Evaluation of falls in the elderly
Summary
Falls are often multifactorial in origin.[1]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 The presence of the following factors is associated with greater probability of future falls, [2]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 [3]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 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]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]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 [5]Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701-7. http://www.ncbi.nlm.nih.gov/pubmed/3205267?tool=bestpractice.com [6]Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol. 1989 Jul;44(4):M112-7. http://www.ncbi.nlm.nih.gov/pubmed/2738307?tool=bestpractice.com [7]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 [8]Luukinen H, Koski K, Laippala P, et al. Predictors for recurrent falls among the home-dwelling elderly. Scand J Prim Health Care. 1995 Dec;13(4):294-9. http://www.ncbi.nlm.nih.gov/pubmed/8693215?tool=bestpractice.com
Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment[2]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]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 [9]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 [10]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 [11]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[5]Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701-7. http://www.ncbi.nlm.nih.gov/pubmed/3205267?tool=bestpractice.com [7]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
Orthostatic hypotension[2]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]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 medications (particularly psychotropic medications)[12]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
Impairment of activities of daily living[13]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)[2]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.[2]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
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]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 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]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 [16]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) has not shown benefit in terms of reduction of falls.[17]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
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]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
One network meta-analysis found the following interventions were more effective than usual care at preventing falls that result in injuries:[19]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:
NICE - falls in older people: assessing risk and prevention external link opens in a new window
NICE: falls in older people. Quality standard external link opens in a new window
Falls are the leading cause of death due to unintentional injury in people ages 65 and older in the US.[20]Burns E, Kakara R. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018 May 11;67(18):509-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944976/ http://www.ncbi.nlm.nih.gov/pubmed/29746456?tool=bestpractice.com 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]Burns E, Kakara R. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018 May 11;67(18):509-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944976/ http://www.ncbi.nlm.nih.gov/pubmed/29746456?tool=bestpractice.com 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]Burns E, Kakara R. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018 May 11;67(18):509-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944976/ http://www.ncbi.nlm.nih.gov/pubmed/29746456?tool=bestpractice.com
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
Uncommon
- Vestibular dysfunction
- Gait disorders
- Dementia
- Delirium
- Depression
- Seizure
- Subdural hematoma
- Syncope
- Orthostatic hypotension
- Substance abuse
- Carotid sinus sensitivity
- Postprandial hypotension
Contributors
AuthorsVIEW ALL
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 reviewersVIEW ALL
Professor of Medicine
Division of Geriatric Medicine
Saint Louis University
Saint Louis
MO
Disclosures
DT declares that he has no competing interests.
Consultant Physician
Nuffield Department of Medicine
John Radcliffe Hospital
Oxford
UK
Disclosures
AD declares that he has no competing interests.
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