Keywords

Falls affect approximately 30% of all persons aged 65 years or older each year [1]. Over 27,000 older adults (>65 years old) died from falls or fall-related injuries in 2013 [2]. From 1990 to 2010, the number of Americans over 65 increased by 29%, from 31 to 40 million, and is expected to further increase to 54 million by 2020 [3]. Understanding how to assess for fall risks both before and after an injurious fall can help tailor interventions to prevent future injury [4]. Thus, proper screening before and appropriate assessment after a fall are prerequisites to keeping an older adult independent for a longer period of time.

The definition of a fall is the unintentional change in the position of the body in which it comes to rest on the ground or strikes an object [5]. Falls are considered one of the more common “geriatric syndromes ,” along with urinary incontinence, pressure ulcers, delirium, and functional decline. All of these geriatric syndromes have multiple contributing factors/risks in common (e.g., older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility), in addition to being associated with increased morbidity [6]. The key concept of a geriatric syndrome is that multiple deficits, and impaired capacity to adjust to those deficits, lead to a common, clinically observed condition. In the case of falls, just as in other geriatric syndromes, these deficits are additive, so that the greater the number of deficits, the greater the risk that the syndrome (i.e., a fall) will occur. This chapter outlines prevention strategies, risk assessment, clinical evaluation, and testing in older adults who have fallen or are at risk of falling.

Epidemiology

Although less than half that fall seek medical attention [1], falls come with significant financial and personal cost. Over 27,000 older adults died from fall-related injuries in 2014. In 2013, there were a recorded 2.5 million nonfatal falls correlating to just over 1.2 million emergency department visits for falls in 2010 and resulting in 400,000 hospital admissions [1, 2].

Healthcare providers are caring for older adults who fall and suffer fall-related injuries in a variety of settings. The fall rate of inpatient settings has been reported to range from 2.9 to 13 falls per 1000 institution bed days [7]. Falls often lead to injuries, with 30% of older adults suffering injuries such as hip fractures or head traumas that ultimately reduce mobility and independence [7]. The majority of hip fracture patients never regain pre-fracture function, and up to 25% of those who survive remain institutionalized at 1 year, while another 25% do not survive the first year post-fracture [8]. Subsequent to a fall, fear of future falling can lead to a significant curtailment in activity, resulting in additional functional decline [9, 10].

Risk Factors and Screening

As we age, there is less redundancy in sensory and motor systems that preserve our postural stability. A fall occurs when there is a perturbation in the underlying mechanisms that control our postural stability [11]. Examples of perturbations range from an acute medical illness to hazards in the environment. A thorough assessment of risk factors can yield critical information to help prevent a future fall, particularly given that falls in older adults are often multifactorial. Risk factors can be divided into intrinsic and extrinsic factors, as well as precipitating events [12, 13]. Multiple prospective cohort studies as well as the updated clinical practice guidelines from the American Geriatrics Society and British Geriatrics Society identify a number of risk factors. The intrinsic risk factors include lower extremity weakness, previous falls, gait and balance disorders, visual impairment, depression, functional and cognitive impairment, dizziness, low body mass index, urinary incontinence, orthostatic hypotension, female sex, and being over age 80. Extrinsic risk factors include polypharmacy (i.e., taking over four prescription medications), psychotropic medications, and environmental hazards such as poor lighting, loose carpets, and lack of bathroom safety equipment [13].

“SAFE AND SOUND ” is a useful mnemonic to allow rapid recall of the major causes of falls for screening purposes and was developed by the Saint Louis Veterans Administration Geriatric Research Education and Clinical Center. “SAFE” is an acronym for strength problems, alcohol, food-associated hypotension, and environmental factors. “AND” stands for atherosclerotic disease (syncope), no freedom (restraints), and drugs. “SOUND” stands for sight problems, orthostasis, unsteady balance, nocturia, and delirium [14].

It is well established that the greatest predictor of a future fall is a history of falling . In light of this, as part of the annual encounter with an older adult, the American Geriatrics Society and British Geriatrics Society Practice Guidelines recommend that healthcare providers screen for falls or risk of falling (Fig. 3.1) [13]. In addition, an initiative from the Centers for Disease Control and Prevention (CDC), called STEADI (stopping elderly accidents, deaths, and injuries ), reinforces the importance of screening for falls in older adults. The initiative includes tools and educational materials to help providers identify patients at low, moderate, and high risk for falls, identify modifiable risk factors, and offer effective interventions. The CDC projects the STEADI initiative could result in as many as 6 million more patients screened for falls, 1 million falls prevented, and $3.5 billion in direct medical costs saved over a 5-year period for every 5000 providers who incorporate STEADI into their daily practice [15]. Because of the significant morbidity [16] and mortality [17] associated with fall-related injuries, a careful post-fall evaluation in an older adult is essential.

Fig. 3.1
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Algorithm for screening and assessment (Reproduced with permission from Ref. [13])

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Fall Assessment

Post-fall Assessment and Evaluation

First Fall

The assessment after the first fall should begin with a targeted history and the evaluation of lower extremity strength, gait, and balance [13]. There are a variety of tests that can be utilized to assess postural stability.

The “get up and go” test is well known and widely utilized. To perform this test, one asks a patient to rise from a chair without using their arms, walk 10 feet, turn and then return to the chair, and sit down. The previous time-based scoring has been modified to consider the mean time of adults in respective age groups [18]. There are also modified qualitative scores ranging from “no fall risk” to “very high fall risk” that are based upon observation of the gait and need for supervision or physical or standby support . Using the original “get up and go” time cutoff, a performance of greater than 20 seconds is indicative of increased risk of fall, and further evaluation is appropriate.

There are a number of additional tests that can be utilized to assess mobility, gait, and balance. These include the performance-oriented mobility assessment, the functional reach test, the short physical performance battery, and the Berg balance test .

If abnormalities are observed during the mobility assessment, a multifactorial post-fall risk assessment should be performed (Table 3.1).

Table 3.1 Risk factors and causes for falling in older adults
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Recurrent Falls

The approach to a patient presenting with multiple falls requires a comprehensive history and physical examination, functional and cognitive assessment, medication review, vision evaluation, and mobility assessment (Table 3.2) [13, 19]. Circumstances surrounding the fall should focus on the location, activity at the time of the fall, and any symptoms prior to the fall. The history and physical examination include the evaluation of acute and chronic medical conditions. In addition to orthostatic vital sign measurements, special attention on physical examination to the musculoskeletal, neurologic, and cardiovascular systems is essential. It is important to review medications, including over-the-counter drugs, and perform medication reconciliation, as well as inquire about the use of alcohol and illicit drugs. If there is baseline cognitive impairment or new cognitive impairment is revealed during the examination, a reliable reporter should be included to assure the information obtained is accurate and complete.

Table 3.2 Comprehensive post-fall assessment
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While there is no standard diagnostic evaluation for a patient presenting with falls , there are a number of serologic and diagnostic tests that may be appropriate as part of the post-fall evaluation. Basic laboratory studies include blood chemistries, complete blood count, thyroid-stimulating hormone, vitamin B12 level, and vitamin D level. If cardiac etiology is suspected based upon history and physical examination, electrocardiogram, echocardiogram, and/or Holter monitoring may be performed. Patients with new neurologic abnormalities may warrant carotid Doppler or imaging of the brain or spine.

Fall Prevention

Prevention of a fall is the ultimate goal of screening and assessment. When looking at the different prevention strategies, they can be described as primary, secondary, and tertiary. If a “fall” is the event, then preventing a “fall” would be considered a primary prevention. A secondary prevention would be the one that reduces injury from the event or “fall.”

Primary Prevention

Primary preventive interventions are intended to prevent falls and thus prevent the resultant fractures or other injuries. These preventive interventions are the ones that primary medical providers should be advising and educating older adults about early in the geriatric assessment process.

Exercise

Exercise has long been deemed important in primary prevention, with walking, balance training, and muscle strengthening each having been demonstrated to reduce falls and subsequent fractures [20, 21]. Varied exercises over a longer period of time (most positive trials were longer than 12 weeks) are recommended to prevent falls in community dwellers [13]. The evidence for exercise programs in those in long-term care settings is less robust, and some studies have shown an increase in falls in the frail elderly [22]. Exercise programs should take into account the physical capabilities of the individual. Table 3.3 provides simple exercises that can be done in the patient’s home with the assistance of a stable chair [23]. Any provider can quickly explain these exercises to the patient or caregiver in a short amount of time.

Table 3.3 Simple balance and strengthening exercises
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Tai chi has also been studied extensively and shown to be helpful in preventing falls, principally by improving balance. One study that compared tai chi three times per week to stretching showed that the risk of multiple falls over a 6-month time period was 55% lower in the tai chi group [24]. There was also significant improvement in measures of functional balance, physical performance , and reduced fear of falling. Cost-benefit analysis shows that tai chi classes have a significantly positive return on investment [25]. Tai chi classes have spread widely and are now often offered at community senior centers [26].

Screening and intervention for those who have a history of falls are elements of secondary prevention. Simply asking the patient on an annual basis if they have ever fallen is a useful screen. However, more focused assessment based on a risk factor-targeted history and on physical examination is necessary to prescribe subsequent interventions .

Vitamin D and Calcium Supplementation

Vitamin D of at least 1000 international units (IU) per day, along with calcium supplementation, is recommended because it reduces falls [27, 28]. Supplementation reduces both fall risk and fracture risk by having a positive effect on functional performance, reaction time, and balance [29]. In meta-analysis, it has been shown to reduce the risk of falls in both ambulatory and institutionalized older individuals with stable health by 22% [30]. Routine measurement of vitamin D (25-OH) is not required prior to supplementation [28]. If clinicians do choose to obtain 25-OH levels, it is recommended to do so after 4 months of supplementation . Conservative targets for 25-OH levels have been shown to be at least 30 ng/ml or 75 nmol/L in order to achieve benefits [28, 31,32,33]. However, vitamin D is not a panacea; there is evidence that high doses of vitamin D (60,000 IU) may actually increase the risk of falls when compared to lower doses [34].

Sarcopenia and Nutrition

Screening for those at risk of sarcopenia , or those who have sarcopenia, identifies another target for intervention. Sarcopenia is a condition associated with frailty. Sarcopenia is defined as low muscle mass secondary to lack of specific nutrients, lack of adequate macronutrients (protein and calories), and/or lack of trophic factors (often mediated via exercise). A brief clinical evaluation can be useful in classifying individuals at risk of nutritionally associated complications, including falls and fractures. Of these, the Mini-Nutritional Assessment (MNA) has had the most extensive validation in acute and long-term care settings [35]. A shortened version of the full MNA has been developed and validated. It uses eight items: decreased food intake due to loss of appetite, digestive problems, chewing or swallowing difficulties, weight loss, mobility , neuropsychological problems, acute illnesses, and the person’s body mass index [35]. The MNA-SF (short form) has a sensitivity of 0.96 for identifying those clinically judged to be “undernourished.” The recommended use of the MNA-SF is as the first step in a two-step process – those who score above 12 on the MNA-SF should be evaluated with the full MNA [36]. Using this approach , there is a 14% false-positive rate for the MNA-SF but only a 3.4% false-negative rate. To emphasize the importance of the relationship between cognitive function and nutritional risk, both clinical guidelines [37] and the MNA use the Folstein Mini-Mental Status Examination for cognitive assessment, the Katz ADL screen for assessment of self-care function, and the Geriatric Depression Scale (short form) for depression screening .

Loss of weight, and the pattern of weight loss, is assigned primary importance in the above paradigm. If an individual loses substantial weight but then starts to regain some weight, they are assigned less risk than an individual who is still losing weight. Change in dietary intake is the primary cause of fluctuations. When making assessments, the duration of the dietary change and the current diet type should be noted. These types are (1) suboptimal solid diet, (2) full liquid diet, (3) hypocaloric liquids, and (4) starvation. Daily nutrient intake can also be mitigated by the presence of significant gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea, and anorexia). Patients with changes in their nutrient consumption often present as weak and are easily fatigued. These nutrient changes can also result in physical changes such as skin breakdown, infections, loss of subcutaneous fat, and muscle wasting.

Having a prior weight and a current weight is crucial to assess nutritional status. Since obtaining reliable historical data may be difficult, those who have had recent contact with the medical system or reside in institutional settings (e.g., nursing homes) may well have a prior weight available, which should be obtained. All patients should be weighed on admission or at first evaluation.

Secondary Prevention

The aim of secondary prevention is to prevent injury from a fall or the prevention of future falls. There are several classes of devices that are employed in secondary prevention: those that alert others when a person at risk of falling is rising to a sitting or standing position, those that identify individuals when they have fallen (to reduce their downtime), and those that buffer the faller in order to reduce injury.

Technological Devices

There are many devices available; however, the evidence does not support utilizing many of them. Some devices attach directly to the older adult’s clothing that alert staff members in facilities that a fall may be imminent. This is helpful if the patient hears the alarm and sits backdown. Long-term care communities often use bed or chair alarms attached to the resident that trigger with standing or sitting up, but often staff are not able to get to the patient quickly enough to prevent the actual fall. Some also feel that the alarms are too startling and are a dignity issue for those residing in long-term care communities. As such, these types of devices have fallen out of favor. Often, a low bed with surrounding mats can be utilized to help decrease the chance of injury rather than prevent the fall.

Other types of fall detectors include user-activated alarms and pendants, automatic wearable fall detectors (watches), video monitoring-based fall detectors, and floor vibration-based fall detectors [38,39,40]. Independently living older adults may also be offered technology to monitor for falls and even fall risks. There are diagnostic technology systems that consist of a personal wearable device that can monitor pulse ox, blood glucose, heart rate, respiratory rate, and other information, with the integration of a home telecare system and camera which may alert family or healthcare providers of the increasing risk of a fall [41, 42].

Hip Protectors

Hip protectors have become more commonly recognized for potentially protecting the older adult fall from a hip fracture. One healthcare equipment supplier quotes under $40 per set [43]. The most recent Cochrane review included 19 studies, involving 17,000 older adults [44]. The studies on those in long-term care communities found that hip protectors probably reduce the risk of hip fracture for those residing in long-term care communities by a risk ratio (RR) of 0.82, confidence interval (CI) 0.67–1.00, with an absolute effect of 11 fewer people (95% CI, from 20 fewer to 0) per 1000 having a hip fracture when provided with hip protectors. Studies looking at community dwelling older adults did not show such positive results and rather reported issues with adherence to wearing the device, as well as skin irritation, depending on the type of hip protector. While hip protectors may protect the hip, there was a risk for pelvic fractures found as an absolute effect of one more person (95% CI 1 fewer to 5 more) per 1000 having a pelvic fracture when provided with hip protectors. Overall, there is substantial variation in hip protector styles (hard versus soft) and pricing, with only probable effectiveness in the long-term care setting, and little evidence to support using them in community dwellers , especially if they are not likely to be worn. These factors make it difficult to know how beneficial or cost-effective they are [44,45,46].

Post-fall Interventions

Post-fall interventions vary depending on the given situation. Both single interventions (e.g., balance training) and multifactorial interventions have been studied. Table 3.4 provides an overview of the recommendations for good single-intervention strategies [47]. Medication review is a single-intervention strategy applicable to potential fallers in all settings. Medication links to fall risk in older adults are listed in Table 3.5.

Table 3.4 Overview of single-intervention fall prevention strategies
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Table 3.5 Medications linked to fall risk in older adults
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Community-Based Older Adults

Recommendations for community dwellers include appropriate use of assistive devices, review and modification of medications, exercise programs with strength and balance training, treatment of postural hypotension, corrections of environmental hazards, and treatment of cardiac disorders. Medications should be evaluated whether or not they are new to the patient regimen, and their side effect profiles should be reviewed with respect to contributions to potential fall risk. Special attention should be paid to those medications that have been linked to falls, which include antipsychotics, sedatives/hypnotics, neuroleptics, antidepressants, and benzodiazepines [48,49,50,51,52,53,54,55]. In general, older adults tend be at higher risk of developing side effects from medications due to pathophysiological changes associated with aging. For example, the slower reaction times found among the elderly, which impair balance, are further exacerbated with the use of benzodiazepines , making balance even more tenuous.

The set of interventions for community dwelling fallers should vary directly with the number of risk factors identified. As with other geriatric syndromes, there is no single cause of falls to identify from a list of differential diagnostic possibilities. Therefore, there is no single intervention to be prescribed for all fallers.

Facility-Based Older Adults

In the long-term care setting, comprehensive assessment, staff education, gait training, proper use of assistive devices, as well as review and modification of medications have been shown to be important [19]. Tools such as STOPP/START [53] and Beers Criteria [48] provide a guideline for medication review and their implementation. Using the STOPP/START criteria has been shown to decrease the number of medications, cost of medications, and falls per year for facility-based individuals [54]. As in other settings, each patient should have an individualized treatment plan depending on their assessment and evaluation of their current clinical situation.

Inpatient-Based Older Adult

In the hospital setting, a multifactorial approach is best used to target risk factors. Evaluation should emphasize medication review, orthostatic blood pressure monitoring, screening for and addressing underlying causes for delirium, balance and gait assessment, care of bowel or bladder incontinence, and physical therapy assessment of muscle strength [7, 56].

As summarized in Table 3.5, medications are extremely important for the care of the elderly, which is a common aspect of inpatient fall prevention strategies [57]. One study showed that when practitioners were prompted with suggestions for recommended doses of psychotropic medications , elderly patients had a lower in-hospital fall rate (0.28 versus 0.64 falls per 100 patient days; P = 0.001) [58].

Tertiary Prevention

Tertiary prevention focuses on rehabilitation from a fall with injury and is beyond the scope of this chapter.

Key Points

  • Falls are a significant public health concern for older adults.

  • Risk factors for falls are intrinsic, extrinsic, and environmental.

  • The greatest risk factor of a fall is a history of falls.

  • Older adults should be screened for falls at least once per year.

  • A history of recurrent falls should prompt a diagnostic evaluation and identification of reversible risk factors.

  • Exercise, nutrition, and vitamin supplementation should be optimized to prevent occurrences of falls and prevent morbidity/mortality from falls.

  • Avoidance of polypharmacy and high-risk drugs is crucial and can be aided by clinical tools such as STOPP/START and Beers Criteria.