Geriatrics

Fall Risk Evaluation and Prevention in Older Adults

SUMMARY:

Falls are among the most common causes of morbidity and mortality in older adults, with nearly a third of community dwelling adults over the age of 65 experiencing a fall within the past year. Roughly 1 in 5 older adults sustain a head injury or fracture following a fall, and the CDC estimates that “an older adult in the US dies from a fall every 20 minutes” – a staggering statistic. Many falls and their resultant injuries can be prevented with appropriate screening, starting with identifying patients at greatest risk of falling, and then implementing appropriate prevention strategies.

Fall Risk Factors

Major risk factors
- Age ≥ 65 years | Peripheral neuropathy | Parkinson disease | Cognitive impairment | Stroke | Gait abnormality | Vertigo | Dizziness
Moderate risk factors
- Arthritis | Frailty | Orthostatic hypotension | Urinary incontinence | Visual impairment | Hearing impairment | Pain
Minor risk factors
- Diabetes | Heart disease | Low BMI (≤18.5 kg/m²) | High BMI (≥37 kg/m²)
Extrinsic risk factors
- Medications (e.g., Opiates | Anticholinergics | Antihistamines | Anxiolytics | Antidepressants | Diuretics | Beta blockers) are the most common extrinsic risk factor for falls in older adults
- Other extrinsic risk factors include: Walking barefoot | Walking in stockings | Environmental hazards (e.g., Poor lighting | Low seating | Rug/furniture tripping hazards | Bathroom hazards)

Screening

Screen all older adults (i.e., age ≥ 65 years old) or any patient with ≥ 1 major fall risk factor for risk of falling
Ask about prior falls within the past 12 months
- Prior fall history is one of the most reliable indicators for subsequent falls
Assess for any major fall risk factors (see above)
- Most common major risk factor is neurologic disease
Discuss patient’s subjective fear of falling
- Fear of falling, in the absence of prior falls, has been found to be associated with increased risk of falls in the future
Conduct a mobility screening test
- Gait Speed Measurement (see “Learn More”
- Timed Get Up and Go Test (TUG) (see “Learn More”)

Patient History and Examination

Abnormalities in any of the above screening questions should prompt further work up with a more in-depth exam based on risk factors and co-morbidities
Medication review for any meds that affect balance and coordination
- Psychoactive (Anxiolytics | Antipsychotics)
- Diabetes medications (e.g., Sulfonylureas | Insulin)
- Antihypertensives (e.g., Diuretics | Beta blockers)
- Anticholinergic (e.g., Antihistamines | Antidepressants)
Review environmental hazards in the home
- Seating too high or too low
- Tripping hazards (e.g., Rugs | Steps | Walking in socks or barefoot)
- Bathroom hazards (e.g., Slippery floors | Step into bathtub/shower | Low toilet | Lack of grab bars)
- Poor lighting
Conduct a physical exam including:
- Orthostatic vitals check
- Vision and hearing assessment
- Peripheral neuropathy
- Foot or spine deformity
- Gait speed
- Leg strength
- Short Physical Performance Battery (SPPB) score (can refer to PT for this) (see “Learn More”)

Prevention and Interventions

Prevention and intervention strategies should take a targeted approach based on findings of patient history and physical exam
Medications
- Deprescribe or lower to lowest effective dose contributing medications
- Aim for age appropriate A1c target (e.g., 7.5% to 8.5% mg/dL)
- Consider non-pharmacologic treatment when possible (e.g., Cognitive behavior therapy in lieu of antidepressants or anxiolytics | Sleep hygiene practices in lieu of medicinal sleep aides)
- Deprescribing and/or reducing contributing medications is not effective on its own at reducing fall risk, and should be combined with other interventions in a multifactorial approach
Vision Intervention
- Cataract surgery has been found to decrease fall risk and improve gait and balance
Exercise
- Physical therapy (PT) referral for exercises to improve leg strength and balance
- Studies have shown that a minimum PT “dose” of 50 exercise hours was needed to achieve significant fall prevention
- Walking programs alone were not found to be effective and may in fact increase fall risk
Environmental Modifications
- Occupational therapy (OT) home safety referral
- Install guard rails
- Nonslip bathmats
- Remove tripping hazards | Declutter
- Obtain fall alert button
Assist Devices
- Canes and walkers should be used as part of a multifactorial approach to reduce fall risk
Podiatry care
- Custom footwear can be used as part of a multifactorial approach to decrease fall risk

KEY POINTS:

Falls are a major cause of preventable morbidity and mortality in older adults
All patients over the age of 65 should be screened for fall risk, and any patients who screen positively should be further examined for contributing modifiable risk factors
First line therapy for patients at increased fall risk includes exercise programs to improve leg strength and balance
A multifactorial risk reduction approach is otherwise recommended, and should be tailored to the patient’s specific risk factors
The USPSTF recommends the following

Exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls (Grade B – offer or provide service)

Individualize the decision to offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls (Grade C – offer or provide this service for selected patients depending on individual circumstances)