventions are

most effective
• AGS falls prevention guidelines are available and
recommend multifactorial interventions
 CASE 1 (1 of 4)

• An 80-year-old woman comes to the urgent care center

because she slipped on wet steps yesterday while watering
her plants. She scraped her leg but did not hit her head.
• She has fallen 3 other times in the last year.
• Her last fall was 3 months ago.
 On that occasion, she went to the ED because she struck her head
on the bathroom vanity.
 Non-contrast CT of the head showed nonspecific microvascular
ischemic changes and no acute bleeding.
• History: hypertension, well-controlled diabetes mellitus, atrial
fibrillation
• Medications: lisinopril, carvedilol, metformin, warfarin
 CASE 1 (2 of 4)

• Examination
Blood pressure 132/86 mmHg (no postural changes),
heart rate 80 bpm and irregularly irregular
Neurologic findings are normal.
INR: 3.0
The posterior surface of her right leg has a superficial
abrasion with surrounding ecchymoses; there are no
other injuries.
She walks slowly, with a shortened stride length on a
slightly wide base, and turns en bloc.
 CASE 1 (3 of 4)

Which one of the following is the best next step?

A. Discontinue warfarin.
B. Refer to a community exercise program.
C. Begin cholecalciferol 50,000 IU weekly.
D. Provide educational materials about fall risk.
 CASE 1 (4 of 4)

Which one of the following is the best next step?

A. Discontinue warfarin.
B. Refer to a community exercise program.
C. Begin cholecalciferol 50,000 IU weekly.
D. Provide educational materials about fall risk.
•
 CASE 2 (1 of 4)

• 79-year-old man is concerned about falling. He wants to get his eyes

examined, because he thinks his vision has deteriorated. He lives
alone.
• Four days ago, he missed a step and slid down 5 or 6 steps.
 He had no injury other than bruising over his buttocks.
 He purchased a medical alert necklace after the fall, and he is
thinking about moving his bedroom to a spare room downstairs.
• He last fell 1 year ago, when he got out of bed to go to the bathroom.
• History: heart failure with preserved ejection fraction, gout, chronic
insomnia
 Neurologic and cardiovascular findings are unremarkable.
 CASE 2 (2 of 4)

• Medications: furosemide, carvedilol, lisinopril, aspirin, allopurinol,

temazepam
• At his last eye exam 2 years ago, findings were normal except for
presbyopia and myopia in both eyes.
• Examination
 He completes the Timed Up and Go test in 20 seconds.
 Using the Snellen eye chart, visual acuity is 20/40 in both eyes
when he wears his glasses.
 Neurologic and cardiovascular findings are unremarkable.
 CASE 2 (3 of 4)

Which one of the following would most likely reduce this

patient’s fall risk?

A. Bifocal glasses
B. Cognitive-behavioral therapy for fall-related anxiety
C. Taper of temazepam
D. Lower bed
 CASE 2 (4 of 4)

Which one of the following would most likely reduce this

patient’s fall risk?

A. Bifocal glasses
B. Cognitive-behavioral therapy for fall-related anxiety
C. Taper of temazepam
D. Lower bed
 GNRS6 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF, FGSA
GNRS6 Teaching Slides modified from GRS10 Teaching Slides
based on chapter by Sarah D. Berry, MD, MPH and Douglas P. Kiel, MD, MPH
and questions by Lee A. Jennings, MD, MSHS
Managing Editor: Andrea N. Sherman, MS

Copyright © 2019 American Geriatrics Society