Review

Assessment and management of falls in older people

Emily Kwan and Sharon E. Straus
CMAJ November 04, 2014 186 (16) E610-E621; DOI: https://doi.org/10.1503/cmaj.131330

Worldwide, 30% of people aged 65 years or older who are living in the community fall each year, and among people aged 85 years or older, this proportion increases to nearly 40%.1,2 Falls frequently have serious consequences in this population, with concomitant effects on the health care system. Falls are defined in numerous ways; one commonly used definition is that of the World Health Organization (WHO): “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”3

Of older people living in the community who fall, 12% to 42% will have a fall-related injury, with up to 20% requiring medical attention and 10% experiencing a fracture secondary to osteoporosis.4 Older people who have a fall-induced fracture can experience devastating consequences. For example, up to 20% of patients with hip fracture die within the first year, and many survivors do not return to their previous level of functioning.1,4–7 Other fall-related injuries include head injuries in older people.8 Given the serious consequences of falls, physicians need to specifically ask about falling because many patients do not tell their physicians about their previous falls.8 It is also essential that physicians appropriately assess and manage the care of patients who experience a fall. In this article, we present the evidence contained within high-quality systematic reviews pertaining to assessment of patients who have fallen and management of their subsequent care. A summary of the evidence appears in Box 1.

Box 1:

Evidence used in this review

To identify relevant systematic reviews, we did a comprehensive search of the literature (i.e., MEDLINE, CINAHL, Embase, AgeLine and The Cochrane Library) for articles published between Jan. 1, 2005 and Sept. 30, 2012. We used the following terms in the search: “falls,” “accidental falls,” “aged,” “geriatric,” “elderly,” “senior,” “old age” and “older adult.” We identified additional articles (which may be outside of the range of dates) by reviewing reference lists of previous articles and discussing the topic with experts. We included only articles that were published in English.

We included systematic reviews of studies assessing risk factors for falls, as well as studies evaluating interventions to prevent falls among older people (mean age ≥ 60 yr).

Two reviewers independently evaluated the systematic reviews using AMSTAR (a measurement tool for the assessment of multiple systematic reviews).9 If multiple reviews on a single topic were identified, we included only those that were rated as high quality (defined as a score of ≥ 7 out of 11). If a particular topic was covered by only one review, that review was included even if it scored less than 7 on the AMSTAR tool.

What causes older people to fall?

A clinical examination, addressing potential home hazards, medications, cognitive and visual impairment, functional limitations, orthostatic hypotension, and gait and balance abnormalities, can be used to identify risk factors for falls.

Various factors can increase a person’s risk of falling (Table 1). Because the causes of falls are usually multiple, one approach to assessing these risk factors is through a targeted history and physical examination.

View this table:
Table 1:

Studies evaluating risk factors for falls

History

Older age (i.e., ≥ 65 yr) has been associated with an increased risk of falls. One systematic review2 showed that among patients aged 65 through 74 years, the risk of falling was 31% per year, and among those 80 years of age and older, the risk of falling increased to 37% per year.

The clinician’s interview with the patient (or a caregiver) at the time of presentation should focus on eliciting information about previous falls and their causes, as well as any previous injuries resulting from such falls. The occurrence of a fall increases the risk of additional falls within the next year.2 Symptoms that may cause falls, such as dizziness and palpitations, should also be elicited, as they may be related to potential causes of the fall, such as arrhythmias. Similarly, during the assessment, any injuries due to the current fall should be determined.

Other aspects of the patient’s medical history may provide additional clues about risk factors for falls. For example, in their systematic review, Ganz and colleagues2 identified 2 studies in which cognitive impairment increased the likelihood of a fall (likelihood ratio [LR] 4.2, 95% confidence interval [CI] 1.9–9.6; LR 13, 95% CI 2.3–79, respectively). In addition, visual impairment may slightly increase the likelihood of a fall (LR range 1.6–2.0).2 Other comorbidities that have been linked with increased risk of falls include Parkinson disease, arthritis of the knees, sensory impairment, and any comorbidity that impairs gait or balance (e.g., stroke).2

Several medications have been found to increase the risk of falls, so it can be helpful to obtain an accurate medication history. For example, in a systematic review of 22 cohort, cross-sectional and case–control studies, the use of various types of drugs was shown to increase the risk of falls among people aged 60 years and older:10 for sedatives and hypnotics (not including benzodiazepines), odds ratio (OR) 1.47 (95% CI 1.35–1.62); for neuroleptics and antipsychotics, OR 1.59 (95% CI 1.37–1.83); for antidepressants, OR 1.68 (95% CI 1.47–1.91); and for benzodiazepines, OR 1.57 (95% CI 1.43–1.72). Systematic reviews of observational studies involving other medications have shown similar increased risks of falls: for nonsteroidal anti-inflammatory drugs, OR 1.21 (95% CI 1.01–1.44); and for antihypertensive medications, OR 1.24 (95% CI 1.01–1.50).10–12 Use of cognitive enhancers (i.e., cholinesterase inhibitors) increased the risk of syncope, which may lead to falls (OR 1.53, 95% CI 1.02–2.30).13

Assessment of the patient’s functional status should include an assessment of activities of daily living (ADLs) (e.g., bathing, toileting, feeding, dressing, grooming and ambulation) and instrumental ADLs (e.g., use of the telephone, shopping, food preparation, managing own finances, housekeeping, laundry and transportation). A systematic review of randomized controlled trials and observational studies showed that the presence of any difficulties with ADLs was associated with an increased risk of falling (for ADLs, OR 2.26, 95% CI 2.09–2.45; for instrumental ADLs, OR 2.10, 95% CI 1.68– 2.64).14

The social history should address the patient’s living conditions, including various environmental factors and hazards, both indoors and outdoors, such as rugs, bathroom equipment, lighting, bath rails, clutter, wet surfaces, gait aids, assistive devices, weather conditions and footwear. One systematic review of cohort and cross-sectional studies showed an increased risk of falls in the presence of mobility aids in both the community (OR 2.07, 95% CI 1.59–2.71) and institutional settings such as retirement homes and long-term care facilities (OR 1.77, 95% CI 1.66–1.89). It was concluded that home hazards increased the risk of falling (OR 1.15, 95% CI 0.97–1.36).15

Physical examination

The physical examination should focus on injuries related to the fall, as well as factors that may have contributed to its occurrence. In particular, positional blood pressure (both supine and standing) can be assessed to check for orthostatic hypotension, defined as a drop in systolic blood pressure of 20 mm Hg or in diastolic blood pressure of 10 mm Hg at 1 to 3 minutes after the patient repositions from supine to standing. One study found orthostatic hypotension to predict falls when there was a pulse rate that was less than an increase of 6 beats/min measured 30 seconds after standing up.2

A full neurologic examination with a focus on strength, reflexes, sensory and gait should be done. A clinically detected abnormality of gait or balance may increase the likelihood of a fall (LR range 1.7–2.4).2,16 In their systematic review, Ganz and colleagues2 found one prospective cohort study showing that the presence of any lower extremity disability increased the likelihood of falling (LR 1.8, 95% CI 1.5–2.2). In another systematic review of cohort and cross-sectional studies, Letts and associates15 found that mobility aids were associated with an increased risk of falls both in the community and in institutions.

Are there any tools to help assess the risk of falling?

Systematic reviews have identified several tools to assess the risk of falls, including the Tinetti Gait and Balance Assessment Tool, the Berg Balance Scale, the Timed Up and Go test, and the one-legged and tandem stance assessments.17–19 According to the systematic reviews, these tools poorly predict patients who will or will not fall.17–19

What interventions are effective for preventing falls?

Management of falls is complex. There have been numerous studies in different settings (i.e., community, acute hospital or long-term care) that have considered a combination of interventions such as an exercise program, medication review, home assessment and vitamin D supplementation for groups of older people. The causes of falls are usually multiple, and management should be tailored to each patient depending on the history and physical examination. It is unclear whether a single- or multiple-intervention approach should be used for patients who fall. Based on existing evidence, a specified exercise regimen should always be included in the management, but there is support for other interventions such as home assessments and treatment of first-time cataracts.

We identified 19 recent systematic reviews of interventions to prevent falls.20–38 These reviews included studies involving older patients living in various settings (e.g., the community, acute care hospitals and long-term care institutions). Both single and multiple interventions have been tested. Numerous individuals can be involved in the assessment and management of falls, including caregivers, family members, pharmacists, physicians, and occupational and physical therapists.

Community

Tables 2 and 3 outline interventions for preventing falls among older adults. For those living in the community, the following single interventions have been found to be effective: home assessment (best if led by an occupational therapist),21 and various exercise programs including the Otago Exercise Programme20 (Box 2) (associated with reduced fall rates), tai chi,22,23 group exercises, home-based exercises, and exercise training with either gait, balance or functional training.

View this table:
Table 2:

Studies evaluating interventions for preventing falls among older people, by setting

View this table:
Table 3:

Interventions for preventing falls among older people living in the community (Gillespie et al.23)

Box 2:

Otago Exercise Programme39

The Otago Exercise Programme is a system of home-based exercises combining progressively more difficult leg-strengthening and balance-retraining exercises to prevent falls in older people living in the community. It also includes a walking plan. The program is usually delivered by a physiotherapist.

Fear of falling declined following single interventions such as tai chi, use of hip protectors or exercise interventions, and after programs based on combinations of these interventions.24 A multicomponent group exercise intervention showed benefit, with decreases in both the rate of falls and the risk of falling.23 Multicomponent home-based exercise also decreased the rate of falls (rate reduction 0.68, 95% CI 0.58–0.80).23

Several interventions have been associated with a reduction in the rate of falls (e.g., tai chi, exercise training, multicomponent interventions, home safety assessment, gradual withdrawal of psychotropic medication, use of an antislip shoe device for icy conditions, multifaceted podiatry) or the risk of falling (e.g., multicomponent home-based exercise programs, tai chi, home safety assessment).23 No reduction in the rate of falls or the risk of falling has been shown with vitamin D supplementation as a single intervention for older adults living in the community.23 Similarly, a recent systematic review of randomized trials assessing strength and resistance training found no reduction in the rate or the risk of falling.25 Cognitive behavioural interventions also had no significant effect on the rate or the risk of falling.23 Treatment of vision problems (via single-lens glasses) resulted in an increase in the rate of falls and the risk of falling. Among women, surgery for first-time cataracts reduced the rate of falls, but surgery for second-time cataracts did not.23

Six recent systematic reviews of multicomponent interventions in older adults living in the community assessed various combinations of interventions, including combinations of exercises (balance, aerobic and/or strengthening exercises), vitamin D supplementation, home assessment, comprehensive geriatric assessment, reviews of vision and medications, and follow-up by an occupational therapist and physiotherapist.21–24,26,27 It was unclear whether a multicomponent intervention was better than a single intervention for reducing falls.27 One systematic review indicated that multicomponent interventions may have benefit in terms of reducing the rate of falls but not the risk of falling.23 Similarly, it is unclear from studies of multicomponent interventions which interventions might be most effective in preventing falls.

Retirement homes and long-term care

Two systematic reviews28,29 examined studies of interventions to prevent falls among those living in retirement homes or long-term care institutions. Vitamin D supplementation was associated with a reduction in the rate of falls but did not reduce the risk of falling (rate ratio 0.72, 95% CI 0.55–0.95, risk ratio 0.98, 95% CI 0.89–1.09).28 Studies of multicomponent interventions were done in both reviews. One review29 showed some efficacy but did not provide a compiled average in risk for all studies used. The other review28 initially showed no significant reduction in rate of falls or risk of falling, but post hoc analysis did show significance.

Acute care hospitals

Two systematic reviews28,30 examined studies of multicomponent interventions to prevent falls among patients admitted to acute care hospitals. These interventions reduced the rate of falls and the risk of falling relative to usual care (rate ratio 0.60, 95% CI 0.51–0.72; risk ratio 0.85, 95% CI 0.77–0.95).28 There was a small but significant benefit with a multicomponent intervention (including exercise) that differed from “usual hospital care.”30

Mixed settings

Eight recent systematic reviews31–38 evaluated interventions to prevent falls among patients living in various settings, including the community, acute care hospitals and long-term care institutions. Studies of vitamin D supplementation showed a benefit in reducing the risk of falls.31–33 Tai chi also decreased the risk but not the rate of falling.34 A systematic review on whole-body vibration programs (combined with strength and dynamic exercises) have shown some benefit compared with a control group (which did the same exercise as the intervention group but without a vibration platform) but not compared with a conventional group (which performed specific exercises based on guidelines of the American College of Sports Medicine).35 Similar to the results of studies involving community-dwelling older adults, multicomponent interventions to prevent falls in all settings decreased the number of falls and injuries from falls (relative risk 0.91, 95% CI 0.82–1.02, and in number of fall-related injuries relative risk 0.90, 95% CI 0.68–1.20).36 One systematic review found an improvement in patients’ quality of life with evaluation of the extent to which measurement of a person’s participation in interventions to prevent falls (as assessed by the individual’s functioning in his or her various life roles) was reported in trials of such interventions.37 Another systematic review concluded that participation in exercise may improve participation in life roles (i.e., social interaction; employment; use of transportation; and community, social and civic life).38

How can this review be applied in practice?

On the basis of the evidence reviewed, we suggest that assessment of a patient who has fallen should incorporate the history and physical examination as described. This assessment can then be used to target implementation of strategies to prevent falls in the future. Exercise interventions such as tai chi and the Otago Exercise Programme have been shown to be beneficial and should be considered. A stepwise management plan that is applicable to all those at risk for falling is challenging to outline because individuals have different reasons for falling.

Interventions to address prevention have also been studied. In both primary and secondary prevention of falls, exercise has been proven to be beneficial and should be recommended. Further consideration of interventions is dependent on the patient’s setting.

Gaps in knowledge

Although we found information about numerous risk factors for falls, evidence is lacking about tools for assessing the risk of falls that are accurate, precise and easy to use. Optimal management for patients who have had falls is also unclear. Although many high-quality systematic reviews of interventions to prevent falls have been conducted, none have ranked all of the available interventions using a network meta-analysis approach; our group has undertaken such a study, which is currently in progress.40 Similarly, it is unclear whether a single intervention is as good as a multicomponent approach for preventing falls. In addition, although exercise has been shown to be beneficial for patients who have had a fall, the types of exercise and the requirements of each exercise component in a multicomponent intervention vary.

Conclusion

Falls are common among older people and can have devastating consequences. Physicians should ask patients about falls during a comprehensive assessment and include an assessment for relevant risk factors. When a patient has a fall, through a careful history and physical examination, the clinician may be able to identify risk factors that can be targeted for interventions to prevent future falls. At a minimum, older patients who have experienced a fall should be counselled about starting an exercise program (e.g., tai chi or the Otago Exercise Programme) to prevent falls and associated fractures.

KEY POINTS

  • A targeted history and physical examination, covering potential home hazards, cognitive and visual impairment, functional limitations, medications, orthostatic hypotension, and gait and balance abnormalities, can be used to identify risk factors for falls.

  • No specific assessment tools have been shown to accurately predict the risk of falls.

  • Numerous interventions (single and multicomponent) have been shown to decrease the risk of falls.

  • At a minimum, patients who have experienced a fall should be encouraged to participate in an approved exercise program to help prevent further falls.

Acknowledgement

The authors thank Peggy Robinson for assistance with manuscript preparation.

Footnotes

  • Competing interests: None declared.

  • Disclaimer: Sharon Straus is an associate editor for the CMAJ and was not involved in the editorial decision-making process for this article.

  • This article has been peer reviewed.

  • Contributors: Both authors drafted and revised the article, and approved the final version submitted for publication. Both authors are guarantors of the work.

  • Funding: Sharon Straus receives funding from a Tier 1 Canada Research Chair.

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Canadian Medical Association Journal: 186 (16)
CMAJ
Vol. 186, Issue 16
4 Nov 2014

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Assessment and management of falls in older people
Emily Kwan, Sharon E. Straus
CMAJ Nov 2014, 186 (16) E610-E621; DOI: 10.1503/cmaj.131330
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