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Abstract: Falls in community-dwelling older adults are often preventable, yet remain the leading cause of deaths due to injury and a major cost to the healthcare system. Primary care nurse practitioners who care for older adults can minimize the risk for falls by using specific assessment and prevention strategies.
Despite being preventable, falls are prevalent in the older adult population. One-third of all community-dwelling adults age 65 years and older experience at least one fall every year.1 Living at home does not prevent an older adult from falling. The probability of a community-dwelling older adult falling one or more times within the next year is approximately 27% (95% confidence interval, 19% to 36%).2 Older adults who have had at least one fall incur 29% higher healthcare costs than those who have not fallen; multiple falls are associated with 79% higher healthcare costs.3 Falls also threaten the independence of older adults as institutionalization rates increase among those who have had multiple falls.4 Falls can also lead to psychological disturbances such as social withdrawal, increased anxiety, and fear of falling.5
Given the significant impact of falls on the lives and healthcare of older adults,3 there have been many efforts to reduce the incidence of falls.6-9 Research has focused on the prevalence of falls2 and identified that older adults are at greatest risk.6 In addition, several intervention studies have been conducted in an attempt to reduce fall risk and prevent the occurrence of falls in older adults.7-9 Despite these efforts, falls in community-dwelling older adults continue to occur, and healthcare providers may play the most important role in fall prevention.10
The strongest predictor for future falls is a history of a previous fall.11 Therefore, reducing the incidence of a first-time event may significantly decrease the falls rate in general. A routine visit is an opportune time to screen for risk and promptly enact prevention strategies.2,10
A fall is defined as an incident that occurs when a person, with or without losing consciousness, comes in contact with the surface ground or lower level unintentionally.12 Elderly patients experience altered equilibrium, postural instability, and decreased muscle strength and agility, all of which predispose this population to falls.13 Decreased sensory sensation such as poor vision is also prevalent in aging patients, further increasing their risk of a fall. The majority of patients admitted to hospitals after a fall had poor vision: 40% needed glasses; 37% had cataracts; and 14% suffered from senile macular degeneration.14 Falls can also be iatrogenically caused by many medications commonly prescribed to older adults. For example, the incidence of falls caused by orthostatic hypotension induced by antihypertensives, such as diuretics, beta blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers, is estimated to be between 5% and 32%.15
In recognition of the important role that primary care providers play in falls prevention, the American Geriatrics Society (AGS) and British Geriatrics Society (BGS) recently published a clinical algorithm for prevention of falls in older persons living in the community.10 The algorithm describes the systematic process of decision making and intervention that should occur when managing older persons who present in a clinical setting with recurrent falls. This algorithm recommends a routine multifactorial fall risk assessment for all older adults who present with a fall or gait and balance problems in any clinical setting, including the ED. A falls risk assessment is not considered necessary for older persons reporting only a single fall without reported or demonstrated difficulty with gait or unsteadiness.10 Conducting a multifactorial assessment allows for multifactorial interventions that target identified risk factors.
A previous fall history and an unsteady gait are the most important risk factors consistently linked to falls in community-dwelling older adults.1,2,6,16 Asking, "Have you had any falls in the past year?" and following with questions regarding gait or balance problems are simple, but may be the most effective way to assess for risk of falls.2 However, one study noted that of 2,909 older adults reporting falls in the previous year, only 1,384 (47.6%) had spoken with a healthcare provider about their fall.3 Of those who did mention the fall to a healthcare provider, 25.8% said the provider did not ask why the patient fell, and 39.3% did not receive any counseling on preventing future falls. Porter et al. noted that older adults who were able to identify a reason for their falls may benefit from discussing specific prevention strategies with a healthcare provider.17 However, a multifactorial approach to falls risk reduction may be more appropriate for older adults who were unable to identify reasons for their falls. As a higher falls rate is associated with older adults who have cognitive impairment, it is especially important to conduct a routine falls risk assessment when caring for older individuals with dementia.16
The Panel on Prevention of Falls in Older Persons suggests including the following in the risk assessment: history of falls; medications; gait, balance, and mobility; visual acuity; other neurologic impairments; muscle strength; heart rate and rhythm; postural hypotension; feet and footwear; and environmental hazards.10 The Get-Up and Go Test and the Timed Up and Go Test assess gait, balance, and mobility.10,17,18 A physical exam should address visual acuity, other neurologic impairments, muscle strength, heart rate and rhythm, and postural hypotension.10 During the physical exam, providers must also examine the feet and footwear.
The use of a fall risk assessment scale as part of routine care for older adults in primary care may be a sensible approach to quantify the risk for falls for prompt intervention. To date, a plethora of falls risk assessment tools exist, but the majority were developed for elderly populations, mainly in hospital or long-term care (LTC) settings. Many of these tools are readily available and assess similar patient characteristics, and most can be applied in primary care settings. When deciding which tool to use, the nurse practitioner (NP) should always consider which factors are predominant and predictive of falls among patients in primary care, as well as the practicality of using the tool as part of clinical care. In outpatient settings, for example, acuity of illness and medications do not generally vary much within short time periods, but mobility and balance are quite predictive of falls. Consequently, functional assessment tools to determine the risk of falls may be more appropriate in outpatient settings (see Falls risk assessment tools for outpatient settings).
The multifactorial risk assessment allows healthcare providers to offer interventions targeted to address individual factors contributing to falls (see Examples of individualized fall prevention strategies). Multifactorial or multicomponent interventions are the most effective to prevent falls.19 The five broad types of interventions are exercise and physical activity, medical assessment and management, medication adjustment, environmental modification, and education.10
While many different exercises and physical activities have been the focus of interventional studies, the most effective are those that include strength training and balance, gait, and coordination training.10,14,20 However, for exercise programs to be most effective as a fall prevention intervention, they must last longer than 12 weeks, with one to three sessions per week.10 According to the 2012 U.S. Preventive Services Task Force (USPSTF) recommendation statement, Prevention of Falls in Community-Dwelling Older Adults, there is convincing evidence that exercise or physical therapy has moderate benefit in the prevention of falls in adults ages 65 and older.21
Tai chi, a traditional Chinese martial art, is an effective way for older adults to exercise and promote strength training. A meta-analysis that included 13 randomized control trials and 2,151 participants supports tai chi for falls prevention, but cautions against recommending tai chi for the frail elderly.22 Tai chi is often enjoyed by older adults, is cost-effective, and does not require any professional supervision or special equipment. Collaborating with physical and occupational therapists for training for balance and muscle strength, and fall recovery techniques has been related to positive patient outcomes as well.23
Healthcare providers need to address postural hypotension in older adults because this is a falls risk factor that can be effectively managed.10 Hydration, elastic stockings, abdominal binders, and medications are suggested ways to manage postural hypotension. Additionally, NPs should assess for abnormal heart rate and rhythm, and intervene promptly as these abnormalities are often associated with falls. Placement of a pacemaker in older adults with carotid sinus hypersensitivity reduces falls risk for this population and correcting other bradydysrhythmias and tachydysrhythmias may prevent syncope that may be associated with falls in community-dwelling older adults.10,20
Older adults with dementia are at increased risk for falls and a cognitive assessment should therefore be included as part of their routine medical care.9,16 The rate of falls in older adults with dementia is higher than the rate of falls for older adults without dementia and a fear of falling in cognitively impaired older adults may lead to additional consequences, such as social isolation and avoidance.5,9,16 Similarly, older adults should be assessed for delirium and subsyndromal delirium, a less severe delirium with motor activity, cognitive, and psychotic disturbances.24 A history of falls is a predisposing factor for delirium.25 In order to prevent further morbidity, these older adults should also be screened for other precipitating factors of delirium common to older adults, such as depression, dehydration, treatment with multiple drugs, myocardial infarction, and infection.25
Older adults ages 85 years or older have similar risk factors for falls as older adults younger than 85.6 However, in the very old, feelings of anxiety, nervousness, and fear are additional risk factors for falls, as are a history of recurrent falls, the use of antipsychotic drugs, and trouble with vision when moving.6 Consequently, providers caring for the very old should be mindful of these increased risk factors and assess this population with care.
Medications should be reviewed in every primary care visit. Polypharmacy as well as the use of psychotropic medications place older adults at risk for falls. Medications such as hypnotics, cough preparations, antihypertensives, antiplatelets, and opioids have also been identified as major contributors to elderly falls.23 Antiplatelet and anticoagulant medications place older adults at increased risk for injury from falls due to bleeding that may occur following a fall.26 These therapies are associated with traumatic brain injury (TBI) from intracerebral hemorrhage in older adults; most fall-related TBI occur in older adults.26 As with all medication use in older adults, providers are obligated to assess the benefit these medications may provide in comparison to the increased risks of use in this at-risk population.20
Anticholinergic toxicity, the burden of drug-related anticholinergic symptoms, places older adults at increased risk for falling due to vision impairment, drowsiness, delirium, and cognitive decline.27,28 Even with recommendations to avoid or replace anticholinergic medications, older adults are still prescribed these drugs for allergies, depression, and urine incontinence.27 When appropriate, decreasing or a gradual withdrawal of medications for sleep, anxiety, and depression should be considered.20 According to the AGS and BGS, vitamin D supplements demonstrate no clear benefit for reducing falls in community-dwelling older adults, but are effective when used in older adults residing in LTC and those with a vitamin D deficiency.10 The USPSTF 2012 recommendations state that vitamin D supplements have moderate benefit in the prevention of falls in older adults, and this benefit occurs within 1 year from the start of therapy. 21
A prospective study conducted by Nachreiner et al.29 identified that among community-dwelling older women, 61% of falls occurred in the living room, dining room, kitchen, bathroom, and bedroom, mostly during the daytime while walking, carrying an object, or reaching for an object. A comprehensive, focused home visit for home safety checks by an occupational therapist can be successful in decreasing falls to high-risk groups.30 Mitigation of home falls hazards may include placement of handrails and grab bars and lighting improvements.10 When part of a multicomponent fall prevention program, home environment assessment and intervention is effective, yet demonstrates little benefit when occurring in isolation.
Results of a comprehensive physical exam may provide additional strategies to prevent falls. When foot problems are identified, the referral for treatment demonstrates an improvement in falls risk.10 In addition, antislip shoe devices are also effective for preventing falls in icy conditions.10,20
Providing education and information to both older adults and their caregivers is the fifth broad category for intervention and prevention of falls.10 Involving older adults in the plan of care and understanding their thoughts about falling and fall prevention provides a foundation for education.5 Older adults may be unaware of the reason for a fall, which can make them fearful. (see Online resources).
Multicomponent cognitive behavioral group interventions aimed at reducing excessive fall-related fear and unnecessary avoidance of activity showed beneficial outcomes in community-living older people.31 For education to be effective, a trusting relationship between a provider and the patient is necessary especially when discussing home modifications because these may threaten older adults' self-image and identity.32
Scenario 1: Mr. C is a 73-year-old who presents to the clinic for arm pain. He has a history of dementia and his most current Mini-Mental State Examination was 22. He also has a history of type 2 diabetes, his latest A1C was 5.3%. Mr. C also has peripheral neuropathy and cataracts in both eyes. Mr. C is accompained by his wife who reports Mr. C was not wearing shoes and slipped and fell on the wood floor. His arm pain began immediately following the fall. Mr. C and his wife confirm two additional falls in the past 6 months, but had not previously reported them because they were not asked specifically for fall occurrence. His arm is bruised, but not broken as confirmed by X-ray. Mr. C has difficulty with the "Get-up and Go Test". During this visit, Mr. C's antipsychotics are stopped and he is instead prescribed citalopram for depression. He is also advised to take acetaminophen for his arm pain. Mr. C and his wife are offered a 12-week tai chi exercise program. Cataract surgery is not appropriate for him, but he is advised to wear shoes at all times and to avoid wearing multifocal lenses when walking because these lenses impair depth perception and contrast sensitivity. He will be reassessed in 2 weeks. His chart will be flagged as high risk for falls, with a recommendation to assess for falls and fall risks at every visit.
Scenario 2: Ms. K is a 68-year-old who presents for her annual gynecologic exam. She has a history of heart disease and takes clopidogrel. When asked, she reports falling in the past year. Upon further questioning, Ms. K describes only a single fall in the last year and states she once tripped over her dog who was sleeping in the hallway. Ms. K performs the "Get-up and Go Test" without difficulty. She reports no concern for her balance or gait. Ms. K does not take any medications for overactive bladder. Assuming no new falls, Ms. K will be reassessed for fall risk at her next annual exam, and she is advised of her increased risk of bleeding following a fall.
NIH Senior Health: Falls and Older Adults
Centers for Disease Control and Prevention: Home and Recreational Safety - Falls and Older Adults
Agency for Healthcare Research and Quality: The Falls Management Program
National Center for Patient Safety Falls Toolkit 2004
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