A fall results in 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.

Annually, 30 to 40% of elderly people living in the community fall; 50% of nursing home residents fall. In the US, falls are the leading cause of accidental death and the 7th leading cause of death in people ≥ 65; 75% of deaths caused by falls occur in the 12.5% of the population who are ≥ 65. In 2000, direct medical costs totaled $0.2 billion ($179 million) for fatal falls and $19 billion for nonfatal fall injuries. By 2020, the costs are projected to reach $44 billion.

Falls threaten the independence of elderly 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 elderly 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.

Etiology

The best predictor of falling is a previous fall. However, falls in elderly people rarely have a single cause or risk factor. A fall is usually caused by a complex interaction among the following:

• Intrinsic factors (age-related decline in function, disorders, and adverse drug effects)
• Extrinsic factors (environmental hazards)
• Situational factors (related to the activity being doneeg, rushing to the bathroom)

Intrinsic factors

Age-related changes can impair systems involved in maintaining balance and stability (eg, while standing, walking, or sitting). 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).

Chronic and acute disorders (see Table 1: Falls in the Elderly: Some Disorders That Contribute to Risk of Falls) and use of drugs (see Table 2: Falls in the Elderly: Some Drugs That Contribute to Risk of Falls) are major risk factors for falls. The risk of falls increases with the number of drugs taken. Psychoactive drugs are the drugs most commonly reported as increasing the risk of falls and fall-related injuries.

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 or being distracted by dual-tasking or multitasking and then failing to attend to 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.

Complications

Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death, particularly in elderly people who are frail and have preexisting disease comorbidities and deficits in activities of daily living. 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 elderly 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 elderly people with hip fractures die while hospitalized; overall mortality in the 12 mo after a hip fracture ranges from 18 to 33%.

About half of elderly people who fall cannot get up without help. Remaining on the floor for > 2 h 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 elderly people who were ambulatory before fracturing a hip do not recover their previous level of mobility. After falling, elderly 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.

Table 1
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Some Disorders That Contribute to Risk of Falls Functional Impairment Disorder BP regulation Anemia Arrhythmias Cardioinhibitory carotid sinus hypersensitivity COPD Dehydration Infections (eg, pneumonia, sepsis) Metabolic disorders (eg, thyroid disorders, hypoglycemia, hyperglycemia with hyperosmolar dehydration) Neurocardiogenic inhibition after micturition Postural hypotension Postprandial hypotension Valvular heart disorders Central processing Delirium Dementia Gait Arthritis Foot deformities Muscle weakness Postural and neuromotor function Cerebellar degeneration Myelopathy (eg, due to cervical or lumbar spondylosis) Parkinson's disease Peripheral neuropathy Stroke Vertebrobasilar insufficiency Proprioception Peripheral neuropathy (eg, due to diabetes mellitus) Vitamin B12 deficiency Otolaryngologic function Acute labyrinthitis Benign paroxysmal positional vertigo Hearing loss Meniere's disease Vision Cataract Glaucoma Macular degeneration (age-related)

Table 2
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Some Drugs That Contribute to Risk of Falls Drugs Mechanism Aminoglycosides Direct vestibular damage Analgesics (especially opioids) Reduced alertness or slow central processing Antiarrhythmics Impaired cerebral perfusion Antihypertensives (especially vasodilators) Impaired cerebral perfusion Antipsychotics Extrapyramidal syndromes, other antiadrenergic effects Diuretics (especially when patients are dehydrated) Impaired cerebral perfusion Loop diuretics (high-dose) Direct vestibular damage Psychoactive drugs (especially antidepressants, antipsychotics, and benzodiazepines) Reduced alertness or slow central processing

Table 3
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Home Assessment Checklist for Hazards That Increase Risk of Falling Location Hazard Correction Rationale General household Lighting Too dim Provide ample lighting in all areas Improves visual acuity and contrast sensitivity Too direct, creating glare Reduce glare with evenly distributed light, indirect lighting, or translucent shades Improves visual acuity and contrast sensitivity Inaccessible light switches Provide night-lights or touch-activated lights Install switches that are immediately accessible when entering a room or motion sensors that activate lights Reduces risk of tripping over or bumping into unseen obstacles in a dark room Carpets, rugs, linoleum Torn Repair or replace torn carpet Reduces risk of tripping and slipping, especially for people who have difficulty stepping Slippery Provide rugs with nonskid backs Reduces risk of slipping Curled edges Tack or tape down rugs or linoleum to prevent curling Replace rugs or linoleum Reduces risk of tripping Chairs, tables, other furnishings Unstable Provide furniture stable enough to support the weight of a person leaning on table edges or chair arms and backs Do not use chairs that have wheels or that swivel Repair legs that are loose Increases support for people with impaired balance and helps with transferring Chairs without armrests Provide chairs with armrests that extend forward enough to provide leverage when getting up or sitting down Helps people with proximal muscle weakness and helps with transferring Obstructed pathways Arrange furnishings so that pathways are not obstructed Remove clutter from hallways Reduces risk of tripping over or bumping into obstacles, making movement in the home easier and safer, especially for people with impaired peripheral vision Wires and cords Exposed in pathways Tack cords above the floor or run beneath floor coverings Reduces risk of tripping Kitchen Cabinets, shelves Too high Keep frequently used items at waist level Install shelves and cupboards at an accessible height Reduces risk of falls due to frequent reaching or climbing on ladders or chairs Floors Wet or waxed Place a rubber mat on the floor in the sink area Wear rubber-soled shoes in the kitchen Use nonslip wax Reduces risk of slipping, especially for people with a gait disorder Bathroom Bathtub Slippery tub floor Install skid-resistant strips or rubber mat Use shower shoes or a bath seat (a bath seat enables people with impaired balance to sit while showering) Reduces risk of sliding on a wet tub floor Need to use the side of the bathtub for support or transfer Install a portable grab bar on the side of the tub Take grab bar on trips Helps with transferring Towel racks, sink tops Unstable for use as support while transferring from the toilet, tub, or shower Fasten grab rails to wall studs Helps with transferring Toilet seat Too low Use elevated toilet seat Helps with transferring to and from the toilet Doors Locks Remove locks from bathroom doors or use locks that can be opened from both sides of the door Enables other people to enter if a person falls Stairways Height Height of steps too high Correct step height to < 15 cm Reduces risk of tripping, especially for people who have difficulty stepping Handrails Missing Install and anchor rails well on both sides of the stairway Use cylindrical rails placed 2.5–5 cm from the wall Provides support and enables people to grasp the rail with either hand Too short and end of rail unclear Extend beyond the top and bottom step and turn ends inward Signals that the top or bottom step has been reached Configuration Too steep or too long Install landings on stairways Provides a rest stop, especially for people with heart or pulmonary disorders Condition Slippery Place nonskid treads securely on all steps Prevents slipping Lighting Inadequate Install adequate lighting at both the top and bottom of stairway Provide night-lights or bright-colored adhesive strips to clearly mark steps Outlines location of steps, especially for people with impaired vision or perception Home Assessment Checklist for Hazards That Increase Risk of Falling Location Hazard Correction Rationale General household Lighting Too dim Provide ample lighting in all areas Improves visual acuity and contrast sensitivity Too direct, creating glare Reduce glare with evenly distributed light, indirect lighting, or translucent shades Improves visual acuity and contrast sensitivity Inaccessible light switches Provide night-lights or touch-activated lights Install switches that are immediately accessible when entering a room or motion sensors that activate lights Reduces risk of tripping over or bumping into unseen obstacles in a dark room Carpets, rugs, linoleum Torn Repair or replace torn carpet Reduces risk of tripping and slipping, especially for people who have difficulty stepping Slippery Provide rugs with nonskid backs Reduces risk of slipping Curled edges Tack or tape down rugs or linoleum to prevent curling Replace rugs or linoleum Reduces risk of tripping Chairs, tables, other furnishings Unstable Provide furniture stable enough to support the weight of a person leaning on table edges or chair arms and backs Do not use chairs that have wheels or that swivel Repair legs that are loose Increases support for people with impaired balance and helps with transferring Chairs without armrests Provide chairs with armrests that extend forward enough to provide leverage when getting up or sitting down Helps people with proximal muscle weakness and helps with transferring Obstructed pathways Arrange furnishings so that pathways are not obstructed Remove clutter from hallways Reduces risk of tripping over or bumping into obstacles, making movement in the home easier and safer, especially for people with impaired peripheral vision Wires and cords Exposed in pathways Tack cords above the floor or run beneath floor coverings Reduces risk of tripping Kitchen Cabinets, shelves Too high Keep frequently used items at waist level Install shelves and cupboards at an accessible height Reduces risk of falls due to frequent reaching or climbing on ladders or chairs Floors Wet or waxed Place a rubber mat on the floor in the sink area Wear rubber-soled shoes in the kitchen Use nonslip wax Reduces risk of slipping, especially for people with a gait disorder Bathroom Bathtub Slippery tub floor Install skid-resistant strips or rubber mat Use shower shoes or a bath seat (a bath seat enables people with impaired balance to sit while showering) Reduces risk of sliding on a wet tub floor Need to use the side of the bathtub for support or transfer Install a portable grab bar on the side of the tub Take grab bar on trips Helps with transferring Towel racks, sink tops Unstable for use as support while transferring from the toilet, tub, or shower Fasten grab rails to wall studs Helps with transferring Toilet seat Too low Use elevated toilet seat Helps with transferring to and from the toilet Doors Locks Remove locks from bathroom doors or use locks that can be opened from both sides of the door Enables other people to enter if a person falls Stairways Height Height of steps too high Correct step height to < 15 cm Reduces risk of tripping, especially for people who have difficulty stepping Handrails Missing Install and anchor rails well on both sides of the stairway Use cylindrical rails placed 2.5–5 cm from the wall Provides support and enables people to grasp the rail with either hand Too short and end of rail unclear Extend beyond the top and bottom step and turn ends inward Signals that the top or bottom step has been reached Configuration Too steep or too long Install landings on stairways Provides a rest stop, especially for people with heart or pulmonary disorders Condition Slippery Place nonskid treads securely on all steps Prevents slipping Lighting Inadequate Install adequate lighting at both the top and bottom of stairway Provide night-lights or bright-colored adhesive strips to clearly mark steps Outlines location of steps, especially for people with impaired vision or perception

Evaluation

• Clinical evaluation
• Performance testing
• Sometimes laboratory testing

After treatment of acute injuries, assessment aims to identify risk factors and appropriate interventions, thus decreasing the risk of future falls and fall-related injuries.

Some falls are promptly recognized because of an obvious fall-related injury or concern about a possible injury. However, because elderly people often do not report falls, they should be asked about falls at least once per year.

Patients who report a single fall should be evaluated for a balance or gait problem using the Get-Up-and-Go Test. For the test, patients are observed as they rise from a standard armchair, walk 3 m (about 10 ft) 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.

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 multiple falls during screening
• 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 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 OTC 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. BP should be measured with patients supine and after patients stand for 1 and 5 min 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.

A neurologic examination should be done (see Approach to the Neurologic Patient: Neurologic Examination); it includes testing muscle strength and tone, 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 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 sec with their eyes open and have an accurate 3-m (10-ft) tandem gait, any intrinsic postural control deficit is likely to be minimal. Physicians should evaluate positional vestibular function (eg, with the Dix-Hallpike maneuver—see Sidebar 1: Approach to the Patient With Ear Problems: Nystagmus) and mental status (see Approach to the Neurologic Patient: Mental status).

Performance tests

The Performance-Oriented Assessment of Mobility or Get-Up-and-Go Test can identify problems with balance and stability during walking and other movements that may indicate increased risk of falls.

Laboratory tests

There is no standard diagnostic evaluation. Testing should be based on the history and examination and helps rule out various causes: a CBC for anemia, blood glucose measurement for hypoglycemia or hyperglycemia, and electrolyte measurement for dehydration. Tests such as 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 CT or MRI are indicated only when the history and physical examination detect new neurologic abnormalities.

Prevention

The focus is 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. For more information, see the Cochrane review abstract interventions for preventing falls in older people living in the community, the American Geriatrics Society guideline for the prevention of falls in older persons, and the British Medical Journal interventions for the prevention of falls in older adults.

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 3: Falls in the Elderly: Home Assessment Checklist for Hazards That Increase Risk of Falling).

Exercise

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 are tailored to the patient's deficit, are provided by a trained professional, have a sufficient balance challenge component, and are provided over the long term (eg, ≥ 4 mo).

Assistive devices

Some patients benefit from use of an assistive device (eg, cane, walker). Canes may be adequate for those 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 (see Rehabilitation: Therapeutic and Assistive Devices).

Medical management

Drugs that can increase the risk of falls should be stopped, or the dosage should be adjusted to the lowest effective dose. Patients should be evaluated for 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, drugs and physical therapy may reduce risk for patients with Parkinson's disease. Vitamin D, particularly taken with Ca, can reduce fall risk, especially in those with reduced blood vitamin D levels. 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 management

Correcting environmental hazards in the home may reduce the risk of falls (see Table 3: Falls in the Elderly: Home Assessment Checklist for Hazards That Increase Risk of Falling). 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, severe arthritis, 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 people with poor sitting balance or severe weakness when they are sitting or transferring.

Restraints may lead to more falls and other complications and thus should 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 to the triggered alarm.

Hip protectors (padding sewn into special undergarments) may help protect patients who have fallen and are at risk of a hip injury, but 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.

Last full review/revision January 2010 by Neil B. Alexander, MD