II. Epidemiology

  1. Falls occur in >25-30% of age over 65 years in community each year
    1. Results in 7 million injuries, and 2.8 million emergency department visits per year
    2. Each fall increases the risk of future falls by 2-6 fold, and a harbinger of more serious falls
  2. Serious injury (Fractures, Traumatic Brain Injury) occurs in >20% of falls in older adults
    1. Leading cause of fatal and nonfatal injury in those over age 65 years
    2. Results in 27,000 deaths per year
  3. Most falls occur in and around the patient's home
    1. Fear of falling, may result in social isolation and functional decline

III. Risk Factors: Strongest modifiable risk factors for falls

  1. Environmental hazards (most common)
  2. Lower extremity Muscle Weakness
  3. Altered gait or balance
    1. Parkinsonism
    2. Peripheral Neuropathy
    3. Dizziness or Vertigo
    4. Syncope or Postural Hypotension
  4. Medication use (especially more than 4 medications)
    1. See Polypharmacy
    2. See Medications to Avoid in Older Adults (Beer's List, STOPP)
    3. Cardiovascular medications
      1. Class IA Antiarrhythmics
      2. Digoxin
      3. Diuretics
      4. Antihypertensives
    4. Neurologic and psychiatric medications
      1. Anticonvulsants
      2. Antiparkinsonism medications
      3. Antipsychotics
      4. Tricyclic Antidepressants
      5. Benzodiazepines (and other sedatives and hypnotics)
    5. Miscellaneous medications
      1. Opioids
      2. Laxatives

IV. Risk Factors: Other, less modifiable risk factors for falls

  1. Age over 80 years old
  2. Female gender
  3. History of prior falls or Fractures
  4. Hospital discharge in the last month
  5. History of Cerebrovascular Accident or transient ischemia attack
  6. Decreased visual acquity
  7. Arthritis
  8. Dementia, Delirium or Altered Level of Consciousness
  9. Major Depression
  10. Alcohol Abuse
  11. Diabetes Mellitus
  12. Vitamin D Deficiency
  13. Nocturia or Urinary Incontinence
  14. Cardiovascular disease (CHF, Hypertension, cardiac arrhythmias)

V. History

  1. Screening questions
    1. Did you fall in the last year?
      1. How many times did you fall?
      2. Were you injured?
    2. Do you feel unsteady when standing or walking?
    3. Are you worried about falling?
  2. Detailed questions (when screening positive)
    1. Medications predisposing to falls (see above, and e.g. Beers List)
    2. Assistive Device use

VI. Exam: Fall risk

  1. Perform annually for those over age 65 years
    1. Screen at Welcome to Medicare Physical
    2. Evaluate gait, strength and balance
    3. Includes Fall Risk History (see above)
  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 (e.g. SLUMS Exam)
  5. Miscellaneous exam
    1. Visual Acuity
    2. Joint exam
    3. Feet and shoe exam
      1. Prefer flat, Rubber soled shoes

VII. 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

VIII. Diagnostics

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

IX. Evaluation

  1. Step 1: Obtain history as above
    1. Positive history for falls, unsteadiness or concerns
      1. Go to Step 2
    2. Negative history for falls, unsteadiness or concerns
      1. Go to Step 3
  2. Step 2: Perform gait, strength and balance testing (e.g. Get Up and Go Test)
    1. Positive exam for gait, strength or balance problem
      1. 0-1 fall in the last year, and no injury: Go to Step 4
      2. 1-2 or more falls in the last year or fall with injury: Go to Step 5
    2. Negative exam for gait, strength or balance problem
      1. Go to Step 3
  3. Step 3: Low Risk Management
    1. Educate on Fall Prevention
    2. Osteoporosis Prevention (Vitamin D supplementation, Calcium Supplementation)
    3. Consider community Exercise program or Fall Prevention program
  4. Step 4: Moderate Risk Management
    1. Includes low risk interventions as above (education, Osteoporosis Prevention, community programs)
    2. Review and modify medications
    3. Consider physical therapy for improvement of gait, strength and balance
  5. Step 5: High Risk Management
    1. Review "Stay Independent" publication (see below)
      1. https://www.cdc.gov/steadi/pdf/stay_independent_brochure-a.pdf
    2. Includes low risk and moderate risk interventions as above
    3. Complete fall history and full examination as above
    4. Hypotension evaluation and management
    5. Manage foot problems
    6. Optimize vision
    7. Fall Prevention with Home Adaptation
    8. Reassess in 30 days
      1. Fall risk reduction plan compliance and barriers
      2. Exercise program as able

X. Management: Falls - General Approach

  1. See Evaluation protocol above
  2. Treat falls as a sentinel event
    1. Falls should not be considered a normal part of aging
  3. Consider Syncope evaluation
    1. Evaluate for Carotid Sinus Hypersensitivity (a risk for recurrent unexplained falls)
      1. Management with cardiac Pacemaker placement
  4. 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

XI. 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]

XII. 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

XIII. 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. Encourage single lens glasses over multifocal glasses for outdoor activities, walking, stairs
      1. Haran (2010) BMJ 340:c2265 [PubMed]
    3. Check for Cataracts
      1. Minimize delay between Cataract replacement
      2. Fall risk increases after the first Cataract replacement and decreases after the second
      3. Meuleners (2014) Age Ageing 43(3): 341-6 [PubMed]
    4. Assess for depth perception
    5. Refer to ophthalmology as needed
  5. Blood Pressure
    1. Orthostatic Blood Pressure and pulse
    2. Control systolic Hypertension (but avoid overzealous lowering of Blood Pressure)
      1. Systolic Hypertension affects balance and fall risk
      2. Hausdorff (2003) Am J Cardiol 91:643-5 [PubMed]
  6. Foot Care
    1. Prefer flat, Rubber soled shoes
    2. Consider podiatry Consultation
      1. Spink (2011) BMJ 342:d3411 [PubMed]

XIV. Prevention: Modify home environment

XV. 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]

XVI. Resources

  1. CDC Home and Recreational Safety - Falls in Older Adults
    1. https://www.cdc.gov/homeandrecreationalsafety/falls/index.html
  2. Stay Independent Bronchure (CDC)
    1. https://www.cdc.gov/steadi/pdf/stay_independent_brochure-a.pdf

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Ontology: Elderly fall (C0575122)

Concepts Finding (T033)
SnomedCT 298344006
English elderly falling, elderly falls, fall elderly, fall geriatrics, falls geriatrics, elderly fall, falls geriatric, Elderly fall, Geriatric fall, Elderly fall (finding)
Spanish caída de un anciano (hallazgo), caída de un anciano