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Falls in Older Adults

By

Richard G. Stefanacci

, DO, MGH, MBA, Thomas Jefferson University, Jefferson College of Population Health;


Jayne R. Wilkinson

, MD, MSCE, University of Pennsylvania, Perelman School of Medicine

Reviewed/Revised Nov 2023
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Topic Resources

A fall is defined as an event that occurs when a person inadvertently drops down to 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.

In the United States, about 14 million (about 28%) adults age ≥ 65 report falling each year, accounting for a total of about 36 million falls each year according to the Centers for Disease Control and Prevention (CDC [ 2 References A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ]). Not all falls result in an injury, but about 37% of people who fall report an injury that required medical treatment or that restricted their activity for at least one day, resulting in an estimated 8 million fall injuries each year (3 References A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ).

Falls threaten the independence of older adults and cause a cascade of individual and socioeconomic problems. However, clinicians 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 adults 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. Reporting falls to clinicians is necessary for prevention of future falls. When falls are not reported and preventive measures are not instituted, patients are at risk of falling again, thereby placing a significant burden on the health care system. This burden is expected to increase given the projected growth of the aging population.

References

  • 1. Burns E, Kakara R: Deaths from falls among persons aged ≥ 65 years — United States, 2007–2016. MMWR Morb Mortal Wkly Rep 67 (18):509–514, 2018. doi: 10.15585/mmwr.mm6718a1

  • 2. CDC : Older Adult Falls Data. Accessed 10/18/23.

  • 3. Moreland B, Kakara R, Henry A: Trends in nonfatal falls and fall-related injuries among adults aged ≥ 65 years — United States, 2012–2018. MMWR Morb Mortal Wkly 69 (27):875–881, 2020.doi: 10.15585/mmwr.mm6927a5

Etiology of Falls

The most consistent predictor of falling is a previous fall. However, falls in older adults rarely have a single cause or risk factor. A fall is usually multifactorial, caused by a complex interaction among the following:

  • Intrinsic factors (age-related decline in function, disorders, and adverse effects of medications)

  • Extrinsic factors (environmental hazards)

  • Situational factors (related to the specific activity or circumstances of an activity—eg, rushing to the bathroom in the middle of the night)

Intrinsic factors

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. Sensory loss or disturbances and cerebellar dysfunction can diminish postural reflexes and impair balance. 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. As cognitive impairment increases with age, so does the risk of falls, partly because older adults with cognitive impairment may not remember to take the safety measures that reduce falls.

Chronic and acute disorders (see table ) and use of medications (see table ) are major risk factors for falls. The risk of falls increases with the number of medications taken. Several classes of medications increase risk, but psychoactive medications are most commonly reported as increasing both risk of falls and fall-related injuries.

Risk of a traumatic fall that results in a fracture is increased by

  • Osteoporosis and age-related changes in bone quality, which increase bone fragility

  • Loss of muscle (sarcopenia), which reduces protective responses to perturbations

Extrinsic factors

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).

Situational factors

Certain activities or decisions may increase the risk of falls and fall-related injuries. Examples are

  • Walking while talking

  • Being distracted by multitasking and then not noticing 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)

  • Rushing to answer the telephone

Dementia can exacerbate many of these hazardous situations that lead to falls. Impaired cognition, judgment, and hazard awareness can cause older adults to become distracted, rush, and not notice environmental hazards, significantly increasing fall risk.

Complications

Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death in older adults 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.

Each year, approximately 36 million falls are reported in older adults, resulting in more than 32,000 deaths, and each year, emergency departments treat approximately 3 million older adults for injuries due to falls. Most falls do not cause serious harm, but about 20% cause a serious injury such as fractures or a head injury. Each year, at least 300,000 older adults are hospitalized for hip fractures, which result from falling in> 95% of cases. Women tend to fall more often than men, and about 75% of all hip fractures occur in women (1 Etiology references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ).

About half of older adults who fall cannot get up without help (2 Etiology references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ). Remaining on the floor for> 2 hours after a fall increases the risk of dehydration Volume Depletion Volume depletion, or extracellular fluid (ECF) volume contraction, occurs as a result of loss of total body sodium. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use... read more , pressure injuries Pressure Injuries Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more Pressure Injuries , rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is a clinical syndrome involving the breakdown of skeletal muscle tissue. Symptoms and signs include muscle weakness, myalgias, and reddish-brown urine, although this triad is... read more , hypothermia Hypothermia Hypothermia is a core body temperature < 35° C. Symptoms progress from shivering and lethargy to confusion, coma, and death. Mild hypothermia requires a warm environment and insulating blankets... read more , and pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more .

Function and quality of life may deteriorate drastically after a fall; up to 60% of older adults do not recover their previous level of mobility (3 Etiology references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ). After falling, older adults 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.

Table
Table

Etiology references

Evaluation of Falls

  • Clinical evaluation

  • Performance testing

  • Sometimes laboratory testing

After treatment of acute injuries, assessment should aim to identify risk factors and appropriate interventions, thus decreasing the risk of future falls and fall-related injuries (1 Evaluation references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ).

Some falls are promptly recognized because of an obvious fall-related injury or concern about a possible injury. However, because older adults often do not report falls, they should be asked about falls or mobility problems at every visit. Clinicians should also ask about previous falls as well as conditions, medications, and situational factors that increase fall risk.

Patients who report a single fall should be evaluated for a balance or gait problem using the basic Get-Up-and-Go Test (2 Evaluation references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ). 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

  • Those who have difficulty during the Get-Up-and-Go Test

  • Those who report having had multiple falls

  • Those who are being evaluated after a recent fall (after acute injuries are identified and treated)

History and physical examination

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. However, eliminating all risk of future falls may be impossible.

Patients are asked open-ended questions about their 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 medications, and use of alcohol or psychoactive medications. 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 Orthostatic Hypotension Orthostatic (postural) hypotension is an excessive fall in blood pressure (BP) when an upright position is assumed. The consensus definition is a drop of > 20 mm Hg systolic, > 10 mm Hg... read more . Auscultation can detect many types of cardiac valvular disorders Overview of Cardiac Valvular Disorders Any heart valve can become stenotic or insufficient (also termed regurgitant or incompetent), causing hemodynamic changes long before symptoms occur. Depending on which valve is involved, the... read more . Visual acuity Visual acuity The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more 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.

A neurologic examination Introduction to the Neurologic Examination The purpose of the neurologic examination is to establish whether the patient’s brain, special senses, spinal cord, peripheral nerves, and muscle and skin receptors are functioning normally... read more should begin with a mental status examination How to Assess Mental Status The mental status examination is used to evaluate the patient’s level of consciousness and the content of consciousness. Patients are considered alert if they are actively perceiving the world... read more to check for cognitive impairment. The neurologic examination also includes testing motor function (including muscle strength and tone and range of motion), sensation (including proprioception), coordination (including cerebellar function), stationary balance, and gait. Basic postural control and the proprioceptive and vestibular systems are evaluated using the Romberg test (in which patients stand with feet together and eyes both open and closed). Tests to establish high-level balance function include the one-legged stance and tandem gait. If patients can stand on one leg for 10 seconds with their eyes open and have an accurate 3-meter (10-feet) tandem gait, any intrinsic postural control deficit is likely to be minimal. Clinicians should evaluate positional vestibular function (eg, with the Dix-Hallpike maneuver—see Nystagmus Nystagmus Nystagmus is a rhythmic movement of the eyes that can have various causes. Vestibular disorders can result in nystagmus because the vestibular system and the oculomotor nuclei are interconnected... read more ).

Performance tests

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.

The Performance-Oriented Assessment of Mobility test includes quantitative scoring of various aspects of balance and gait and takes about 10 to 15 minutes to do. Low scores predict increased risk of falls (see table ).

Laboratory tests

There is no standard diagnostic laboratory evaluation to determine the exact cause of a fall. Testing should be based on the history and examination results and helps rule out various causes. Tests include

  • A complete blood count (CBC) for anemia or leukocytosis

  • Blood glucose measurement for hypoglycemia or hyperglycemia

  • Electrolyte measurement for dehydration

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.

Evaluation references

  • 1. U.S. Preventive Services Task Force (USPSTF): Final Recommendation Statement: Falls Prevention in Community-Dwelling Older Adults: Interventions. Accessed 10/18/23.

  • 2. Podsiadlo D, Richardson S: The timed "Up & Go": A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 39 (2), 142–148, 1991. https://doi.org/10.1111/j.1532-5415.1991.tb01616.x

Prevention of Falls

The focus should be on preventing or reducing the number of future falls and fall-related injuries and complications while maintaining as much of the patient’s function and independence as possible. In the periodic physical or wellness examination, patients should be asked about falls in the past year and difficulty with balance or ambulation (1 Prevention references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ).

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 medications safely and reduce environmental hazards (see table ).

Table

Physical therapy and exercise

Patients who have fallen more than once or who have problems during initial balance and gait testing should be referred to physical therapy Physical Therapy (PT) Physical therapy aims to improve joint and muscle function (eg, range of motion, strength) and thus improve the patient’s ability to stand, balance, walk, and climb stairs. For example, physical... read more or an exercise program. Physical therapy and exercise programs can be done in the home if patients have limited mobility.

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

  • Are tailored to the patient’s deficit

  • Are provided by a trained professional

  • Have a sufficient balance challenge component

  • Are provided over the long term (eg, ≥ 4 months)

Many senior citizen centers, YMCAs, or other health clubs offer free or low-cost group exercise classes tailored to senior citizens, and these classes can help with accessibility and adherence. The savings from decreased fall-related expenses exceed the costs of these programs (3 Prevention references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ).

Assistive devices

Some patients benefit from use of an assistive device Therapeutic and Assistive Devices Orthoses provide support for damaged joints, ligaments, tendons, muscles, and bones. Most are customized to a patient’s needs and anatomy. Orthoses designed to fit into shoes may shift the patient’s... read more (eg, cane, walker). Canes may be adequate for patients with minimal unilateral muscle or joint impairment, but walkers, especially wheeled walkers, are more appropriate for patients with increased risk of falls attributable to bilateral leg weakness or impaired coordination (wheeled walkers can be dangerous for patients who cannot control them properly). Physical therapists can help fit or size the devices and teach patients how to use them.

Medical management

Medications that can increase the risk of falls should be stopped, or the dosage should be adjusted to the lowest effective dose (see table ). Patients should be evaluated for osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more Osteoporosis and, if osteoporosis is diagnosed, treated to reduce risk of fractures from any future falls.

If any other specific disorder is identified as a risk factor, targeted interventions are required. For example, medications and physical therapy may reduce risk for patients with Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more . 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.

Environmental and situational management

Correcting environmental hazards in the home may reduce the risk of falls (see table ). Environmental hazards that commonly increase fall risk, (eg, throw rugs, inadequate lighting, lack of grab bars and handrails, unstable furniture, clutter), should be mitigated or eliminated (6 Prevention references A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more ).

Patients should also be advised on how to reduce risk due to situational factors. For example, footwear should have flat heels, some ankle support, and firm, nonskid midsoles. Many patients with chronic limited mobility (eg, caused by severe arthritis or paresis) benefit from combined medical, rehabilitative, and environmental strategies. Wheelchair adaptations (eg, removable foot plates to reduce tripping during transfers, antitip bars to prevent backward tipping), removable belts, and wedge seating may prevent falls in patients with poor sitting balance or severe weakness when they are sitting or transferring.

Restraints may lead to more falls and other complications and should generally not be used. Surveillance by a caregiver or companion is more effective. 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 adults 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 when they are alone. 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. The following can decrease time on the floor after a fall:

  • Having frequent contact with family members or friends

  • A phone that can be reached from the floor

  • A remote alarm

  • A wearable alert device

Newer technologies (eg,smartwatches, mobile medical alert systems, in-home motion sensors) can automatically detect falls and trigger a call for help. Voice-activated smart speakers and AI (artificial intelligence) camera systems may be used to monitor seniors and alert caregivers about potential falls. Combining human contact, wearable devices, and in-home monitoring can optimize the likelihood of a timely response to a fall.

Prevention references

Key Points

  • Each year in the United States, about one in four adults age ≥ 65 report a fall each year, for a total of about 14 millions falls.

  • Not all falls result in an injury, but about 37% of adults who fall report an injury that required medical treatment or restricted activity for at least one day.

  • Causes are multifactorial and include age-related functional declines (eg, reduced vision, slowed reaction time, muscle weakness), chronic illnesses that impair balance and mobility (eg, Parkinson disease, arthritis, dementia), adverse effects of medications, and environmental hazards.

  • Use validated tools such as the Timed Up and Go test to determine the need for fuller assessment of predisposing intrinsic, extrinsic, and situational factors.

  • To the extent possible, optimize treatment of comorbidities and contributing conditions, modify or eliminate causative medications, and correct environmental hazards.

  • Emphasize the need to eliminate environmental hazards that commonly increase fall risk (eg, throw rugs, inadequate lighting, lack of grab bars and handrails, unstable furniture, clutter).

  • Use multifactorial interventions for patients who have fallen more than once or have abnormalities in initial gait or impaired balance; interventions include referral for physical therapy and exercise programs, which are most effective when tailored and continued for ≥ 3 months.

  • High-risk disorders such as Parkinson disease often require targeted treatment (eg, physical therapy, assistive devices) to reduce fall risk.

  • Teach patients techniques to get up after a fall, especially when they are alone, and the importance of having a phone or emergency alert device accessible from the floor.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

Drugs Mentioned In This Article

Drug Name Select Trade
Calcidol, Calciferol, D3 Vitamin, DECARA, Deltalin, Dialyvite Vitamin D, Dialyvite Vitamin D3, Drisdol, D-Vita, Enfamil D-Vi-Sol, Ergo D, Fiber with Vitamin D3 Gummies Gluten-Free, Happy Sunshine Vitamin D3, MAXIMUM D3, PureMark Naturals Vitamin D, Replesta, Replesta Children's, Super Happy SUNSHINE Vitamin D3, Thera-D 2000, Thera-D 4000, Thera-D Rapid Repletion, THERA-D SPORT, UpSpring Baby Vitamin D, UpSpring Baby Vitamin D3, YumVs, YumVs Kids ZERO, YumVs ZERO
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