Assessment of falls in the elderly
- Overview
- Theory
- Emergencies
- Diagnosis
- Resources
Summary
Older adults aged ≥65 years are more likely to fall than younger adults (OR 2.84 [1.77-4.53]).[1]Just KS, Dormann H, Schurig M, et al. The phenotype of adverse drug effects: do emergency visits due to adverse drug reactions look different in older people? Results from the ADRED study. Br J Clin Pharmacol. 2020 Nov;86(11):2144-54. https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.14304 http://www.ncbi.nlm.nih.gov/pubmed/32250457?tool=bestpractice.com Falls are often multifactorial in origin.[2]Deandrea S. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010 Sep;21(5):658-68. http://www.ncbi.nlm.nih.gov/pubmed/20585256?tool=bestpractice.com 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]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [4]McInnes L, Gibbons E, Chandler-Oatts J. Clinical practice guideline for the assessment and prevention of falls in older people. Worldviews Evid Based Nurs. 2005;2(1):33-6. http://www.ncbi.nlm.nih.gov/pubmed/17040554?tool=bestpractice.com 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]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [5]Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. http://www.ncbi.nlm.nih.gov/pubmed/17200478?tool=bestpractice.com [6]Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the Chinese elderly. Ann Acad Med Singapore. 2005 Jan;34(1):60-72. http://www.annals.edu.sg/pdf200502/ChuW.pdf http://www.ncbi.nlm.nih.gov/pubmed/15726221?tool=bestpractice.com [7]Centers for Disease Control and Prevention. Fact sheet: risk factors for falls. 2017 [internet publication]. https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf
Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment[3]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [5]Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. http://www.ncbi.nlm.nih.gov/pubmed/17200478?tool=bestpractice.com [8]Bergland A, Jarnlo GB, Laake K. Predictors of falls in the elderly by location. Aging Clin Exp Res. 2003 Feb;15(1):43-50. http://www.ncbi.nlm.nih.gov/pubmed/12841418?tool=bestpractice.com [9]Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975 Oct;23(10):433-41. http://www.ncbi.nlm.nih.gov/pubmed/1159263?tool=bestpractice.com [10]Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. 2004 May;111(5):857-62. http://www.ncbi.nlm.nih.gov/pubmed/15121359?tool=bestpractice.com
Cognitive or mood impairment: dementia, depression, delirium[6]Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the Chinese elderly. Ann Acad Med Singapore. 2005 Jan;34(1):60-72. http://www.annals.edu.sg/pdf200502/ChuW.pdf http://www.ncbi.nlm.nih.gov/pubmed/15726221?tool=bestpractice.com [7]Centers for Disease Control and Prevention. Fact sheet: risk factors for falls. 2017 [internet publication]. https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf
Orthostatic hypotension[3]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [5]Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. http://www.ncbi.nlm.nih.gov/pubmed/17200478?tool=bestpractice.com
Polypharmacy or certain medicines (particularly psychotropic medicines and opioids)[11]Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci. 2007 Oct;62(10):1172-81. http://www.ncbi.nlm.nih.gov/pubmed/17921433?tool=bestpractice.com [12]Taipale H, Hamina A, Karttunen N, et al. Incident opioid use and risk of hip fracture among persons with Alzheimer disease: a nationwide matched cohort study. Pain. 2019 Feb;160(2):417-23. https://journals.lww.com/pain/Fulltext/2019/02000/Incident_opioid_use_and_risk_of_hip_fracture_among.15.aspx http://www.ncbi.nlm.nih.gov/pubmed/30325873?tool=bestpractice.com [13]Izza MAD, Lunt E, Gordon AL, et al. Polypharmacy, benzodiazepines, and antidepressants, but not antipsychotics, are associated with increased falls risk in UK care home residents: a prospective multi-centre study. Eur Geriatr Med. 2020 Dec;11(6):1043-50. https://link.springer.com/article/10.1007/s41999-020-00376-1 http://www.ncbi.nlm.nih.gov/pubmed/32813154?tool=bestpractice.com
Impairment of activities of daily living[14]Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969 Autumn;9(3):179-86. http://www.ncbi.nlm.nih.gov/pubmed/5349366?tool=bestpractice.com
Environmental hazards (e.g., loose rugs, poor lighting, clutter)[3]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com
Additional factors such as age or comorbid illnesses.[3]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com
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]Centers for Disease Control and Prevention. Home and recreational safety: older adult falls. Feb 2017 [internet publication]. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 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]US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, et al. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. JAMA. 2018 Apr 24;319(16):1696-704. https://jamanetwork.com/journals/jama/fullarticle/2678104 http://www.ncbi.nlm.nih.gov/pubmed/29710141?tool=bestpractice.com [17]Guirguis-Blake JM, Michael YL, Perdue LA, et al. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018 Apr 24;319(16):1705-16. https://jamanetwork.com/journals/jama/fullarticle/2678103 http://www.ncbi.nlm.nih.gov/pubmed/29710140?tool=bestpractice.com 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]Bolland MJ, Grey A, Gamble GD, et al. Vitamin D supplementation and falls: a trial sequential meta-analysis. Lancet Diabetes Endocrinol. 2014 Jul;2(7):573-80. http://www.ncbi.nlm.nih.gov/pubmed/24768505?tool=bestpractice.com [19]Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. 2018 Nov;6(11):847-58. http://www.ncbi.nlm.nih.gov/pubmed/30293909?tool=bestpractice.com Subgroup analysis found no evidence that the effects of vitamin D supplementation varied significantly between community-dwelling populations and those in residential care.[19]Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. 2018 Nov;6(11):847-58. http://www.ncbi.nlm.nih.gov/pubmed/30293909?tool=bestpractice.com 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]Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2018 Sep 7;9(9):CD005465. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005465.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/30191554?tool=bestpractice.com 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]Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2018 Sep 7;9(9):CD005465. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005465.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/30191554?tool=bestpractice.com
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]Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2018 Jul 23;(7):CD012221.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012221.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/30035305?tool=bestpractice.com
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Can multifactorial interventions help prevent falls among older people living in the community?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2296/fullShow me the answer
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Can multicomponent interventions help prevent falls among older people living in the community?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2295/fullShow me the answer
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]Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD012424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/30703272?tool=bestpractice.com Exercise programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises, plus resistance exercises) and Tai Chi.[22]Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD012424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/30703272?tool=bestpractice.com [23]Li F, Harmer P, Fitzgerald K, et al. Effectiveness of a therapeutic Tai Ji Quan intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: a randomized clinical trial. JAMA Intern Med. 2018 Oct 1;178(10):1301-10. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2701631 http://www.ncbi.nlm.nih.gov/pubmed/30208396?tool=bestpractice.com The effectiveness of resistance exercise alone, dance, or walking remained uncertain.[22]Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD012424. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012424.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/30703272?tool=bestpractice.com
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]Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. JAMA. 2017 Nov 7;318(17):1687-99 http://www.ncbi.nlm.nih.gov/pubmed/29114830?tool=bestpractice.com
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:
US Preventive Services Task Force: osteoporosis to prevent fractures: screening Opens in new window
NICE - falls in older people: assessing risk and prevention Opens in new window
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]Public Health England. Public health profiles [internet publication]. https://fingertips.phe.org.uk/search/falls#page/0/gid/1/pat/6/par/E12000004/ati/302/are/E06000015/cid/4/page-options/ovw-do-0 Falls were the leading cause of injury in England in 2013.[26]Public Health England. Guidance - Falls: applying All Our Health. 31 January 2020 [internet publication]. https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health 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
Uncommon
- Vestibular dysfunction
- Gait disorders
- Dementia
- Delirium
- Depression
- Seizure
- Subdural haematoma
- Syncope
- Orthostatic hypotension
- Substance abuse
- Carotid sinus sensitivity
- Post-prandial hypotension
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
OH
Disclosures
RF is a Pfizer stockholder.
Peer reviewers
David Thomas, MD
Professor of Medicine
Division of Geriatric Medicine
Saint Louis University
Saint Louis
MO
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
UK
Disclosures
AD declares that he has no competing interests.
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- 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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