What is the approach to preventing falls in the elderly?

Approach to Falls in the Elderly

Immediate Recommendation

For community-dwelling older adults at increased risk for falls, prescribe exercise or physical therapy focusing on balance and strength training, plus vitamin D supplementation at 800 IU daily—these interventions have the strongest evidence for preventing falls and reducing injury-related morbidity and mortality. 1

---

Risk Identification Algorithm

Annual Screening (All Adults ≥65 Years)

Ask three screening questions yearly: 2

• Have you fallen in the past year?
• Do you feel unsteady when standing or walking?
• Do you worry about falling?

If ANY answer is "yes", proceed to functional testing. 2

Functional Testing

Perform the Timed Get-Up-and-Go Test: 1, 2

• Patient rises from armchair, walks 3 meters (10 feet), turns, walks back, and sits down
• >10 seconds = HIGH RISK requiring immediate intervention 1, 2
• <10 seconds = average risk, still warrants preventive measures 1

Additional Risk Stratification

High-risk features requiring comprehensive assessment: 3, 4

• History of fall in past year
• Gait speed <0.8-1.0 m/s
• Multiple falls or fall with injury
• Wheelchair use or significant mobility impairment

---

Core Interventions (Evidence-Based Priority Order)

1. Exercise/Physical Therapy (HIGHEST PRIORITY)

This has the strongest evidence with 23% reduction in fall rates. 2, 4

Prescribe structured programs including: 1, 2

• Balance training (primary focus)
• Gait training
• Lower extremity strength training
• Moderate-intensity aerobic activity

Dosing: 1

• Minimum 150 minutes/week moderate-intensity OR 75 minutes/week vigorous-intensity aerobic activity
• Muscle-strengthening activities twice weekly
• Balance training ≥3 days/week for high-risk patients

Delivery options: 1

• Group classes
• Home-based physiotherapy
• Intensity ranges from low (≤9 hours total) to high (>75 hours total)—both effective

2. Vitamin D Supplementation

Prescribe 800 IU daily for all at-risk elderly. 1, 2

Evidence: 1

• Moderate benefit demonstrated at 12 months
• Median effective dose in trials: 800 IU daily
• Greater benefit in vitamin D-deficient populations

Note: Institute of Medicine recommends 600 IU for ages 51-70 and 800 IU for >70 years, but fall prevention data support 800 IU for all at-risk patients. 1

3. Medication Review and Deprescribing

Systematically reduce or eliminate: 3, 2

• Psychotropic medications (sedatives, antipsychotics, antidepressants)
• Medications causing dizziness/sedation (including tramadol)
• Polypharmacy (≥4 medications)

Critical assessment: 3

• Perform orthostatic blood pressure measurements (lying, sitting, standing)
• Review all medications for fall-risk potential

---

Comprehensive Assessment for High-Risk Patients

History Documentation

Document specific fall circumstances: 3

• Location and cause of fall
• Time spent on floor/ground
• Loss of consciousness or altered mental status
• Near-syncope or orthostatic symptoms
• Presence of injuries

Physical Examination Components

Neurological assessment: 3

• Presence/absence of neuropathies
• Proximal motor strength
• Mental status
• Lower extremity peripheral nerve function
• Proprioception and reflexes
• Cortical, extrapyramidal, and cerebellar function

Additional assessments: 3

• Vision screening
• Gait and balance evaluation
• Lower extremity joint function
• Orthostatic blood pressure (mandatory)

Multifactorial Risk Assessment

For patients with recurrent falls or very high risk, perform comprehensive evaluation addressing: 1, 3

• Gait and balance disorders
• Orthostatic hypotension
• Sensory impairment (vision, proprioception)
• Cognitive function
• Environmental hazards
• Medication effects
• Comorbidities (dementia, Parkinson's, diabetes, hypertension)

Important caveat: Routine in-depth multifactorial assessment for ALL elderly is NOT recommended (Grade C) due to small benefit, but should be individualized based on fall history, comorbidities, and patient values. 1

---

Additional Targeted Interventions

Environmental Modifications (High-Risk Patients Only)

Home hazard modification reduces falls by 26% when combined with other interventions: 2

• Remove tripping hazards (rugs, clutter, cords)
• Improve lighting (especially stairs, bathrooms)
• Install bathroom safety equipment (grab bars, raised toilet seats)
• Ensure stair safety (handrails, non-slip treads)

Specific Medical Interventions

Consider based on assessment findings: 4, 5

• Cataract surgery (68% reduction in falls if cataracts present)
• Multicomponent podiatry interventions (23% reduction)
• Treatment of postural hypotension
• Management of foot problems and appropriate footwear
• Vision and hearing optimization

---

Implementation Algorithm

For Average-Risk Elderly (Positive Screen, Get-Up-and-Go <10 seconds)

1. Initiate exercise/physical therapy program with balance focus 2
2. Start vitamin D 800 IU daily 2
3. Review and optimize medications (reduce psychotropics, address polypharmacy) 2
4. Annual reassessment 2

For High-Risk Elderly (Recurrent Falls, Get-Up-and-Go >10 seconds, Prior Injury)

1. Comprehensive multifactorial assessment (as detailed above) 2
2. Exercise/physical therapy program (mandatory) 2
3. Vitamin D 800 IU daily 2
4. Targeted interventions based on identified risks:
   • Medication deprescribing 2
   • Home safety evaluation and modification 2
   • Treatment of orthostatic hypotension 3
   • Vision/hearing correction 6
   • Assistive device optimization 3
5. Close case management with frequent reassessment 2

---

Common Pitfalls to Avoid

Do not rely solely on patient history in cognitively impaired patients—physical examination may also yield false-negatives; maintain high suspicion for occult injuries. 3, 6

Do not overlook "occult" traumatic injuries—perform complete head-to-toe examination even with seemingly isolated injuries, with particular attention to hip fractures. 3

Do not prescribe vestibular suppressants or increase psychotropic medications—these significantly increase fall risk in elderly patients. 3

Do not assume exercise alone is sufficient for high-risk patients—multifactorial interventions addressing multiple risk factors are necessary for those with recurrent falls. 4

Do not discharge high-risk patients without ensuring safety—arrange expedited outpatient follow-up including home safety assessments, or consider admission if safety cannot be ensured. 3

Critical question to guide assessment depth: "If this patient was a healthy 20-year-old, would they have fallen?" If no, comprehensive assessment of underlying causes is mandatory. 3