What are the best strategies for preventing falls in the elderly?

Fall Prevention in the Elderly

Screening and Risk Assessment

All adults aged 65 years and older should be asked annually about falls, and those reporting any fall or demonstrating gait/balance problems should undergo immediate risk stratification using the Timed Get-Up-and-Go test. 1, 2

• Ask three key screening questions yearly: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? 2, 3
• Perform the Timed Get-Up-and-Go test for any positive screen: patient rises from chair without using arms, walks 3 meters, turns, walks back, and sits down 1
• Completion time >10 seconds indicates high fall risk requiring intervention 2, 3
• Average healthy adults >60 years complete this in <10 seconds 1

Primary Prevention Interventions

Exercise Programs (Highest Evidence)

Exercise programs with balance training demonstrate the strongest evidence for fall prevention, reducing fall rates by 23% and number of fallers by 15%, and should be prescribed to all at-risk elderly. 2, 4

• Include balance and functional exercises, gait training, strength training, and moderate-intensity aerobic activity 2
• Recommend balance training 3 or more days per week for those with recent falls or walking difficulty 1, 5
• Effective interventions range from low intensity (≤9 hours) to high intensity (>75 hours) 1
• Aim for at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic activity, plus muscle-strengthening activities twice weekly 1

Vitamin D Supplementation

Prescribe vitamin D 800 IU daily to all elderly at increased fall risk, with treatment continued for at least 12 months to achieve benefit. 1, 2, 5

• Greater benefit occurs in vitamin D-deficient populations 2
• This dose aligns with Institute of Medicine recommendations for adults >70 years 1

Medication Management

Systematically review and reduce psychotropic medications, sedating drugs, and polypharmacy (≥4 medications) in all elderly patients. 1, 2, 3

• High-risk medication classes requiring special attention: vasodilators, diuretics, antipsychotics, sedative/hypnotics, benzodiazepines, and antidepressants 3
• Withdrawal or minimization of psychoactive medications reduces fall risk 1
• Medication review is particularly critical in patients taking four or more medications 3

Environmental Modifications

Home hazard modification reduces falls by 26% in high-risk individuals when combined with other interventions and should be led by occupational therapists. 2, 4

• Address tripping hazards, inadequate lighting, bathroom safety, and stair safety 2
• Most effective in high-risk groups when professionally assessed 4
• Recommend appropriate footwear with low heels and hard soles for better balance 5

Risk-Stratified Management Algorithm

Average-Risk Elderly (No Recent Falls, Normal Gait Test)

• Initiate exercise/physical therapy program with balance focus 2
• Start vitamin D 800 IU daily 2
• Review and optimize medications 2
• Conduct annual reassessment 2

High-Risk Elderly (≥2 Falls in Past Year, Abnormal Gait Test, or Acute Fall Presentation)

Perform comprehensive multifactorial assessment including evaluation of balance, mobility, vision, orthostatic hypotension, cardiovascular status, neurological function, and home environment. 1, 2, 3

• Exercise/physical therapy program (mandatory) 2
• Vitamin D 800 IU daily 2
• Gait training and advice on assistive devices 1
• Treatment of postural hypotension 1
• Management of cardiovascular disorders including cardiac arrhythmias 1
• Targeted interventions based on identified risk factors 2
• Close case management with frequent reassessment 2

Additional Targeted Interventions

• First eye cataract surgery for those with cataracts reduces falls 4
• Pacemakers for patients with cardio-inhibitory carotid sinus hypersensitivity 4
• Multifaceted podiatry for patients with specific foot disability 4
• Anti-slip shoe devices for those walking outdoors during icy conditions 4

Critical Caveats

The USPSTF does not recommend automatically performing in-depth multifactorial risk assessment with comprehensive management in ALL community-dwelling elderly because the likelihood of benefit is small in unselected populations. 1

• This differs from the AGS guideline which recommends multifactorial assessment for those with ≥2 falls, gait/balance problems, or acute fall presentation 1
• The key distinction: screen first, then apply intensive multifactorial assessment only to high-risk individuals 1
• For average-risk elderly, focus on exercise and vitamin D rather than comprehensive assessment 1

Common Pitfalls to Avoid

• Treating fall-related injuries without investigating the underlying cause of the fall 6
• Failing to perform annual screening in all elderly patients 1, 2
• Discharging patients who cannot pass the Get-Up-and-Go test without intervention 3
• Overlooking medication review, especially psychotropic drugs and polypharmacy 3
• Using physical restraints for fall prevention (not recommended) 6