A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders (eg, stroke, seizure) or overwhelming environmental hazards (eg, being struck by a moving object) are not considered falls. Show Falls threaten the independence of older people and cause a cascade of individual and socioeconomic consequences. However, physicians are often unaware of falls in patients who do not present with an injury because a routine history and physical examination typically do not include a specific evaluation for falls. Many older people are reluctant to report a fall because they attribute falling to the aging process or because they fear being subsequently restricted in their activities or institutionalized. The best predictor of falling is a previous fall. However, falls in older people rarely have a single cause or risk factor. A fall is usually caused by a complex interaction among the following:
Age-related changes can impair systems involved in maintaining balance and stability (eg, while standing, walking, or sitting) and increase the risk of falls. Visual acuity, contrast sensitivity, depth perception, and dark adaptation decline. Changes in muscle activation patterns and ability to generate sufficient muscle power and velocity may impair the ability to maintain or recover balance in response to perturbations (eg, stepping onto an uneven surface, being bumped). In fact, muscle weakness of any type is a major predictor of falls. Environmental factors can increase the risk of falls independently or, more importantly, by interacting with intrinsic factors. Risk is highest when the environment requires greater postural control and mobility (eg, when walking on a slippery surface) and when the environment is unfamiliar (eg, when relocated to a new home). Certain activities or decisions may increase the risk of falls and fall-related injuries. Examples are walking while talking or being distracted by multitasking and then failing to notice an environmental hazard (eg, a curb or step), rushing to the bathroom (especially at night when not fully awake or when lighting may be inadequate), and rushing to answer the telephone. Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death, particularly in older people who are frail and have preexisting disease comorbidities (eg, osteoporosis) and deficits in activities of daily living (eg, incontinence). Longer-term complications can include decreased physical function, fear of falling, and institutionalization. Falls reportedly contribute to > 40% of nursing home admissions. Over 50% of falls among older people result in an injury. Although most injuries are not serious (eg, contusions, abrasions), fall-related injuries account for about 5% of hospitalizations in patients ≥ 65. About 5% of falls result in fractures of the humerus, wrist, or pelvis. About 2% of falls result in a hip fracture. Other serious injuries (eg, head and internal injuries, lacerations) occur in about 10% of falls. Some fall-related injuries are fatal. About 5% of older people with hip fractures die while hospitalized. Overall mortality in the 12 months after a hip fracture ranges from 18 to 33%. About half of older people who fall cannot get up without help. Remaining on the floor for > 2 hours after a fall increases risk of dehydration, pressure ulcers, rhabdomyolysis, hypothermia, and pneumonia. Function and quality of life may deteriorate drastically after a fall; at least 50% of older people who were ambulatory before fracturing a hip do not recover their previous level of mobility. After falling, older people may fear falling again, so mobility is sometimes reduced because confidence is lost. Some people may even avoid certain activities (eg, shopping, cleaning) because of this fear. Decreased activity can increase joint stiffness and weakness, further reducing mobility. 
Some falls are promptly recognized because of an obvious fall-related injury or concern about a possible injury. However, because older people often do not report falls, they should be asked about falls or mobility problems at least once per year. Patients who report a single fall should be evaluated for a balance or gait problem using the basic Get-Up-and-Go Test. For the test, patients are observed as they rise from a standard armchair, walk 3 meters (about 10 feet) in a straight line, turn, walk back to the chair, and sit back down. Observation may detect lower-extremity weakness, imbalance while standing or sitting, or an unsteady gait. Sometimes the test is timed. A time of > 12 seconds indicates a significantly increased risk of falls. Patients who require a more complete assessment of risk factors for falls include
When a more complete assessment of fall risk factors is needed, the focus is on identifying intrinsic, extrinsic, and situational factors that can be reduced by interventions targeted at them. Patients are asked open-ended questions about the most recent fall or falls, followed by more specific questions about when and where a fall occurred and what they were doing. Witnesses are asked the same questions. Patients should be asked whether they had premonitory or associated symptoms (eg, palpitations, shortness of breath, chest pain, vertigo, light-headedness) and whether consciousness was lost. Patients should also be asked whether any obvious extrinsic or situational factors may have been involved. The history should include questions about past and present medical problems, use of prescription and over-the-counter drugs, and use of alcohol. Because eliminating all risk of future falls may be impossible, patients should be asked whether they were able to get back up without help after falling and whether any injuries occurred; the goal is reducing the risk of complications due to future falls. The physical examination should be comprehensive enough to exclude obvious intrinsic causes of falls. If the fall occurred recently, temperature should be measured to determine whether fever was a factor. Heart rate and rhythm should be assessed to identify obvious bradycardia, resting tachycardia, or irregular rhythms. Blood pressure should be measured with patients supine and after patients stand for 1 and 3 minutes to rule out orthostatic hypotension. Auscultation can detect many types of valvular heart disorders. Visual acuity should be evaluated with patients wearing their usual corrective lenses if needed. Abnormalities in visual acuity should trigger a more detailed visual examination by an optometrist or ophthalmologist. The neck, spine, and extremities (especially the legs and feet) should be evaluated for weakness, deformities, pain, and limitation in range of motion. The Performance-Oriented Assessment of Mobility or the Timed Get-Up-and-Go test can identify problems with balance and stability during walking and other movements that may indicate increased risk of falls. These tests are especially helpful if the patient had difficulty doing the basic Get-Up-and-Go test. There is no standard diagnostic evaluation to determine the exact cause of a fall. Testing should be based on the history and examination and helps rule out various causes:
Tests such as electrocardiography (ECG), ambulatory cardiac monitoring, and echocardiography are recommended only when a cardiac cause is suspected. Carotid massage under controlled conditions (IV access and cardiac monitoring) has been proposed to determine carotid hypersensitivity and ultimately who might respond to pacemaker treatment. Spinal x-rays and cranial computer tomography (CT) or magnetic resonance imaging (MRI) are indicated only when the history and physical examination detect new neurologic abnormalities. Patients who report a single fall and who do not have problems with balance or gait on the Get-Up-and-Go Test or a similar test should be given general information about reducing risk of falls. It should include how to use drugs safely and reduce environmental hazards (see table
Home Assessment Checklist
Home Assessment Checklist for Hazards That Increase Risk of Falling Patients who have fallen more than once or who have problems during initial balance and gait testing should be referred to physical therapy or an exercise program. Physical therapy and exercise programs can be done in the home if patients have limited mobility. Physical therapists customize exercise programs to improve balance and gait and to correct specific problems contributing to fall risk. More general exercise programs in health care or community settings can also improve balance and gait. For example, tai chi may be effective and can be done alone or in groups. The most effective exercise programs to reduce fall risk are those that
If any other specific disorder is identified as a risk factor, targeted interventions are required. For example, drugs and physical therapy may reduce risk for patients with Parkinson disease. Pain management, physical therapy, and sometimes joint replacement surgery may reduce risk for patients with arthritis. A change to appropriate lenses (single lenses rather than bifocals or trifocals) or surgery, particularly for removal of cataracts, may help patients with visual impairment. Correcting environmental hazards in
the home may reduce the risk of falls (see table Home Assessment Checklist
Home Assessment Checklist for Hazards That Increase Risk of Falling Restraints may lead to more falls and other complications and should generally not be used. Surveillance by a caregiver is more effective and safer. Motion detectors may be used, but a caregiver must be present to respond promptly to the triggered alarm. Hip protectors (padding sewn into special undergarments) have been shown to reduce hip fractures in high-risk patients in nursing facilities, but are less effective in older people living in the community. Furthermore, many patients are reluctant to wear protectors indefinitely. Compliant flooring (eg, firm rubber) can help dissipate the impact force, but a floor that is too compliant (eg, soft foam) may destabilize patients. Patients should also be taught what to do if they fall and cannot get up. Useful techniques include turning from the supine position to the prone position, getting on all fours, crawling to a strong support surface, and pulling up. Having frequent contact with family members or friends, a phone that can be reached from the floor, a remote alarm, or a wearable emergency response system device can decrease the likelihood of lying on the floor for a long time after a fall.
The following are English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Click here for Patient Education Which factor contributes to an increase in falls in older patients?Risk factors for falls in the elderly include increasing age, medication use, cognitive impairment and sensory deficits.
Which of the following is a risk factor for falls in the elderly?The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors.
What factors contribute to falls?Behavioural risk factors include history of falls, fear of falling, poor nutrition and/or hydration, lack of physical activity, inappropriate footwear and clothing, and taking multiple medications, particularly psychoactive medications like tranquilizers or antidepressants.
What is the most common predictor of an older adults increased risk of falling?Skeletal muscle strength and mass decline with age 57 , 58 , 71 and immobility. Impaired strength is a strong predictor of falls in most studies (Table 15-1) and may also increase the risk of injury from a fall.
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Which factors contribute to an increase in falls in older patients select all that apply?
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