What is the best approach to manage a patient with recurrent falls?

Management of Patients with Recurrent Falls

Patients with recurrent falls should undergo a comprehensive multifactorial fall evaluation and receive targeted interventions addressing their specific risk factors to reduce morbidity and mortality. 1

Assessment

Initial Evaluation

• All older persons should be asked at least once a year about falls 1
• Patients who report recurrent falls should undergo a comprehensive fall evaluation 1
• The "Get Up and Go Test" should be performed - observing the patient stand from a chair without using arms, walk several paces, and return 1
• Patients demonstrating difficulty or unsteadiness require further assessment 1

Comprehensive Fall Evaluation

A fall evaluation should include:

• History of fall circumstances, medications, acute/chronic medical problems, and mobility levels 1
• Examination of vision, gait, balance, and lower extremity joint function 1
• Basic neurological examination including mental status, muscle strength, peripheral nerve function, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function 1
• Assessment of cardiovascular status including heart rate, rhythm, postural blood pressure, and if appropriate, carotid sinus stimulation 1

Multifactorial Interventions

For Community-Dwelling Older Adults

• Gait training and advice on appropriate use of assistive devices 1
• Review and modification of medications, especially psychotropic medications and those taking four or more medications 1
• Exercise programs with balance training as a key component 1, 2
• Treatment of postural hypotension 1
• Modification of environmental hazards 1
• Treatment of cardiovascular disorders including cardiac arrhythmias 1

For Long-Term Care Settings

• Staff education programs 1
• Gait training and advice on assistive devices 1
• Review and modification of medications 1

Evidence-Based Interventions

Exercise

• Offer long-term exercise and balance training to older people with recurrent falls 1, 2
• Exercise interventions reduce falls by approximately 23% (rate ratio 0.77; 95% CI, 0.71-0.83) 2
• Balance and functional exercises are most effective for fall prevention 2
• Tai Chi is a promising balance exercise, though requires further evaluation 1

Medication Management

• Review and modify medications, particularly psychotropic drugs (neuroleptics, benzodiazepines, antidepressants) 1
• Patients taking four or more medications should have their regimen reviewed 1
• Selective serotonin reuptake inhibitors (OR: 1.04; 95% CI: 1.04,2.67), antipsychotics, opiates, and non-antihypertensive diuretics increase fall injury risk 3

Environmental Modification

• Consider facilitated environmental home assessment for high-risk patients, especially after hospital discharge 1
• Environmental modifications for high-risk individuals can reduce falls (RR, 0.74; 95% CI, 0.61-0.91) 2

Medical Interventions

• Treat postural hypotension 1
• Address cardiovascular disorders 1
• Consider cataract surgery which can reduce falls (RR, 0.68; 95% CI, 0.48-0.96) 2
• Consider multicomponent podiatry interventions (RR, 0.77; 95% CI, 0.61-0.99) 2

Risk Factors for Recurrent Falls

• Balance and mobility issues (RR: 1.32; 95% CI: 1.10,1.59) 4
• Medication use (RR: 1.53; 95% CI: 1.11,2.10) 4
• Psychological factors (RR: 1.35; 95% CI: 1.03,1.78) 4
• Sensory and neuromuscular deficits (RR: 1.51; 95% CI: 1.18,1.92) 4
• Increasing age, stroke diagnosis, or lower extremity amputation 5

Special Considerations

Fall Risk Counseling

• Counsel patients and families about the risk of falls and recurrence 1
• Educate about home safety, activity restrictions, and supervision needs 1
• Recurrence rates increase over time, reaching up to 36% 1
• Emphasize the importance of follow-up after diagnosis 1

Hospital-Based Fall Prevention

• Engage patients and families in the fall prevention process throughout hospitalization 6
• Patient-centered fall prevention tool kits can reduce falls by 15% and injurious falls by 34% 6

Common Pitfalls to Avoid

• Relying solely on fall risk screening without implementing targeted interventions 1
• Providing advice about fall risk modification without measures to implement recommended changes 1
• Overlooking medication review, especially psychotropic medications 1
• Failing to address multiple risk factors in high-risk individuals 1
• Not recognizing that 79% of hospitalized patients who fall were already designated as "high" fall risk 3