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Fall prevention
Dr.Ahmed M Rashad
PGY1 Family Medicine

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Objectives
 To know the causes of fall in elderly population
 To outline Fall risk assessment
 To outline fall preventive measures

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Introduction
 Each year, one out of three adults age 65 and older falls,
according to the CDC.
 In 2000, falls among older adults cost the U.S. healthcare
system more than $19 billion
 Falls are equally common between men and women, but
were more likely to result in injury in women.

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Causes
Medical Risk factors
Impaired musculoskeletal function, gait abnormality and
osteoporosis
Cardiac arrhythmias (irregular heartbeat), blood pressure
fluctuation
Depression, Alzheimer's disease and senility
Arthritis, hip weakness and imbalance
Neurologic conditions, stroke, Parkinson's disease, multiple sclerosis
Vision or hearing loss
Side effects of medications

5. + Personal Risk Factors
• Age. The risk for a fall increases with age. Normal aging affects
our eyesight, balance, strength, and ability to quickly react to our
environments.
• Activity. Lack of exercise leads to decreased balance,
coordination, and bone and muscle strength.
• Habits. Excessive alcohol intake and smoking decrease bone
strength. Alcohol use can also cause unsteadiness and slow
reaction times.
• Diet. A poor diet and not getting enough water will deplete
strength and energy, and can make it hard to move and do
everyday activities.
 Risk Factors at Home (e.g. Slippery floors)

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Prevention
 Falls in older persons occur commonly and are a major
factor threatening the independence of older individuals.
 Falls often go without clinical attention for a variety of
reasons:
a. The patient never mentions the event to a health care
provider;
b. There is no injury at the time of the fall
c. The provider fails to ask the patient about a history of falls;
or either provider or patient erroneously believes that falls
are an inevitable part of the aging process

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Evaluation of patients at risk
 History
a. Several studies report that the most important consideration
in the history is a previous fall, which places the patient at
increase risk of future falls
b. For patients presenting with a fall, important components of
the history include the activity of the faller at the time of the
incident, prodromal symptoms, and where and when the fall
occurred.
 Physical Examination
Comprehensive examination including vital signs, visual
acuity, cardiovascular and examination of extremities.

9. +  Muscloskeletal function
• 'Get Up and Go' test — The test is performed by observing
the subject rising from a standard arm chair, walking a fixed
distance across the room, turning around, walking back to
the chair, and sitting back down. Observation of the different
components of this test may help to identify deficits in leg
strength, balance, vestibular dysfunction, and gait.
 Diagnostic testing
• Laboratory tests such as a hemoglobin concentration and
serum urea nitrogen, creatinine, and glucose concentrations
can help to rule out causes of falling such as anemia,
dehydration, and dehydration and autonomic neuropathy
related to diabetes. Serum 25-hydroxyvitamin D levels can
identify individuals with vitamin D deficiency who will
benefit from vitamin D supplementation.

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Exercise
 Multiple meta-analyses of randomized trials conducted in
various populations find that general exercise reduces the risk
of falls, and that exercise programs that include balance
components are most effective.
 Exercise interventions can be grouped into six categories:
• Gait and balance training
• Strength training
• Flexibility
• Movement (such as Tai Chi)
• General physical activity
• Endurance

11. +  Exercise classes incorporating multiple categories of
exercise reduced the risk of falling (risk ratio, RR 0.85, 0.76-
0.96)
 Home-based exercises that included more than one type of
exercise also decreased the fall rate and fall risk.
 In one trial, a program that integrated balance and strength
training into everyday home activities resulted in a 31
percent decrease in the rate of falls (RaR 0.69, 95% CI 0.48-
0.99) and was more effective than a structured exercise
program done three times a week.

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Medication modification
 Sedatives, anti-depressants, and anti-psychotic drugs can
contribute to falls by reducing mental alertness, worsening
balance and gait, and causing drops in systolic blood
pressure while standing.
 Additionally, people taking multiple medications are at
greater risk of falling.
 Beers Criteria is a list of medications that are potentially
inappropriate for use in the elderly and some of them
increase the risk of falls.
(http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf)

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Vitamin D supplementation
 Although the evidence is not definitive, because of low risk
of harm, we suggest that older patients be given
cholecalciferol (vitamin D3) supplements for fall prevention,
which can be given daily, weekly, or monthly with the dose
adjusted upward to achieve the dosing equivalence of at
least 800 units daily.
 Men and women over age 65 years with low serum 25-
hydroxyvitamin D concentrations (<10 ng/mL [25 nmol/L])
are at greater risk for loss of muscle mass, strength, and hip
fractures.

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Control Environmental Hazards
 At least one-third of all falls in the elderly involve
environmental hazards in the home.The most common
hazard for falls is tripping over objects on the floor.
 Other factors include poor lighting, loose rugs, lack of grab
bars or poorly located/mounted grab bars, and unsturdy
furniture.
 It is useful to conduct a walk-through of the home to identify
possible problems that may lead to falling. A home visit by
occupational therapist might also be useful to identify risk
factors and recommend appropriate actions.

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Resources
 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl
J Med 1988; 319:1701.
 Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic
review and meta-analysis of randomised clinical trials. BMJ 2004; 328:680.
 Centers for Disease Control and Prevention (CDC). Self-reported falls and fall-related injuries among persons
aged > or =65 years--United States, 2006. MMWR Morb Mortal Wkly Rep 2008; 57:225.
 Centers for Disease Control and Prevention (CDC). Public health and aging: nonfatal injuries among older
adults treated in hospital emergency departments--United States, 2001. MMWR Morb Mortal Wkly Rep 2003;
52:1019.
 Nachreiner NM, Findorff MJ,Wyman JF, McCarthy TC. Circumstances and consequences of falls in community-
dwelling older women. J Womens Health (Larchmt) 2007; 16:1437.
 Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med
Clin North Am 2006; 90:807.
 Nickens H. Intrinsic factors in falling among the elderly. Arch Intern Med 1985; 145:1089.
 Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society,
and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001; 49:664.
 Hartholt KA, van der Velde N, Looman CW, et al.Trends in fall-related hospital admissions in older persons in
the Netherlands. Arch Intern Med 2010; 170:905

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