Fall Prevention in the Elderly

1. See Also
   1. Osteoporosis Prevention
   2. No-fail Environment in Dementia
   3. Fall Prevention with Home Adaptation
2. Epidemiology
   1. Falls occur in >30% of age over 65 years in community
   2. Serious injury occurs in >20% of falls in older adults
   3. Most falls occur in and around the patient's home
3. 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. Class IA Antiarrhythmics
       2. Digoxin
       3. Diuretics
       4. Anticonvulsants
       5. Psychotropic medications
          1. Tricyclic Antidepressants
          2. Benzodiazepines
          3. Antipsychotics
4. Evaluation: Fall risk
   1. Get Up and Go Test
   2. Cardiovascular exam
      1. Postural Hypotension
      2. Arrhythmias
      3. Carotid Bruits
   3. Neurologic Exam
      1. Assess coordination and balance
      2. Lower extremity muscle strength
      3. Proprioception and vibration sense
      4. Consider Mental Status Exam
   4. Miscellaneous exam
      1. Visual Acuity
      2. Joint exam
5. 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
6. Diagnostics
   1. Electrocardiogram
   2. Echocardiogram
   3. Brain Imaging (CT Head, MRI Brain, MRA Brain and Neck)
7. Management: Falls
   1. Treat falls as a sentinel event
   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
8. 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
9. Prevention: Education
   1. Proper lifting technique
      1. No stooping; bend knees and keep back straight
10. Prevention: Optimize Comorbid Conditions
    1. Vitamin D Replacement if Vitamin D Deficiency
    2. Consider DEXA Scan for Osteoporosis if not done recently
    3. Assess medications
       1. Assess number/type of medications (evaluate Polypharmacy)
       2. Review patient's medication list against those Medications to Avoid in Older Adults
       3. 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
    6. Avoid medications that increase fall risk
       1. Medications causing Hypotension or Dizziness
       2. Medications causing Sedation
          1. Benzodiazepines
             1. High risk of falls and Hip Fracture
             2. Highest risk within first 2 weeks of starting
             3. Wagner (2004) Arch Intern Med 164:1567-72
11. Prevention: Modify home environment
    1. See Fall Prevention with Home Adaptation
12. Prevention: Regular Exercise (30 minutes, 4-5/week)
    1. Walking Program
    2. Exercise classes twice weekly reduces fall risk
       1. Day (2002) BMJ 325:128-31
       2. Lord (2003) J Am Geriatr Soc 51:1685-92
    3. 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
13. Resources
    1. CDC Home and Recreational Safety - Falls in Older Adults
       1. http://www.cdc.gov/homeandrecreationalsafety/falls/index.html
14. References
    1. Rao (2005) Am Fam Physician 72:81-94
    2. Tinetti (2003) N Engl J Med 348:42-9
    3. Van Voast Moncada (2011) Am Fam Physician 84(11): 1267-76