People 65 and older are at an increased risk for falls in the community, hospital setting and long-term care facilities. An estimated one-third of people between ages 65 and 79 fall at least once per year, while half of all people 80 and older fall at least once per year.1,2
Studies show a direct correlation between falls and a decrease in overall quality of life, as well as an increase in morbidity and mortality.1 More than 1 million healthy U.S. adults experience debilitating falls per year, however, this number is expected to rise due to the aging population (25% of the total national population by 2040).3 People who have experienced a fall face a 50% chance of subsequent falls.4
Falls by older adults is a serious public health problem that is largely preventable.5 These falls are a drain on the U.S. economy, costing approximately $55 billion annually.3 Screenings for fall risk can help identify people who may be at risk for falling, as well as indicate who may benefit from further fall prevention strategies. Primary healthcare providers should screen all geriatric patients for falls and, if deemed necessary, should complete a multifactorial fall risk assessment.6
Definition and Risk Factors
A fall occurs when a person unintentionally comes to rest on the ground, floor or a lower level.7 Falls are the leading source of fatal and nonfatal injuries in the geriatric population.8 Of those who fall, 20% to 30% experience moderate to severe injuries.8 Among people 65 and older, falls are one of the leading causes of death and a common cause of hospital admissions.3 Not only are falls a burden on the national economy, but they are also a drain on the U.S. healthcare system.
A number of risk factors are associated with falls: age, a history of past falls, a history of mobility problems, and poor performance on risk assessment screenings.9 Normal age-related changes result in increased postural swaying with standing and ambulating, delayed reflexes, diminished muscle and bone strength, and reduced visual acuity.3
Risk factors can be classified in three categories: intrinsic, extrinsic and behavioral. Intrinsic risk factors develop within the patient, such as an issue with balance or mobility.1 Extrinsic risk factors develop from something external to the patient and are mechanical, such as ambulating on uneven ground.1 Risk factors that are behavioral include physical inactivity or wearing improper footwear.1
Healthcare providers should screen patients for other possible risk factors, including visual or hearing impairment, cognitive impairment, arthritis, depression, use of assistive devices, polypharmacy, drug or alcohol abuse, and impaired activities of daily living.3,4
Complications of Falls
Many complications may be encountered after a geriatric patient experiences a fall, even if the fall is not debilitating. A patient may experience impaired mobility leading to an inability to carry out activities of daily living such as washing, dressing, cooking, cleaning and shopping.4 The patient can experience a decline in overall quality of life after a fall, due to a loss of confidence or dignity, leading to social isolation. Risk of future falls increases because there is a decline in physical activity, reducing balance and muscular strength.4 Additional factors such as pain, fear of falling and loss or perceived loss of balance can increase the likelihood of subsequent falls.3
Approximately 5% of geriatric patients who fall require hospitalization.5 In comparison to people ages 65 to 74, patients 75 years or older are four to five times more likely to be admitted to a long-term care facility for a year or more after a fall.8 The loss of independence that occurs after a fall can lead to a significant cost to individuals, families and public services.10 A fall can be detrimental to a geriatric patient’s mental health, leading to the possible development of depression or anxiety.3 The most common fall-related fractures affect the spine, hip, leg, ankle, pelvis, forearm, upper arm and hand.8 However, hip or pelvic fractures and traumatic brain injuries related to falls are the most debilitating and life-threatening injuries.3
Several screening tools for fall risk are easily accessible and cost effective for primary care providers.9 The Centers for Disease Control and Prevention created the Stopping Elderly Accidents, Deaths and Injuries (STEADI) tool kit for healthcare providers. This tool kit provides cost effective assessment options for identifying patients who are at risk for falls.11 The STEADI tool kit’s recommended tests to assess for patients’ fall risk factors include The Timed Up and Go Test, The 4-Stage Balance Test, The 30-Second Chair Stand Test, and measuring orthostatic blood pressure.11 These recommended tests are assessing a geriatric patient’s mobility, balance, leg strength and endurance, and determining if a patient may have postural hypotension.11
Primary care providers should ask all geriatric patients about any history of falls, especially falls within the last year.3 The American Geriatrics Society’s current recommendations indicate that all older people should be screened for falls or fall risk. A fall risk screening is considered positive if the person has had two or more falls in the past year, presents with an acute fall, or has difficulty ambulation or balance. When a patient has a positive fall risk screening, the healthcare provider should conduct a history and physical examination, cognitive and functional assessment, and determine the multifactorial fall risk. The multifactorial fall risk includes: history of falls; medications; gait, balance and mobility; visual acuity; other neurological impairments; muscle strength; heart rate and rhythm; postural hypotension; feet and footwear; and environmental hazards.6
For a geriatric patient who reports a single fall within the past year, the healthcare provider should assess for gait and balance abnormalities. If there are any abnormalities, a multifactorial fall risk assessment should be completed. However, if the person has not had any falls within the past year, fall risk should be reevaluated periodically at future visits. In either case, if the multifactorial fall risk assessment proves that there is no indication for further intervention, the patient should be reevaluated periodically for fall risk.6 The multifactorial fall risk assessment may prove a need for further intervention, which would include the multifactorial or multicomponent intervention.6 This intervention includes:6
Providing individually tailored exercise programs
Treating visual impairment
Managing postural hypotension
Managing heart rate or rhythm abnormalities
Supplementing vitamin D
Managing foot and footwear problems
Modifying the home environment
Providing education and information.
Fall Prevention Techniques
Primary and second prevention techniques aimed at fall prevention are especially important.1 To reduce fall-related injuries, emergency department visits and overall functional deterioration, effective fall prevention techniques are necessary. Fall prevention techniques are primarily aimed toward reducing environmental risk factors. These environmental prevention strategies include:3
Installing nonslip mats in bathtubs and showers
Storing household necessities within easy reach
Securing loose rugs with slip-resistant backing
Wearing shoes with nonskid soles
Repairing loose floorboards or carpeting
Keeping the home well illuminated
Removing any electrical cords or telephone cords from walkways
Placing nightlights throughout the home for ease of ambulating at night.
Incorporating regular exercises that focus on the improvement of balance, strength and gait training are key to fall prevention. A recommended exercise program is Tai Chi.8 The U.S. Department of Health and Human Services recommends that the geriatric population engage in muscle-strengthening activities twice per week, at least 150 minutes per week of moderate-intensity aerobic activity, or 75 minutes per week of vigorous-intensity aerobic activity.9 Additionally, the U.S. Preventive Services Task Force and the American Geriatrics Society recommend vitamin D supplementation of 800 international units per day in geriatric adults who are deemed to be at an increased risk for falls.6-9
Healthy People 2020’s goal for the geriatric population is to improve the health, function and quality of life of older adults.12 Healthcare providers are meeting this goal by providing fall prevention education and assessing for fall risk. However, many barriers to fall prevention exist. These barriers include: older adults considering fall prevention strategies as only relevant to other older adults; older adults viewing falls as a potential problem for other older adults; older adults viewing fall prevention as a potential threat to identity; and, an older adult’s unwillingness to admit to non-injurious falls.1-10
A Growing Problem
Falls by older adults is a growing problem that is an immense burden on the U.S. healthcare system and economy. Prevention is key. Primary healthcare providers must screen all elderly patients for frequency of falls and, if necessary, perform further screening assessments. By performing these screenings, primary care providers are able to identify those at risk for falls, and essentially provide education, prevention techniques and suggest interventions to prevent any future falls.
1. Dollard J, et al. Falls in old age: A threat to identity. J Clin Nurs. 2012;21(17-18):2617-2625.
2. Campbell J, Robertson, MC. Fall prevention: Single or multiple interventions? Single Interventions for fall prevention. J Amer Geriatr Soc. 2013;61(2):281-284.
3. Honaker JA, et al. Life in balance. ASHA Leader. 2013;18(12):40-46.
4. Jones D, Whitaker T. Preventing falls in older people: Assessment and interventions. Nurs Stand. 2011;25(52):50-55.
5. Medline Plus. Falls. http://www.nlm.nih.gov/medlineplus/falls.html
6. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guidelines for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.
7. Vieira ER, et al. Reducing falls among geriatric rehabilitation patients: A controlled clinical trial. Clin Rehabil. 2012;27(4):325-335.
8. Centers for Disease Control and Prevention. Falls among older adults: An overview. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
9. U.S. Preventive Services Task Force. Prevention of falls in community-dwelling older adults. http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/fallsprevrs.htm
10. Roe B, et al. Older people and falls: Health status, quality of life, lifestyle, care networks, prevention and views on service use following a recent fall. J Clin Nurs. 2009;18(16):2261-2272.
11. Centers for Disease Control and Prevention. STEADI: Stopping elderly accidents, deaths and injuries tool kit for health care providers. http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html?s_cid=tw_injdir15
12. Healthy People 2020. Older adults. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults
Lacey Jade Toomey is a family nurse practitioner at University of Pittsburgh Medical Center in Pittsburgh.