Evaluation of falls in the elderly

Last reviewed: 15 Sep 2021

Last updated: 31 Mar 2021

Older adults ages ≥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 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.

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 medications (particularly psychotropic medications 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 programs include addressing the risk factors, advocating exercise (including strength and balance training), reviewing medications, assessing vision, and assessing home safety, with interventions as deemed necessary.[15] However, the evidence base supporting these programs 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 ages ≥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 institutionalized 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 programs 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 ages 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:

Falls are the leading cause of death due to unintentional injury in people ages ≥65 in the US.[25] 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.[25] 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.[25]

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

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.

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Differentials

Common

Uncommon

Contributors

Authors

Ronan Factora, MD, FACP, AGSF

Disclosures

Peer reviewers

David Thomas, MD

Disclosures

Adam Darowski, MA, MBBS, MD, FRCP

Disclosures

Patient leaflets

Videos

Evaluation 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

Patient leaflets

Videos