≥65 岁的老年人相比年轻人更可能跌倒（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
跌倒往往是多原因的。[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
对跌倒周围情况和相关症状的识别可以帮助确定潜在病因，而这些病因的发现又反过来强调了解跌倒细节的重要性。 病因的识别可以决定是否有必要进行更多的紧急的医学评价，以应对危及生命的病因及其后果。
评估跌倒风险
识别跌倒原因还有助于识别最有可能导致跌倒的危险因素，并且有助于采取恰当的干预措施来降低再次跌倒的风险。
某些因素与日后再次跌倒的可能性更高有关。[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
跌倒筛查指南建议，在实施跌倒预防策略时，识别有风险人群的这些特征可能有帮助：
运动问题：步态和平衡障碍；肌无力[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
感觉障碍：周围神经病变、前庭功能障碍、视觉障碍[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
认知或情绪障碍：痴呆、抑郁、谵妄[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
体位性低血压[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
多重用药或使用某些药物（尤其是精神类药物和阿片类药物）[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
日常活动能力障碍[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
环境危害（如松动的地毯、光线不足、杂物堆砌）[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
其他因素如年龄或伴发疾病。[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
跌倒预防策略
许多跌倒预防方案的内容包括：处理危险因素、提倡锻炼（包括力量和平衡训练）、审查用药情况、评估视力、评估居家安全性，以及在认为必要时采取干预措施。[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
然而，支持这些方案的证据基础存在不一致性。
对于跌倒风险增加的 ≥65 岁社区居住成人，美国预防服务工作组推荐采用锻炼（例如团体锻炼、太极、多元化锻炼）或物理治疗来预防跌倒，但不建议通过补充维生素 D 来预防跌倒。[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
关于对社区居住者和收容机构居住患者这一混合人群补充维生素 D（单独或搭配钙补充）的 meta 分析显示，该治疗在减少跌倒方面没有益处。[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
亚组分析发现，暂无证据表明补充维生素 D 的效果在社区居住人群和疗养机构居住人群之间存在具有统计学意义的差异。[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
然而，一项针对在疗养机构和医院开展的研究的 Cochrane 评价发现，补充维生素 D 可能会减少疗养院内发生跌倒的次数，但未降低跌倒风险（证据质量中等）。[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
Cochrane 评价中评估的所有其他干预措施（包括锻炼、补充维生素 D、一般药物治疗或多方面干预）都与证据不足或者得出的结论不确定有关。[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
一项 Cochrane 系统评价发现，与常规治疗或注意力控制相比，多元干预措施（抛开所有对跌倒风险的评估，为所有人提供相同组分的干预措施；其中大多数干预包括锻炼）可能减少生活在社区的老年人跌倒次数和摔倒风险。另外还发现，与常规治疗或注意力控制相比，多因素干预措施（根据对跌倒风险的评估，不同人的组分干预措施有所不同）可能减少社区老年人的跌倒次数。[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/full展示答案
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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/full展示答案
随后一项 Cochrane 评价得出了具有高度确定性的结论，即锻炼（主要包括平衡锻炼和功能锻炼）可降低跌倒发生率，并能减少社区居住老人发生跌倒的次数。[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
可能减少跌倒的锻炼方案包括多种锻炼类型（通常是平衡锻炼和功能锻炼，联合抗阻训练）和太极拳。[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
尚不确定单独抗阻训练、跳舞或行走的效果。[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
关于 65 岁及以上人群的跌倒预防干预措施的网络 meta 分析发现，以下干预措施在预防导致受伤的跌倒方面比常规护理更有效：[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
若干指南已对采用此类干预措施预防跌倒进行评估：
从 2017 年到 2018 年，与 ≥65 岁患者跌倒相关的急诊科入院次数超过 200,000 次，其中三分之二患者的年龄 ≥80 岁。[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
跌倒是 2013 年英国人受伤的主要原因。[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
髋部骨折与 1 年死亡率增加 18%-33% 有关，而且影响日常生活活动，例如购物和行走。
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