Resident Editor:  Lena Makaroun, MD; Jocelyn Ko, MD

Faculty Editor:  Don Ng, MD

Background

• Annual incidence of falls: 25% patients > 65 years old, up to 50% patients > 80 years old (community dwelling adults)
• Falls are the leading cause of hospitalizations and injury-related deaths in patients > 75 years old

Risk Factors

• Medications: Antiarrhythmics, antihistamines, antihypertensives, anticonvulsants, antipsychotics, BZDs, diuretics, muscle relaxants, narcotics, laxatives, MAOIs, SSRIs, TCAs, vasodilators, systemic corticosteroids
• Alcohol use
• Autonomic insufficiency
• Sensory impairments: Vision, proprioception, or vestibular problems
• Motor impairments: Stroke, myelopathy, neuromuscular junction disorder, neuropathy, myopathy, muscle weakness
• Anatomic: Ligamentous injury, joint contractures, foot deformities, neglected toenail care, degenerative osteoarthritis, poor footwear
• Cognitive impairment: Gait apraxia, problems with executive function and following commands
• Movement disorders (eg, Parkinsonism)
• Cerebellar dysfunction 
• Environmental hazards: Obstacles, slippery floor, clutter (Diogenes Syndrome for elderly with pathologic hoarding and isolation), inadequate DME, poor lighting, loose carpets

Evaluation

• History:
  • Screen for falls and fall risk 
    • Have you fallen in the past year?
    • Do you feel unsteady when standing or walking?
    • Are you worried about falling? 
  • If patient has had a fall, first exclude systemic/metabolic process (eg, infection, electrolyte imbalance) and syncope. Evaluate circumstances of the fall (activity and environment at time of fall), associated symptoms (lightheadedness, vertigo, joint pain or instability), and injuries. 
  • Take a comprehensive approach to evaluating the risk factors above as falls are typically multifactorial 
    • Make sure to do a thorough medication review, including OTC medications, alcohol use, and recent medication changes  
• Physical Exam: 
  • If a patient screens positive for fall and fall risk, evaluate gait, strength and balance.
    • Eg, Timed Up and Go (TUG) Test: Patient asked to rise from sitting position, walk 10 feet, turn around, return to chair and sit down. OK to use any usual walking assistance such as cane or walker, and patient should wear typical footwear. If patient takes more than 12 seconds to complete test, suggests higher risk of falls and need for therapy or assistive aid
• If history of multiple falls or fall with injury, consider assessing visual acuity, cognitive impairment (eg, MiniCog), neurologic impairment, muscle strength, peripheral neuropathy, feet and foot wear, and use of assistive devices 
  • If patient uses a cane, make sure the top of the cane is in line with the top of the greater trochanter or at the break of the wrist when patient is holding arm at the side with a 15-degree bend at the elbow
• Consider orthostatic BP to evaluate for postural hypotension and cardiovascular exam to evaluate for arrhythmia or valvular disease if concern for possible presyncope or syncope

Diagnostic Tests

• For those at risk for falls, check CBC, serum electrolytes, BUN, Cr, glucose, B12, thyroid function
• Cardiac work-up if concern for possible syncope 
• Head imaging if head injury, new focal neurologic deficits or concern for CNS process 
• Spine imaging to evaluate for cervical spondylosis or lumbar stenosis in patients with abnormal gait, lower extremity spasticity or hyperreflexia

Management

• Physical Therapy: Strength, balance, gait training, transfer skills, and assessment for assistive devices such as walkers or canes
  • Home PT evaluation to assess home safety and need for other durable medical equipment 
• Refer to Tai Chi classes or local exercise programs
• Periodic podiatry evaluation: proper footwear, foot care (calluses, hard to trim nails), orthotics if needed 
• Treat any vision impairment, cataracts
• Manage postural hypotension 
• Modify or discontinue medications that may be contributory
• Address environmental hazards: Improve lighting; remove loose carpeting; install railings, grab bars, elevated toilet seats; use shower chairs and nonslip bath mats; ensure furniture is the correct height and stable 
• Consider neurology referral if any focal neurologic deficits or signs of parkinsonism
• Screen for osteoporosis and treat osteoporosis as necessary, although vitamin D supplementation alone as an intervention does not appear to reduce rates of falls or risk of falling
• Ask about availability of phone, life line, etc. should the patient fall again

References

Elsawy B, Higgins KE. The Geriatric Assessment. Am Fam Physician 2011;83(1):48-56.

Fuller, G. Falls in the Elderly. Am Fam Physician 2000;61(7):2159-2168.

Gillespie LD, Robertson MC, Gillespie WJ et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146.

Tinetti, ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc., 1986;34(2):119-26.

Johnston CB, Harper GM, Landefeld CS. “Geriatric Disorders”. Common Medical Diagnoses and Treatment. 2011. USA. McGraw Hill Publishing Company.

Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips: 2016, 18^th Edition. New York: The American Geriatrics Society; 2016. 

Moncada LVV, Mire LG. Preventing Falls in Older Persons. Am Fam Physician 2017;96(4):240-247.