II. Epidemiology

  1. Falls occur in >25-30% of age over 65 years in community each year
    1. Results in 7 million injuries per year
  2. Serious injury occurs in >20% of falls in older adults
    1. Results in 27,000 deaths per year
  3. Most falls occur in and around the patient's home

III. Risk Factors: Falls

  1. Environmental hazards (most common)
  2. Age over 80 years old
  3. Female gender
  4. History of prior falls or Fractures
  5. Hospital discharge in the last month
  6. Altered gait or balance
    1. Parkinsonism
    2. Peripheral Neuropathy
    3. Dizziness or Vertigo
    4. Syncope
  7. Lower extremity Muscle Weakness
  8. History of Cerebrovascular Accident or transient ischemia attack
  9. Postural Hypotension
  10. Decreased visual acquity
  11. Arthritis
  12. Dementia or Altered Level of Consciousness
  13. Major Depression
  14. Alcohol Abuse
  15. Diabetes Mellitus
  16. Vitamin D Deficiency
  17. Medication use (especially more than 4 medications)
    1. See Polypharmacy
    2. See Medications to Avoid in Older Adults (Beer's List, STOPP)
    3. Class IA Antiarrhythmics
    4. Digoxin
    5. Diuretics
    6. Anticonvulsants
    7. Psychotropic medications
      1. Tricyclic Antidepressants
      2. Benzodiazepines
      3. Antipsychotics

IV. Evaluation: Fall risk

  1. General
    1. Screen at Welcome to Medicare Physical
    2. Evaluate gait, strength and balance
  2. Get Up and Go Test
  3. Cardiovascular exam
    1. Postural Hypotension
    2. Arrhythmias
    3. Carotid Bruits
  4. Neurologic Exam
    1. Assess coordination and balance
    2. Lower extremity Muscle Strength
    3. Proprioception and vibration sense
    4. Consider Mental Status Exam
  5. Miscellaneous exam
    1. Visual Acuity
    2. Joint exam

V. Labs: Consider as part of acute fall evaluation

  1. Urinalysis
  2. Complete Blood Count
  3. Thyroid Function Tests
  4. Basic Metabolic Panel including Renal Function tests
  5. Serum Vitamin B12
  6. Vitamin D level

VI. Diagnostics

  1. Electrocardiogram
  2. Echocardiogram
  3. Brain Imaging (CT Head, MRI Brain, MRA Brain and Neck)

VII. Management: Falls

  1. Treat falls as a sentinel event
    1. Falls should not be considered a normal part of aging
  2. Consider Syncope evaluation
  3. Use this to prompt team evaluation
    1. Fall safety and home safety evaluation
    2. Evaluate for Osteoporosis
    3. Hearing and sight evaluation
    4. Review medications (see Polypharmacy)
    5. Discuss Advanced Directives

VIII. Prevention: Assistive Devices

  1. Wear flat, Rubber soled shoes
  2. Use ambulatory aid as needed (cane or walker)
  3. Consider Hip Protection Device
  4. References
    1. Heidrich (2003) AAFP Board Review, Seattle
    2. Kannus (2000) N Engl J Med 343:1506-13 [PubMed]

IX. Prevention: Education

  1. Stand slowly and stand near support for 1-2 minutes or until equilibrated
  2. Proper lifting technique
    1. No stooping; bend knees and keep back straight

X. Prevention: Optimize Comorbid Conditions

  1. Vitamin D Replacement 800 to 1000 IU/day (esp. if Vitamin D Deficiency)
    1. May reduce fall risk
  2. Consider DEXA Scan for Osteoporosis if not done recently
  3. Assess medications that may increase fall risk
    1. Focus on medications causing Orthostatic Hypotension, Dizziness, Sedation, Hypoglycemia
    2. Assess number/type of medications
      1. See Polypharmacy
    3. Review patient's medication list against medications that increase fall risk (also see above)
      1. See Medications to Avoid in Older Adults (Beer's List, STOPP)
      2. Reevaluate Opioids, Antipsychotics, Benzodiazepines and sedatives
        1. Benzodiazepines are high risk of falls and Hip Fracture (esp. in first 2 weeks of starting)
        2. Wagner (2004) Arch Intern Med 164:1567-72 [PubMed]
      3. Reevaluate antihypertensives for Orthostatic Hypotension (e.g. Beta Blockers)
      4. Reevaluate diabetes medications for Hypoglycemia (e.g. Sulfonylureas, Insulin)
      5. Avoid first-generation Antihistamines (e.g. Diphenhydramine)
    4. Obtain levels on medications with toxicity risk (e.g. Digoxin, anticonvulsants)
  4. Check Visual Acuity
    1. Vision <20/60 is a risk for falls
    2. Check for Cataracts
    3. Assess for depth perception
    4. Refer to ophthalmology as needed
  5. Blood Pressure
    1. Orthostatic Blood Pressure and pulse
    2. Control systolic Hypertension
      1. Systolic Hypertension affects balance and fall risk
      2. Hausdorff (2003) Am J Cardiol 91:643-5 [PubMed]

XI. Prevention: Modify home environment

XII. Prevention: Regular Exercise

  1. Goal Exercise for 30 minutes, 4-5 times per week
  2. Walking Program
  3. Exercise classes twice weekly reduces fall risk
    1. Day (2002) BMJ 325:128-31 [PubMed]
    2. Lord (2003) J Am Geriatr Soc 51:1685-92 [PubMed]
  4. Encourage balance-type activities
    1. Dance
    2. Tai-chi
      1. Does not appear to decrease fall risk
      2. Wolf (2003) J Am Geriatr Soc 51:1693-701 [PubMed]

XIII. Resources

  1. CDC Home and Recreational Safety - Falls in Older Adults
    1. http://www.cdc.gov/homeandrecreationalsafety/falls/index.html

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