Evaluation of falls in the elderly

Last reviewed: February 2019

Last updated: January 2019

Summary

Falls are often multifactorial in origin. [1] The presence of the following factors is associated with greater probability of future falls, [2] [3] and falls screening guidelines suggest identification of these characteristics in at-risk people can be useful in the implementation of falls prevention strategies:

Motor problems: gait or balance impairment; muscle weakness [2] [4] [5] [6] [7] [8]
Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment [2] [4] [9] [10] [11]
Cognitive or mood impairment: dementia, depression, delirium [5] [7]
Orthostatic hypotension [2] [4]
Polypharmacy or certain medications (particularly psychotropic medications) [12]
Impairment of activities of daily living [13]
Environmental hazards (e.g., loose rugs, poor lighting, clutter) [2]
Additional factors such as age or comorbid illnesses. [2]

Key components of many fall-prevention programs include addressing the risk factors, advocating exercise (including strength and balance training), review of medications taken, vision assessment, and a home safety assessment, with modifications as deemed necessary. [14] The United States Preventive Services Task Force, for example, recommends exercise (e.g., group exercise, tai chi, multicomponent exercises) or physical therapy for prevention of falls in community-dwelling adults ≥65 years of age who are at increased risk of falls. [15] [16] Meta-analyses of vitamin D supplementation (alone or with calcium) has not shown benefit in terms of reduction of falls. [17]

One Cochrane systematic review found that multiple component interventions (that offer 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. It 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. [18]

One network meta-analysis found the following interventions were more effective than usual care at preventing falls that result in injuries: [19]

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:

Falls are the leading cause of death due to unintentional injury in people ages 65 and older in the US. [20] One in four older adults report falling at least once yearly, leading to approximately 3 million emergency department visits. Data collected from 2007 to 2016 demonstrate that this rate has been increasing by approximately 3% per year. [20] Almost all age and demographic categories experienced an increase, but the greatest increase was noted in individuals ages 85 and older. The death rate from falls was also higher in this age group. [20]

Identifying the circumstances surrounding, and the symptoms associated with, a fall helps to determine the underlying cause, which in turn emphasizes 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. This investigation will also help to identify the risk factor(s) most likely to be contributing to falls and allow the implementation of appropriate interventions to reduce the risk of future falls.

Differentials

Common

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

Full details

Uncommon

Vestibular dysfunction
Gait disorders
Dementia
Delirium
Depression
Seizure
Subdural hematoma
Syncope
Orthostatic hypotension
Substance abuse
Carotid sinus sensitivity
Postprandial hypotension

Full details

Contributors

Authors VIEW ALL 

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 VIEW ALL 

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.

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Evaluation of falls in the elderly

Summary

Differentials

Common

Uncommon

Contributors

Authors VIEW ALL 

Ronan Factora, MD, FACP, AGSF

Disclosures

Peer reviewers VIEW ALL 

David Thomas, MD

Disclosures

Adam Darowski, MA, MBBS, MD, FRCP

Disclosures

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