Assessment of falls in the elderly

Last reviewed: 25 Aug 2022

Last updated: 31 Mar 2021

Older adults aged ≥65 years are more likely to fall than younger adults (OR 2.84 [1.77-4.53]).[1] Falls are often multifactorial in origin.[2] Identifying the circumstances surrounding, and the symptoms associated with, a fall helps to determine the underlying cause, which in turn emphasises the importance of obtaining a detailed history of the fall. Identifying the cause will determine whether a more urgent medical evaluation is necessary to address life-threatening causes of falls and their consequences.

Fall-risk assessment

Identifying the cause of a fall will also help to identify the risk factor(s) most likely to be contributing to falls and facilitate appropriate interventions to reduce the risk of future falls.

The presence of certain factors is associated with greater probability of future falls.[3][4] Falls screening guidelines suggest that identifying these characteristics in at-risk people can be useful when implementing falls prevention strategies:

Motor problems: gait or balance impairment; muscle weakness[3][5][6][7]
Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment[3][5][8][9][10]
Cognitive or mood impairment: dementia, depression, delirium[6][7]
Orthostatic hypotension[3][5]
Polypharmacy or certain medicines (particularly psychotropic medicines and opioids)[11][12][13]
Impairment of activities of daily living[14]
Environmental hazards (e.g., loose rugs, poor lighting, clutter)[3]
Additional factors such as age or comorbid illnesses.[3]

Fall-prevention strategies

Components of many fall-prevention programmes include addressing the risk factors, advocating exercise (including strength and balance training), reviewing medicines, assessing vision, and assessing home safety, with interventions as deemed necessary.[15] However, the evidence base supporting these programmes is inconsistent.

The US Preventive Services Task Force recommends exercise (e.g., group exercise, Tai Chi, multicomponent exercises) or physical therapy for the prevention of falls in community-dwelling adults aged ≥65 years who are at increased risk of falls, but does not recommend vitamin D supplementation for the prevention of falls.[16][17] Meta-analyses of vitamin D supplementation (alone or with calcium) in mixed populations of community-dwelling individuals and institutionalised patients have not shown benefit in terms of reduction of falls.[18][19] Subgroup analysis found no evidence that the effects of vitamin D supplementation varied significantly between community-dwelling populations and those in residential care.[19] However, in one Cochrane review of studies conducted in care facilities and hospitals, vitamin D supplementation was found to probably reduce the number, but not the risk, of falls in care homes (moderate-quality evidence).[20] All other interventions examined in the Cochrane review (including among others: exercise, vitamin D supplementation, general medication, or multifactorial interventions) were associated with a paucity of evidence or uncertainty around any conclusions that might be drawn.[20]

One Cochrane systematic review found that multiple component interventions (offering the same component interventions to all people without taking into account any assessment of risk of falls; most of which include exercise) may reduce the number of falls, and the risk of falling, compared with usual care or attention control in older people living in the community. The review also found that multifactorial interventions (component interventions that differ between people depending on their assessment of risk of falls) may reduce falls in older people in the community compared with usual care or attention control.[21] [ ] [ ]

A subsequent Cochrane review concluded with high certainty that exercise (primarily involving balance and functional exercises) reduces the rate of falls and the number of community-dwelling older people experiencing falls.[22] Exercise programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises, plus resistance exercises) and Tai Chi.[22][23] The effectiveness of resistance exercise alone, dance, or walking remained uncertain.[22]

Network meta-analysis of fall-prevention interventions for people aged 65 years and older found that the following were more effective than usual care at preventing falls that result in injuries:[24]

Exercise
Combined exercise, vision assessment and treatment
Combined exercise, vision assessment and treatment, environmental assessment and modification
Combined clinic-level quality-improvement strategies (e.g., case management), multifactorial assessment and treatment, calcium and vitamin D supplementation.

Several guidelines have examined the implementation of such interventions to prevent falls:

From 2017 to 2018 there were more than 200,000 accident and emergency hospital admissions related to falls in patients aged ≥65 years, with two-thirds of these patients aged ≥80 years.[25] Falls were the leading cause of injury in England in 2013.[26] Hip fracture has been associated with an increased 1-year mortality of between 18% and 33%, and affects daily living activities such as shopping and walking.

Differentials

Common

Stroke
Transient ischaemic attack
Joint buckling/instability/mechanical gait disorders
Deconditioning
Medicine effects or polypharmacy
Environmental or home hazards
Visual impairment
Peripheral sensory neuropathy

Full details

Uncommon

Vestibular dysfunction
Gait disorders
Dementia
Delirium
Depression
Seizure
Subdural haematoma
Syncope
Orthostatic hypotension
Substance abuse
Carotid sinus sensitivity
Post-prandial hypotension

Full details

Contributors

Authors

Ronan Factora, MD, FACP, AGSF

Assistant Professor

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University

Geriatric Medicine Fellowship Program Director

Center for Geriatric Medicine, Medicine Institute

Cleveland Clinic

Cleveland

Disclosures

RF is a Pfizer stockholder.

Peer reviewers

David Thomas, MD

Professor of Medicine

Division of Geriatric Medicine

Saint Louis University

Saint Louis

Disclosures

DT declares that he has no competing interests.

Adam Darowski, MA, MBBS, MD, FRCP

Consultant Physician

Nuffield Department of Medicine

John Radcliffe Hospital

Oxford

Disclosures

AD declares that he has no competing interests.

Guidelines
- Professional resources: fall prevention guidelines, training and tools
- Occupational therapy in the prevention and management of falls in adults: practice guideline
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Assessment of falls in the elderly

Summary

Differentials

Common

Uncommon

Contributors

Authors

Ronan Factora, MD, FACP, AGSF

Disclosures

Peer reviewers

David Thomas, MD

Disclosures

Adam Darowski, MA, MBBS, MD, FRCP

Disclosures

Guidelines

Patient leaflets

Calculators

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice