Rotation Prep


Published July 10, 2019

Falls

Falls can have severe consequences in the elderly and are one of the most common nonfatal injuries in this population. On average, more than 200 older adults per hour are evaluated at an emergency department for fall-related injuries. Falls from a standing height account for the vast majority of hip fractures in adults older than 70 years, and one in four elderly people with hip fracture die within 1 year of fracture.

Guiding Questions

  • What factors predispose the elderly to falls?

  • What are the health consequences of hip fractures?

  • How does one assess for causes of falls?

  • Which interventions mitigate the risk of falling?

  • What evidence supports the use of vitamin D supplementation for fall and fracture prevention?

Risk Factors

Falls and fall-related injuries increase with age. Risk factors for falls can be intrinsic or extrinsic as follows:

Risk Factors for Falls

Intrinsic FactorsExtrinsic Factors
Advanced ageLack of stair handrails
Previous fallsPoor stair design
Muscle weaknessLack of bathroom grab bars
Gait and balance problemsDim lighting or glare
Poor visionObstacles and tripping hazards
Postural hypotensionSlippery or uneven surfaces
Fear of fallingPsychoactive medications
Chronic conditions
(including arthritis, stroke,
incontinence, diabetes,
Parkinson’s disease,
dementia)
Improper use of assistive device

Screening

The Timed Up-and-Go Test is a useful screening tool for assessing fall risk (view video demonstration here).

The STEADI algorithm (Stopping Elderly Accidents, Deaths & Injuries) is a risk stratification tool developed by the Centers for Disease Control and Prevention (CDC) that details each step of fall risk screening and assessment and guides intervention based on risk level.

Guidelines

Falls generally occur in people with multiple risk factors and an acute precipitating event, such as a new medication or a wet floor. A thorough history and examination are required to identify potentially modifiable risk factors to prevent future falls.

The American and British Geriatrics Societies Guideline for Prevention of Falls in Older Persons offer the following recommendations:

  • Multifactorial assessment of fall risk should include:

    • examination of feet and footwear

    • gait assessment

    • environmental assessment that includes home safety

    • asking patients about fear of falling

    • minimizing or withdrawing medications, particularly antipsychotics and psychoactive medications

  • Assess and treat postural hypotension

  • Recommend 800-IU supplement of vitamin D for all older adults at increased risk for falling

  • Multifactorial intervention in community-dwelling older people should include an exercise component that focuses on balance, gait, and strength training (e.g., tai chi or an individualized physical therapy program)

  • Assess visual acuity; expedite cataract surgery when older patients require the intervention

  • Consider assessment of hearing

The authors of a Cochrane Database Systematic Review on interventions for preventing falls in older people living in the community made the following conclusions:

  • Group and home-based exercise programs, as well as home safety interventions, reduce the rate of falls and risk of falling.

  • Multifactorial assessment and intervention programs reduce rates of falls but not risk of falling; tai chi reduces risk of falling.

  • Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

NEJM Knowledge+