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.
Annually, 30 to 40% of older people living in the community fall; 50% of nursing home residents fall. In the United States, falls are the leading cause of accidental death and the 7th leading cause of death in people ≥ 65. In 2018, there were 32,522 fall deaths in people ≥ 65 versus 4,933 in those younger; thus 85% of deaths caused by falls occur in the 13% of the population who are ≥ 65 (1 References 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... read more ). In addition, falls were responsible for over 3 million emergency department visits in older people. Medical costs for nonfatal fall injuries were about $50 billion in 2018 and will surely increase (2 References 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... read more ).
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.
Etiology of Falls
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:
Intrinsic factors (age-related decline in function, disorders, and adverse drug effects)
Extrinsic factors (environmental hazards)
Situational factors (related to the activity being done, eg, rushing to the bathroom)
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.
Chronic and acute disorders (see table Some Disorders That Contribute to Risk of Falls Some Disorders That Contribute to Risk of Falls ) and use of drugs (see table Some Drugs That Contribute to Risk of Falls 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.
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.
Evaluation of Falls
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 (1 Evaluation reference 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... read more ).
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
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 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.
A neurologic examination Introduction to the Neurologic Examination The neurologic examination begins with careful observation of the patient entering the examination area and continues during history taking. The patient should be assisted as little as possible... read more should be done; 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 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. Physicians 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 ) and mental status How to Assess Mental Status The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see Examination... read more .
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 Performance-Oriented Assessment of Mobility Performance-Oriented Assessment of Mobility ).
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:
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.
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 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... 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 drugs safely and reduce environmental hazards (see table Home Assessment Checklist Home Assessment Checklist for Hazards That Increase Risk of Falling ).
Patients who report more than one fall or a problem with balance or gait should receive a fall evaluation Evaluation 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... read more to identify risk factors and opportunities to lower risk.
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 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
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 (2 Prevention references 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... read more ).
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.
Drugs that can increase the risk of falls should be stopped, or the dosage should be adjusted to the lowest effective dose (see table Some Drugs That Contribute to Risk of Falls Some Drugs That Contribute to Risk of Falls ). 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 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 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.
A recent meta-analysis of randomized controlled trials suggests that the use of supplementary vitamin D can significantly reduce the incidence of falls (3 Prevention references 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... read more ).
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 ). 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 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.
2. Sherrington C, Fairhall N, Wallbank G, et al: Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med 54(15):885-891, 2020. doi: 10.1136/bjsports-2019-101512. Epub 2019 Dec 2. PMID: 31792067.
3. Thanapluetiwong S, Chewcharat A, Takkavatakarn K, et al: Vitamin D supplement on prevention of fall and fracture: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 99(34):e21506, 2020. doi: 10.1097/MD.0000000000021506. PMID: 32846760; PMCID: PMC7447507.
The following are English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Cochrane: Interventions for preventing falls in older people living in the community: Podcast and transcript with assessment of the effects of these interventions
Centers for Disease Control and Prevention: STEADI (Stopping Elderly Accidents, Deaths, & Injuries): Materials for healthcare providers with guidance to screen, assess, and intervene to reduce fall risk by giving older adults tailored interventions
Each year, 30 to 40% of older people living in the community and 50% of nursing home residents fall.
Falls contribute to > 40% of nursing home admissions and are the 7th leading cause of death in people ≥ 65.
Causes are multifactorial and include age- and illness-related decline in function, environmental hazards, and adverse drug effects.
Assess the patient for predisposing factors and assess the home for hazards.
To the extent possible, treat causative disorders, change or stop causative drugs, and correct environmental hazards.
Patients who have fallen more than once or who have problems during balance and gait testing may benefit from physical therapy or an exercise program.
Teach techniques for getting off the floor and consider use of a wearable emergency response device.