There is no universal consensus among clinicians, researchers or persons who fall, on the definition of a fall. A fall has been defined as an involuntary change from standing, walking, bending, reaching, etc. to no longer being supported by both feet, accompanied by (partial or full) contact with the ground or floor1. The World Health Organization defines a fall as “inadvertently coming to rest on the ground, floor or other lower level, excluding a major intrinsic event or overwhelming hazard or intentional change in position, to rest on furniture, wall or other objects.”
Other related definitions found in the literature on falls include:
- Syncopal fall: A fall associated with or resulting from a loss of full consciousness, such as from fainting or a seizure. Most falls are non-syncopal.1
- Injurious fall: A fall associated with any detectable residual adverse physical change persisting after the fall.1
The etiologies of an individual fall are not always obvious to the person falling or to others and most falls are unobserved and under-recognized. Falls in older persons are usually multifactorial, resulting from the accumulation of multiple modest impairments, rather than any single deficit.1 It may be difficult to know the precise etiology or “cause” of any given fall. Therefore, when investigating the etiology of falls, it may be better to identify the possible factors that an individual may have and to determine what factors could have actively contributed to the fall.
The most important categories of contributing factors include:
- Intrinsic: Examples – age >80 years, prior fall in the past year, lower extremity muscle weakness, gait/balance deficits, cognitive impairment, depression, visual or hearing impairment, poor health status. Poor health status, symptoms such as syncope, dizziness as well as specific diagnoses including Parkinson’s, stroke, and/or peripheral neuropathy.1,2
- Extrinsic: Polypharmacy (>4; especially antihypertensives, benzodiazepines and sedatives), environmental hazards (e.g., slippery surfaces, obstacles, stairs, poor lighting, unstable furniture, clutter, loose throw rugs, pets), ill-fitting clothing, and inappropriate footwear.1,2
- Situational: inattention, divided attention, rushing, impulsivity, poor safety awareness, extreme or unusual activity, unfamiliar setting, and risk-taking behavior.1
Epidemiology including risk factors and primary prevention
Unintentional injuries are the 5th leading cause of death in older adults; Falls are responsible for 2/3rd. of the mortalities from unintentional injuries. 75% of fall related deaths effect the elderly.1 About 1/3rd. of community-dwelling people over the age of 65 fall annually; half of these persons fall multiple times.3,4 Risk of fall in nursing home is nearly three times that of persons living in the community, and this population has the highest injury percentage. Elderly hospitalized patients have 35-40% fall incidence.
Approximately 25% of persons who fall have moderate to severe injuries, ranging from bruises or lacerations to hip fractures or TBI, resulting in more than 1.9 million emergency department visits annually.4 Older adults are hospitalized for fall-related injuries five times more than they are for injuries from other causes. Risk of fracture is 5%; risk of other injuries 10-20%. Hip fracture mortality is approximately 15% and is the seventh leading cause of death in older persons1.
Older adults who fall have a two- to six-fold increased risk of falling again. Also, risk of fall increases with age non-linearly as health deteriorates; thus, an 80-year-old may have 8 times the risk of a 65-year-old.1 Reduced mobility including slow walking speed is a prominent predictor of falling. Knee and ankle muscle weakness are the most potent risk factor; odds increase 4.4-fold if present.
Gait and balance disorders affect 20-50% of individuals >65 yrs. Use of an assistive device for ambulation is associated with a 2.6-fold increased risk of a fall.
Fear of falling can cause significant social isolation, institutionalization, and depression. Low self-efficacy/self-esteem is increased among fallers. Falls result in an increased incidence of disability; the presence of a disability increases fall risk. 
Falls occur as a result of a complex interaction amongst intrinsic, extrinsic, and situational factors. As the number of risk factors increase, the likelihood of falls is also increased. Active persons can be exposed to high-intensity forces at impact.
Medical comorbidities like diabetes mellitus (DM), Parkinson’s disease, incontinence, depression, or Alzheimer’s disease increase the risk of falls. Weak knee extensors and ankle dorsiflexors, decreased ankle flexibility, impaired proprioception, visual impairment (e.g., decreased visual acuity and altered depth perception), and weight loss/ low body mass index (BMI) are all associated with falls. Postural hypotension leads to loss of balance, and is usually caused by dehydration, concomitant medication use, or autonomic neuropathy. Common cardiovascular disorders associated with falls include carotid sinus hypersensitivity, vasovagal syndrome, bradyarrythmias, and tachyarrythmias.5,6 Vitamin D deficiency can impair muscle strength and neuromuscular function.5
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
- New onset/acute: May be related to an isolated non-recurring event or may occur in relatively short-lived clusters, perhaps from an acute illness or exposure to a new drug or environmental hazard.7
- Subacute: Falls may increase in frequency over time, possibly due to the progression of a disease or disability.7
- Chronic/stable: People with chronic, recurrent falls have the highest rate of injurious falls and fractures and seem to occur in people with multiple co-morbidities, and depressive symptoms.7 Older persons should be screened at least annually regarding falls, and a multifactorial intervention initiated as appropriate5
Specific secondary or associated conditions and complications
Complications from falls include: lacerations, fractures, spinal cord/head injuries, hypothermia, pneumonia, pressure ulcers, rhabdomyolysis, venous thromboembolism, and dehydration. Falls can also lead to hospitalization, greater dependence, loss of autonomy, and depression as well as nursing home residency. Persons hospitalized for falls are more likely discharged to nursing homes and to need more in-home services; they are less-likely to regain pre-injury mobility status. Fear of falling alone can result in functional decline.1
2. ESSENTIALS OF ASSESSMENT
All older persons should be asked at least annually if they have fallen.5 A positive response to falls screening questions (>2 falls in past 12 months, medical evaluation for an acute fall, difficulty with walking or balance) should prompt a multifactorial falls risk assessment.2,5
Focused history including when and how the fall occurred, location of the fall, if patient has fallen multiple times is there a pattern, and any fall associated symptoms (syncope, dizziness, vertigo, generalized or lower limb weakness, pain, visual problems etc.)5 Conduct a medication review including over-the-counter and herbal medications. Social history should include alcohol use, activity history, and use of assistive device.1,2
The physical examination should focus on the following areas:
- Vital signs: Pulse rate/rhythm, blood pressure with orthostatic assessment
- Vision: Acuity using Snellen chart.1
- Neurologic: Mental status (e.g., Short Portable Mental Status, Mini Mental Status Examination), cranial nerve function, Motor (especially lower extremities), Sensation (proprioception/vibration), Reflexes (e.g., hyperreflexia), Cerebellar function, Balance, Gait/Station observational analysis, Romberg test1,5
- Musculoskeletal: Lower and upper extremity joint range of motion, feet, and footwear evaluation. 1,5
Functional evaluation: There is no evidence supporting one test over another.2
Get Up & Go/Timed Up & Go (TUG)
- Patient attempts to rise from chair, walk 3 meters and then return.
- The Timed Up & Go version times this same task performance
- <10 sec – independent
- <20 secs – independent with transfers, stairs, and outdoors
- 20-29 sec – variable balance, gait speed, functional capacity
- ≥30 secs – needs help with chair, toilet transfer & stairs,
- Pros: simple, quick, and inexpensive to perform. Assessment includes some functional task data.
- Cons: There is limited change sensitivity data.2,8
Tinetti Balance & Gait Index
- Functional performance test with a 9-item balance scale (max. score = 16); and a 7-item gait scale (max. score = 12).
- Balance tasks include sitting & standing balance with eyes both open and closed, sitting & arising from chair, and performing a 360 degree turn.
- Gait test assesses initiation, step symmetry, length and height, foot clearance, trunk sway, path and stance.
- Pros: Simple and widely used. Assessment does include some functional tasks.
- Cons: Subjective scoring8.
Berg Balance Scale (BBS)
- Consists of 14 items assessing ability to stand and maintain standing despite internally produced perturbations. Items are scored on 0 (unable) to 4 (safely done) scale (max. score = 56)
- In elderly, score >45 indicates a low fall risk.
- Change of 8 points indicates a genuine function change for ADL dependent older people.
- Good inter- and intra-rater reliability
- Pros: Easy, quick (10-15 min.) to administer. This test is familiar to and is typically performed by most physical therapists.
- Cons: Low validity and sensitivity for non-ambulatory stroke patients.8
Direct observation of the patient’s independence with basic Activities of Daily Living (ADL), including use of gait aids/assistive equipment.5 Assess perceived functional ability and fear of falling.5 If warranted, assess for depression (Geriatric Depression Scale).
- Complete Blood Count (CBC) to evaluate anemia, leukocytosis, platelet abnormalities.
- Basic Metabolic Panel to evaluate electrolytes and renal function.
- Albumin for nutritional status.
- Glucose and HgbA1c for evaluation of diabetes.
- Thyroid Stimulating Hormone (TSH), Vitamin B12 and D levels for thyroid and vitamin status.
- Urinalysis, if suspicion of urinary tract infection.
- Check for toxicity of medications, such as digoxin or anticonvulsants.
A DEXA scan may be performed to evaluate bone mineral density, if warranted.
Other imaging may be performed as necessary to evaluate abnormalities/deficits noted by history, physical examination, and/or laboratory testing.
Supplemental assessment tools
One-Leg Stance (OLS) Test: Ask patient to stand unassisted on one limb of their choice; record stance time from when foot leaves floor until it touches again
- Stance >30 sec indicates very low fall risk; stance >5 sec is good predictor of injurious fall in elderly.
- Good inter-rater reliability but limited evidence for reliable change over time measurement.
- Pros: very simple and quick
- Cons: accurate but nonspecific as prolonged OLS not a functional activity8
Sharpened (modified) Romberg Test: Measures static standing balance by assessing the length of time the patient can stand heel-to-toe with arms across chest and eyes closed for 60 seconds over a series of 4 trials.
- Perfect score is 240 seconds.
- Pros: easy, and inexpensive to administer; timing adds objectivity
- Cons: non-specific for a particular problem, pathway or system; no functional information8
Functional Reach (FR): Ask patient to stand parallel to a wall-mounted yardstick with arms held at 90 degrees of flexion. The patient is instructed to reach forward maximally without taking a step. The distance change from start position is the patient’s functional reach.
- Reach ≤ 6 inches predicts a fall.
- Pros: Simple, inexpensive to administer. There are established reliability and validity data. This test is also sensitive to change over time.
- Cons: This test yields limited functional information.8
Elderly fall screening test: sensitivity 93%, specificity 78%. Dynamic Gait Index: sensitivity 85%, specificity 38%. Morse Falls Risk Assessment (acute care or acute rehabilitation setting). Long-term care minimum dataset (LTCMDS) for all aspects of care in Nursing Home settings: captures falls and injury histories at regular intervals in the resident’s day.
Early predictions of outcomes
Primary sequelae of falls include injuries and post-fall anxiety. There is a four-fold greater fracture rate with falls in stroke patients than in the general population.
Multifactorial risk assessment and a multifactorial intervention focused on identified deficits and risk factors are effective in reducing falls. However, few studies have shown benefits for fall prevention programs on quality of life.
Identification and removal of environmental hazards in the home is recommended, although study results are mixed.2 Evaluation should be done by trained individuals to remove hazards (e.g., throw rugs), and modify the home environment (e.g., improve lighting, move electrical cords, install handrails/grab bars) to reduce falls.2,5
Social role and social support system
The older person’s living situation and social support may significantly impact their fall risk. Supportive, attentive family, friends, neighbors and/or caregivers may assist in reducing falls.
However, this may result in significant caregiver burden if 24-hour supervision and/or assistance with ambulation, ADLs, shopping, housekeeping, and financial oversight are required. Telecommunication alarm devices can facilitate safety.
State legislatures have been establishing protocols and programs to address falls by providing funding, setting up task forces, and enacting laws to protect seniors. Thirteen states have new laws establishing statewide fall prevention programs and reporting of falls; these include CA, CT, FL, ME, MA, MN, NM, NJ, OR, TX and WA.4
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Initial management entails a multifactorial intervention to address specific contributing risk factors or impairments customized to an individual patient’s multifactorial risk assessment. A sound general management strategy should be to fix things that are identified and fixable, help the person to compensate for, substitute for, or avoid non-fixable conditions or factors
Interventions include the following:
- Medications: Eliminate, or reduce the dose of high-risk medications especially psychotropic medications (e.g., sedative hypnotics, anxiolytics, antidepressants, antipsychotics)1,2,5
- Management of contributing neuromuscular and musculoskeletal problems
- Exercise: Initiate a personalized exercise program including strength, balance, gait and coordination training.2,5 Formal therapy may be needed for home exercise program to address aforementioned exercises, transfer and function training, and training with a gait aid. Exercise programs reduce injury and non-injury fall rate by 15-50% with better outcomes in higher intensity exercise programs.1,9
- Correct vision impairments (e.g., cataract removal). Advise patients to not wear multifocal lenses while walking.1,2
- Correct cardiovascular problems (e.g., postural hypotension, abnormal rate/rhythm)5
- Calcium and Vitamin D supplementation1,2,5
- Address foot/footwear problems. Older persons should be advised to wear shoes with low heels and high surface contact area.2,5
- Home/environmental hazard evaluation and modification as needed.
- Patient/caregiver education/information regarding falls/falls prevention
Single exercise alone, health education alone, or single exercise + health education is not effective. Comprehensive (physical behavioral, environmental) interventions targeting multiple risk factors in high risk individuals significantly reduces falls.1
At different disease stages
- New onset/acute: If risk factors for future falls identified, schedule follow-up to re-evaluate patient, complete medication review. May need to initial multi-factorial treatment intervention, if necessary.
- Scheduled follow-up should be arranged as needed to re-evaluate the patient for compliance with the treatment interventions and to assess for recurrent falls. Medication review should be completed again.
- Treatment of other complicating conditions (e.g., incontinence, depression, osteoporosis) may be initiated.
- The older person needs to be reassessed for falls with any change in medical condition.
- Home safety evaluation can be done by home health agencies and occupational therapists.
- Scheduled, or as needed, follow-up, to re-evaluate for fall risk, repeat multifactorial risk assessment and revise the multifactorial treatment intervention, if necessary.
Patient & family education
Detailed explanations in simple language (i.e., appropriate to patient’s/caregiver’s cognitive level) should be provided to the patient/caregiver regarding the older person’s risk assessment and the plan for fall prevention.
Written educational/informational materials with instructions for improved safety at home and in the community should be provided, as well as information about helplines for emergencies.5
Clinically important effects of interventions for study may include the number of people sustaining falls, rates of falls, number of fall-related injuries, and quality of life (physical, psychologic, social and environmental domains) after the intervention. Measuring falls prospectively over 12 months with regular follow-up/ diaries is the gold standard for data collection in community-based trials. Randomized controlled trials of multifactorial interventions in at-risk patients can give high-quality evidence. This needs to include review of medications, exercise programs incorporating balance training of sufficient duration and frequency, and educational interventions.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
All older persons should be asked at least once per year if they have fallen, and/or queried with the above noted falls screening questions. The American Geriatrics Society (AGS)/British Geriatrics Society (BGS) clinical algorithm should then be instituted, depending upon the patient responses.5
Individually prescribed and group exercises that include balance and gait training, and strengthening can reduce risk of falling and reduce fractures, but is less effective in people at higher risk of falling.
Multifactorial interventions integrating assessment with individualized intervention, usually involving a multidisciplinary team, are effective in reducing rate of falls but not risk of falling.
Home safety interventions reduce rate of falls and risk of falling, especially when delivered by an occupational therapist.3
Implementation of a falls screening program could be challenging and would be suitable for a PIP project. Similarly, compliance with the multifactorial intervention program (e.g., gait/balance exercise program, medication modifications, home modifications) may be problematic, and coordination with the patient’s primary care provider may be difficult; these issues may be potential PIP projects as well.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
As more hospital systems adopt electronic medical records, better coordination of care and communication between physicians and caregivers should become much easier; research into epidemiology and efficacy of falls prevention interventions can be undertaken.
Also, adverse drug interactions can be avoided through automatic messages to ordering physicians. Social marketing campaigns regarding fall prevention might be delivered to the at-risk population through mail or the internet to change practices and attitudes.
Emerging technology has the potential to assist patients and clinicians in understanding more about the occurrence and mechanisms involved in falls, enhancing intervention efforts, and identifying and monitoring falls. There is a growing body of literature describing the development and use of wearable sensors (accelerometers) that can measure movement and detect falls, and monitor physiological and environmental parameters. This can lead to better understanding of factors related to the fall, which can in turn lead to prevention. Other technology applications, such as the use of exercise gaming devices (Microsoft Kinnect,® Nintendo Wii Fit®) or the use of virtual reality devices have been used to successfully enhance balance training in persons who fall or who are at risk for falling.10 In the future, existing computerized gait analysis and recognition systems will combine with embedded or wearable sensors in “smart homes” to detect near-falls or falls and will trigger appropriate responses or alarms.11
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Commonly used Fall Risk Assessment Tools (FRAT) have varying validity and reliability. Poor standardization of data collection and analysis have made interpretation challenging and thus it is difficult to determine trends. Public health initiatives to reduce falls are necessary to translate the positive evidence that exists towards developing more effective fall prevention strategies.
Research targeting health professionals is needed to increase implementation of effective interventions. More studies exploring methods for increasing acceptance and adherence to effective programs by older people are also needed.12
The impact of management programs for risk factors, such as cognitive impairment and urinary incontinence needs additional investigation. Better standardization of research methods need to be adopted in future studies.
Economic evaluations should be conducted alongside randomized controlled trials to establish the cost-effectiveness of each intervention being tested. Measuring health related quality of life as an outcome, defining the perspective and timeframe for costs, collecting data on healthcare use, costing healthcare resources, calculating cost-effectiveness ratios (if the intervention is effective in reducing falls), and evaluating uncertainty is needed. Guidelines for carrying out and reporting economic evaluations in falls prevention trials have recently been published.
- K. Means, “Neurologic: Falls in Geriatrics,” in Rehabilitation Medicine Quick Reference Series, New York, NY, Demos Medical Publishing, 2013, pp. 162-164.
- Moncada, Lainie and V. Voast, “Management of Falls in Older Persons: A Prescription for prevention,” American Family Physician, vol. 84, no. 11, pp. 1267-1276, 2011.
- L. Gillespie, M. Robertson, W. Gillespie, C. Sherrington, S. Gates, L. Clemson and S. Lamb, “Interventions for preventing falls in older people living in the community,” Cochrane Database of Systematic Reviews, no. 9, 2012.
- “Elderly Falls Prevention Legislation and Statutes,” National conference of State Legislatures, [Online]. Available: http://www.ncsl.org/research/health/elderly-falls-prevention-legislation-and-statutes.aspx>. [Accessed 4 January 2016].
- “Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons,” J Am Geriatr Soc, 2010.
- M. Stenhagen, H. Ekström, E. Nordell and S. Elmståhl, “Falls in the General Elderly Population: A 3- and 6- Year Prospective Study of Risk Factors Using Data from the Longitudinal Population Study ‘Good Ageing in Skane,” BMC Geriatrics, vol. 13, no. 1, 2013.
- A. Tchalla, A. Dufour, T. Travison, D. Habtemariam, I. Iloputaife, B. Manor and L. Lipsitz, “Patterns, Predictors, and Outcomes of Falls Trajectories in Older Adults: The MOBILIZE Boston Study with 5 Years of Follow-Up,” PLoS ONE, vol. 9.9, 2014.
- K. Means, “Evaluation of Balance and Mobility in Geriatrics,” in Rehabilitation Medicine Quick Reference Series, New York, NY, Demos Medical Publishing, 2013, pp. 42-51.
- C. Sherrington, A. Tiedemann, N. Fairhall, J. Close and S. Lord, “Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations,” NSW Public Health Bulletin, vol. 22, no. 3-4, pp. 78-83, 2011.
- L. Donath, R. Rössler and O. Faude, “Effects of Virtual Reality Training (Exergaming) Compared to Alternative Exercise Training and Passive Control on Standing Balance and Functional Mobility in Healthy Community-Dwelling Seniors: A Meta-Analytical Review,” Sports Medicine, vol. 46, p. 1293, 2016.
- L. Juang and M. Wu, “Fall down detection under smart home system,” Journal of Medical Systems, vol. 39, no. 10, pp. 1-12, 2015.
- F. Thilo, B. Hürlimann, S. Hahn, S. Bilger, J. Schols and R. Halfens, “Involvement of older people in the development of fall detection systems: a scoping review,” BMC Geriatrics, vol. 16, no. 42, 2016.
Original Version of the Topic
J. George Thomas, MD. Fall Prevention in the Elderly. 11/14/2011.
Kevin M Means, MD
|National Advisory Board for Medical Rehabilitation Research||Travel expense reimbursement||Board member|
|Demos Medical Publishing||royalties||Book editor|
Lindsay E Mohney, DO
Nothing to Disclose