MOUNT SINAI JOURNAL OF MEDICINE 78:590–595, 2011 590

Falls in Older AdultsSara M. Bradley, MD

Mount Sinai School of Medicine, New York, NY

OUTLINE

IDENTIFYING PATIENTS AT RISK

PATIENT ASSESSMENT

INTERVENTIONS TO PREVENT FALLS

MULTIFACTORIAL INTERVENTIONS

INTERVENTIONS FOR ACUTE AND LONG-TERM CARE

CONCLUSION

ABSTRACT

Falls are prevalent among older adults and can leadto injury, hospitalization, and increased healthcarecosts. Environmental hazards, medications, visionproblems, and impairments in strength, gait, orbalance can increase fall risk. A multifactorial fall-riskassessment including a fall history, physical exam,gait and balance evaluation, and environmentalassessment is recommended for all older adultswho present with a fall or problem with gaitor balance. Multiple-component exercise programs,tai chi, vitamin D supplementation, withdrawalof psychotropic medications, and early cataractsurgery have all been shown to reduce fall rates.Multifactorial interventions that include medicationreview, vision correction, management of orthostasis,environmental modification, and balance, strength,and gait training can also be beneficial in preventingfalls. Mt Sinai J Med 78:590–595, 2011. 2011Mount Sinai School of Medicine

Key Words: fall prevention, falls, older adults.

The Prevention of Falls Network Europe (ProFANE)group has defined a fall as ‘‘an unexpected eventin which the participant comes to rest on theground, floor, or lower level.’’1 Approximately one-third of adults aged >65 years experience a fall

Address Correspondence to:

Sara M. BradleyMount Sinai School of Medicine

New York, NYEmail: sara.bradley@mssm.edu

every year resulting in significant morbidity andmortality.2 Fall-related injuries among older adultsaccounted for 2.2 million emergency room visits and>580,000 hospitalizations in 2009 in the United Statesalone.2

Fall-related injuries among olderadults accounted for 2.2 millionemergency room visits and>580,000 hospitalizations in2009 in the United States alone.

About 30%–50% of these falls result in minorinjuries such as bruises or lacerations, and 10% resultin major injuries such as fractures or traumatic braininjury (TBI).3 Hip fractures result from about 1% offalls although 90% of hip fractures are caused by afall.3 This is particularly serious because the 1-yearmortality after a hip fractures approaches 25%, and ofthose surviving, only half regain their baseline abilityto perform their activities of daily living (ADL).4 Fallsare also the most common cause of TBI in olderadults, which accounts for 46% of all deaths due tofalling.2

Additionally, half of those who fall are unableto get up on their own afterward, which can leadto dehydration, rhabdomyolysis, pressures sores, andpneumonia. In one prospective cohort study of adultsaged >90 years, 60% fell in 1 year. Eighty percent ofthose who fell were unable to get up afterward, and30% were on the floor >1 hour.5 Many who fallwill also develop a fear of falling, and up to 40%will restrict their activities as a result.6,7 This furtherdecreases their physical fitness, causes social isola-tion and depression, and leads to an even higher riskof falling.

Furthermore, falls are the major reason for40% of nursing home placements and contributeto increased healthcare costs.3 In the United States,total direct medical costs for fall-related injuriesamong older adults were >$19 billion in 2000.8 Thisexpected to approach $55 billion by 2020 as thepopulation ages.8

Published online in Wiley Online Library (wileyonlinelibrary.com).DOI:10.1002/msj.20280

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IDENTIFYING PATIENTS AT RISK

Older adults are predisposed to falling becauseof multiple comorbid conditions and age-relatedphysiologic decline.9,10 Most falls result from theinteraction between this individual susceptibil-ity and environmental hazards or activities thatincrease risk.9 For community-dwelling older adults,these hazards may include poor lighting, loosecarpet, stairwells, bathtubs without grab bars,cords or clutter obstructing walking paths, orunsafe footwear.3 In the nursing home or hospital,hazards often include wet surfaces, restraints,bedrails, or tethers such as oxygen tubing orcatheters.9

Many factors have been identified that contributeindependently to a patient’s risk of falling or expe-riencing a fall-related injury. Not surprisingly, a per-son’s risk of falling increases with an increasing num-ber of risk factors, from an 8% risk of falling with zerorisk factors to a 78% risk with ≥4.11 However, somerisk factors are associated with a higher relative riskof falling than others. One univariate analysis of riskfactors from 16 studies found that lower-extremitymuscle weakness increased the odds of falling by4×, and gait and balance impairments and having hadprevious falls increased the odds of falling by 3×.9

Other risk factors, such as vision problems, arthritis,cognitive impairment, depression, and age >80 yearsdoubled the risk of falling.9 A recent systematicreview found that previous falls, medications, andimpairments in strength, gait, and balance were therisk factors that were the most highly correlated withfalling.10

Previous falls, medications, andimpairments in strength, gait,and balance were the riskfactors that were the mosthighly correlated withfalling.

Polypharmacy, defined as using >4 medica-tions, and the use of certain classes of medicationsalso increase fall risk.9 A meta-analysis evaluat-ing the effect of 9 medication classes on risk offalling in older adults found the use of sedativesand hypnotics, antidepressants, and benzodiazepinessignificantly associated with falls.12 Antidepressantswere the most strongly associated with falling, withan odds ratio of 1.68. Of note, narcotics were theclass least associated with falling, with an odds ratioof 0.96.12

PATIENT ASSESSMENT

The Assessing Care of Vulnerable Elders (ACOVE)project is a collaboration between RAND Health andPfizer Inc. that has created evidence-based measuresfor the assessment and quality improvement of thecare provided to older adults.13 The ACOVE projectadvocates that all vulnerable elders should be askedat least annually about falls; ACOVE also recom-mends a multifactorial fall-risk assessment for thosereporting a history of ≥2 falls or 1 injurious fall in thepast year.14 The American Geriatrics Society (AGS)and British Geriatrics Society (BGS) recently updatedtheir Guidelines for Prevention of Falls in Older Per-son. The AGS and BGS also recommend that olderadults be asked annually about frequency of fallsand problems with walking or balance. A multifacto-rial fall-risk assessment is recommended for all olderadults presenting with a fall, or who have or reporthaving a gait or balance problem.15

The multifactorial fall-risk assessments advo-cated by these organizations and other authorsinclude a basic fall history, a physical examinationincluding a gait and balance evaluation, and an envi-ronmental assessment. The fall history should includequestions about circumstances of falls, associatedsymptoms, injuries, chronic medical conditions, med-ication review, substance use, and ability to performADLs.14–17 The AGS/BGS guidelines also recommendasking about perceived functional ability and fear offalling. The physical exam should include evaluationof orthostatic vital signs, visual acuity, the cardiac sys-tem, muscle strength and range of motion, neurologicfunction including proprioception and vibration, gait,balance, and cognitive status.10,14–17

Multifactorial fall-risk assessmentsinclude a basic fall history, aphysical exam including a gaitand balance evaluation, and anenvironmental assessment.

Numerous fall-risk assessment tools have beendeveloped to help assess gait and balance and esti-mate fall risk. One systematic review compared thevalidity and reliability of these tools used in com-munity, long-term care, and acute-care settings toassess fall risk.18 The review found the strongestpredictive validity for the 5-step test, the 5-minutewalk, and the Functional Reach in the communitysetting; the Mobility Fall Chart in long-term care; andthe fall-risk assessment and St. Thomas Risk Assess-ment Tool (STRATIFY) tools in acute care.18 Other

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authors recommend the timed ‘‘Get Up and Go’’ testbecause it can be easily and rapidly used in a varietyof settings.10,15 The Performance-Oriented MobilityAssessment has also been advocated as a more for-mal gait and balance assessment, but it is also moretime-intensive.10,15,17

Two of the main reasons clinicians cite for notincorporating fall-risk assessments into routine careare time and competing priorities.19 For this reason,the Functional Reach and the Get Up and Go testsare particularly useful to screen for balance and gaitdisorders, as both require only a few minutes toadminister.

The Functional Reach and the GetUp and Go tests are particularlyuseful to screen for balance andgait disorders, as both require onlya few minutes to administer.

The Functional Reach involves mounting a yard-stick on a wall at shoulder height. The patientis asked to stand close to the wall with his armoutstretched and is directed to reach as far for-ward as he can without taking a step, keepingthe arm at the level of the yardstick.20 A score of<8 inches is indicative of limited functional balanceand has sensitivity of 73% and specificity of 88% forpredicting fallers from nonfallers.18 A video demon-stration of the test being administered is availableat http://www.youtube.com/watch?v= aJqJzt-U2s. Inthe Get Up and Go test, the patient is asked to risefrom a chair without using his arms, walk 10 feet,turn around, walk back, and sit down again.21

The patient is observed for postural stability, step-page, stride length, and sway.21 Those unable tocomplete this test or demonstrate unsteadiness per-forming it require referral to physical therapy forfurther evaluation.10,21 Video instruction on how toperform the Get Up and Go test is available online athttp://www.reynolds.med.arizona.edu/EduProducts/podcasts/GetUpAndGo.cfm.

Expert opinion recommends that routine evalu-ation of patients who have fallen or are identifiedas at high risk of falling should include labora-tory tests of serum chemistry, complete blood count,vitamin B12 level, thyroid function studies, and anelectrocardiogram.16 Additional neuroimaging stud-ies to evaluate for ischemic disease or hydrocephalus,electroencephalogram for seizure activity, or cardiacmonitoring for arrhythmia are only indicated if thehistory or physical exam is highly suggestive of theseconditions.16 However, the use of laboratory tests

and additional studies in evaluation of patients whofall has not been extensively evaluated.16

INTERVENTIONS TO PREVENT FALLS

Several individual interventions have been shownto effectively prevent falls. Exercise is one of themost commonly prescribed and most frequentlystudied interventions. One meta-analysis found thatexercise interventions could prevent falls and weremost effective when they included a higher doseof exercise and exercises to challenge balance,and did not include a walking program.22 Anothermeta-analysis found that exercise interventions wereeffective in preventing falls if they targeted ≥2of 4 components: strength, balance, flexibility, orendurance.23 Multiple-component exercise programsdone in groups or individually at home were foundto decrease falls rates by 22% and 44%, respectively.Tai chi group exercise, which involves balance andstrength training, was also found to decrease rates offalling by 47%.23

Vitamin D supplementation has been shownto prevent falls in several studies, although whichpatients are most likely to benefit from supplementa-tion, the ideal dose, and target serum concentrationremain controversial. A meta-analysis by Gillespieet al. found that supplementation did not signifi-cantly reduce the rate of falls except in patientswith low serum levels of 25-hydroxyvitamin D.23

On the contrary, several other meta-analyses foundsupplementation of all older adults to be beneficial.Bischoff-Ferrari et al. found that 700–1000 IU per dayof vitamin D decreased risk of falling by 19%.24 Morerecently, Kalyani et al. found 200–1000 IU per dayresults in 14% fewer falls.25 In these analyses, adverseeffects such as hypercalcemia were rare.23 The num-ber needed to treat with vitamin D to prevent 1person from falling was only 15.23,26 The AGS/BGSGuidelines for Prevention of Falls in Older Personsnow recommend 800 IU of vitamin D daily for allolder adults at risk of falling.15

The American and Britishgeriatric societies’ Guidelines forPrevention of Falls in OlderPersons now recommend 800 IUof vitamin D daily for all olderadults at risk of falling.

Other medication interventions have been foundto prevent falls. One randomized controlled study of

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gradual withdrawal of psychotropic medications inadults aged >65 years reduced rate of falls by 66%.27

Additionally, an intensive prescription review pro-gram reduced risk of falling by 39% in one study.28

This intervention included prescriber education, med-ication review, feedback on prescribing practices,financial incentives, and a medication-risk assessmentcompleted by patients.28

The gradual withdrawal ofpsychotropic medications inadults aged >65 years reducedrate of falls by 66%.

Nonsurgical vision correction alone has not beenshown to prevent falls, and may even increase fallrisk.15,29 However, one trial of expedited first cataractsurgery, within 4 weeks versus 12 months, decreasedthe risk of recurrent falls by 40%, all falls by 34%,and the relative risk of fracture by 67%.30 Within6 months, the intervention group had significantlydecreased disability and improved quality of life.30

The number needed to treat with early cataractsurgery to prevent 1 fall was only 19. Subsequently,a trial of having a cataract surgery on the second eyewas not found to have additional benefit in reducingfall rates.31

Home hazard interventions involve assessmentof a patient’s home to remove things that contributeto fall risk, such as area rugs or clutter, and to pro-vide safety measures such as grab bars or improvedlighting. A meta-analysis found that home hazardmodification did not significantly reduce fall ratesexcept in those with severe vision impairments.23

Although, in a subgroup analysis of patients at higherrisk of falling, the intervention did reduce rates of fallsand risk of falling.23 A more recent meta-analysisfound insufficient evidence that modification of thehome environment reduced injuries, but called forfurther evaluation of these interventions with largerrandomized controlled trials.32 The AGS/BGS Guide-lines for Prevention of Falls in Older Persons dorecommend home safety interventions for those witha previous fall history or other fall risk factors.15

MULTIFACTORIAL INTERVENTIONS

Because falls result from impairments in multipledomains, interventions to prevent falls need toaddress >1 of those areas. Two types of inter-ventions that target >1 risk factor have been stud-ied: multicomponent and multifactorial interventions.

In multicomponent interventions, all participantsreceive a fixed set of interventions. In multifactorialinterventions, participants receive different combina-tions of interventions based on individual fall-riskassessment.23 Despite studies of these interven-tions having mixed results, several meta-analyseshave concluded that this approach was benefi-cial for community-dwelling older adults and wasmost effective when involving direct implementationof interventions, and not just recommendations orreferrals.10,15,23,29,33

The areas targeted by these multifactorial inter-ventions that have the most impact are bal-ance, strength, and gait training; medication reviewand reduction; management of orthostasis; envi-ronmental adaptation; and correction of visionimpairment.10,14–16 The AGS/BGS guidelines recom-mend that all such interventions should includeexercise, such as physical therapy or tai chi. Table 1gives an example of a multifactorial approach andintervention.

Within multifactorialinterventions, the areas that havethe most impact are balance,strength, and gait training;medication review and reduction;management of orthostasis;environmental adaptation; andcorrection of vision impairment.

Population-based interventions are programs inwhich fall-prevention interventions are introducedto entire communities, using measures such aspolicy development, home visits, engagement oflocal health professionals, and education throughbrochures, posters, television, or radio. The entirecommunity then shares responsibility for uptake offall-prevention measures, with the goal of reduc-ing injury rates in the population as a whole.34 Asystematic review of 6 prospective nonrandomizedcontrolled trials of population-based interventionsfound a significant decrease or downward trend infall-related injuries, with the relative reduction infall-related injuries ranging from 6% to 33%.34 Themost successful of these programs, which engagedlocal physicians, nurses, and home-care workers,decreased lower-extremity fractures by 33%. Theintervention included education, promotion of men-tal and physical activity, home visits and home hazardremoval, medication management, and treatment ofmedical and psychiatric illness.34

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594 S. M. BRADLEY.: FALLS IN OLDER ADULTS

Table 1. Multifactorial Intervention for Fall Prevention.

Risk Factor Provider Intervention Patient Education

Polypharmacy(≥4medications)

Review and reduce medications at everyvisit, particularly psychotropics. Suggestnonpharmacological treatments, such asdiet and exercise, whenever possible.

Keep an updated medication list, includingover-the-counter medicines, and bring it toevery visit with all healthcare providers.Use a pillbox to avoid medication errors.Take vitamin D 800 IU daily.

Balance or gaitinstability

Refer to physical therapy for strength,balance, and gait training. Recommendtai chi. Prescribe an assistive device(such as cane or walker) and reviewpatient’s use of it.

Use assistive devices as prescribed. Wearshoes that cover the entire foot, with thinsole and low heel. Consider an emergencycall device to use in case of a fall.

Posturalhypotension

Check orthostatic vital signs. Reducemedications that may contribute.Liberalize salt in patient’s diet.

Drink sufficient water every day. Take yourtime when changing positions. Trycompression stockings.

Visionimpairment

Ask about vision problems, such asdifficulty driving, watching TV, orreading due to poor vision. Test visualacuity and consider ophthalmologyreferral.

Have your vision checked. Do not wearreading glasses when walking.

Home hazards Do home visit or refer to visiting nurse toassess home safety. Give patient orcaregiver checklist to assess home safety.

Make sure home is well-lit and usenightlights. Install handrails on both sidesof stairs and grab bars in bathrooms. Usebathmats or nonslip strips in bathroom.Remove slippery throw rugs.

INTERVENTIONS FORACUTE AND LONG-TERM CARE

In the acute-care setting, individual interventionsused to prevent falls such as rails, restraints, fall-alert bracelets, and bed alarms have not been clearlyproven beneficial and may actually increase fallrisk.35–37 Hospital fall-prevention programs have alsonot been shown to reduce fall rates.38 However,one meta-analysis that included subacute and rehabwards in addition to acute care did find multifactorialinterventions effective in decreasing the rate of fallsby 31% and the risk of falling by 27%.36 In thesubacute setting, supervised exercise was found todecrease the risk of falling by 66%.36

In long-term care, fall-prevention interventionshave had conflicting results.15,36 Multifactorial inter-ventions were not found to be effective in this setting,except when provided by an interdisciplinary team,in which case they did decrease the rate of falls by40%.36 Vitamin D supplementation also decreasedrate of falls by 28%.36 Studies of supervised exercisein this setting yielded inconsistent results.36

CONCLUSION

Falls are prevalent among older adults and can leadto injury, hospitalization, and increased healthcarecosts. Environmental hazards, medications, visionproblems, and impairments in strength, gait, or

balance can increase fall risk. A multifactorial fall-risk assessment, including a fall history, physicalexam, gait and balance evaluation, and environ-mental assessment, is recommended for all olderadults who present with a fall or problem with gaitor balance. Multiple-component exercise programs,tai chi, vitamin D supplementation, withdrawal ofpsychotropic medications, and early cataract surgeryhave all been shown to reduce fall rates. Multifac-torial interventions that include medication review,vision correction, management of orthostasis, envi-ronmental modification, and balance, strength, andgait training can also be beneficial in preventing falls.

DISCLOSURES

Potential conflict of interest: Nothing to report.

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