Preventing Falls in Older Persons

LAINIE VAN VOAST MONCADA; L. GLEN MIRE

LAINIE VAN VOAST MONCADA, MD, AND L. GLEN MIRE, MD

Am Fam Physician. 2017;96(4):240-247

Patient information: See related handout on tips for preventing falls, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

The American Geriatrics Society and British Geriatrics Society recommend that all adults older than 65 years be screened annually for a history of falls or balance impairment. The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling older adults who are at increased risk of falls. Although the U.S. Preventive Services Task Force and American Academy of Family Physicians do not recommend routine multifactorial intervention to prevent falls in all community-dwelling older adults, they state that it may be appropriate in individual cases. The Centers for Disease Control and Prevention developed an algorithm to aid in the implementation of the American Geriatrics Society/British Geriatrics Society guideline. The algorithm suggests assessment and multifactorial intervention for those who have had two or more falls or one fall-related injury. Multifactorial interventions should include exercise, particularly balance, strength, and gait training; vitamin D supplementation with or without calcium; management of medications, especially psychoactive medications; home environment modification; and management of postural hypotension, vision problems, foot problems, and footwear. These interventions effectively decrease falls in the community, hospital, and nursing home settings. Fall prevention is reimbursed as part of the Medicare Annual Wellness Visit.

Falls are the leading cause of fatal and nonfatal injuries in persons older than 65 years.¹ In a survey, 37.5% of fallers responded that they required medical treatment or activity restriction.² Fall injuries result in 2.8 million emergency department visits annually,¹ and 25% of falls cause serious injuries, such as fractures or traumatic brain injury.³ The risk of falls and resulting serious injury increases with age. Injuries, such as hip fracture, and falls are risk factors for placement in a nursing home,⁴ where the fall risk is nearly three times that of persons living in the community.⁵ A history of falls is associated with a two- to sixfold increased risk of a future fall.⁶ Noninjurious falls are a harbinger of potentially life-threatening events and are an opportunity for physicians to intervene.

Clinical recommendation		Evidence rating	References
Community-dwelling older persons at low to moderate risk of falls should participate in an exercise program or physical therapy and take vitamin D supplements.		B	⁷, ⁸, ²⁰, ²³, ²⁹
Community-dwelling older persons at high risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs.		C	⁸, ²⁰, ²³
Older persons at risk of falls who are hospitalized in an acute setting or for an extended time in a subacute setting should receive a multifactorial risk assessment and intervention tailored to their needs.		B	²¹, ³⁸, ³⁹, ⁴²
Nursing home residents at risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs that are administered by a multidisciplinary team.		B	²²
The following components should be included in multifactorial interventions for falls in older persons:
	Exercise, particularly balance, strength, and gait training	A	⁷, ⁸, ²²
	Vitamin D₃ supplementation of at least 800 IU daily	B	⁷, ⁸, ²⁹
	Withdrawal or minimization of psychoactive and other medications	B	⁷, ⁸, ²², ³⁹
	Adaptation or modification of the home environment for those who have fallen or have visual impairment	B	⁷, ⁸, ²²
	Management of foot problems and footwear	B	⁷, ⁸, ²², ³⁹
	Management of postural hypotension	B	⁷, ⁸, ²²
Dual chamber cardiac pacing should be considered in patients with carotid sinus hypersensitivity who experience unexplained recurrent falls.		B	⁶, ²⁰, ³⁷

Recommendation	Sponsoring organization
Do not let older adults lie in bed or only get up to a chair during their hospital stay.	American Academy of Nursing
Do not use physical restraints with an older hospitalized patient.	American Academy of Nursing
Do not use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agitation, or delirium.	American Geriatrics Society
Do not prescribe a medication without conducting a drug regimen review.	American Geriatrics Society
Do not prescribe under-dosed strength training programs for older adults. Instead, match the frequency, intensity, and duration of exercise to the individual's abilities and goals.	American Physical Therapy Association

Many of the recommendations in this article are based on the American Geriatrics Society/British Geriatrics Society (AGS/BGS) clinical practice guideline for the prevention of falls in older persons.⁷ The Centers for Disease Control and Prevention (CDC) developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit for physicians based on the AGS/BGS guideline.⁸ The tool-kit includes resources such as an algorithm for fall risk assessment and interventions (Figure 1⁹ ) and the Stages of Change Model (Table 1¹⁰ ). Fall prevention is reimbursed as part of the Medicare Annual Wellness Visit.

Risk Factors

There are many risk factors for falls, some of which are modifiable (Table 2).^6,11–16 The strongest modifiable risk factors are balance impairment, gait impairment, muscle weakness, and medication use. Fear of falling can result in a downward cascade of events leading to social isolation and loss of function, as well as more falls.¹⁷ Approximately 60% of falls are the result of multiple factors.¹⁸

Potentially modifiable
Cardiac
	Cardiac arrhythmias
	Congestive heart failure
	Hypertension
Environmental hazards
Medication use (see Table 3; risk is higher when four or more medications are used simultaneously)
Metabolic
	Diabetes mellitus
	Low body mass index
	Vitamin D deficiency
Musculoskeletal
	Balance impairment
	Foot problems
	Gait impairment
	Impaired activities of daily living
	Limited activity
	Lower extremity muscle weakness
	Musculoskeletal pain
	Use of an assistive device
Neurologic
	Delirium
	Dizziness or vertigo
	Parkinson disease and other movement disorders
	Peripheral neuropathy
Psychological
	Depression
	Fear of falling
Sensory impairment
	Auditory impairment
	Multifocal lens
	Visual impairment
Other
	Acute illness
	Anemia
	Cancer
	Inappropriate footwear
	Nocturia
	Obstructive sleep apnea
	Postural hypotension
	Urinary incontinence
Nonmodifiable
Age older than 80 years
Arthritis
Cognitive impairment/dementia
Female sex
History of cerebrovascular accident/transient ischemic attack
History of falling
History of fractures
Recently discharged from the hospital (within one month)
White race

Assessment

All persons older than 65 years should be asked annually about whether they have fallen, the number of falls they have had and if they caused injury, and whether they have difficulty with walking or balance.⁷ The CDC STEADI initiative encourages physicians to screen for fall risk by asking these questions and about fear of falling, or by administering the Stay Independent self–risk assessment brochure.⁸ It is important for physicians to elicit a falls history because, in one study, only 36% of men and 50% of women who fell in the previous year talked to their physician about falls.¹⁹ A gait, strength, and balance evaluation should be performed if a patient answers positively to any of the screening questions. The Timed Up and Go (TUG) test, 30-Second Chair Stand test, and 4-Stage Balance test are quick and easy to administer. These tests are shown in online instructional videos at https://www.youtube.com/playlist?list=PLWqeMoseZ2MwwznjB-TFrq4dtHX8hPsSE. The TUG test is recommended as the primary measure of functional assessment. It involves timing the patient as he or she rises from a chair with armrests, walks 10 feet (with an assistive device if applicable), turns, walks back to the chair, and sits.⁸

A multifactorial fall risk assessment should be performed for all high-risk persons who require 12 or more seconds to complete the TUG test and report two or more falls or one fall-related injury.^8,9 The assessment should include circumstances and frequency of falls, associated symptoms, injuries, medications (prescription and over-the-counter), other relevant acute or chronic medical problems, activities of daily living and use of assistive devices, and fear of falling.⁷ The physical examination should include evaluation of muscle strength; cognitive examination; cardiovascular examination, including postural dizziness/postural hypotension; assessment of visual acuity; and examination of the feet and footwear.⁷ An environmental assessment, including home safety, is also recommended.⁷ Checklists for home safety and risk factors for falling (Stay Independent brochure) are available at http://www.cdc.gov/steadi/patient.html (click the Brochures tab). Any person seeking medical attention immediately after a fall should be evaluated for underlying acute illness.

Multifactorial vs. Single Interventions

In each setting (community, hospital, and nursing home), assessment with corresponding individualized multifactorial intervention involving a combination of components (e.g., exercise, medication reduction) reduces fall rates.^20–22 Studies vary widely on which components were used. Single interventions such as exercise alone are also effective (without a complete multifactorial assessment) in falls prevention.²⁰

Community Setting

MULTIFACTORIAL INTERVENTIONS

The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians do not recommend routine multifactorial intervention in all community-dwelling older adults at risk of falling, but they state that multifactorial assessment and management may be appropriate in individual cases.^23,24 The CDC advises that moderate-risk patients (those with gait, strength, or balance impairment and a history of zero or one noninjurious fall) receive vitamin D supplementation with or without calcium, a medication review, and a referral to physical therapy or a community fall prevention program.⁹

High-risk patients should receive a multifactorial intervention, including an exercise program with muscle strengthening and gait and balance training; vitamin D supplementation with or without calcium; management of medications; home environment modification; and management of postural hypotension, vision problems, foot problems, and footwear.⁷ These patients should follow up within 30 days. A Cochrane review concluded that assessment and multifactorial interventions in community-dwelling older adults reduce the number of falls by 24%.²⁰ These strategies can also reduce hip and other fractures, head injuries, use of medical services related to falls,²⁵ and death.²⁶

eTable A includes tips for implementing interventions for fall prevention in community-dwelling older adults. eTable B is a falls prevention electronic medical record template. All components on the template are based on the evidence discussed in this article.

1.	Screen all persons older than 65 years annually for history of falls, frequency of falls, and difficulty with gait and balance as recommended by the American Geriatrics Society and British Geriatrics Society.^A1 Also, solicit any history of fear of falling.^A2 Consider screening at the same time every year, such as during the season of fall or at the Medicare Annual Wellness Visit.
2.	Train medical assistants or nursing staff to automatically document postural blood pressure and pulse, Timed Up and Go (and possibly 30-Second Chair Stand and 4-Stage Balance) test results, visual acuity, functional history, and activities-of-daily-living findings, as well as conduct a cognitive screen, such as a three-item recall, for any patient with a recent fall or history of falls.
3.	Assign office staff to identify group exercise programs and/or tai chi programs with strength, gait, and balance components.
	The local Council on Aging, hospitals, YMCAs, and senior centers may offer these programs.
	The Tai Ji Quan: Moving for Better Balance tai chi program* (http://tjqmbb.org) reduces the risk of recurrent falls by 55%.^A3
	The Stepping On program* (https://wihealthyaging.org/national-stepping-on_1), which teaches fall prevention strategies, decreases the risk of falls by 30%.^A3
4.	Assign office staff to identify outpatient programs that specialize in physical therapy for falls or balance impairment.
	The Otago Exercise Program* (https://www.med.unc.edu/aging/cgec/exercise-program) is an individually tailored home exercise program administered by a trained physical therapist that reduces the risk of falls by 35%.^A3
5.	Assign office staff to identify home health companies that provide home safety evaluations and follow up for adherence to recommendations.
6.	Assign office staff to identify companies that provide home safety modification, such as installation of grab bars in the bathroom.
	Find National Association of Homebuilders–certified aging-in-place specialists at http://www.nahb.org/en/find/directory-designee.aspx.
	Contact the local Council on Aging for resources.
7.	Input resources from numbers 4 to 6 into the fall prevention EMR template (eTable B) for high-risk fallers.
8.	Input patient education materials into the fall prevention EMR template (eTable B) for high-risk fallers.
	Examples: http://www.cdc.gov/steadi/patient.html and http://health.gov/dietaryguidelines/2015/guidelines/appendix-11/
9.	Recommend vitamin D₃ supplementation (minimum of 800 IU daily) with or without calcium to all older adults at risk of falling.
10.	Refer older adults who are at low risk of falling to a community exercise or fall prevention program (see number 3). Refer older adults who are at moderate risk of falling to a community fall prevention exercise program or physical therapy for fall prevention (see number 4) and review or modify their medications.
11.	Complete the fall prevention EMR template (eTable B) for high-risk older adults who have impairment on gait or balance evaluation and report two or more falls or one fall causing injury.

Chief problem
History of a fall
History
Number of falls in the past year
Feeling of unsteadiness when standing or walking
Fear of falling
Injuries due to a fall
Environmental hazards
Dizziness
Syncope
Assistive devices needed
Assistive device used at the time of the fall
Assistance needed with transferring, bathing, dressing, or toileting
Review of systems
Vision problems
Date of the most recent eye examination by an ophthalmologist or optometrist
Urinary or fecal incontinence
Acute or chronic musculoskeletal problems
History of osteoporosis
Foot pain
Footwear worn at the time of the fall
Acute or chronic neurologic problems
History of acute or chronic cognitive impairment
Medications
Current medications, including over-the-counter, herbal, and psychoactive medications
New medications or recent dosage changes
Social history
History of alcohol use
Physical examination
Visual acuity
	Left eye with glasses
	Right eye with glasses
	Bilateral eyes with glasses
	Use of multifocal glasses
Postural blood pressure and pulse
Cardiovascular examination
Musculoskeletal strength
Gait and use of assistive device
	Number of seconds for Timed Up and Go test with assistive device (12 or more seconds indicates a high risk of falling)
	4-Stage Balance test (inability to hold first three stages for 10 seconds or more without assistive device indicates increased risk of falling)
Number of seconds with feet side by side
Number of seconds in semitandem stance
Number of seconds in tandem stance
Number of seconds standing on one foot
Number of stands in 30-Second Chair Stand test
Below-average scores (number of stands) by age and sex:
60 to 64 years: < 14 men, < 12 women
65 to 69 years: < 12 men, < 11 women
70 to 74 years: < 12 men, < 10 women
75 to 79 years: < 11 men, < 10 women
80 to 84 years: < 10 men, < 9 women
85 to 89 years: < 8 men and women
Feet examination
Footwear
Neurologic examination
Cognitive examination (number of items recalled at three minutes)
Assessment
ICD-10 codes
R26.2 for difficulty in walking, not elsewhere classified
R26.81 for unsteadiness on feet
R29.6 for repeated falls
Z91.81 for history of falling
Plan for those at high risk of falling
Referral to a physical therapist for gait, strength, and balance training
Vitamin D₃ supplementation (minimum of 800 IU daily) with or without calcium
List of how medications were reviewed and modified
Referral to occupational therapist for home safety evaluation
Postural hypotension treatment
Referral to ophthalmologist or optometrist
Advice to wear single lens glasses for outdoor activities, walking, or climbing stairs
Referral to a podiatrist
Recommendation to wear footwear with a low heel and high surface contact area
Bone density scan (dual energy x-ray absorptiometry)
25-hydroxyvitamin D measurement
Osteoporosis treatment
Personal emergency response system
Complete blood count, chemistry panel, urinalysis, or chest radiography (if patient may have underlying acute or subacute illness)
List of patient education materials distributed (e.g., http://www.cdc.gov/steadi/patient.html, http://health.gov/dietaryguidelines/2015/guidelines/appendix-11/)
Follow-up visit scheduled for one month to encourage fall risk reduction behaviors, assess adherence, and address any barriers to the care plan

SINGLE INTERVENTIONS

Exercise or Physical Therapy. The USPSTF and the American Academy of Family Physicians conclude that exercise or physical therapy alone has moderate net benefit in preventing falls.^23,24 All older adults who are at risk of falling should be offered physical therapy or an exercise program incorporating balance, gait, and strength training.⁷ A Cochrane review found that the number of fallers was reduced by 15% to 29% with group exercise containing multiple components, individual home-based exercise, or tai chi.²⁰ In most studies, the exercise program was a minimum of 12 weeks with 30- to 90-minute sessions one to three times per week.²⁰ In a meta-analysis, fall prevention exercise programs reduced falls resulting in fracture by 61% and reduced falls resulting in the need for medical care by 43%.²⁷ Exercise interventions have also been effective in reducing the fall rate in cognitively impaired older adults.²⁸

Vitamin D. The evidence supporting vitamin D supplementation to reduce the risk of falls in community-dwelling adults is mixed. Although the USPSTF, American Academy of Family Physicians, and AGS recommend vitamin D, a Cochrane review did not find benefit.^20,23,24,29 The USPSTF recommends vitamin D supplementation in older adults at increased fall risk.²³ The recommended dietary allowance of vitamin D is 800 IU per day ³⁰; however, the AGS recommends vitamin D₃ plus calcium supplements that include at least 1,000 IU of vitamin D per day for older persons to reduce fall risk.²⁹

Medication Review. Patients and caregivers must be educated about increased fall risk with polypharmacy and certain medications, especially benzodiazepines, opioids, and sleep medications (Table 3^11,31 ). In one study, withdrawal of psychotropics reduced the fall rate by 66%.³² Another study showed that educating family physicians about their prescribing practices can reduce falls by 39%.³³ When possible, physicians should limit high-risk medications and the total number of medications used. Any medication that was initiated or increased shortly before a fall should be considered a possible cause.

Home Safety. The physician should monitor progress toward improving home safety,⁷ which may be done with the assistance of a home health agency. Training patients about proper use of assistive devices for mobility is an important part of improving safety. Home safety modification interventions reduce falls and are most effective in patients who have a high risk of falls or who have severe visual impairment and when delivered by an occupational therapist.²⁰

Vision Correction. Falls are reduced when regular wearers of multifocal glasses who routinely participate in outdoor activities are given single lens glasses.³⁴ Patients who use multifocal glasses may benefit from wearing single lens glasses for activities such as walking or climbing stairs. The risk of injurious falls increases after a first-eye cataract surgery. Second-eye cataract surgery decreases fall risk, although fall risk remains above baseline.³⁵ Delays in second-eye cataract surgery should be minimized.

Foot Care. Podiatry intervention involving routine podiatry care, home-based foot and ankle exercises, foot orthoses, and advice about footwear reduces the fall rate in community-dwelling older adults with disabling foot pain.³⁶ Older persons should be advised that walking in shoes with low heels and a high surface contact area may reduce the risk of falls.⁷

Pacemakers. Carotid sinus hypersensitivity should be considered when a patient has unexplained recurrent falls. Pacemakers reduce falls and syncope in patients with this syndrome.^20,37

Hospital Setting

MULTIFACTORIAL INTERVENTIONS

Multifactorial interventions have been effective in the extended-care and rehabilitation hospital settings.²¹ A systematic review suggested that multicomponent interventions may also reduce fall rates in U.S. acute care hospitals, but the pooled risk reduction was not statistically significant.³⁸ This review included several successful individual trials in which fall risk was reduced by up to 30%. Components included a standardized assessment to identify risk factors, such as delirium, for which patient-specific care plans could be developed; patient and staff education; alert signs; safety and toileting rounds; bed and chair alarms; footwear advice; and medication review.^38,39 There is little evidence that low beds and bed alarms reduce falls.⁴⁰ Improved bed alarms and wearable movement sensors are currently being developed, but the evidence for their ability to prevent falls is inconsistent.⁴¹

The Agency for Healthcare Research and Quality has developed a toolkit to assist in the implementation of interdisciplinary best practices for fall prevention in hospitals (available at http://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit_0.pdf).⁴² The Centers for Medicare and Medicaid Services has designated falls occurring during hospitalization as preventable; therefore, any additional cost of care or increased length of stay because of resulting fracture or brain injury is the hospital's responsibility. Physicians must be diligent about avoiding restraints whenever possible because they increase the risk of injurious falls.⁴³

SINGLE INTERVENTIONS

Although data are limited, supervised exercise in the extended-care hospital setting has been shown to decrease fall risk.²¹

Nursing Home Setting

MULTIFACTORIAL INTERVENTIONS

Multidisciplinary team administration of multifactorial assessment and intervention in nursing homes reduces falls by 33% and the number of recurrent fallers by 21%.²² The individualized interventions contained many similar components to the interventions provided for community-dwelling persons but also included staff education. Falls and fall-related injuries were not increased when nursing homes implemented interventions to reduce the use of restraints such as belts and full-enclosure bed rails.⁴⁴

SINGLE INTERVENTIONS

Exercise. The effectiveness of exercise programs in long-term care is controversial.^21,22 A meta-analysis concluded that exercise intervention to prevent falls is most effective if balance exercise is combined with other types of exercise, usually resistance training, and performed two to three times per week for more than six months.⁴⁵ Exercise interventions have demonstrated effectiveness in preventing falls in cognitively impaired older adults who are in the nursing home settings.²⁸

Vitamin D. Vitamin D supplementation decreases the number of falls in long-term care residents.²¹ The Institute of Medicine recommends that persons older than 70 years (including those who are institutionalized) receive 800 IU of vitamin D₃ daily,³⁰ and the AGS recommends at least 1,000 IU of vitamin D₃ daily.²⁹

Interventions to Reduce Fall-Related Injuries

Bisphosphonates are recommended for patients with osteoporosis to reduce fractures from falls.⁴⁶ A Cochrane review found that vitamin D plus calcium supplementation resulted in nine fewer hip fractures per 1,000 institutionalized older adults per year,⁴⁷ but the USPSTF concludes that the evidence is insufficient for the use of vitamin D for the primary prevention of fractures in noninstitutionalized adults.⁴⁸ Hip protectors may reduce hip fractures but may also slightly increase the risk of pelvic fractures.⁴⁹

New sensors, such as wristwatches, cameras, microphones, and floor sensors, are being developed to detect falls quickly in various settings, but trials have been small and inconclusive.⁵⁰ Personal emergency response systems decrease hospitalization and may be considered for community-dwelling older adults.⁵¹

This article updates previous articles on this topic by Van Voast Moncada,^¹⁶ Rao,^⁵² and Fuller.^⁵³

Data Sources: An Ovid Medline search was completed using the term accidental falls. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Agency for Healthcare Research and Quality evidence reports, the Cochrane database, the National Guideline Clearinghouse database, the U.S. Preventive Services Task Force website, and Essential Evidence Plus. Search dates: March 30, 2016, and December 6, 2016.

Centers for Disease Control and Prevention. National Center for Injury Prevention and Control (WISQARS). http://www.cdc.gov/injury/wisqars/. Accessed March 13, 2016.

Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged ≥65 Years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(37):993-998.

Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-1707.

Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337(18):1279-1284.

Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121(6):442-451.

Tinetti ME, Kumar C. The patient who falls: “It's always a trade-off”. JAMA. 2010;303(3):258-266.

Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.

Centers for Disease Control and Prevention. STEADI materials for health care providers. http://www.cdc.gov/steadi/materials.html. Accessed May 5, 2016.

Centers for Disease Control and Prevention. Algorithm for fall risk assessment and interventions. http://www.cdc.gov/steadi/pdf/algorithm_2015-04-a.pdf. Accessed May 5, 2016.

Centers for Disease Control and Prevention. Talking about fall prevention with your patients. http://www.cdc.gov/steadi/pdf/talking_about_fall_prevention_with_your_patients-a.pdf. Accessed May 5, 2016.

Bloch F, Thibaud M, Tournoux-Facon C, et al. Estimation of the risk factors for falls in the elderly: can meta-analysis provide a valid answer?. Geriatr Gerontol Int. 2013;13(2):250-263.

Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J Am Geriatr Soc. 1994;42(3):269-274.

Stenhagen M, Ekström H, Nordell E, Elmståhl S. Falls in the general elderly population: a 3- and 6-year prospective study of risk factors using data from the longitudinal population study ‘Good ageing in Skane’. BMC Geriatr. 2013;13:81.

LeFevre ML. Screening for vitamin D deficiency in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;162(2):133-140.

Onen F, Higgins S, Onen SH. Falling-asleep-related injured falls in the elderly. J Am Med Dir Assoc. 2009;10(3):207-210.

Moncada LV. Management of falls in older persons: a prescription for prevention. Am Fam Physician. 2011;84(11):1267-1276.

Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26(3):189-193.

Campbell AJ, Robertson MC. Implementation of multi-factorial interventions for fall and fracture prevention. Age Ageing. 2006;35(suppl 2):ii60-ii64.

Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012;43(1):59-62.

Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012(9):CD007146.

Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012(12):CD005465.

Vlaeyen E, Coussement J, Leysens G, et al.; Center of Expertise for Fall and Fracture Prevention Flanders. Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials. J Am Geriatr Soc. 2015;63(2):211-221.

Moyer VA. Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(3):197-204.

American Academy of Family Physicians. Clinical preventive service recommendation. Fall prevention in older adults. https://www.aafp.org/patient-care/clinical-recommendations/all/fall-prevention.html. Accessed July 23, 2016.

Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359(3):252-261.

Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008;371(9614):725-735.

El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f6234.

Chan WC, Yeung JW, Wong CS, et al. Efficacy of physical exercise in preventing falls in older adults with cognitive impairment: a systematic review and meta-analysis. J Am Med Dir Assoc. 2015;16(2):149-154.

American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. Recommendations abstracted from the American Geriatrics Society consensus statement on vitamin D for prevention of falls and their consequences. J Am Geriatr Soc. 2014;62(1):147-152.

Ross AC, Taylor CL, Yaktine AL, Cook HD; Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011:363.

By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246.

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999;47(7):850-853.

Pit SW, Byles JE, Henry DA, Holt L, Hansen V, Bowman DA. A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. Med J Aust. 2007;187(1):23-30.

Haran MJ, Cameron ID, Ivers RQ, et al. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. BMJ. 2010;340:c2265.

Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing. 2014;43(3):341-346.

Spink MJ, Menz HB, Fotoohabadi MR, et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial. BMJ. 2011;342:d3411.

Kenny RA, Richardson DA, Steen N, Bexton RS, Shaw FE, Bond J. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). J Am Coll Cardiol. 2001;38(5):1491-1496.

Hempel S, Newberry S, Wang Z, et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Geriatr Soc. 2013;61(4):483-494.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 pt 2):390-396.

Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2012(1):CD008931.

Kosse NM, Brands K, Bauer JM, Hortobagyi T, Lamoth CJ. Sensor technologies aiming at fall prevention in institutionalized old adults: a synthesis of current knowledge. Int J Med Inform. 2013;82(9):743-752.

Agency for Healthcare Research and Quality. Preventing falls in hospitals. A toolkit for improving quality of care. 2013. http://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf. Accessed October 31, 2016.

Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18(2):141-158.

Gulpers MJ, Bleijlevens MH, Ambergen T, Capezuti E, van Rossum E, Hamers JP. Belt restraint reduction in nursing homes: effects of a multicomponent intervention program. J Am Geriatr Soc. 2011;59(11):2029-2036.

Silva RB, Eslick GD, Duque G. Exercise for falls and fracture prevention in long term care facilities: a systematic review and meta-analysis. J Am Med Dir Assoc. 2013;14(9):685-689.e2.

Florence R, Allen S, Benedict L, et al. Diagnosis and treatment of osteoporosis. Institute for Clinical Systems Improvement. Updated July 2013. https://www.icsi.org/_asset/vnw0c3/osteo.pdf. Accessed October 31, 2016.

Avenell A, Mak JC, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014(4):CD000227.

Moyer VA. Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(9):691-696.

Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2014(3):CD001255.

Chaudhuri S, Thompson H, Demiris G. Fall detection devices and their use with older adults: a systematic review. J Geriatr Phys Ther. 2014;37(4):178-196.

Roush RE, Teasdale TA, Murphy JN, Kirk MS. Impact of a personal emergency response system on hospital utilization by community-residing elders. South Med J. 1995;88(9):917-922.

Rao SS. Prevention of falls in older patients. Am Fam Physician. 2005;72(1):81-88.

Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-2174.

Precontemplation stage: The patient is not thinking about change and does not feel that anything can be done to prevent falls.
	Physician's response: Offer the patient education about the benefits of making a change.
Contemplation stage: The patient is weighing the benefits of a behavior change to prevent falls (e.g., home modification) vs. the cost.
	Physician's response: Offer encouragement and specific suggestions for change. Involve family for support.
Preparation stage: The patient begins to consider making a change to prevent falls.
	Physician's response: Help patient set specific goals and create action plan.
Action stage: The patient is ready to make a behavior change to prevent falls.
	Physician's response: Make referrals and provide support with follow-up.
Maintenance stage: The patient continues the new behavior (e.g., exercise) for at least six months.
	Physician's response: Offer praise and encouragement to continue.

Risk Factors

Assessment

Multifactorial vs. Single Interventions

Community Setting

MULTIFACTORIAL INTERVENTIONS

SINGLE INTERVENTIONS

Hospital Setting

MULTIFACTORIAL INTERVENTIONS

SINGLE INTERVENTIONS

Nursing Home Setting

MULTIFACTORIAL INTERVENTIONS

SINGLE INTERVENTIONS

Interventions to Reduce Fall-Related Injuries

Continue Reading

More in AFP

More in PubMed