Stand by me! Reducing the risk of injurious falls in older adults
ABSTRACTAbout one-third of community-dwelling adults age 65 and older fall each year, and some suffer fractures, traumatic brain injury, and even death. Therefore, it is important to identify older adults at risk and recommend helpful interventions.
KEY POINTS
- Practitioners can reduce fall-related injury by screening older adults yearly with questions about problems with balance and gait, performing a focused history and examination when necessary, and implementing evidence-based interventions.
- Cognitive impairment itself is an independent predictor of falls because it can reduce processing speed and impair executive function.
- An exercise program with resistance, balance, and gait training is usually prescribed to patients at high risk, along with a home assessment and withdrawal or minimization of psychoactive and antipsychotic medications.
- Combined calcium and vitamin D supplements should be given to most older adults in long-term care facilities to reduce fracture rates.
- There are no specific evidence-based recommendations for fall prevention in community-living older adults with cognitive impairment or dementia.
Falls and fall-related injuries are common in older adults Every year, 30% of those who are 65 and older fall,1 and the consequences are potentially serious. Falls are the primary cause of hip fracture, which requires an extensive period of rehabilitation. However, rehabilitation does not always restore the older adult to his or her preinjury functional state. In fact, at 6 to 12 months after a hip fracture, 22% to 75% of elderly patients have not recovered their prefracture ambulatory or functional status.2
Falls are also the most common cause of traumatic brain injury in older adults,3 often resulting in long-term cognitive and emotional problems and pain that compromise quality of life. Falls can be fatal and in fact are the leading cause of death from injury in older adults.4
Practitioners can reduce fall-related injury5 and potentially improve quality of life by screening older adults yearly, performing a focused history and examination when necessary, and implementing evidence-based interventions.
RISK FACTORS
A single identifiable factor may account for only a small portion of the fall risk. Falls in older adults are, in general, multifactorial and can be caused by medical conditions (eg, sarcopenia, particularly of the lower limbs, vision loss, urinary incontinence, neuropathies), cognitive impairment, medications such as psychotropic drugs, and home hazards such as area rugs, extension cords, and dimly lit stairways.
The strongest predictors of falls are a recent fall and the presence of a gait or balance disorder.6
SCREENING TESTS
Joint guidelines from the American Geriatrics Society and British Geriatrics Society,7 published in 2011, recommend that practitioners screen older adults yearly for fall risk by asking two questions: “Have you fallen in the past year?” and “Are you having difficulty with gait or balance?” A negative response to both questions suggests a low risk of falling in the near future. Patients with two or more falls, a balance or gait problem (subjective or objective), or history of a fall requiring medical attention should undergo a focused history and physical examination plus a multifactorial risk assessment.
A report of one fall without injury should prompt a simple office-based test of balance. Examples of tests include the Get Up and Go, the Timed Up and Go, and the One-Legged Stance (the Unipedal Stance).
In the Get Up and Go test, patients sit comfortably in a chair with a straight back. They rise from the chair, stand still, walk a short distance (about 3 meters), turn around, walk back to the chair, and sit down.8 The clinician notes any deviation from a confident, smooth performance.
In the Timed Up and Go test, the clinician records the time it takes for the patient to rise from a hardback chair, walk 10 feet (3 meters), turn, return to the chair, and sit down.9 Most older adults complete this test in less than 10 seconds. Taking longer than 14 seconds is associated with a high risk of falls.10
For the One-Legged Stance test, the clinician asks the patient to stand on one leg. A patient without significant balance issues is able to stand for at least 5 seconds.11
Figure 1 summarizes the approach for a community-dwelling patient who presents to the outpatient setting. A complete multifactorial risk assessment may require a dedicated appointment or referral to a specialist such as a geriatrician, physiatrist, or neurologist.
WHAT INFORMATION DOES A FOCUSED HISTORY INCLUDE?
The fall-focused history includes:
A detailed description of the circumstances of the fall or falls, symptoms (such as dizziness), and injuries or other consequences of the fall.7
A medication review. Table 1 includes commonly prescribed drug classes associated with increased fall risk.12 Be especially vigilant for eyedrops used to treat glaucoma (some can potentiate bradycardia) and for psychotropic drugs.
Drug regimens with a high psychotropic burden can be identified with the Drug Burden Index13 or the Anticholinergic Risk Scale,14 but these scales are cumbersome and are usually used only as part of a research study. The updated Beers criteria15 and use of a structured medication review such as the START and STOPP algorithms16 can help prune unnecessary, inappropriate, and high-risk medications such as:
- Selective serotonin reuptake inhibitors in the absence of current major depression. These drugs increase the risk of falls and decrease bone density.17
- Proton pump inhibitors in the absence of a true indication for this drug class to treat reflux. Drugs in this class reduce bone density and increase the risk of hip fracture after 1 year of continuous use18
- Cholinesterase inhibitors in the absence of demonstrated benefit to dementia symptoms for the particular patient. Drugs in this class are associated with falls, hip fracture, bradycardia, and possible need for pacemaker placement.19
Review of activities of daily living (ADLs). A functional assessment of the patient’s ability to complete ADLs helps identify targets for therapy. Assess whether the patient is afraid of falling and, if so, what impact this fear has on ADLs. This can help determine whether the fear protects the patient from performing risky tasks, or harms the patient by contributing to deconditioning.
Medical conditions. Consider chronic conditions that can impair mobility and increase fall risk. These include urinary incontinence, cognitive impairment (eg, dementia), neuropathy, degenerative neurologic conditions such as Parkinson disease, and degenerative arthritis. Osteoporosis increases the risk of fracture in a fall. Vitamin D deficiency increases both fall and fracture risk.20
PHYSICAL EXAMINATION FINDINGS
Assess the patient’s vision, proprioception, reflexes, and cortical, extrapyramidal, and cerebellar function.7
Perform a detailed assessment of the patient’s gait, balance, and mobility. Assess the lower extremities for joint and nerve function, muscle strength, and range of motion.7 The use of brain imaging, if appropriate, is guided by gait abnormalities. Unexpected findings such as neuropathy may require referrals for further evaluation.
Examine the patient’s feet and footwear for signs of poor fit and for styles that may be inappropriate for someone at risk of falling, such as high heels.
Conduct a cardiovascular examination. In addition to assessing heart rate and rhythm and checking for heart murmurs, evaluate the patient for postural changes in heart rate and blood pressure. Wait at least 2 minutes before asking the patient to change position from supine to seated and from seated to standing. A longer interval (3 to 5 minutes) can be used depending on the patient’s history. For example, an older adult reporting a syncopal episode standing by the kitchen sink may need a longer standing interval prior to blood pressure measurement than an older adult who falls right after standing up from a chair.
If there is a strong suspicion that an orthostatic condition contributed to a fall but it is not possible to elicit orthostasis in the office, it may be necessary to refer the patient for tilt-table testing. If the circumstances suggest that pressure along the neck, or turning the neck, contributed to a fall, referral for carotid sinus stimulation may be appropriate. If there is a concern that a brady- or tachyarrhythmia contributed to the fall, a referral for 24- or 48-hour Holter monitoring or a 30-day loop monitor may be indicated.
Assess the patient’s mental status. Cognitive impairment itself is an independent predictor of falls7 because it can reduce processing speed and impair executive function.21 Executive dysfunction may contribute to falls by causing problems with multitasking, drug compliance, and judgment. The presence and severity of cognitive impairment may affect recommendation options (see below), so the assessment should include a screening test. Consider using the Mini-Cog, which requires the patient to recall three words and draw an analog clock (Figure 2).22
Some cognitive screening tests validated for use in the general older population include the General Practitioner Assessment of Cognition and the Memory Impairment Screen.23 More involved cognitive testing such as the Folstein Mini-Mental State Examination, Montreal Cognitive Assessment, and the Saint Louis University Mental Status Examination are routinely performed in a geriatric or neurologic setting. The Folstein is a proprietary test; the other two are not.
Conditions such as circulatory disease, chronic obstructive pulmonary disease, depression, and arthritis are associated with a higher risk of falling, even with adjustment for drug use and other potential confounding factors.24
A brief mood assessment is part of the multifactorial assessment because mood disorders in older adults can lead to deconditioning, drug noncompliance, and other conditions that lead to falls and fall-related injuries. Options for screening include the Geriatric Depression Scale (15 or 30 questions) and the Patient Health Questionnaire (the PHQ-2 or the PHQ-9).7
