One of the major public health concerns of older adults is falls. Falls are defined as an unintentional loss of balance that results in a position change and contact with the ground.1 Practitioners who work with older adults must know and understand the implications of falls and work to improve the quality of life for the older adult who has fallen.
Epidemiology
Approximately one third of individuals over the age of 65 fall each year, rising to 50% by the age of 80.2-6 Falls in older adults are the leading cause of nonfatal and fatal injuries. In 2012, EDs treated almost 2.5 million older adults who had suffered nonfatal falls resulting in 722,000 hospitalizations.7 The CDC reported that in 2012, the adjusted medical cost of falls was approximately 30 billion dollars. As the population ages, the number of falls is expected to increase as well as the cost of treating them.8 Over the last 10 years, death rates from falls have risen dramatically with almost 23,000 fall-related deaths in 2011. Men have a higher death rate from falls than women, and older White men are almost three times more likely to die from a fall than older Black men.8
Pathophysiology of falls
The origin of falls is multifactorial. While hazardous behavior may cause falls, walking, stepping, or position changes cause the majority of falls. Lower extremity weakness, balance disorders, postural hypotension, central nervous system diseases, abnormalities in cognition and sensation, and unsafe environments all contribute to falls.9
During the normal aging process, visual impairment and ocular disease increase. Glare intolerance and slow adaptation to changes in light level are normal and related to the aging process.10
Peripheral and central vestibular function as well as sensory cues help to maintain balance. Age-related changes in the inner ear and changes in transmission signals from the periphery cause disequilibrium and unsteadiness in older adults.11 Depression and acute changes in mental status also contribute to falls in older adults. Other factors that can lead to falls include medications, especially sedating drugs, BP changes, and imbalances in fluid and electrolytes.12,13
Changes in the aging cardiovascular system impair normal homeostatic mechanisms of BP control and perfusion, leading to hypotension and an inability to maintain proper balance. Balance and gait are affected by joint disease and musculoskeletal changes as well as environmental factors, such as scattered rugs, loose electric cords, and clutter. Fear of falling after a fall has occurred is common among older adults because they have lost their self-confidence and feel that they are losing control over their lives.14 Fear of falling produces additional cautious behaviors as well as diminished activity and ambulation, which may put the older adult at risk for future falls.15
Conditions for fall predisposition
Disorders that are common in older adults, such as musculoskeletal diseases, are often the cause of falls and fall-related injuries. Osteoarthritis, osteoporosis, and low back pain have a significant association to fall-related injuries.16 Neurologic conditions in older adults that can increase fall risk include gait and balance disorders, sensory impairments, stroke, Parkinson disease, and cognition impairments. Cardiovascular risk factors for falls include orthostatic hypotension, which is a common medical condition in older adults. Chronic illness such as hypertension, kidney disease, diabetes mellitus, and arteriosclerosis also place the patient at risk for orthostatic hypotension, which increases the fall risk.17,18 Additional risk factors for falls include medications, especially the use of multiple medications known to increase the risk of falls, alcohol abuse, visual disturbances, foot problems, coordination and balance impairment, and urinary incontinence.19-30 (See Risk factors for falls.)
History and physical exam
Is the fall an isolated event? If not, is there a pattern to the falls? If there is a pattern to the falls, how often and when do the falls occur, and are the falls increasing in frequency? Is there a particular triggering factor or event to the fall? Was any alcohol consumed? What caused the fall? What activity was the patient doing at the time of the fall?
Patients who are arising from bed or off a toilet may do so quickly, thus, inadvertently causing orthostatic hypotension. Did the fall involve exertion, change of position of the head (looking up then down)? Patients who are reaching up or extending their neck can cause vertebrobasilar insufficiency, thereby decreasing blood flow to the brain, causing dizziness or blackouts. Micturition syncope, which can affect older adult males especially at night, occurs after rapid urination that causes a sudden drop in BP resulting in syncope.9,31
The level of consciousness should be asked about. Was there any loss of consciousness? Does the patient remember falling? Sudden “blackouts” or falling can be caused by underlying cardiac or neurologic disorders and require further investigation. The patient should be asked if there was a warning or associated symptoms before the fall (palpitations, shortness of breath, dizziness, chest pain, vertigo, dizziness).32 Did the patient have a loss of balance? Patients may state they felt weak, dizzy, or faint prior to falling; these symptoms require a more in-depth evaluation. What was the patient status after the fall? Continued weakness, disorientation, incontinence, and a bitten tongue can indicate neurologic dysfunction and require further evaluation.
Witnesses are important in the evaluation of a witnessed fall, as they can report the circumstances before, during, and after a fall. This is important in describing fall behaviors, such as tonic-clonic movements, mental status, and level of consciousness.
Patients reporting a history of tripping and falling should be further assessed. Are there visual defects present? Has the patient had a recent eye exam? Does the patient have blurred vision, or is vision loss present? Patients who present with visual disturbances, such as presbyopia, cataracts, glaucoma, and age-related macular degeneration, should be followed for appropriate evaluation and treatment.14,27
Components of the physical exam should include vital signs—particularly postural vital signs—and cardiovascular/neurologic evaluations. The cardiovascular examination should include an assessment of pulses for irregularities in rhythm or an abnormal rate—especially atrial fibrillation or bradycardia. The recording of BP in lying, sitting, and standing positions is critical, especially if there is evidence of postural hypotension in the history. A drop of 20 mm Hg in the systolic pressure with standing is noteworthy, as a 20 mm Hg drop can cause changes in balance, leading to falls. Carotid bruits should be assessed for. Auscultation of the heart can provide evidence of murmurs, such as aortic stenosis, regurgitation, mitral stenosis, or regurgitation.14,33
The neurologic examination includes assessment of muscle wasting, muscle strength, tone, and a sensory system assessment—especially if neuropathies are suspected. Muscle wasting can be seen in diseases of disuse, such as arthritis. Mobility and gait testing are quick and easy and can predict the risk of falls. The 'timed up and go” test is a timed test that is the modified version of the “get up and go” test; it entails regular footwear and any regular walking aid where the patient rises from a seated position in a chair with their arms folded across the chest, ambulates 10 feet, then turns around to return to the chair to sit down. The ease of gait, mobility, balance, position, change, and turning is evaluated. Patients taking longer than 30 seconds to complete the test are considered functionally dependent.34
Another performance test for gait and balance and fall risk is The Tinetti Performance Oriented Mobility Assessment (POMA). The Tinetti POMA measures 16 items (9 items of balance and 7 items of gait) in older adults with three-point ordinal scores ranging from 0 to 2; the higher score indicates independence, a score of less than 19 is an individual at high risk for falls, 19 to 24 medium risk for falls, and 25 to 28 low risk for falls.35,36
Fall prevention in the older adult
Patient history and physical exam are key in the formulation of differential diagnosis specific to fall risk and prevention. A thorough and comprehensive history and physical exam should be performed to provide a baseline assessment of neurologic and cognitive function, visual and hearing acuity, musculoskeletal strength and stability, as well as cardiopulmonary stamina. Questionable or suggestive findings will then guide the provider's choice for further study.
Metabolic studies. Metabolic factors should be considered, such as infection, polypharmacy, hypoglycemia, and dehydration. Routine lab testing for the older adult is typically obtained during the annual physical exam or in some cases depending more frequently upon medication regimen and other comorbidities, such as hyperlipidemia, cardiovascular disease, or diabetes. Baseline testing can greatly assist the provider in determining the underlying cause associated with a fall or detect potential conditions that may increase the patient's propensity to fall.
Medicare or other third-party insurance carriers may not always cover some of these baseline blood tests. The complete blood cell count, baseline metabolic panel, thyroid studies, and hemoglobin A1C offer a solid foundation. Anemia, impaired kidney function, electrolyte imbalances, thyroid disease, and diabetes are easily detected with these simple lab studies, and when appropriately corrected, can significantly aid in fall prevention.34
Assessment of balance. Another factor associated with falls is imbalance disturbances that can range from benign positional vertigo (BPV) to more complex neurologic disorders, such as Parkinson disease. Simple screening exams, such as the single leg stance test and the “timed up and go test,” establish a baseline for impaired balance and justification for further investigation with other testing.34
Cardiovascular assessment. Impaired balance can be attributed to cardiovascular conditions, including dysrhythmias (such as atrial fibrillation) and vasculopathies (such as carotid artery atherosclerosis). A simple baseline ECG can detect dysrhythmias, but when symptoms such as syncope are present, Holter monitoring—either a 24-hour study or longer event monitoring (30 days)—may be required to capture more complex dysrhythmias that are transient or paroxysmal. Doppler studies provide a baseline vascular evaluation and can also be used to monitor and track the progression of documented vasculopathies, such as carotid artery occlusion.34,37
Visual and hearing assessment. Many falls occur in the patient's home during the night when there is less light. A routine eye exam and hearing screening will help to complete the comprehensive evaluation for fall prevention. An annual eye exam is recommended, especially if the patient has diabetes or documented retinopathy, cataracts, or other visual pathology. Patients should also be cautioned with regard to certain lens types, such as bifocals, as these types of lenses may alter depth perception and increase the chance of falls.34
Musculoskeletal assessment. During the musculoskeletal assessment, arthritic changes in the joints and limitations in mobility are detected. Arthritis accounts for approximately 15% to 20% of falls in adults over the age of 45 due to decreased strength and limitations in mobility.38 In addition to the musculoskeletal physical assessment of the older adult patient, the provider must also consider the direct correlation of osteoporosis to falls in older adults due to loss of bone density experienced from the effects of osteoporosis. Dual X-ray absorptiometry (also known as the DXA or DEXA scan) is an easy and relatively safe exam with low radiation exposure that greatly assists in the calculation of bone density loss. Results can provide a useful guide for nurse practitioners when considering pharmacologic treatment for osteoporosis as well as other interventions, such as strength training exercise, nutritional supplementation, and therapy.38
Cognitive assessment. There is a significant correlation between falls and dementia. Creating a safe environment for all patients—especially those with dementia—is central to their overall care. Assessing the older adult at baseline and monitoring at least annually (or more frequently if warranted) aids in early detection of dementia. The Mini Mental State Exam (MMSE) is a simple and convenient tool to use when performing a baseline assessment as well as for trending progressive cognitive impairment.34 The MMSE is a standardized test that has sound reliability and validity; it evaluates registration, attention and calculation, recall, language, simple commands, and orientation. The maximum score is 30.
A score of 26 or above is considered normal. If the older adult scores below 26, further evaluation by a neurologist is recommended to differentiate the degree and type of dementia that may be present. Another tool that is used to detect mild cognitive impairment is the Montreal Cognitive Assessment (MoCA). The MoCA is also a 30-point tool that assesses attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. A score of 26 or above in the MoCA is also considered normal. Again, older adults scoring below 26 should be evaluated further.39
Bowel and bladder assessment. A comprehensive history with regard to the patient's bowel and bladder habits is essential. Questions should focus on overall bowel and bladder habits, bladder continence, the presence of constipation, the use of laxatives and diuretics, and any other over-the-counter (OTC) medications the patient may use. Urinary incontinence poses a major risk factor for falls. These falls frequently occur due to the patient's attempting to get to the bathroom quickly to avoid an incontinent episode. In addition, wet bathroom floors due to urinary incontinence increase the risk of slipping. Constipation on the other hand also presents fall risk for the older adult who may use various laxatives and other aids to alleviate constipation. Some laxatives may increase episodes of diarrhea that in turn increases the incidence of dehydration, which may also increase dizziness and syncope.34
Fall assessment tools. In addition to the above discussed fall assessment, there are a number of tools that have been developed for the assessment of falls in the older adult (see Useful provider websites). The CDC has published a pocket guide for providers, which contains an algorithm for fall assessment as well as a fall checklist for providers and their patients to use for additional fall risk screening (www.cdc.gov/homeandrecreationalsafety/pdf/steadi/pocket_guide_preventing-falls.pdf). The Morse Fall Scale (1989) is another tool that was developed by J.M. Morse for the rapid evaluation of fall risk for patients who are either hospitalized or in long-term care.40,41 The Morse Fall Scale assesses six parameters for falls, history of falls, secondary diagnoses, ambulatory aids, current I.V., gait, transference, and mental status. Other assessment and screening tools can also be found on the website created by the Ohio Department of Health (http://www.healthy.ohio.gov/vipp/falls/fallsolder.aspx).
Pharmacology
The pharmacy intervention for falls focuses on supplementation for bone health and careful review of current medication regimens. Falls often occur after a fracture due to osteoporosis and most commonly affect the hip and spine. Increasing the strength of the bones—specifically the longer bones—will decrease the chance of fracture-related falls. Vitamin D, bisphosphonates, raloxifene, denosumab, or teriparatide may be used for the treatment of osteoporosis.34,37
Many older adults experience decreased appetite and eat less. Vitamin supplementation is recommended, and the use of most OTC multivitamins is sufficient. Iron supplementation can also be included if the patient is found to have iron deficiency.
Cognitive impairment and metabolic changes increase the risk of falls. That being said, medication reconciliation should be performed at every visit to ensure proper medication use, evaluation for polypharmacy, medication adherence, and evaluation of adverse events.42,43 It is not uncommon for older adult patients to have more than one provider, specifically those providers in specialty, such as cardiology, neurology, urology, pulmonology, and orthopedics. Each of these providers may prescribe disease-specific medication and frequently, duplication or over prescribing of a specific drug class can occur. A good example is as follows: the patient is seen by the neurologist who prescribes low-dose zaleplon for sleep. The patient is also being seen by an orthopedist for a recent wrist fracture. Unbeknownst to the orthopedist that the patient is taking a sleep aid, the orthopedist prescribes oxycodone and acetaminophen for pain. The combination of the two drugs has the potential to increase somnolence and gait imbalance due to sedation, which in turn increases fall potential. Reviewing the patient's medications regularly can significantly decrease the incidence of polypharmacy. Comprehensive medication reconciliation should include having the patient physically bring all of their medications with them to the provider visit.43
Nonpharmacologic measures
Central to fall prevention are the nonpharmacologic interventions that should be considered and discussed with the older adult and his or her caregivers. When evaluating the risk factors for falls, safety is of paramount concern.
Creating a safe environment. Proper lighting, especially during the evening and nighttime, will increase visibility—especially for those older adults with diminished visual acuity and in some cases, impairment. Ensuring that flooring is secure, such as carpeting and tiles, will decrease the chance of tripping or slipping. Cautioning patients with regard to walking when there is ice, snow, or other wet surfaces outside should be part of the safety conversation and instructions.
Many older adults drive, and this also poses a major safety risk. The National Highway Safety Commission (http://www.nhtsa.gov/Senior-Drivers) provides information with regard to driver safety for the older adult as well as links to driver assessment programs throughout the United States. These programs assess older adult driving ability. This can greatly assist caregivers or children of older adult patients when faced with making the decision to stop the older adult from driving due to limitations, such as sight, reaction time, and hearing. For those patients (depended upon assistive devices for ambulation such as walkers and canes), safety education with regard to proper use and importance of using these devices is key. It is also important to explore the patient's thoughts and opinions regarding the use of assistive devices—especially in their own home environment.
Strength training and improvement of balance
The various musculoskeletal changes that occur in the older adult include decreased muscle tone and strength, which directly affect balance and coordination. Physical therapy (PT) can improve muscle tone and strength through specific exercises that target certain muscle groups. The physical therapist will work on strengthening leg and arm muscle groups as well as incorporate repetitive exercises, such as sitting and standing (getting up from a chair), ambulating, ambulating safely with assistive devices, and stair climbing.34
In addition to PT, occupational therapy is also beneficial for fall prevention. The occupational therapist will evaluate the older adult's environment and make recommendations for increased safety, such as grab bars in the bathroom, modifications with regard to kitchen tools, arranging cabinets for easy access, and other household changes that will promote a safe environment. In addition to the traditional therapies for strength training and improvement of balance, studies looking at yoga, tai chi, and tai ji have demonstrated increased strength and balance through the implementation of these forms of exercise.44,45 Footwear and care of the feet are also recommended for fall prevention. Older patients should have regular visits to a podiatrist for foot care, especially if patients have foot deformities or experience pain—both of which limit mobility.34
Nutritional guidance
In addition to vitamin D supplementation and the other pharmacologic interventions that help to decrease bone loss, proper nutrition is crucial. A diet that is well balanced with fruits, vegetables, and protein provides a great source of vitamins and minerals. Having the older adult patient meet with a nutritionist is also recommended—especially in cases where comorbidities such as hyperlipidemia and diabetes are prevalent.46
Aging–Falls increase with age and increasing frailty
Gender–Women are more likely to have a nonfatal fall, while men who suffer a fall are approximately 50% more likely to have a fatal fall
Medications–Common medications in older adults, such as diuretics, beta-blockers, antidepressants, nitrates, angiotensin-converting enzyme inhibitors, and antihistamines, are thought to precipitate orthostatic hypotension and cause falls as a result of syncopal adverse reactions. Benzodiazepines, psychotropics, and sedatives can cause confusion, leading to falls.
Polypharmacy–Using four or more medications causing interactions and adverse reactions are likely to cause falls. Even using one medication known to cause falls can increase risk
Alcohol abuse–can cause instability from acute intoxication. Alcohol abusers can be predisposed to falls secondary to polyneuropathy, Wernicke encephalopathy, and Korsakoff syndrome
Diabetes–related neuropathy can predispose one to balance impairments, motor weakness, and loss of sensation, leading to lower extremity weakness, which can cause frequent tripping and inability to navigate stairs and rise from a seated position
Visual disturbances–Increased falls related to visual disturbances is becoming more common. Visual disturbances, such as presbyopia, cataracts, glaucoma, and age-related macular degeneration, are associated with increased tripping, slips, and falls
Coordination and balance–impairments related to changes in musculoskeletal impairments, resulting in disorders of gait and lower extremity weakness
Foot problems–Older adults with deformities of toes, bunions, callus nail deformities (even improper footwear) can cause increased pain when ambulating and can lead to balance difficulties and falls
Urinary incontinence–Falls from urinary incontinence are a direct result from trying to do two things at once; urine is to be held before being expelled at the bathroom
Depression–Coupled with the use of antidepressive medication, diminished physical functioning, and cognitive deficits, depression is known to increase the risk of falls in older adults
Useful provider websites
Fall assessment tools
An algorithm for falls risk assessment and interventions
https://www.wehealny.org/services/ipa/files/MAW/algorithm_fall_risk_assessment.pdf
A fall risk checklist
http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi-2015.04/Check_for_Safety_brochure-a.pdf
Common screening and assessment tools
http://www.fallpreventiontaskforce.org/resourcetools/screening-assessment-tools
NICHE fall assessment:
http://www.nicheprogram.org/niche_encyclopedia-assessment-fall_risk_assessment
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