geriatrics
Falls in Older Adults
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 ( Prevention references ). Patients who report a single fall and who do not have problems with balance or gait on the Get-Up-and-Go Test or a similar test should be given general information about reducing risk of falls. It should include how to use medications safely and reduce environmental hazards (see table). Patients who report more than one fall or a problem with balance or gait should receive a Evaluation to identify risk factors and opportunities to lower risk. Patients who have fallen more than once or who have problems during initial balance and gait testing should be referred to Physical Therapy (PT) 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 Physical Therapy (PT) and to correct specific problems and underlying conditions contributing to fall risk (eg, 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 ( Prevention references ). Some patients benefit from use of an Therapeutic and Assistive Devices (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. ). Patients should be evaluated for Osteoporosis and, if osteoporosis is diagnosed, treated to reduce risk of fractures from any future falls. If any other specific disorder is identified as a risk factor, targeted interventions are required. For example, medications 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. can significantly reduce the incidence of falls ( Prevention references , ). Environmental hazards that commonly increase fall risk, (eg, throw rugs, inadequate lighting, lack of grab bars and handrails, unstable furniture, clutter), should be mitigated or eliminated ( Prevention references ). Patients should also be advised on how to reduce risk due to situational factors. For example, footwear should have flat heels, some ankle support, and firm, nonskid midsoles. Many patients with chronic limited mobility (eg, caused by severe arthritis or paresis) benefit from combined medical, rehabilitative, and environmental strategies. Wheelchair adaptations (eg, removable foot plates to reduce tripping during transfers, antitip bars to prevent backward tipping), removable belts, and wedge seating may prevent falls in patients with poor sitting balance or severe weakness when they are sitting or transferring. Restraints may lead to more falls and other complications and should generally not be used. Surveillance by a caregiver or companion is more effective. Motion detectors may be used, but a caregiver must be present to respond promptly to the triggered alarm. Hip protectors (padding sewn into special undergarments) have been shown to reduce hip fractures in high-risk patients in nursing facilities, but are less effective in older adults living in the community. Furthermore, many patients are reluctant to wear protectors indefinitely. Compliant flooring (eg, firm rubber) can help dissipate the impact force, but a floor that is too compliant (eg, soft foam) may destabilize patients. Patients should also be taught what to do if they fall and cannot get up when they are alone. Useful techniques include turning from the supine position to the prone position, getting on all fours, crawling to a strong support surface, and pulling up. The following can decrease time on the floor after a fall: Having frequent contact with family members or friends A phone that can be reached from the floor A remote alarm A wearable alert device Newer technologies (eg,smartwatches, mobile medical alert systems, in-home motion sensors) can automatically detect falls and trigger a call for help. Voice-activated smart speakers and AI (artificial intelligence) camera systems may be used to monitor seniors and alert caregivers about potential falls. Combining human contact, wearable devices, and in-home monitoring can optimize the likelihood of a timely response to a fall. 1.U.S. Preventive Services Task Force (USPSTF): Final Recommendation Statement: Falls Prevention in Community-Dwelling Older Adults: Interventions. Accessed 10/8/23. 2.Allen NE, Sherrington C, Paul SS, Canning CG: Balance and falls in Parkinson's disease: A meta-analysis of the effect of exercise and motor training.Mov Disord26 (9),1605–1615, 2011. doi.org/10.1002/mds.23790 3.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 Med54 (15):885–891, 2020. doi: 10.1136/bjsports-2019-101512. Epub 2019 Dec 2. 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