Preventing Falls in Older Persons

 

The American Geriatrics Society and British Geriatrics Society recommend that all adults older than 65 years be screened annually for a history of falls or balance impairment. The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling older adults who are at increased risk of falls. Although the U.S. Preventive Services Task Force and American Academy of Family Physicians do not recommend routine multifactorial intervention to prevent falls in all community-dwelling older adults, they state that it may be appropriate in individual cases. The Centers for Disease Control and Prevention developed an algorithm to aid in the implementation of the American Geriatrics Society/British Geriatrics Society guideline. The algorithm suggests assessment and multifactorial intervention for those who have had two or more falls or one fall-related injury. Multifactorial interventions should include exercise, particularly balance, strength, and gait training; vitamin D supplementation with or without calcium; management of medications, especially psychoactive medications; home environment modification; and management of postural hypotension, vision problems, foot problems, and footwear. These interventions effectively decrease falls in the community, hospital, and nursing home settings. Fall prevention is reimbursed as part of the Medicare Annual Wellness Visit.

Falls are the leading cause of fatal and nonfatal injuries in persons older than 65 years.1 In a survey, 37.5% of fallers responded that they required medical treatment or activity restriction.2 Fall injuries result in 2.8 million emergency department visits annually,1 and 25% of falls cause serious injuries, such as fractures or traumatic brain injury.3 The risk of falls and resulting serious injury increases with age. Injuries, such as hip fracture, and falls are risk factors for placement in a nursing home,4 where the fall risk is nearly three times that of persons living in the community.5 A history of falls is associated with a two- to sixfold increased risk of a future fall.6 Noninjurious falls are a harbinger of potentially life-threatening events and are an opportunity for physicians to intervene.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Community-dwelling older persons at low to moderate risk of falls should participate in an exercise program or physical therapy and take vitamin D supplements.

B

7, 8, 20, 23, 29

Community-dwelling older persons at high risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs.

C

8, 20, 23

Older persons at risk of falls who are hospitalized in an acute setting or for an extended time in a subacute setting should receive a multifactorial risk assessment and intervention tailored to their needs.

B

21, 38, 39, 42

Nursing home residents at risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs that are administered by a multidisciplinary team.

B

22

The following components should be included in multifactorial interventions for falls in older persons:

Exercise, particularly balance, strength, and gait training

A

7, 8, 22

Vitamin D3 supplementation of at least 800 IU daily

B

7, 8, 29

Withdrawal or minimization of psychoactive and other medications

B

7, 8, 22, 39

Adaptation or modification of the home environment for those who have fallen or have visual impairment

B

7, 8, 22

Management of foot problems and footwear

B

7, 8, 22, 39

Management of postural hypotension

B

7, 8, 22

Dual chamber cardiac pacing should be considered in patients with carotid sinus hypersensitivity who experience unexplained recurrent falls.

B

6, 20, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Community-dwelling older persons at low to moderate risk of falls should participate in an exercise program or physical therapy and take vitamin D supplements.

B

7, 8, 20, 23, 29

Community-dwelling older persons at high risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs.

C

8, 20, 23

Older persons at risk of falls who are hospitalized in an acute setting or for an extended time in a subacute setting should receive a multifactorial risk assessment and intervention tailored to their needs.

B

21, 38, 39, 42

Nursing home residents at risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs that are administered by a mul

The Authors

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LAINIE VAN VOAST MONCADA, MD, is a clinical associate professor in the Department of Family Medicine at Louisiana State University School of Medicine, University Hospital and Clinics in Lafayette....

L. GLEN MIRE, MD, is a clinical associate professor in the Department of Family Medicine at Louisiana State University School of Medicine, University Hospital and Clinics.

Author disclosure: No relevant financial affiliations.

Address correspondence to Lainie Van Voast Moncada, MD, University Hospital and Clinics, 2390 West Congress St., Lafayette, LA 70506 (e-mail: lmonca@lsuhsc.edu). Reprints are not available from the authors.

REFERENCES

show all references

1. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control (WISQARS). http://www.cdc.gov/injury/wisqars/. Accessed March 13, 2016....

2. Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged ≥65 Years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(37):993–998.

3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701–1707.

4. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337(18):1279–1284.

5. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121(6):442–451.

6. Tinetti ME, Kumar C. The patient who falls: “It's always a trade-off”. JAMA. 2010;303(3):258–266.

7. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011; 59(1): 148–157.

8. Centers for Disease Control and Prevention. STEADI materials for health care providers. http://www.cdc.gov/steadi/materials.html. Accessed May 5, 2016.

9. Centers for Disease Control and Prevention. Algorithm for fall risk assessment and interventions. http://www.cdc.gov/steadi/pdf/algorithm_2015-04-a.pdf. Accessed May 5, 2016.

10. Centers for Disease Control and Prevention. Talking about fall prevention with your patients. http://www.cdc.gov/steadi/pdf/talking_about_fall_prevention_with_your_patients-a.pdf. Accessed May 5, 2016.

11. Bloch F, Thibaud M, Tournoux-Facon C, et al. Estimation of the risk factors for falls in the elderly: can meta-analysis provide a valid answer? Geriatr Gerontol Int. 2013;13(2):250–263.

12. Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J Am Geriatr Soc. 1994; 42(3):269–274.

13. Stenhagen M, Ekström H, Nordell E, Elmståhl S. Falls in the general elderly population: a 3- and 6-year prospective study of risk factors using data from the longitudinal population study ‘Good ageing in Skane’. BMC Geriatr. 2013;13:81.

14. LeFevre ML. Screening for vitamin D deficiency in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;162(2):133–140.

15. Onen F, Higgins S, Onen SH. Falling-asleep-related injured falls in the elderly. J Am Med Dir Assoc. 2009; 10(3):207–210.

16. Moncada LV. Management of falls in older persons: a prescription for prevention. Am Fam Physician. 2011; 84(11):1267–1276.

17. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26(3):189–193.

18. Campbell AJ, Robertson MC. Implementation of multi-factorial interventions for fall and fracture prevention. Age Ageing. 2006;35(suppl 2):ii60–ii64.

19. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012; 43(1):59–62.

20. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9): CD007146.

21. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012; (12):CD005465.

22. Vlaeyen E, Coussement J, Leysens G, et al.; Center of Expertise for Fall and Fracture Prevention Flanders. Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials. J Am Geriatr Soc. 2015;63(2):211–221.

23. Moyer VA. Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(3): 197–204.

24. American Academy of Family Physicians. Clinical preventive service recommendation. Fall prevention in older adults. http://www.aafp.org/patient-care/clinical-recommendations/all/fall-prevention.html. Accessed July 23, 2016.

25. Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359(3):252–261.

26. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008;371(9614):725–735.

27. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f6234.

28. Chan WC, Yeung JW, Wong CS, et al. Efficacy of physical exercise in preventing falls in older adults with cognitive impairment: a systematic review and meta-analysis. J Am Med Dir Assoc. 2015;16(2):149–154.

29. American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. Recommendations abstracted from the American Geriatrics Society consensus statement on vitamin D for prevention of falls and their consequences. J Am Geriatr Soc. 2014;62(1): 147–152.

30. Ross AC, Taylor CL, Yaktine AL, Cook HD; Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011:363.

31. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015; 63(11):2227–2246.

32. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999;47(7): 850–853.

33. Pit SW, Byles JE, Henry DA, Holt L, Hansen V, Bowman DA. A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. Med J Aust. 2007;187(1):23–30.

34. Haran MJ, Cameron ID, Ivers RQ, et al. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. BMJ. 2010;340:c2265.

35. Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing. 2014;43(3):341–346.

36. Spink MJ, Menz HB, Fotoohabadi MR, et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial. BMJ. 2011;342:d3411.

37. Kenny RA, Richardson DA, Steen N, Bexton RS, Shaw FE, Bond J. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). J Am Coll Cardiol. 2001;38(5):1491–1496.

38. Hempel S, Newberry S, Wang Z, et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Geriatr Soc. 2013;61(4):483–494.

39. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 pt 2):390–396.

40. Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2012;(1): CD008931.

41. Kosse NM, Brands K, Bauer JM, Hortobagyi T, Lamoth CJ. Sensor technologies aiming at fall prevention in institutionalized old adults: a synthesis of current knowledge. Int J Med Inform. 2013;82(9):743–752.

42. Agency for Healthcare Research and Quality. Preventing falls in hospitals. A toolkit for improving quality of care. 2013. http://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf. Accessed October 31, 2016.

43. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18(2):141–158.

44. Gulpers MJ, Bleijlevens MH, Ambergen T, Capezuti E, van Rossum E, Hamers JP. Belt restraint reduction in nursing homes: effects of a multicomponent intervention program. J Am Geriatr Soc. 2011;59(11):2029–2036.

45. Silva RB, Eslick GD, Duque G. Exercise for falls and fracture prevention in long term care facilities: a systematic review and meta-analysis. J Am Med Dir Assoc. 2013; 14(9):685–689.e2.

46. Florence R, Allen S, Benedict L, et al. Diagnosis and treatment of osteoporosis. Institute for Clinical Systems Improvement. Updated July 2013. https://www.icsi.org/_asset/vnw0c3/osteo.pdf. Accessed October 31, 2016.

47. Avenell A, Mak JC, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014;(4):CD000227.

48. Moyer VA. Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(9):691–696.

49. Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2014;(3):CD001255.

50. Chaudhuri S, Thompson H, Demiris G. Fall detection devices and their use with older adults: a systematic review. J Geriatr Phys Ther. 2014;37(4):178–196.

51. Roush RE, Teasdale TA, Murphy JN, Kirk MS. Impact of a personal emergency response system on hospital utilization by community-residing elders. South Med J. 1995;88(9):917–922.

52. Rao SS. Prevention of falls in older patients. Am Fam Physician. 2005;72(1): 81–88.

53. Fuller GF. Falls in the elderly. Am Fam Physician. 2000; 61(7):2159–2174.

 

 

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