How to identify balance disorders and reduce fall risk
A multifactorial risk assessment, correction of hearing impairment, exercise, and an optimized home environment can help prevent imbalance-related falls.
PRACTICE RECOMMENDATIONS
› Utilize a falls-prevention program for older patients that focuses on balance and functional exercises. A
› Perform a multifactorial assessment of the risk of falls in older patients that includes optimizing medications, managing comorbidities, and addressing environmental hazards. B
› Use a systems-based approach to presentations of imbalance to direct your clinical judgment and highlight the need for referral to specialists for management and rehabilitation. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Preventing falls in primary care
An approach to preventing falls includes the development of individualized programs that account for frailty, a syndrome of physiologic decline associated with aging. Because frailty leads to diminished balance and mobility, a patient’s frailty index—determined using the 5 frailty phenotype criteria (exhaustion, weight loss, low physical activity, weakness, slowness)82 or the Canadian Study of Health and Aging Clinical Frailty Scale83—is a useful tool for predicting falls risk and readmission for falls following trauma-related injury. Prevention of falls in communities is critical for reducing mortality and allowing older people to maintain their independence and quality of life.
Exercise. In some areas, exercise and falls prevention programs are accessible to seniors.84 Community exercise programs that focus on balance retraining and muscle strengthening can reduce the risk of falls.73,85 The Choosing Wisely initiative of the ABIM [American Board of Internal Medicine] Foundation recommends that exercise programs be designed around an accurate functional baseline of the patient to avoid underdosed strength training.54
Multifactorial risk assessment in high-risk patients can reduce the rate of falls. Such an assessment includes examination of orthostatic blood pressure, vision and hearing, bone health, gait, activities of daily living, cognition, and environmental hazards, and enables provision of necessary interventions.73,86 Hearing amplification, specifically, correlates with enhanced postural control, slowed cognitive decline, and a reduced likelihood of falls.87-93 The mechanism behind improved balance performance might be reduced cognitive load through supporting a patient’s listening needs.88-90
Pharmacotherapy. Optimizing medications and performing a complete medication review before prescribing new medications is highly recommended to avoid unnecessary polypharmacy7,8,18,53-56 (TABLE 17-56).
Management of comorbidities associated with a higher risk of falls, including arthritis, cancer, stroke, diabetes, depression, kidney disease, chronic obstructive pulmonary disease, cognitive impairment, hypertension, and atrial fibrillation, is essential.94-96
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