Fall Risk Assessment and Prevention

• Falls are defined as an unintentional change in position that results in a person coming to rest on the floor, ground, or another lower level.
• One-third of people aged over 65 years will fall each year.
• 10% of falls result in major injuries, including hip fracture and traumatic brain injury.
• 16% of ER visits and 7% of hospitalizations in older patients are for fall-related injuries.
• Falls are the major reason for 40% of nursing home placements.
• Complications from falls are the 5th leading cause of death in older adults.
• Nearly 95% of hip fractures are caused by falls.
• 60% of fatal falls happen at home for adults 65 and older, 30% in public places, and 10% in healthcare institutions.
• Post-fall anxiety syndrome is associated with living alone, cognitive impairment, depression, and balance and mobility impairments.
• Almost 60% of those with a history of a fall in the previous year will have a subsequent fall.

Risk Factors

• Intrinsic risk factors include gait and balance impairment, peripheral neuropathy, vestibular dysfunction, muscle weakness, and vision impairment.
• Other intrinsic risk factors are medical illness, advanced age impaired ADL, orthostatic hypotension, dementia, and drugs.
• Precipitating causes are trips and slips, drop attack, syncope, dizziness, and acute medical illness.
• Extrinsic risk factors include environmental hazards, poor footwear, and restraints.

Fall Risk Assessment

• Fall risk assessment should be included in the H&P examination of all geriatric patients.
• Guidelines are issued by the American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons panel on falls prevention.
• Older patients (or their caregivers) should be asked at least once a year about falls, frequency of falling, and difficulties in gait or balance.

Evaluation of Fall Risk Patients - History

• In taking history, determine the activity of the person at the time of the previous fall
• A history of underlying chronic diseases that increase falls risk, complete medication history & history of alcohol use is needed
• Environmental factors and DDROPP (diseases, drugs, recovery, onset, precipitants)

Evaluation of Fall Risk Patients - Physical Exam

• General physical examination includes postural vital signs, visual acuity, hearing function, and examination of extremities.
• A targeted neurologic examination should also be performed.

Musculoskeletal Function

• The Get Up and Go test takes >12 sec which increases falls risk.
• 30 second chair stand test
• STEADI assessment tool
• Performance Oriented Mobility Assessment tool (POMA)

Post Fall Assessment

• Clinicians should focus on gait, balance, and mobility assessment.
• Assessment includes neurological function and cognitive evaluation, and muscle strength tests of lower extremities.
• A cardiovascular status review should include checks of: Heart rate and rhythm, orthostatic vital signs and presence or absence of peripheral edema
• Carotid sinus massage or tilt table testing can be done, and may be useful in patients with unexplained syncope or falls.
• But carotid sinus massage must be done in a monitored environment with continuous ECG monitoring given the false positives in older patients.
• Assessments include visual acuity and foot and footwear examinations.

Fall Risk - Diagnostic Testing

• Complete Blood Count can rule out anemia and infections.
• Electrolytes, BUN, and creatinine can rule out electrolyte imbalance and dehydration.
• Labs should include a serum glucose and stool occult blood test.
• An ECG to rule out rhythm disturbances should be performed.
• A CT is appropriate if patient is on blood thinners and head injury is present.
• MRI is appropriate to rule out brain and spinal cord lesions is the neurologic exam is positive.

Fall Prevention Recommendations

• U.S. Preventive Services Task Force (USPSTF) recommends exercise and vitamin D for adults 65 and older.
• The National Institute on Aging (NIA) recommends exercise, addressing environmental hazards, and regular medical care.
• The American Geriatric Society (AGS) and Center of Disease Control and Prevention (CDC) recommends exercise, vitamin D and home environment modification.

STEADI

• STEADI includes strength/balance program, vitamin D supplementation, and medication management.
• Other STEADI recommendations are corrective eyewear, cataract surgery, orthotics and exercise, home modification, and postural hypotension.
• Assessment tools are: the Stay Independent brochure, Timed Up & Go test, 30-Second Chair Stand, and 4-Stage Balance Test.

Fall Prevention Interventions

Low risk

• Educate patient and provide Vitamin D +/- calcium
• Refer for strength & balance exercise (community exercise or fall prevention program)

Moderate risk

• Educate patient and provide Vitamin D +/- calcium
• Refer to PT to improve gait, strength, and balance OR refer to a fall prevention program

High risk

• Moderate risk interventions +
• Manage & monitor hypotension
• Manage medications
• Address foot problems
• Optimize vision
• Optimize home safety
• Follow-up with HIGH RISK patients within 30 days to review the care plan and assess and encourage fall risk reduction behaviors.

Exercise/Physical Therapy Recommendations

• Consider group classes and at-home exercises.
• Physical activity should be at least 150 min/week of moderate intensity or 75 min/week of vigorous intensity aerobic exercise, or muscle-strengthening activities twice per week.
• Balance traiining 3+ days/week is important for older adults at risk for falling, or those with difficulty walking
• Consider Tai Chi.

Chair Rise Exercise

• Strengthens the muscles in your thighs and buttocks.
• The goal is to do this exercise without using your hands as you become stronger

Vitamin D Supplement Dosing

• 800 IU daily x 12 months for community-dwelling adults 65 y. old and older at increased risk for falls (USPSTF)
• 800 IU daily for persons at increased risk for falls (AGS)
• 600 IU for adults aged 51 to 70 years and 800 IU for adults older than 70 years

Referrals

• Physical therapist (for gait, mobility, balance, lower body weakness)
• Occupational therapist (for home modification)
• Ophtalmologist (vision correction/surgery) / ENT (hearing devices)
• Neurologist (Parkinson's, lumbar stenosis, gait disorders)
• Cardiologist (postural hypotension, heart murmurs, Holter monitor)
• Orthotist (proper footwear)
• Psychologist (for depression)

Explore key aspects of fall risk assessment and prevention in older adults. Understand contributing factors, injury rates, and the impact of falls on nursing home placements. Identify risk factors and appropriate assessment strategies.