Annals of Internal Medicine䊛

In the Clinic®

Fall Prevention in
Community-Dwelling
Older Adults Practice Improvement

F
alls are common among older adults. One
in 3 adults aged 65 years or older and 1 in Risk Factors
2 adults aged 80 years or older fall each
year. Interventions for prevention have been
identified; however, they are often not ad- Evaluation
dressed in primary care practice. Screening all
older adults annually for falls can identify who
will benefit from further clinical evaluation and
management. Falls and the need for care from
Management
subsequent injury increase with age. They ad-
versely affect quality of life and are a financial
burden on the health care industry. As a result, Practice Improvement
risk reduction is a key focus of prevention ef-
forts, even among very elderly persons.

CME/MOC activity available at Annals.org.

Physician Writers doi:10.7326/AITC201812040

Elizabeth A. Phelan, MD, MS
Katherine Ritchey, DO, MPH CME Objective: To review current evidence for risk factors, evaluation, management, and
From the Division of practice improvement of fall prevention in community-dwelling older adults.
Gerontology and Geriatric Funding Source: American College of Physicians.
Medicine, Department of
Medicine, University of Disclosures: Drs. Phelan and Ritchey, ACP Contributing Authors, have disclosed no conflicts
Washington, Seattle, of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterest
Washington. Forms.do?msNum=M18-1801.

With the assistance of additional physician writers, the editors of Annals of Internal
Medicine develop In the Clinic using MKSAP and other resources of the American
College of Physicians.
In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
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 1. The prevention of falls in Falls are common among older adding significantly to the mor-
later life. A report of the
Kellogg International adults and have serious conse- bidity of this geriatric syndrome
Work Group on the Pre- quences. The generally accepted
vention of Falls by the
(5). Short- and long-term care for
Elderly. Dan Med Bull. definition of a fall is “coming to fall-related injuries contributes
1987;34 Suppl 4:1-24.
[PMID: 3595217] rest unintentionally on the significantly to social and eco-
2. Centers for Disease Con- ground or lower level, not due to nomic costs. In 2015, direct
trol and Prevention, Na-
tional Center for Injury an acute event” (e.g., seizure, medical costs were estimated to
Prevention and Control. syncope, or stroke) or an over-
Web-based Injury Statistics exceed $50 billion (6). However,
Query and Reporting whelming external force to which only 1 in 4 community-dwelling
System (WISQARS). Lead-
ing cause of non-fatal any person would be susceptible older adults discusses falls with
injury. 2016. Accessed at (1). Fall rates double with each
www.cdc.gov/injury hir or her health care provider
/wisqars/nonfatal.html on decade of age beyond the sev-
6 June 2018. (7). Evidence suggests that the
enth decade, and falls are the
3. Kannus P, Parkkari J, risk for falling can be reduced by
Niemi S, Palvanen M. third leading cause of death re-
Fall-induced deaths
sulting from unintentional injury 20%– 40% depending on the type
among elderly people. Am
J Public Health. 2005;95: (2). They are also the leading of intervention (8). Health care
422-4. [PMID: 15727970] providers must thus be proactive
4. Sterling DA, O’Connor JA, cause of fatal and nonfatal injury
Bonadies J. Geriatric falls: in older adults (3, 4). Even non- in their primary and secondary
injury severity is high and
disproportionate to mech- injurious falls may precipitate screening efforts and offer ap-
anism. J Trauma. 2001;
50:116-9. [PMID: functional decline, psychological propriate evidence-based
11231681] stress, and loss of independence, recommendations.
5. King MB, Tinetti ME. Falls
in community-dwelling
older persons. J Am Geri-
atr Soc. 1995;43:1146-54.
[PMID: 7560708]
6. Florence CS, Bergen G,
Risk Factors
Atherly A, Burns E, Stevens What factors increase risk for (e.g., orthostatic hypotension),
J, Drake C. Medical costs
of fatal and nonfatal falls falls? musculoskeletal (e.g., arthritis),
in older adults. J Am Geri-
Falls typically do not have a sin- neurologic (e.g., dementia, Par-
atr Soc. 2018;66:693-8.
[PMID: 29512120] gle cause. Like other conditions kinson disease, stroke), and uro-
7. Stevens JA, Ballesteros
MF, Mack KA, Rudd RA, that become more common later logic (e.g., urinary incontinence)
DeCaro E, Adler G. Gender in life, they tend to result from systems (11, 12). Extrinsic factors
differences in seeking care
for falls in the aged Medi- several factors (9) stemming from comprise elements in a person's
care population. Am J surroundings that are difficult to
Prev Med. 2012;43:59- the interaction of age-related
62. [PMID: 22704747] changes, chronic medical condi- navigate (e.g., cords in walkways,
8. Gillespie LD, Robertson
MC, Gillespie WJ, Sher- tions, and other individual and steep or uneven surfaces, poor
rington C, Gates S, Clem-
environmental variables (10). lighting), lack or improper use of
son LM, et al. Interven-
tions for preventing falls Falls frequently have adverse ef- an assistive device, inappropriate
in older people living in
the community. Cochrane fects on function and quality of footwear, medications, and
Database Syst Rev. 2012: life, and similar to other geriatric alcohol or drugs (13, 14). Falls
CD007146. [PMID:
22972103] syndromes, they are largely pre- frequently result from the simul-
9. Phelan EA, Vig EK, Abrass
IB. Some considerations ventable and are not considered taneous interaction of several of
regarding geriatric syn- part of normal aging. these factors.
dromes [Letter]. Ann In-
tern Med. 2001;135:
1095. [PMID: 11747404] Risk factors for falls are classified Fall risk can be estimated by the
10. Inouye SK, Studenski S,
Tinetti ME, Kuchel GA.
as modifiable or nonmodifiable strength of 1 risk factor or the
Geriatric syndromes: and as intrinsic (dependent on cumulative effects of several fac-
clinical, research, and
policy implications of a the individual) or extrinsic (envi- tors. Independent risk factors
core geriatric concept. J ronmental) (11) (see the Box: In- associated with increased proba-
Am Geriatr Soc. 2007;
55:780-91. [PMID: trinsic and Extrinsic Risk Factors bility of falling include a history of
17493201]
11. Tinetti ME, Speechley M, for Falls). Intrinsic risk factors are falls (likelihood ratio [LR], 3), in-
Ginter SF. Risk factors for age-related changes, chronic ability to rise from a chair without
falls among elderly per-
sons living in the com- conditions, and behaviors that using the arms (LR, 4), slow gait
munity. N Engl J Med.
1988;319:1701-7.
limit a person's inherent ability to (LR, 2), self-perceived mobility
[PMID: 3205267] prevent a fall. Many medical con- problem (LR, 2), use of psychoac-
12. Tinetti ME, Kumar C. The
patient who falls: “It's ditions increase fall risk, and they tive medications (LR, 20), demen-
always a trade-off”. cover a range of organ systems, tia (LR, 15), Parkinson disease
JAMA. 2010;303:258-
66. [PMID: 20085954] including the cardiovascular (LR, 5), or stroke (LR, 3) (15). Indi-

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 Intrinsic and Extrinsic Risk Factors for Falls
Intrinsic 13. Lord SR, Menz HB, Sher-
rington C. Home envi-
Ocular: Decreased visual acuity, macular degeneration, glaucoma, cataracts, ronment risk factors for
reduced accommodation, reduced depth perception, vision loss, falls in older people and
retinopathy the efficacy of home
modifications. Age Age-
Cardiovascular: Bradycardia, tachyarrhythmia, orthostatic hypotension, ing. 2006;35 Suppl
decompensated heart failure 2:ii55-ii59. [PMID:
16926207]
Neurologic: Cognitive impairment or dementia, Parkinson disease, 14. Faulkner S, Burns D.
cerebrovascular accident, other movement disorder, peripheral Identifying modifiable
environmental risk fac-
neuropathy, gait deficits and imbalance tors for falls in older
Urologic: Incontinence (any type), nocturia people. Inj Prev. 2010;
16(Suppl 1):A254.
Psychological: Insomnia/sleep deprivation, depression 15. Ganz DA, Bao Y, Shekelle
Musculoskeletal: Osteoarthritis or inflammatory arthritis, pain, PG, Rubenstein LZ. Will
my patient fall? JAMA.
lower-extremity weakness, postural instability or imbalance, 2007;297:77-86. [PMID:
reduced flexibility 17200478]
16. Nevitt MC, Cummings
SR, Hudes ES. Risk fac-
Extrinsic tors for injurious falls: a
Medications: Anticholinergics, antidepressants, prospective study. J
antipsychotics, sedative– hypnotics, benzodiazepines, Gerontol. 1991;46:
M164-70. [PMID:
opiates, antihypertensives, ␣- and ␤-blockers, 1890282]
antiarrhythmics, use of more than 4 medications 17. Tinetti ME, Doucette JT,
Claus EB. The contribu-
Footwear: Backless shoes and slippers; high heels; shoes tion of predisposing and
lacking dorsum, arch, or heel supports; shoes with situational risk factors to
heavy soles or a narrow toe box serious fall injuries. J Am
Geriatr Soc. 1995;43:
Environment: Wet or slippery surfaces, lack of grab bars, 1207-13. [PMID:
uneven flooring, floor rugs, poor lighting, lack of 7594153]
18. Tinetti ME, Doucette J,
handrails for steps, cords or other walkway hazards Claus E, Marottoli R. Risk
factors for serious injury
during falls by older
persons in the commu-
nity. J Am Geriatr Soc.
vidual risk for falling increases male sex, low body weight (body 1995;43:1214-21.
markedly with an increase in risk mass index < 22 kg/m2), and [PMID: 7594154]
19. Liu JY. Fear of falling in
factors. cognitive impairment. Situational robust community-
dwelling older people:
factors include falling on stairs, results of a cross-
In a prospective study of community-dwelling
displacing activity (shifting weight sectional study. J Clin
persons older than 75 years, the percentage Nurs. 2015;24:393-405.
who fell within 1 year nearly doubled with over one's center of gravity, as [PMID: 24787119]

each additional risk factor (11). Even persons when opening a door or reaching 20. Scheffer AC, Schuurmans
MJ, van Dijk N, van der
without any of the aforementioned risk factors into a closet), or falling from a level Hooft T, de Rooij SE. Fear
of falling: measurement
had a 10% chance of falling, suggesting that equal to or greater than one's strategy, prevalence, risk
advancing age by itself increases risk (11). height (17). As with fall risk factors, factors and conse-
quences among older
each predisposing or situational persons. Age Ageing.
What factors put patients at 2008;37:19-24. [PMID:
factor exponentially increases risk
risk for fall-related injuries? 18194967]
for injury, from 0%–5% in persons 21. Kumar A, Carpenter H,
Roughly half of falls result in in- Morris R, Iliffe S, Kend-
with no injury risk factors to 23%– rick D. Which factors are
jury (16), and 10% result in seri-
36% in persons with more than 2 associated with fear of
ous injury (5). The presence of falling in community-
factors (17). dwelling older people?
both predisposing factors (indi- Age Ageing. 2014;43:
vidual features) and situational 76-84. [PMID:
24100619]
factors (fall circumstances) pre- A high-quality, prospective cohort study exam- 22. Maki BE, Holliday PJ,
dicts persons at risk for serious ined risk factors predictive of serious injury. It Topper AK. Fear of falling
and postural perfor-
injury, which includes fractures; followed 1103 community-dwelling persons mance in the elderly. J
for 1 year. Factors that were independently as- Gerontol. 1991;46:
joint dislocations, hemarthroses, M123-31. [PMID:
sociated with serious injury from a fall in- 2071833]
and serious sprains; head injuries
cluded cognitive impairment (adjusted odds 23. Yardley L, Smith H. A
resulting in loss of consciousness ratio [OR], 2.2 [95% CI, 1.5–3.2]), presence of prospective study of the
relationship between
and hospitalization; lacerations at least 2 chronic conditions (OR, 2.0 [CI, 1.4 – feared consequences of
requiring sutures; and internal 2.9]), balance and gait impairment (OR, 1.8 falling and avoidance of
activity in community-
injuries resulting in hospitaliza- [CI, 1.3–2.7]), and low body mass index (OR, living older people.
tion or decreased activity (17). Gerontologist. 2002;42:
1.8 [CI, 1.2–2.5]). In a subset analysis of only 17-23. [PMID:
Predisposing factors include fe- persons who fell, female sex (OR, 1.8 [CI, 1.1– 11815695]

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 2.9]) was also more commonly associated as- its associated morbidity (21). On
24. Young WR, Mark Wil- sociated with injurious falls. The study further a functional level, fear of falling
liams A. How fear of highlighted the most important predictors of is associated with postural
falling can increase fall-
risk in older adults: ap-
serious fall-related injuries (18). changes, reduced balance confi-
plying psychological
theory to practical obser- How does fear of falling dence, activity avoidance, and
vations. Gait Posture.
2015;41:7-12. [PMID: influence fall risk? reduced exercise (22, 23). It is
25278464] Fear of falling has psychological also a strong predictor of future
25. Vellas BJ, Wayne SJ,
Romero LJ, Baumgartner consequences that increase the falls (24). Psychologically, per-
RN, Garry PJ. Fear of
overall risk for falling and func- sons who fear falling have poorer
falling and restriction of
mobility in elderly fallers. tional decline (19). Roughly 21%– mental health, reduced indepen-
Age Ageing. 1997;26:
189-93. [PMID: 85% of community-dwelling dence, and poorer self-rated
9223714] older adults who have fallen and health (25). Fear of falling leads
26. Panel on Prevention of
Falls in Older Persons, 33%– 46% of those who have not to activity restriction and acceler-
American Geriatrics Soci- ates functional decline. Recogniz-
ety and British Geriatrics
report that they fear falling (20).
Society. Summary of the Certain factors, such as difficulty ing this situation can enable pro-
updated American Geri-
atrics Society/British using public transportation, viders to encourage affected
Geriatrics Society clinical poorer perceived health status, patients to engage in fall preven-
practice guideline for
prevention of falls in difficulty with balance, and inabil- tion efforts with the goal of re-
older persons. J Am
Geriatr Soc. 2011;59:
ity to rise from a chair, character- gaining confidence and eventu-
148-57. [PMID: ize persons who may be at ally returning to previously
21226685]
27. Stevens JA, Phelan EA. greater risk for fear of falling and enjoyable activities.
Development of STEADI:
a fall prevention resource
for health care providers.
Health Promot Pract.
2013;14:706-14. [PMID:
23159993] Risk Factors... Falls result from independent but interacting modifiable
28. Rubenstein LZ, Vivrette
R, Harker JO, Stevens JA,
and nonmodifiable intrinsic and extrinsic risk factors. Factors associated
Kramer BJ. Validating an with the greatest risk for falls include use of psychoactive medications,
evidence-based, self- impaired gait, lack of lower-extremity strength and balance, and im-
rated fall risk question-
naire (FRQ) for older paired cognition. Injurious falls are more common in women and per-
adults. J Safety Res. sons with cognitive impairment, several chronic conditions, and low
2011;42:493-9. [PMID:
22152267]
body weight. Severity of fall-related injuries is also affected by situa-
29. Podsiadlo D, Richardson tional factors that increase the impact of a fall. The greater the number
S. The timed “Up & Go”: of risk factors present, the greater the risk for falls and fall-related
a test of basic functional
mobility for frail elderly injuries.
persons. J Am Geriatr
Soc. 1991;39:142-8.
[PMID: 1991946]
30. Schoene D, Wu SM, CLINICAL BOTTOM LINE
Mikolaizak AS, Menant
JC, Smith ST, Delbaere K,
et al. Discriminative
ability and predictive
validity of the Timed Up
and Go Test in identify-
ing older people who
Evaluation
fall: systematic review How often should patients be questions require further assess-
and meta-analysis. J Am
Geriatr Soc. 2013;61: assessed for risk for falls? ment. To encourage adoption of
202-8. [PMID:
23350947] Screening for falls begins with preventive measures by primary
31. Jones CJ, Rikli RE, Beam
obtaining historical or self- care providers, the Centers for
WC. A 30-s chair-stand
test as a measure of reported information on balance, Disease Control and Prevention
lower body strength in
community-residing lower-extremity strength, and (CDC) developed the Stopping
older adults. Res Q Exerc gait. The American and British Elderly Accidents, Deaths & Inju-
Sport. 1999;70:113-9.
[PMID: 10380242] Geriatrics Societies (AGS/BGS) ries (STEADI) tool kit to help
32. Rossiter-Fornoff JE, Wolf
SL, Wolfson LI, Buchner clinical practice guideline recom- integrate these guidelines into
DM. A cross-sectional mends that all persons older than clinical settings (27). It suggests
validation study of the
FICSIT common data 65 years be asked yearly if they using the following key questions
base static balance mea-
sures. Frailty and Inju-
have fallen 2 or more times in the for screening: “Have you fallen in
ries: Cooperative Studies past year, were injured in a fall, the past year?” “Do you feel un-
of Intervention Tech-
niques. J Gerontol A Biol or have any difficulties with walk- steady when standing or walk-
Sci Med Sci. 1995;50: ing or balance (26). Patients who ing?” and “Do you worry about
M291-7. [PMID:
7583799] answer “yes” to any of these falling?” The CDC also offers a

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 Table 1. Functional Tests
Test Description Comments
Timed Up-and-Go test Assesses mobility, balance, transfer ability, and Cut-off scores signaling high risk vary
fall risk. A person rises from a hard-backed depending on population. Specificity
chair with arms, walks 10 feet, turns around, (60%–87%) tends to be better than
and sits back down in chair. Assistive device sensitivity (31%–56%).
(cane or walker) is used if the person usually
uses one.
Berg Balance test 14-item objective measure designed to assess This test may be more time-consuming
static balance (i.e., sitting, standing, than other balance tests and requires
transferring, reaching and turning). training for administration and scoring.
History of falls and score <51 or no
history of falls and score <42 is
predictive of falls (sensitivity 91%,
specificity 82%). Score <40 associated
with almost 100% fall risk.
Four-Stage Balance test Tests static balance. A person moves through Was found in 1 study as being 45%
4 stances, starting with a parallel stance, sensitive and 74% specific to predict
semi-tandem, full tandem, and ending with a recurrent falls. Easy to administer in
single leg stance. The goal is to hold each clinical setting.
stance unsupported for 10 seconds.
Thirty-Second Sit-to-Stand Tests lower-extremity strength. A person Normative values are sex- and
test stands from a seated position as many times age-specific, and completing less than
as possible in 30 seconds without using the the normative value for sex/age
arms. indicates risk for falling. Sensitivity 68%
and specificity 54% for predicting falls
at a cut-off of 11, regardless of sex or
age.
Dynamic Gait Index Assesses ability to maintain balance while No training required; takes less than 10
walking in the presence of external minutes to administer; <19 indicate
demands. increased risk for falling (sensitivity
59%, specificity 64%).
Four-Square Step test A balance test that assesses a person's ability Exceeding 15 seconds for completion
to step forward, sideways, and backward. indicates increased risk for falling.

33. Vellas BJ, Wayne SJ,

Romero L, Baumgartner
screening questionnaire devel- (26). Several functional perfor- RN, Rubenstein LZ, Garry
oped to identify persons at risk mance tests can be used to quan- PJ. One-leg balance is an
important predictor of
for falling who would benefit tify fall risk (Table 1), but many of injurious falls in older
from risk-reducing interventions. them are impractical and unnec- persons. J Am Geriatr
Soc. 1997;45:735-8.
This 14-item “Stay Independent” essary for use in most primary [PMID: 9180669]
34. Chang JT, Ganz DA.
questionnaire is a validated fall care and specialty care clinics. Quality indicators for falls
risk self-assessment that can be Therefore, the AGS/BGS and the and mobility problems in
vulnerable elders. J Am
completed independently by an CDC recommend simple tests, Geriatr Soc. 2007;55
older adult and reviewed by the such as the Timed Up-and-Go
Suppl 2:S327-34. [PMID:
17910554]
health care provider during a (TUG) test, Thirty-Second Sit-to- 35. Hilmer SN, Gnjidic D.
The effects of polyphar-
clinical visit (28). A score of 4 or Stand (STS) test, and Four-Stage macy in older adults.
more on the questionnaire or an Balance test, to identify persons Clin Pharmacol Ther.
2009;85:86-8. [PMID:
affirmative answer to any of the with mobility problems who are 19037203]
key questions in the STEADI tool at risk for falling. The TUG test
36. Woolcott JC, Richardson
KJ, Wiens MO, Patel B,
kit indicates that the patient is at assesses gait, balance, coordina- Marin J, Khan KM, et al.
Meta-analysis of the
risk for falling and requires fur-
tion, and strength; does not re- impact of 9 medication
ther clinical assessment. classes on falls in elderly
quire specialized training; and persons. Arch Intern
Med. 2009;169:1952-
What measures are useful in can be administered in about 5 60. [PMID: 19933955]
screening for fall risk? minutes (29). Its predictive ability 37. By the American Geriat-
rics Society 2015 Beers
For persons with or without a his- and diagnostic accuracy are Criteria Update Expert
moderate (30). Persons who take Panel. American Geriat-
tory of falls or problems with bal- rics Society 2015 up-
ance or gait, clinical guidelines 12 or more seconds to complete dated Beers criteria for
potentially inappropriate
recommend functional assess- the test are at risk for falling; medication use in older
ments to evaluate gait, lower- those who take more than 20 adults. J Am Geriatr Soc.
2015;63:2227-46.
extremity strength, and balance seconds are at greatest risk. The [PMID: 26446832]

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 Table 2. Core Elements of a Fall-Focused History and Physical Examination
Fall History Physical Examination
Symptoms (prodromal): Dizziness/light- Head, eyes, ears, nose and throat: Vision acuity, peripheral vision
headedness, palpitations
Prior falls Cardiovascular: Orthostatic vitals, rate, rhythm, murmurs
Location: Bedroom, bathroom, outside home, Neurologic: Cognitive screen, sensation, proprioception and balance,
community motor function and reflexes, cerebellar testing, gait
Timing: Postprandial, time of day, relationship Psychologic: Depression screen
to medications
Activity: Situation before fall—walking or just Musculoskeletal: Standing posture, range of motion (particularly in joints
stood upright of lower extremities, head and neck, trunk), muscle tone and bulk, foot
and footwear assessment

STS and Four-Stage Balance tests tation of the fall history is one of
are quick, office-based screening the quality indicators for fall pre-
38. Stevens JA. The STEADI tools that gauge lower-extremity vention and management (34).
tool kit: a fall prevention
resource for health care strength and balance, respec- Medication review is a key com-
providers. IHS Prim Care tively, are easy to administer, and
Provid. 2013;39:162-6.
ponent of the risk assessment
[PMID: 26766893] provide useful information to because many medications in-
39. Kempen GI, Yardley L,
van Haastregt JC, Zijlstra
complement the TUG test (31, crease risk for falling (see the
GA, Beyer N, Hauer K, 32). Per the AGS/BGS guideline, Box: Medications that Increase
et al. The Short FES-I: a
shortened version of the any person who has gait or bal- the Risk for Falling). The clinician
Falls Efficacy Scale- ance abnormalities requires a fall
International to assess should review the clinical neces-
fear of falling. Age Age- risk assessment. sity of all medications— use of 4 or
ing. 2008;37:45-50.
[PMID: 18032400] more is an independent risk factor
40. Tinetti ME, Richman D, A longitudinal cohort study investigated the
Powell L. Falls efficacy as
for falling (35). Medications with
a measure of fear of predictive ability of a simple, static balance central nervous system effects,
falling. J Gerontol. 1990; test on risk for falling and serious injury.
45:P239-43. [PMID: including those with anticholin-
2229948] Community-dwelling adults aged 60 years or
ergic and sedating properties, are
41. Applegate WB, Blass JP, older (n = 316) had a physical examination
Williams TF. Instruments
that included single-leg balance testing, de- most strongly associated with fall-
for the functional assess-
ment of older patients. N fined as the ability to stand on 1 leg unsup- ing and should be tapered, re-
Engl J Med. 1990;322: duced, or discontinued whenever
1207-14. [PMID: ported for 5 seconds. At 3 years, age older than
2183053] 73 years was the only significant independent possible (36). These include antip-
42. Tinetti ME, Gordon C,
Sogolow E, Lapin P, predictor of falls, and impaired single-leg bal- sychotics, tricyclic antidepressants,
Bradley EH. Fall-risk ance was the only independent predictor of serotonin reuptake inhibitors, cen-
evaluation and manage-
ment: challenges in
injurious falls (relative risk [RR], 2.13 [CI, trally acting antihypertensives, opi-
adopting geriatric care 1.04 – 4.34]) (33). ates, sedative-hypnotics, and
practices. Gerontologist.
2006;46:717-25. [PMID: What should the clinical nonbenzodiazepine- and
17169927]
43. Tricco AC, Thomas SM, assessment of an at-risk patient benzodiazepine-receptor agonists
Veroniki AA, Hamid JS,
Cogo E, Strifler L, et al. include? (37).
Comparisons of interven-
tions for preventing falls
The fall risk assessment involves Selection of appropriate labora-
in older adults: a system- a focused examination of the pa- tory and radiologic tests should be
atic review and meta-
analysis. JAMA. 2017; tient with attention to vital signs, guided by concerns identified dur-
318:1687-99. [PMID: including orthostatic blood pres-
29114830] ing the fall risk assessment. Testing
44. Reeve E, Wiese MD, sure assessments; hearing and
Hendrix I, Roberts MS, may include hematocrit measure-
vision; the neurologic system,
Shakib S. People's atti- ment; measurement of thyroid-
tudes, beliefs, and expe- including both central and pe-
riences regarding polyp- stimulating hormone, vitamin B12,
harmacy and willingness ripheral systems and cognition;
to deprescribe. J Am and 25-hydroxyvitamin D levels;
and the cardiovascular and mus-
Geriatr Soc. 2013;61: and dual-energy x-ray absorptiom-
1508-14. [PMID: culoskeletal (including examina-
24028356] etry (DEXA) scanning.
45. Martin P, Tannenbaum tion of the feet) systems. Details
C. A realist evaluation of of the fall itself should also be A meta-analysis that included 22 studies with
patients' decisions to
deprescribe in the EM- noted, such as timing, location, a total of 79 081 participants clarified which
POWER trial. BMJ Open. situational factors, and related
2017;7:e015959.
medication classes increase risk for falling
[PMID: 28473524] symptoms (Table 2). Documen- (36). The Bayesian unadjusted OR estimates

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 were highest for antidepressants (OR, 1.68 [CI, ing (ADLs), such as getting
1.47–1.91]), neuroleptics and antipsychotics dressed, preparing meals, or Medications That Increase the
(OR, 1.59 [CI, 1.37–1.83]), benzodiazepines showering. The questionnaire Risk for Falling
(OR, 1.57 [CI, 1.43–1.72]), and sedatives and categorizes people as having Antipsychotics
hypnotics (OR, 1.47 [CI, 1.35–1.62]). Even after mild, moderate, or high concern Sedative/hypnotics
adjustment, OR estimates still indicated that Antidepressants
about falling, with higher scores
neuroleptics and antipsychotics, antidepressants, Antihypertensives (central-acting)
and benzodiazepines were associated with in- correlating with greater concern
and risk (40). It is particularly use- Diuretics
creased risk (ORs, 1.39 [CI, 0.94 –2.00], 1.36 [CI,
ful in the outpatient setting for Antiarrhythmics
1.13–1.76], and 1.41 [CI, 1.20 –1.71], respec-
tively). Antihypertensives (OR, 1.24 [CI, 1.01– addressing fall-related functional Opiates
1.50]), diuretics (OR, 1.07 [CI, 1.01–1.14]), impairment and identifying older
␤-blockers (OR, 1.01 [CI, 0.86 –1.17]), and non- adults who would benefit from
steroidal anti-inflammatory drugs (OR, 1.21 [CI, durable medical equipment, a
1.01–1.44]) were associated with reduced or non- home safety assessment, or an Basic Home Safety
significant risk. Opiates were also not associated occupational therapy evaluation. Recommendations
with elevated risk (OR, 0.96 [CI, 0.78 –1.18]). Entrances: Railings and steps in
However, subsequent studies have informed the What should a home safety good condition, adequate
current recommendation from the AGS Beers Cri- assessment include? lighting
teria for Potentially Inappropriate Medication Use In addition to the FES-I, func- Kitchen: Common items in reach-
in Older Adults to avoid opiates in persons with a tional and fall risk assessments able places, rubber-backed
history of falls or fracture, excluding indications mats
can alert the provider that a
for acute pain management (moderate-quality Bathroom: Nonslip bathmat,
evidence, strong recommendation) (37). home safety assessment should grab bars for toilet and
be considered. Functional histo- bath/shower, raised toilet seat,
Fall risk can be classified as low ries can be obtained by stan- adequate lighting
or high depending on the pa- dardized assessments, such as Stairs: Clutter removed, railings in
tient's self-reported measures the Katz ADL and the Barthel In- good repair, color contrast
strips on steps
and performance on functional dex (41). If the functional or fall
Hallways: Clutter removed,
tests (38). Any person who has history suggests concerns related
night-lights
fallen, feels unsteady when walk- to environmental factors, recom-
ing, or worries about falling and mending home modifications
46. Burton E, Cavalheri V,
has a gait, balance, or strength (see the Box: Basic Home Safety Adams R, Browne CO,
impairment on examination is Recommendations) or referring Bovery-Spencer P, Fen-
ton AM, et al. Effective-
likely to fall. Persons with these the person to occupational ther- ness of exercise pro-
grams to reduce falls in
characteristics and those who apy would be reasonable (16). older people with de-
have fallen 2 or more times or The CDC also offers a self- mentia living in the
community: a systematic
had an injurious fall are consid- guided home safety assessment review and meta-
analysis. Clin Interv Ag-
ered to be at high risk. Risk stratifi- (Check for Safety) that older ing. 2015;10:421-34.
cation can guide providers in adults can complete indepen- [PMID: 25709416]
47. Slaughter SE, Wagg AS,
choosing intervention options, dently (38). This is appropriate Jones CA, Schopflocher
help determine the need for in- for anyone at risk for falling be- D, Ickert C, Bampton E,
et al. Mobility of Vulnera-
depth assessment, and direct deci- cause it offers important, general ble Elders study: effect of
the sit-to-stand activity on
sions about referral to geriatric recommendations for aging suc- mobility, function, and
specialists. cessfully at home and is freely quality of life. J Am Med
Dir Assoc. 2015;16:138-
available on the CDC Web site. 43. [PMID: 25271194]
What tools measure fear of 48. Kendrick D, Kumar A,
falling? When should patients be Carpenter H, Zijlstra GA,
Skelton DA, Cook JR,
For at-risk persons, the provider referred to a specialist? et al. Exercise for reduc-
ing fear of falling in
should explore fears related to There is no specific guideline on older people living in the
falling and the degree to which patient referral to specialty care community. Cochrane
Database Syst Rev. 2014:
they may cause functional impair- for assessment or management CD009848. [PMID:
ment. Such impairment can be of fall risk. However, referral to a 25432016]
49. Stevens JA, Burns E. CDC
qualified and quantified using geriatrics specialist or fall clinic Compendium of Effective
Fall Interventions: What
either the long (16-item) or short could be considered for persons Works for Community-
(7-item) Falls Efficacy Scale- with recurrent falls (≥2 in the past Dwelling Older Adults,
3rd Edition. Accessed at
International (FES-I) (39). This as- year); those who continue to fall www.cdc.gov/homean-
sessment elicits concerns about despite preventive measures; drecreationalsafety/falls
/compendium.html on
falls during activities of daily liv- those who are medically, socially, 28 June 2018.

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 Table 3. Interventions for Fall Prevention and Their Evidence Ratings
Intervention USPSTF† AGS/BGS‡ Cochrane Collaboration§
Strength and balance exercise B A Effective (16 trials)
Tai chi B A Reduced risk for falling (7 trials)
Home modification I* A Effective (6 trials)
Medication—Reduction in psychoactive I* B 2 positive trials
medications
Medication—Reduction in number or dose — B —
Postural hypotension management — C —
Vitamin D supplementation for fall prevention D B Not effective overall (13 trials)
Vision screening and management — I Harmful effect in 1 trial
Hearing screening and management — — —
Foot/shoe screening and management — C Reduced rate of falls in 2 trials
Education alone — D 1 negative trial
Cardiac pacing for carotid sinus hypersensitivity — B Reduced rate of falls in 3 trials
First eye cataract surgery — B 1 positive trial
Multifactorial interventions C A Effective in reducing rate of but not risk for falling
(19 trials)

AGS = American Geriatrics Socieity; BGS = British Geriatrics Society; USPSTF = U.S. Preventive Services Task Force.
† From reference 55. Ratings: A = recommended with high certainty of benefit; B = recommended with moderate certainty of
benefit; C = selectively offer based on professional judgment and patient preferences; D = recommended against based on
moderate or high certainty of no benefit or that harms outweigh the benefit; I = insufficient evidence; I* = evidence report finding
of insufficient evidence/not part of summary recommendation.
‡ From reference 26. Ratings: A = strongly recommended; B = recommended; C = no recommendation; D = recommended
against; I = insufficient evidence.
§ From reference 8. “Effective” and “not effective” based on authors' main conclusions.

or physically complex; or those referred if the provider does not

who have had an injurious fall have the skills or experience to
(26). The patient should also be manage fall risk factors (42).

50. Gardner MM, Buchner Evaluation... Older adults should be asked yearly if they have fallen,
DM, Robertson MC, feel unsteady when walking, or have gait or balance difficulty. The risk
Campbell AJ. Practical
implementation of an assessment should review the intrinsic and extrinsic causes of falls, with
exercise-based falls pre- particular emphasis on risk factors that can also increase risk for injury.
vention programme. Age
Ageing. 2001;30:77-83. Standardized assessments and functional testing can help guide the
[PMID: 11322678] health care provider in identifying potentially modifiable risk factors.
51. Clemson L, Fiatarone Referral is necessary only if the clinician does not feel equipped to
Singh MA, Bundy A,
Cumming RG, Manol- implement screening or preventive measures.
laras K, O’Loughlin P,
et al. Integration of bal-
ance and strength train-
ing into daily life activity
to reduce rate of falls in
CLINICAL BOTTOM LINE
older people (the LiFE
study): randomised par-
allel trial. BMJ. 2012;
345:e4547. [PMID:
22872695]
52. Shubert TE, Smith ML,
Jiang L, Ory MG. Dissem-
inating the Otago exer-
Management
cise program in the
United States: perceived
What is the role of single clinical serious ones (e.g., fractures)
and actual physical per- interventions in preventing (8, 43).
formance improvements
from participants. J Appl falls?
Gerontol. 2018;37:79- Home modification is also effec-
98. [PMID: 27794055]
53. Robertson MC, Campbell Several single interventions are tive, although evidence is lacking
AJ, Gardner MM, Devlin
N. Preventing injuries in
beneficial in preventing falls on whether it reduces fall-related
older people by prevent- (Table 3). Exercise has the stron- injury as a single intervention
ing falls: a meta-analysis
of individual-level data. J gest evidence of any individual (43). Home modification is more
Am Geriatr Soc. 2002; intervention—it reduces both falls effective in persons at higher risk
50:905-11. [PMID:
12028179] and fall-related injuries, including for falling, including those with

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 severe vision impairment. Home injuries: exercise plus vision as-
safety interventions seem to be sessment and management (OR,
more effective when delivered by 0.17 [CI, 0.07– 0.38]), exercise
an occupational therapist (8). plus vision and environmental
assessment and management 54. Agha A, Liu-Ambrose TY,
Elimination or dose reduction of (OR, 0.30 [CI, 0.13– 0.70]), and Backman CL, Leese J, Li
centrally acting medications is clinic-level quality improvement
LC. Understanding the
experiences of rural
effective in reducing falls (8, 26). (e.g., facilitated relay of informa- community-dwelling
older adults in using a
In our clinical experience, most tion to clinicians, clinician remind- new DVD-delivered
older adults have low awareness ers) plus multifactorial assessment Otago exercise program:
a qualitative study. Inter-
of the link between medications and management plus vitamin D act J Med Res. 2015;4:
and falls, but once advised of this e17. [PMID: 26272163]
and calcium supplementation (OR, 55. Guirguis-Blake JM, Mi-
correlation they are typically re- 0.12 [CI, 0.03– 0.55]). chael YL, Perdue LA,
Coppola EL, Beil TL. Inter-
ceptive to reducing the number ventions to prevent falls
or doses of medications. Re- Based on the above findings, in older adults: updated
evidence report and
search on attitudes toward medi- clinicians should encourage systematic review for the
cations in older persons has exercise (focused on strength and US Preventive Services
Task Force. JAMA. 2018;
found similar receptivity, with balance), regular vision evaluation, 319:1705-16. [PMID:
29710140]
68% reporting that they would attention to environmental safety, 56. Grossman DC, Curry SJ,
like to reduce medication use and treatment of osteoporosis to Owens DK, Barry MJ,
Caughey AB, Davidson
and 92% willing to stop use of a help prevent fractures. KW, et al; US Preventive
Services Task Force. Inter-
medication if advised to do so by How can fall prevention be ventions to prevent falls
their physician (44). This study in community-dwelling
addressed for older adults older adults: US Preven-
highlights the importance of pro- tive Services Task Force
with dementia? recommendation state-
vider engagement in medication
reduction and the need to recog- Persons with impaired cognition ment. JAMA. 2018;319:
1696-704. [PMID:
nize medication risks and harms are at high risk for falls and inju- 29710141]
57. Holick MF, Binkley NC,
in older adults (37). Recent ries, although most interventions Bischoff-Ferrari HA, Gor-
have not been tested specifically don CM, Hanley DA,
research found that discourage- Heaney RP, et al; Endo-
in this population subset. Exer- crine Society. Evaluation,
ment of medication discontinua-
cise has been shown to be effec- treatment, and preven-
tion by their health care provider tion of vitamin D defi-
tive in reducing the risk for falling ciency: an Endocrine
is a key barrier to older adults Society clinical practice
in community-living older adults
successfully reducing psychoac- guideline. J Clin Endocri-
with mild to moderate dementia nol Metab. 2011;96:
tive medication use (45). 1911-30. [PMID:
(46). However, engaging persons 21646368]
What is the role of multifactorial with dementia in routine exercise 58. Cosman F, de Beur SJ,
LeBoff MS, Lewiecki EM,
and multicomponent may be met with apathy, resis- Tanner B, Randall S,
et al; National Osteopo-
interventions? tance, and behavioral distur- rosis Foundation. Clini-
Multifactorial interventions iden- bances and is a challenge for cian's guide to preven-
tion and treatment of
tify and address fall risk factors caregivers. A study of nursing osteoporosis. Osteoporos
home residents with dementia Int. 2014;25:2359-81.
based on an individualized as- [PMID: 25182228]
sessment. Multicomponent inter- found that focusing on maintain- 59. Santesso N, Carrasco-
Labra A, Brignardello-
ventions deliver a standardized ing lower-extremity strength Petersen R. Hip protec-
(i.e., nonindividualized) combina- through a simple intervention of tors for preventing hip
fractures in older people.
tion of interventions that address health care aide–prompted, re- Cochrane Database Syst
peated sit-to-stand activity during Rev. 2014:CD001255.
more than 1 risk factor (e.g., [PMID: 24687239]
balance and home safety). daily care routines on day and 60. Aryee E, James SL, Hunt
GM, Ryder HF. Identify-
evening shifts was effective in ing protective and risk
Recent evidence from a compre- maintaining the ability to transfer factors for injurious falls
in patients hospitalized
hensive systematic review and (47). For older adults with ad- for acute care: a retro-
network meta-analysis (43) vanced dementia who are living spective case-control
study. BMC Geriatr.
(based on 54 randomized trials at home, continuing to be able to 2017;17:260. [PMID:
29115921]
with a total of 41 596 participants transfer independently and safely 61. Oliver D, Healey F,
that evaluated 39 interventions (e.g., in and out of bed, on and Haines TP. Preventing
falls and fall-related
plus usual care) suggests that the off the toilet, in and out of a car) injuries in hospitals. Clin
following combinations of single are important to being able to Geriatr Med. 2010;26:
645-92. [PMID:
interventions reduce fall-related remain at home and may be 20934615]

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 more feasible than maintaining being disseminated in the United States (52)
an exercise routine. Recommend- and can also be delivered via DVD (54).
ing sit-to-stand activity is a practical What is the role of vitamin D
62. Dykes PC, Carroll DL, approach for clinicians seeking to and calcium in fall prevention?
Hurley A, Lipsitz S,
Benoit A, Chang F, et al. advise family caregivers of persons
Fall prevention in acute
Vitamin D helps maintain muscle
care hospitals: a random-
who wish to age in place but are at strength and function. However,
ized trial. JAMA. 2010; high risk for falls due to dementia clinical guideline recommenda-
304:1912-8. [PMID:
21045097] and impaired mobility. tions seem to conflict on whether
63. Ganz DA, Huang C,
Saliba D, Shier V, Berlow- What should clinicians vitamin D3 (cholecalciferol) sup-
itz D, VanDeusen Lukas
C, et al. Preventing falls recommend regarding plementation is effective for fall
in hospitals: a toolkit for
exercise? prevention. The AGS (26) and the
improving quality of
care. (Prepared by RAND STEADI initiative (27) recom-
Corporation, Boston Strength and balance exercise
mend daily vitamin D in modest
University School of has the strongest evidence for
Public Health, and (800 –1000 IU) doses, given that
ECRI Institute under prevention of falls and fall-related
Contract No. HHSA vitamin D deficiency is common
injuries. Such exercise also seems
290201000017I TO #1.) and supplementation is reason-
Rockville, MD: Agency to reduce fear of falling if partici-
for Healthcare Research ably safe and inexpensive. The
and Quality; 2013. pation is sustained (48). Most
AHRQ Publication No.
Cochrane Collaboration found
older adults do not exercise to
13-0015-EF. that vitamin D supplementation
64. Ensrud KE, Crandall CJ. improve strength and balance. did not reduce falls overall but
Osteoporosis. Ann Intern
Med. 2017;167:ITC17- Community programs that in- seemed to do so in persons with
ITC32. [PMID:
28761958]
clude strength and balance exer- low levels (8). The U.S. Preventive
65. Bunn F, Dickinson A, cise may be recommended for Services Task Force no longer
Barnett-Page E, McInnes
E. A systematic review of both primary and secondary fall recommends vitamin D supple-
older people's percep- prevention (49). For older adults
tions of facilitators and mentation for fall prevention in
barriers to participation at high risk for falls, one-on-one older adults who do not have
in falls-prevention inter-
ventions. Ageing Soc. exercise supervised by a physical osteoporosis or vitamin D
2008;28:449-72. therapist is the safest initial
66. Voukelatos A, Merom D, deficiency (55, 56). This recom-
Sherrington C, Rissel C, approach, with transition to a mendation is related to recent
Cumming RG, Lord SR.
The impact of a home- community class or home-based evidence, including a large trial
based walking pro-
gramme on falls in older
exercise program (such as the that administered a high dose of
people: the Easy Steps Otago Exercise Program [50] or vitamin D infrequently (500 000
randomised controlled
trial. Age Ageing. 2015; the Lifestyle-integrated Func- IU once annually) and found an
44:377-83. [PMID: tional Exercise Program [51]) increased risk for falls and frac-
25572426]
67. Shubert TE. Evidence- when the patient is ready. tures among community-
based exercise prescrip-
tion for balance and falls dwelling, older, at-risk adults.
prevention: a current A series of trials testing the Otago Exercise Pro-
review of the literature. J gram found that it improved balance and re- However, many older adults who
Geriatr Phys Ther. 2011;
34:100-8. [PMID: duced falls and fall-related injuries by 35% are at risk for falls also have os-
22267151] (fall incidence rate ratio [IRR], 0.65 [CI, 0.57– teoporosis, vitamin D deficiency,
68. Sherrington C, Whitney
JC, Lord SR, Herbert RD, 0.75]; fall-related injury IRR, 0.65 [CI, 0.53– or both, and ensuring that cal-
Cumming RG, Close JC. 0.81]) when led by a physical therapist or
Effective exercise for the cium and vitamin D levels are
prevention of falls: a trained nurse. Developed by the New Zealand
sufficient before osteoporosis
systematic review and Falls Prevention Research Group in the late
meta-analysis. J Am
1990s, the program involves an intervention-
treatment initiation is important.
Geriatr Soc. 2008;56:
2234-43. [PMID: ist (typically a physical therapist) who trains at- Thus, vitamin D supplementation
19093923] (≥800 –1000 IU daily) makes clini-
69. Peterson EW, Finlayson risk adults to practice 17 exercises at home to
M, Elliott SJ, Painter JA, improve gait stability, strength, and balance. cal sense and is consistent with
Clemson L. Unprece-
dented opportunities in The interventionist assesses, coaches, and recommendations from profes-
fall prevention for occu- moves the trainee through progressively more sional societies (26, 57, 58).
pational therapy practi-
tioners. Am J Occup challenging exercises over the course of 6 –12
Ther. 2012;66:127-30. What is the role of protectors
[PMID: 22394521]
months. Improvements may be seen as soon
70. National Institute on as 8 weeks after program initiation (52). The for the hip and other sites?
Aging. Prevent Falls and
program is most effective in reducing fall- Hip protectors, which are either
Fractures. 2017. Ac-
cessed at www.nia.nih related injury among those aged 80 years or hard plastic shields or soft foam
.gov/health/prevent-falls pads, have been studied for pre-
-and-fractures on 14
older (IRR vs. those aged 65–79 years, 0.54
June 2018. [CI, 0.34 – 0.87]) (53). The Otago program is vention of hip fracture. Nearly all

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 (>99%) such fractures in older and thus should not be used for
adults result from a fall. A Coch- fall prevention.
rane meta-analysis of 3 trials of
What is the role of osteoporosis
hip protector use in community-
screening and management?
dwelling older adults showed no
evidence of reduced risk for hip Although osteoporosis is not
fracture (RR, 1.14 [CI, 0.83–1.57]) specific to fall prevention, many
(59). Receptivity to wearing hip older adults at risk for falls have
protectors is low, and from a lo- undetected osteoporosis, and
gistics standpoint they make certain types of fractures (e.g.,
dressing and undressing the hip) are overwhelmingly caused
lower body challenging. There is by falls in this age group. It thus
little to no evidence on the effec- makes clinical sense to screen for
osteoporosis as part of routine
tiveness of other wearable pro-
fall prevention care. Screening
tective devices, such as helmets
can include measurement of
and elbow or knee
bone mineral density by DEXA
protectors.
scan or clinical risk assessment
What strategies are useful in via such tools as the Fracture Risk
preventing falls in hospitalized Assessment Tool (FRAX). The
patients? U.S. Preventive Services Task
Older adults are at risk for falls Force recommends bone mineral
while they are hospitalized. Per- density testing for all women
sons who have had a prior fall aged 65 years or older or at-risk
and those with cognitive impair- postmenopausal women
ment due to any cause (delirium, younger than 65 years. Although
dementia) are at highest risk. evidence on screening in men is
Factors that increase risk for in- insufficient, it should be consid-
jury from inpatient falls include ered if the patient has at least 1
joint replacement (OR, 5.58 [CI, risk factor for osteoporosis (e.g.,
1.84 –16.9]), psychotropic agents smoking, androgen-deprivation
(OR, 2.23 [CI, 1.39 –3.60]), male therapy, history of or current ex-
sex (OR, 2.08 [CI, 1.28 –3.45]), cessive use of alcohol, hypogo-
and history of a fall (OR, 2.08 [CI, nadism, and long-term use of
1.12–3.85]) (60). corticosteroids or anticonvul-
sants) because the mortality rate
A few single interventions have from hip fractures in men is high.
been found to reduce risk for There are a range of therapeutic
falls in the inpatient setting. options as well as lifestyle
These include medication man- changes that should be discussed
agement and, for cognitively in- with patients whose DEXA scan
tact patients, education with shows a bone mineral density
health professional follow-up T-score of –2.5 or less and those
(61). Multifactorial interventions who have higher T-scores but
are supported by current whose FRAX score indicates high
evidence (62, 63). risk for fracture. More information
on management can be found
Studies of single environmental elsewhere (64).
modifications (low-low beds,
bedside [“crash”] mats, bed How should clinicians counsel
alarms, floor material modification) patients and caregivers about
have found no evidence of benefit. fall prevention?
Bedside mats may actually in- Development of the STEADI ini-
crease risk for falls in ambulatory tiative stemmed in part from the
persons. No randomized trials of recognition that few patients
bed rails have been done, but they raise the issue of falls with their
are typically considered a restraint health care provider (7). The pro-

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 gram provides useful guidance ance is essential for fall preven-
and tools for clinicians seeking to tion (67), that balance exercises
counsel their patients and care- must be done in a standing posi-
givers about fall prevention (see tion at least 3 times per week on
Talking about Fall Prevention a routine basis for a sustained
with Your Patients at www.cdc effect, and that the benefit of re-
.gov/steadi/materials.html). Rec- duction in fall risk will not be ap-
ognition of the need for patient parent until after several months
acceptance and willingness to (> 50 hours) of routine balance
act on recommendations is para- practice (68). The importance of
mount, and open discussion of maintaining a balance exercise
what a patient is willing to do is regimen over time cannot be
essential for formulating a realis- overemphasized, and it is impor-
tic care plan in partnership with tant to recognize that this is chal-
the patient. lenging for several reasons
unique to this age group (e.g.,
Research has shown that the rec-
ommendation of a health profes- personal or family illnesses; acute
sional is an important facilitator in life stressors, such as death of a
engaging in fall prevention be- partner, sibling, or friend). Pro-
haviors (65). Other facilitators viders should ask about exercise
include providing a range of op- adherence at each clinic visit.
tions to address a given risk fac- Suggesting that patients incorpo-
tor (e.g., community- or home- rate exercises into their daily rou-
based exercise class), framing tine (e.g., standing on 1 leg while
the recommended changes in a brushing the teeth) is a practical
positive light (e.g., return of con- way to encourage long-term ex-
fidence and ability to engage in ercise adherence (51).
activities one used to enjoy) as
To facilitate management of envi-
opposed to a negative one (hav-
ronmental risks, identifying and
ing to give up belongings to
prioritizing hazards collabora-
which the patient may be at-
tively with the patient and enlist-
tached, such as throw rugs or
ing family support to accomplish
open-back shoes), and emphasiz-
any changes to which the patient
ing the life-enhancing effects and
is receptive is advisable. Identify-
increased opportunities to partic-
ing risky behaviors (e.g., carrying
ipate in enjoyable activities (e.g.,
bags of groceries, not holding
exercise class presents an oppor-
tunity for social connection). onto the stair railing) and encour-
aging adaptive strategies (e.g.,
The patient must be made aware carrying 1 bag at a time, identify-
that walking (66) or upper body ing which entrance allows the
stretching exercises will not pre- easiest ingress into the building)
vent falls and that improving bal- can also be helpful (69).

Management... Fall risk must be managed with a patient-centered ap-

proach. Clinicians should recommend interventions to address modifi-
able risk factors and reduce injury from falls in the context of patient
preferences and values. Maintaining the highest possible level of mo-
bility and social and daily functioning is the key goal of fall prevention
management. Engaging a caregiver can be helpful in achieving fall
risk reduction in vulnerable older adults.

CLINICAL BOTTOM LINE

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 Practice Improvement
What measures do The National Institute on Aging
stakeholders use to evaluate recommends strength and bal-
the quality of care for patients ance exercise, assessment of en-
at risk for falls? vironmental hazards, optimiza-
The Merit-based Incentive Pay- tion of hearing and vision, and
ment System (www.aafp.org/ medication management (70).
news/macra-ready/20180411
The AGS (26) recommends an-
mipstool.html) has a quality mea-
nual fall screening (asking about
sure for fall risk assessment, which
falls in the prior year) along with
is the percentage of patients
gait and balance assessment.
aged 65 years or older with a his-
Anyone who has fallen two or
tory of falls (i.e., ≥2 falls in the
more times in the prior year, pre-
past year or any injurious fall in
sented for medical attention for a
the past year) who had a risk as-
fall, or has difficulty on gait and
sessment completed within 12
balance testing should have a
months. A patient-reported his-
multifactorial fall risk assessment.
tory of falls is sufficient. The risk
The AGS recommends the fol-
assessment must cover balance
lowing interventions: balance
and gait and 1 or more of the fol-
and strength exercise, home
lowing: postural blood pressure,
modification, withdrawal or mini-
vision, home fall hazards, and
mization of psychoactive or other
documentation of whether medi-
medications, management of
cations contributed to falls in the
postural hypotension, manage-
past 12 months.
ment of foot problems and
The Patient Protection and Afford- footwear, and vitamin D supple-
able Care Act established the mentation of at least 800 IU/d for
Centers for Medicare & Medicaid persons who have vitamin D defi-
Services' “star ratings” (www.aafp ciency or are at increased risk for
.org/news/practice-professional falls.
-issues/20180109physiciancom-
pare.html) of health care quality The CDC's STEADI initiative
for various measures that form the (www.cdc.gov/steadi) is a health
basis of quality bonus payments care provider– oriented set of
to Medicare Advantage Plans. materials to facilitate implemen-
Measures relevant to fall preven- tation of the AGS fall prevention
tion in 2018 include medication guidelines in routine clinical
review, functional status assess- practice. STEADI consists of 3
ment, and osteoporosis manage- key strategies: screen to identify
ment in women who have had a fall risk, assess modifiable risk
fracture. factors, and intervene using ef-
fective strategies to reduce the
What do professional identified risk factors. Recom-
organizations recommend mended clinical strategies reflect
regarding fall prevention? the recommendations of the
Several professional organiza- AGS/BGS and emphasize exer-
tions endorse interventions to cise, vitamin D supplementation,
prevent falls among older adults. medication management, and
The recommendations vary. home modification.

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 In the Clinic Patient Information
https://medlineplus.gov/falls.html

Tool Kit
Resources related to falls in MedlinePlus from the

IntheClinic
National Institutes of Health (NIH).
www.bones.nih.gov/health-info/bone/osteoporosis
/fracture/prevent-falls-ff
www.bones.nih.gov/health-info/bone/espanol
/osteoporosis/fracturas-ff-espanol

Fall Prevention Recommendations in English and Spanish on prevention

of falls and related fractures from the NIH Osteoporosis
and Related Bone Diseases National Resource Center.
in Community- www.nia.nih.gov/health/prevent-falls-and-fractures
Dwelling Older www.nia.nih.gov/health/prevenga-caidas-fracturas
Information in English and Spanish on prevention of falls
Adults in older adults from the National Institute on Aging.
www.mayoclinic.org/healthy-lifestyle/healthy-aging
/in-depth/fall-prevention/art-20047358
Tips on fall prevention from the Mayo Clinic.

Clinical Guidelines and Other Information for

Health Professionals
www.uspreventiveservicestaskforce.org/Page
/Document/RecommendationStatementFinal/falls
-prevention-in-older-adults-interventions1
U.S. Preventive Services Task Force clinical recommenda-
tions for fall prevention in older adults.
www.cdc.gov/steadi/materials.html
Resources for providers on preventing falls in older adults
from the Centers for Disease Control and Prevention.

姝 2018 American College of Physicians ITC94 In the Clinic Annals of Internal Medicine 4 December 2018

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 WHAT YOU SHOULD In the Clinic
Annals of Internal Medicine
KNOW ABOUT FALLS
Am I at Risk for Falls?
Getting older can increase your risk for falling.
Even a minor fall can cause serious injury. You
might be at higher risk for a fall if you:
• Have eye problems, like glaucoma or cataracts
• Have heart disease
• Have Parkinson disease or dementia
• Can't hold your urine (called incontinence)
• Are not getting enough sleep
• Have arthritis or chronic pain
• Use certain medicines, like sedatives or
opiates
How Can I Prevent Falls?
• If you are over 65, talk with your doctor about
how you can prevent falling.
• Exercise has been shown to help prevent falls.
It helps you stay strong and keep your there are no slippery surfaces or throw rugs
balance. Ask your doctor what exercise is safe that could trip you.
for you.
• If you take medicines, ask your doctor if they Questions for My Doctor
increase your risk for falls. • Am I at risk for falling?
• Talk with your doctor about your risk for • How can I prevent falls?
osteoporosis. • Do I need to be tested for osteoporosis?
• Check your home for safety. If you have stairs, • Do any of my health conditions put me at risk
make sure the banisters are sturdy. Make sure for a fall?

For More Information

National Institutes of Health
www.bones.nih.gov/health-info/bone/osteoporosis/fracture

Patient Information
/prevent-falls-ff
National Institute on Aging
www.nia.nih.gov/health/prevent-falls-and-fractures
www.nia.nih.gov/health/prevenga-caidas-fracturas

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 In the Clinic
Annals of Internal Medicine

Notes

姝 2018 American College of Physicians ITC96 In the Clinic Annals of Internal Medicine 4 December 2018

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