What fall-prevention measures should be taken for a patient with an unsteady gait?

Fall Precautions for Patients with Unsteady Gait

Patients with unsteady gait require immediate implementation of exercise-based balance training combined with systematic assessment and modification of all fall risk factors, as this approach reduces falls by 23% and represents the strongest evidence-based intervention. 1

Immediate Risk Stratification

Unsteady gait itself places patients at high risk, with a relative risk of 2.9 for future falls—making it one of the top three independent predictors. 2 Any patient reporting difficulty walking or demonstrating balance problems should automatically trigger comprehensive fall prevention protocols. 3

Perform Functional Testing at Every Encounter

• Timed Up and Go (TUG) test: Have the patient rise from a chair, walk 3 meters, turn, return, and sit. A time >12 seconds indicates high fall risk and mandates comprehensive intervention. 4, 2
• 4-Stage Balance Test: Progress through feet side-by-side, semitandem, tandem, and single-foot stands for 10 seconds each. Inability to hold tandem stand <10 seconds confirms high risk. 4
• Never discharge a patient who fails the "Get Up and Go" test without further reassessment or admission—this is a critical safety threshold. 4, 5

Core Interventions (Implement All)

1. Exercise and Physical Therapy (Highest Priority)

Prescribe balance and functional exercises immediately—this is the single most effective intervention with the strongest evidence base. 1 The American Geriatrics Society recommends:

• Balance training 3 or more days per week 3
• Gait training protocols with assistive device prescription as needed 2
• Lower extremity strength training twice weekly 3
• Minimum 150 minutes per week of moderate-intensity aerobic activity 3

Exercise interventions reduce falls from 850 per 1000 patient-years to 655 per 1000 patient-years (rate ratio 0.77), with most benefit from balance and functional exercises. 1

2. Comprehensive Medication Review (Mandatory)

Review and modify all medications, especially if the patient takes ≥4 medications (polypharmacy threshold) or any psychotropic agents. 4, 2

High-risk medications requiring immediate attention:

• Psychotropic medications (antipsychotics, sedative-hypnotics, benzodiazepines): OR 1.7 for falls 2
• Antidepressants and benzodiazepines: Must be tapered or discontinued when possible 4
• Vasodilators and diuretics: OR 1.1, contribute to orthostatic hypotension 2
• Class 1a antiarrhythmics: OR 1.6 2
• Digoxin: OR 1.2 2

Medication review and modification is a Class B recommendation with consistent evidence of benefit. 2

3. Assess and Treat Orthostatic Hypotension

Measure orthostatic vital signs at every visit: A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic defines orthostatic hypotension and requires intervention. 4 This is present in many patients with unsteady gait and is highly modifiable. 3, 1

4. Systematic P-SCHEME Risk Factor Assessment

The Mayo Clinic recommends evaluating all modifiable factors: 4

• Pain: Axial or lower-extremity pain limiting mobility 4
• Shoes: Inappropriate footwear (loose-fit, high heels) 4
• Cognitive impairment: Screen with Mini-Cog (<5 minutes); RR 1.8 for falls 2
• Hypotension: Already addressed above
• Eyesight: Visual impairment has RR 2.5; refer to ophthalmology if identified 2, 1
• Medications: Already addressed above
• Environmental factors: Address home hazards (see below) 4

5. Environmental Modifications

Conduct home safety assessment and implement modifications immediately: 4, 2

• Remove loose rugs and floor clutter 4
• Ensure adequate lighting throughout residence, especially at night 4
• Install handrails in hallways and grab bars in bathrooms 4
• Address slippery surfaces with non-slip mats 4

Critical caveat: Environmental modification alone without other interventions is not beneficial—it must be part of multifactorial approach. 2

6. Vitamin D Supplementation

Prescribe vitamin D ≥800 IU daily for patients with deficiency or at increased fall risk. 3, 2 The American Geriatrics Society specifically recommends 800 IU per day for persons at increased risk for falls. 3

Additional Assessments for Unsteady Gait

Identify Underlying Medical Conditions

Document and manage: 4

• Parkinson's disease, stroke, or neurodegenerative disorders 4
• Peripheral neuropathy (impairs proprioception) 4
• Diabetes mellitus 4
• Cardiovascular disease 4
• Depression (RR 2.2): Screen with PHQ-2 4, 2
• Arthritis (RR 2.4) 2

Consider Syncope as Underlying Cause

Approximately 30% of falls in older adults represent unrecognized syncope because patients cannot recall loss of consciousness. 4 If gait unsteadiness is episodic or associated with near-syncope:

• Obtain 12-lead ECG (mandatory) 4
• Assess for cardiac arrhythmias, structural heart disease 4
• Evaluate for prodromal symptoms: absent or brief prodrome (<5 seconds) suggests cardiac cause 4

Disposition and Follow-Up

Admission Criteria

Admit if patient safety cannot be ensured at home, specifically: 4, 2

• Inability to ambulate steadily or pass "Get Up and Go" test 4
• Unsafe home environment without available modifications 4
• GCS <15 or abnormal head CT findings 4

All admitted patients must receive evaluation by physical therapy and occupational therapy. 2

Discharge Planning (If Safe)

• Arrange expedited outpatient follow-up within 1-2 weeks 2
• Include home safety assessment in follow-up plan 2
• Provide structured fall-prevention education before discharge 4
• Ensure physical therapy referral is scheduled 2

Multifactorial Intervention Effectiveness

When all components are implemented together in high-risk patients (which includes those with unsteady gait), multifactorial interventions reduce falls from 2317 per 1000 patient-years to 1784 per 1000 patient-years (rate ratio 0.77). 1 The American Geriatrics Society reports an 11% reduction in fall risk with comprehensive multifactorial assessment and intervention. 2

Common Pitfalls to Avoid

• Failing to perform functional testing (TUG or 4-Stage Balance) at every encounter misses objective risk quantification 4, 2
• Discharging patients who fail "Get Up and Go" test without reassessment markedly increases immediate fall risk 4
• Omitting medication review, especially in patients on ≥4 medications or psychotropics, overlooks the most modifiable risk factor 4
• Prescribing assistive devices without gait training can paradoxically increase fall risk (RR 2.6 for assistive device use) 2
• Implementing environmental modifications alone without exercise and medication review is ineffective 2
• Attributing unsteady gait to "old age" without investigating multifactorial causes is inadequate 4

Documentation Requirements

For every patient with unsteady gait, document: 5

• TUG test result and 4-Stage Balance Test performance 5
• Complete medication list with total count and high-risk classes 5
• Orthostatic vital signs 5
• All fall precautions implemented (environmental modifications, patient education, assistive devices) 5
• Physical therapy and occupational therapy referrals 5
• Objective safety assessment before discharge 5