Clinical Pearls & Morning Reports
Population-based studies suggest that 10% of older adults fall at least twice annually. Read the NEJM Clinical Practice article here.
Q: What are some of the main causes of falls in older adults?
A: Most falls result from a combination of intrinsic risks (e.g., balance impairment) and extrinsic risks (e.g., trip or slip). Deficits in gait and balance are the most prominent predisposing risk factors at the population level. Medications (including over-the-counter drugs), alcohol, visual deficits, impairments in cognition and mood, and environmental hazards can also contribute. Because some syncopal events manifest as unexplained falls, cardiovascular disease can also play a role.
Q: What office-based tests can be used to assess an older person’s risk of falling?
A: Screening questions about the number of falls in the past year and about whether a fear of falling limits daily activities can be asked as part of a previsit questionnaire or during the intake interview. Simple office-based tests of gait, balance, and strength are routinely indicated in patients who have a positive screening result for a history of falls or a fear of falling that limits daily activities. The assessment, which generally takes 5 minutes, includes watching the patient walk to assess gait speed and any obvious gait abnormalities; testing balance by asking the patient to stand with feet in side-by-side, semi-tandem, and full-tandem positions; and watching the patient rise from a chair of normal height without using the hands to push off.
A: All patients should be encouraged to exercise, if they can. A meta-analysis of 59 randomized trials, which included both healthy participants and those with chronic conditions who were recruited from generalist and specialist outpatient clinics, supports the benefits of fall-prevention exercise in those at average or high risk for falls. Both home-based exercise programs (e.g., the Otago Exercise Program) and group-based exercise programs have been shown to reduce the rate of falls. The most effective programs have been specifically designed to reduce the risk of falls and include exercises that improve leg strength and challenge balance with progressively more difficult activities. Walking is often included in exercise programs but on its own has not been shown to prevent falls. Persons with clinically significant balance impairments should avoid exercise programs that focus exclusively on brisk walking.
A: All prescribed and over-the-counter drugs should be reviewed, with a focus on tapering or discontinuing medications without a compelling indication or for which the potential harm is greater than the benefit. Particular attention should be paid to medications that may cause sedation, confusion, or orthostatic hypotension. For patients with difficulties in basic activities of daily living, a home-safety evaluation ordered through a home-health agency is appropriate among those who are eligible. Eye examinations are recommended every 1 to 2 years for adults 65 years of age or older. Brief instruments, such as the Mini-Cog and the Patient Health Questionnaire-9, are helpful screening tools to assess cognitive impairment and depressive symptoms, respectively. Both of these conditions are associated with an increased risk of falls, independent of the medications prescribed for them.