Risk factors and impairments

Assessment

Interventions

Balance impairment: Underlying vestibular and somatosensory impairment, muscle weakness, and delayed reaction time

Gait speed, TUG, BBS, Tinetti test (POMA), and SPPB (see Screening and Risk Stratification) 

– Resistance, balance, gait, and coordination training (eg, sit to stand, stepping): Formal outpatient and home-based programs (eg, tai chi, group and home-based exercise programs, physiotherapy); ideally ≥3 times weekly for ≥12 weeks for the best effect

– Mobility aids and assistive devices, eg, cane, wheeled walker

Gait impairment (gait speed <0.8 m/s): Difficulties in navigating obstacles or stairs

Visual impairment: Contrast and depth perception

Check eye examination records in the past 1-2 years for new issues and use of multifocal lenses

– Eye examinations every 1-2 years

– Cataract surgery if indicated

– Use of single-lens distance glasses when outdoors

– Note that vision correction can paradoxically increase the risk of falls thought to be secondary to adjustment to new glasses

Cognitive impairment: Impairment in the executive function domain (responsible for planning and self-regulation)

Screen using Mini-Cog, MMSE, or MoCA

– Adequate patient supervision during daily activities

– Nonpharmacologic interventions for dementia preferred, as cholinesterase inhibitors are associated with increased risk of syncope

Orthostatic hypotension: Transient cerebral hypoperfusion and subsequent loss of balance

Assess orthostatic vital signs by measuring blood pressure and heart rate in the supine position after 5 minutes of bed rest, then in the standing position in 1-minute intervals for up to 5 minutes. If positive, assess for etiologies of orthostatic hypotension including medication review

– Medication review and consideration of deprescribing

– Nonpharmacologic therapies such as adequate hydration, compression stockings, and abdominal binders

– Pharmacologic treatment with fludrocortisone or midodrine, but evidence of benefit is lacking

Depressive symptoms: Psychomotor retardation, loss of motivation and confidence to mobilize

Screen using GDS or PHQ-9

– Evaluate and treat for reversible causes such as hypothyroidism

– Nonpharmacologic interventions are preferred given the potential increased risk of falls with antidepressants

– Pharmacologic interventions should be considered after weighing risks and benefits

Difficulties with ADL

Assess basic activities of daily living, eg, with the Bristol ADL Scale

– Home modification: see “Environmental hazards” below

– Mobility aids and assistive devices, eg, cane, wheeled walker

Difficulties with IADL

Assess instrumental activities of daily living, eg, with the Lawton-Brody IADL Scale

Sarcopenia

Assess grip strength with a dynamometer. Assess proximal muscle strength with the 30-second chair stand test, where a below-average number of stands for the age group in 30 seconds indicates a high risk of falls

– Identify modifiable comorbidities such as osteoporosis, osteopenia, obesity, type 2 diabetes mellitus

– Some evidence for resistance training and nutrition optimization with focus on protein intake

Arrhythmias: May be reported as fall rather than syncope if patient is amnesic following the event

A complete cardiovascular assessment is recommended including cardiac history, auscultation, orthostatic vitals, and a 12-lead electrocardiogram. Holter monitoring has no proven benefit as part of a routine falls assessment but can be done depending on clinical suspicion

– Refer for cardiac evaluation

– Cardiac pacing for treatment of bradyarrhythmia

Urinary incontinence: Urge incontinence, stress incontinence, and nocturia

Differentiate between the types of urinary incontinence using 3IQ

– Refer for urologic evaluation or to a specialized continence clinic

– Nonpharmacologic management including continence products, timed toileting, bladder retraining, weight loss

– Pharmacologic management differs depending on incontinence type

Malnutrition

Assess for adequate vitamin D intake, vitamin levels, substance use, excessive alcohol use, obesity, and sarcopenia. Screening tools such as MNA can be used

– Lifestyle modification for foods rich in proteins and calcium

– Recent evidence showed no benefit in falls reduction in community-dwelling older adults who did not have other indications for vitamin D supplementation. Therefore, vitamin D should only be prescribed for those at risk of deficiency

Medications

Assess for the use of medicines without a compelling indication and screen for FRIDs (table 8.1-2) using instruments such as STOPPFall

– Taper or discontinue medications that are not indicated or have greater harm than benefit

– Encourage nonpharmacologic strategies to address certain conditions when applicable (eg, sleeping hygiene education and cognitive behavioral therapy for insomnia)

Environmental hazards: ≥2 home hazards such as tripping hazards (rugs, electrical cords), slippery surfaces, and poor lighting

Home-safety evaluation performed by a trained professional with follow-up for recommended modifications

– Home modification such as removal of identified hazards and lighting improvements

– Installation of adaptive equipment such as handrails and bathroom grab bars

– Attention to hazards outside of home

Foot health and footwear

Foot assessment looking for bunions, nail deformities, and ulcers; assess if footwear are ill-fitting, with worn soles, high heels, or not laced or buckled

– Advice on appropriate footwear

– Referral for appropriate treatment if issues are identified