A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders (eg, stroke, seizure) or overwhelming environmental hazards (eg, being struck by a moving object) are not considered falls.
In people ≥ 65, falls are the leading cause of injury-related death and the seventh leading cause of all deaths (1).
In the United States, about 14 million (about 28%) adults age ≥ 65 report falling each year, accounting for a total of about 36 million falls each year according to the Centers for Disease Control and Prevention (CDC [2]). Not all falls result in an injury, but about 37% of people who fall report an injury that required medical treatment or that restricted their activity for at least one day, resulting in an estimated 8 million fall injuries each year (3).
Falls threaten the independence of older adults and cause a cascade of individual and socioeconomic problems. However, clinicians are often unaware of falls in patients who do not present with an injury because a routine history and physical examination typically do not include a specific evaluation for falls. Many older adults are reluctant to report a fall because they attribute falling to the aging process or because they fear being subsequently restricted in their activities or institutionalized. Reporting falls to clinicians is necessary for prevention of future falls. When falls are not reported and preventive measures are not instituted, patients are at risk of falling again, thereby placing a significant burden on the health care system. This burden is expected to increase given the projected growth of the aging population.
References
1. Burns E, Kakara R: Deaths from falls among persons aged ≥ 65 years — United States, 2007–2016. MMWR Morb Mortal Wkly Rep 67 (18):509–514, 2018. doi: 10.15585/mmwr.mm6718a1
2. CDC : Older Adult Falls Data. Accessed 10/18/23.
3. Moreland B, Kakara R, Henry A: Trends in nonfatal falls and fall-related injuries among adults aged ≥ 65 years — United States, 2012–2018. MMWR Morb Mortal Wkly 69 (27):875–881, 2020.doi: 10.15585/mmwr.mm6927a5
Etiology of Falls
The most consistent predictor of falling is a previous fall. However, falls in older adults rarely have a single cause or risk factor. A fall is usually multifactorial, caused by a complex interaction among the following:
Intrinsic factors (age-related decline in function, disorders, and adverse effects of medications)
Extrinsic factors (environmental hazards)
Situational factors (related to the specific activity or circumstances of an activity—eg, rushing to the bathroom in the middle of the night)
Intrinsic factors
Age-related changes can impair systems involved in maintaining balance and stability (eg, while standing, walking, or sitting) and increase the risk of falls. Visual acuity, contrast sensitivity, depth perception, and dark adaptation decline. Sensory loss or disturbances and cerebellar dysfunction can diminish postural reflexes and impair balance. Changes in muscle activation patterns and ability to generate sufficient muscle power and velocity may impair the ability to maintain or recover balance in response to perturbations (eg, stepping onto an uneven surface, being bumped). In fact, muscle weakness of any type is a major predictor of falls. As cognitive impairment increases with age, so does the risk of falls, partly because older adults with cognitive impairment may not remember to take the safety measures that reduce falls.
Chronic and acute disorders (see table Some Disorders That Contribute to Risk of Falls) and use of medications (see table Some Medications That Contribute to Risk of Falls) are major risk factors for falls. The risk of falls increases with the number of medications taken. Several classes of medications increase risk, but psychoactive medications are most commonly reported as increasing both risk of falls and fall-related injuries.
Risk of a traumatic fall that results in a fracture is increased by
Osteoporosis and age-related changes in bone quality, which increase bone fragility
Loss of muscle (sarcopenia), which reduces protective responses to perturbations
Extrinsic factors
Environmental factors can increase the risk of falls independently or, more importantly, by interacting with intrinsic factors. Risk is highest when the environment requires greater postural control and mobility (eg, when walking on a slippery surface) and when the environment is unfamiliar (eg, when relocated to a new home).
Situational factors
Certain activities or decisions may increase the risk of falls and fall-related injuries. Examples are
Walking while talking
Being distracted by multitasking and then not noticing an environmental hazard (eg, a curb or step)
Rushing to the bathroom (especially at night when not fully awake or when lighting may be inadequate)
Rushing to answer the telephone
Dementia can exacerbate many of these hazardous situations that lead to falls. Impaired cognition, judgment, and hazard awareness can cause older adults to become distracted, rush, and not notice environmental hazards, significantly increasing fall risk.
Complications
Falling, particularly falling repeatedly, increases risk of injury, hospitalization, and death in older adults who are frail and have preexisting disease comorbidities (eg, osteoporosis) and deficits in activities of daily living (eg, incontinence). Longer-term complications can include decreased physical function, fear of falling, and institutionalization.
Each year, approximately 36 million falls are reported in older adults, resulting in more than 32,000 deaths, and each year, emergency departments treat approximately 3 million older adults for injuries due to falls. Most falls do not cause serious harm, but about 20% cause a serious injury such as fractures or a head injury. Each year, at least 300,000 older adults are hospitalized for hip fractures, which result from falling in> 95% of cases. Women tend to fall more often than men, and about 75% of all hip fractures occur in women (1).
About half of older adults who fall cannot get up without help (2). Remaining on the floor for> 2 hours after a fall increases the risk of dehydration, pressure injuries, rhabdomyolysis, hypothermia, and pneumonia.
Function and quality of life may deteriorate drastically after a fall; up to 60% of older adults do not recover their previous level of mobility (3). After falling, older adults may fear falling again, so mobility is sometimes reduced because confidence is lost. Some people may even avoid certain activities (eg, shopping, cleaning) because of this fear. Decreased activity can increase joint stiffness and weakness, further reducing mobility.
Some Disorders That Contribute to Risk of Falls
Functional Impairment | Disorder |
|---|---|
Blood pressure regulation | Cardioinhibitory carotid sinus hypersensitivity COPD (chronic obstructive pulmonary disease) Dehydration Infections (eg, pneumonia, sepsis) Metabolic disorders (eg, diabetes, thyroid disorders, hypoglycemia, hyperosmolar states) Neurocardiogenic inhibition after micturition Orthostatic (postural) hypotension Postprandial hypotension |
Central processing | |
Gait | Foot deformities |
Postural and neuromotor function | Myelopathy (eg, due to cervical or lumbar spondylosis) Vertebrobasilar insufficiency |
Proprioception | Peripheral neuropathy (eg, due to diabetes mellitus) |
Otolaryngologic function | Acute labyrinthitis |
Vision | Macular degeneration (age-related) |
Some Medications That Contribute to Risk of Falls
Medications | Mechanism |
|---|---|
Aminoglycosides | Direct vestibular damage |
Analgesics (especially opioids) | Reduced alertness or slow central processing |
Antiarrhythmics | Impaired cerebral perfusion |
Anticholinergics | Confusion/delirium |
Antihypertensives (especially vasodilators) | Impaired cerebral perfusion |
Antipsychotics | Extrapyramidal syndromes, other antiadrenergic effects, reduced alertness, or slow central processing |
Diuretics (especially when patients are dehydrated) | Impaired cerebral perfusion |
Loop diuretics (high-dose) | Direct vestibular damage |
Psychoactive medications (especially antidepressants, antipsychotics, and benzodiazepines) | Reduced alertness or slow central processing |
Etiology references
1. Centers for Disease Control and Prevention (CDC): Keep on Your Feet—Preventing Older Adult Falls. Accessed 10/18/23.
2. Gurley RJ, Lum N, Sande M, et al: Persons found in their homes helpless or dead. N Engl J Med 334 (26), 1710–1716, 1996, doi.org/10.1056/nejm199606273342606
3. Haslam-Larmer L, Donnelly C, Auais M, et al: Early mobility after fragility hip fracture: a mixed methods embedded case study. BMC Geriatr 21 (1):181, 2021. doi: 10.1186/s12877-021-02083-3
Evaluation of Falls
Clinical evaluation
Performance testing
Sometimes laboratory testing
After treatment of acute injuries, assessment should aim to identify risk factors and appropriate interventions, thus decreasing the risk of future falls and fall-related injuries (1).
Some falls are promptly recognized because of an obvious fall-related injury or concern about a possible injury. However, because older adults often do not report falls, they should be asked about falls or mobility problems at every visit. Clinicians should also ask about previous falls as well as conditions, medications, and situational factors that increase fall risk.
Patients who report a single fall should be evaluated for a balance or gait problem using the basic Get-Up-and-Go Test (2). For the test, patients are observed as they rise from a standard armchair, walk 3 meters (about 10 feet) in a straight line, turn, walk back to the chair, and sit back down. Observation may detect lower-extremity weakness, imbalance while standing or sitting, or an unsteady gait. Sometimes the test is timed. A time of > 12 seconds indicates a significantly increased risk of falls.
Patients who require a more complete assessment of risk factors for falls include
Those who have difficulty during the Get-Up-and-Go Test
Those who report having had multiple falls
Those who are being evaluated after a recent fall (after acute injuries are identified and treated)
History and physical examination
When a more complete assessment of fall risk factors is needed, the focus is on identifying intrinsic, extrinsic, and situational factors that can be reduced by interventions targeted at them. However, eliminating all risk of future falls may be impossible.
Patients are asked open-ended questions about their most recent fall or falls, followed by more specific questions about when and where a fall occurred and what they were doing. Witnesses are asked the same questions. Patients should be asked whether they had premonitory or associated symptoms (eg, palpitations, shortness of breath, chest pain, vertigo, light-headedness) and whether consciousness was lost. Patients should also be asked whether any obvious extrinsic or situational factors may have been involved. The history should include questions about past and present medical problems, use of prescription and over-the-counter medications, and use of alcohol or psychoactive medications. Patients should be asked whether they were able to get back up without help after falling and whether any injuries occurred; the goal is reducing the risk of complications due to future falls.
The physical examination should be comprehensive enough to exclude obvious intrinsic causes of falls. If the fall occurred recently, temperature should be measured to determine whether fever was a factor. Heart rate and rhythm should be assessed to identify obvious bradycardia, resting tachycardia, or irregular rhythms. Blood pressure should be measured with patients supine and after patients stand for 1 and 3 minutes to rule out orthostatic hypotension. Auscultation can detect many types of cardiac valvular disorders. Visual acuity should be evaluated with patients wearing their usual corrective lenses if needed. Abnormalities in visual acuity should trigger a more detailed visual examination by an optometrist or ophthalmologist. The neck, spine, and extremities (especially the legs and feet) should be evaluated for weakness, deformities, pain, and limitation in range of motion.
A neurologic examination should begin with a mental status examination to check for cognitive impairment. The neurologic examination also includes testing motor function (including muscle strength and tone and range of motion), sensation (including proprioception), coordination (including cerebellar function), stationary balance, and gait. Basic postural control and the proprioceptive and vestibular systems are evaluated using the Romberg test (in which patients stand with feet together and eyes both open and closed). Tests to establish high-level balance function include the one-legged stance and tandem gait. If patients can stand on one leg for 10 seconds with their eyes open and have an accurate 3-meter (10-feet) tandem gait, any intrinsic postural control deficit is likely to be minimal. Clinicians should evaluate positional vestibular function (eg, with the Dix-Hallpike maneuver—see Nystagmus).
Performance tests
The Performance-Oriented Assessment of Mobility or the Timed Get-Up-and-Go test can identify problems with balance and stability during walking and other movements that may indicate increased risk of falls. These tests are especially helpful if the patient had difficulty doing the basic Get-Up-and-Go test.
The Performance-Oriented Assessment of Mobility test includes quantitative scoring of various aspects of balance and gait and takes about 10 to 15 minutes to do. Low scores predict increased risk of falls (see table Performance-Oriented Assessment of Mobility).
Laboratory tests
There is no standard diagnostic laboratory evaluation to determine the exact cause of a fall. Testing should be based on the history and examination results and helps rule out various causes. Tests include
A complete blood count (CBC) for anemia or leukocytosis
Blood glucose measurement for hypoglycemia or hyperglycemia
Electrolyte measurement for dehydration
Tests such as electrocardiography (ECG), ambulatory cardiac monitoring, and echocardiography are recommended only when a cardiac cause is suspected. Carotid massage under controlled conditions (IV access and cardiac monitoring) has been proposed to determine carotid hypersensitivity and ultimately who might respond to pacemaker treatment. Spinal x-rays and cranial computer tomography (CT) or magnetic resonance imaging (MRI) are indicated only when the history and physical examination detect new neurologic abnormalities.
Evaluation references
1. U.S. Preventive Services Task Force (USPSTF): Final Recommendation Statement: Falls Prevention in Community-Dwelling Older Adults: Interventions. Accessed 10/18/23.
2. Podsiadlo D, Richardson S: The timed "Up & Go": A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 39 (2), 142–148, 1991. https://doi.org/10.1111/j.1532-5415.1991.tb01616.x
Prevention of Falls
The focus should be on preventing or reducing the number of future falls and fall-related injuries and complications while maintaining as much of the patient’s function and independence as possible. In the periodic physical or wellness examination, patients should be asked about falls in the past year and difficulty with balance or ambulation (1).
Patients who report a single fall and who do not have problems with balance or gait on the Get-Up-and-Go Test or a similar test should be given general information about reducing risk of falls. It should include how to use medications safely and reduce environmental hazards (see table Home Assessment Checklist).
Patients who report more than one fall or a problem with balance or gait should receive a fall evaluation to identify risk factors and opportunities to lower risk.
Home Assessment Checklist for Hazards That Increase Risk of Falling
Location | Hazard | Correction | Rationale |
|---|---|---|---|
General household | |||
Lighting | Too dim | Provide ample lighting in all areas | Improves visual acuity and contrast sensitivity |
Too direct, creating glare | Reduce glare with evenly distributed light, indirect lighting, or translucent shades | Improves visual acuity and contrast sensitivity | |
Inaccessible light switches | Provide night-lights or touch-activated lights Install switches that are immediately accessible when entering a room or motion sensors that activate lights | Reduces risk of tripping over or bumping into unseen obstacles in a dark room | |
Carpets, rugs, linoleum | Torn | Repair or replace torn carpet | Reduces risk of tripping and slipping, especially for people who have difficulty stepping |
Slippery | Provide rugs with nonskid backs | Reduces risk of slipping | |
Curled edges | Tack or tape down rugs or linoleum to prevent curling Replace rugs or linoleum | Reduces risk of tripping | |
Chairs, tables, other furnishings | Unstable | Provide furniture stable enough to support the weight of a person leaning on table edges or chair arms and backs Do not use chairs that have wheels or that swivel Repair legs that are loose | Increases support for people with impaired balance and helps with transferring |
Chairs without armrests | Provide chairs with armrests that extend forward enough to provide leverage when getting up or sitting down | Helps people with proximal muscle weakness and helps with transferring | |
Obstructed pathways | Arrange furnishings so that pathways are not obstructed Remove clutter from hallways | Reduces risk of tripping over or bumping into obstacles, making movement in the home easier and safer, especially for people with impaired peripheral vision | |
Wires and cords | Exposed in pathways | Tack cords above the floor or run beneath floor coverings | Reduces risk of tripping |
Kitchen | |||
Cabinets, shelves | Too high | Keep frequently used items at waist level Install shelves and cupboards at an accessible height | Reduces risk of falls due to frequent reaching or climbing on ladders or chairs |
Floors | Wet or waxed | Place a rubber mat on the floor in the sink area Wear rubber-soled shoes in the kitchen Use nonslip wax | Reduces risk of slipping, especially for people with a gait disorder |
Bathroom | |||
Bathtub or shower | Slippery tub or shower floor | Install skid-resistant strips or rubber mat Use shower shoes or a bath seat (a bath seat enables people with impaired balance to sit while showering) | Reduces risk of sliding on a wet tub or shower floor |
Need to use the side of the bathtub for support or transfer | Install grab bars in shower Install a portable grab bar on the side of the tub Take grab bar on trips | Helps with transferring | |
Towel racks, sink tops | Unstable for use as support while transferring from the toilet, tub, or shower | Fasten grab rails to wall studs | Helps with transferring |
Toilet seat | Too low | Use elevated toilet seat | Helps with transferring to and from the toilet |
Doors | Locks | Remove locks from bathroom doors or use locks that can be opened from both sides of the door | Enables other people to enter if a person falls |
Stairways | |||
Height | Height of steps too high | Correct step height to < 15 cm | Reduces risk of tripping, especially for people who have difficulty stepping |
Handrails | Missing | Install and anchor rails well on both sides of the stairway Use cylindrical rails placed 2.5–5 cm from the wall | Provides support and enables people to grasp the rail with either hand |
Too short and end of rail unclear | Extend beyond the top and bottom step and turn ends inward | Signals that the top or bottom step has been reached | |
Configuration | Too steep or too long | Install landings on stairways when feasible or select a residence with a stairway landing | Provides a rest stop, especially for people with heart or pulmonary disorders |
Condition | Slippery | Place nonskid treads securely on all steps | Prevents slipping |
Lighting | Inadequate | Install adequate lighting at both the top and bottom of stairway Provide night-lights or bright-colored adhesive strips to clearly mark steps | Outlines location of steps, especially for people with impaired vision or perception |
Physical therapy and exercise
Patients who have fallen more than once or who have problems during initial balance and gait testing should be referred to physical therapy or an exercise program. Physical therapy and exercise programs can be done in the home if patients have limited mobility.
Physical therapists customize exercise programs to improve balance and gait and to correct specific problems and underlying conditions contributing to fall risk (eg, Parkinson disease [2]).
More general exercise programs in health care or community settings can also improve balance and gait. For example, tai chi may be effective and can be done alone or in groups. The most effective exercise programs to reduce fall risk are those that
Are tailored to the patient’s deficit
Are provided by a trained professional
Have a sufficient balance challenge component
Are provided over the long term (eg, ≥ 4 months)
Many senior citizen centers, YMCAs, or other health clubs offer free or low-cost group exercise classes tailored to senior citizens, and these classes can help with accessibility and adherence. The savings from decreased fall-related expenses exceed the costs of these programs (3).
Assistive devices
Some patients benefit from use of an assistive device (eg, cane, walker). Canes may be adequate for patients with minimal unilateral muscle or joint impairment, but walkers, especially wheeled walkers, are more appropriate for patients with increased risk of falls attributable to bilateral leg weakness or impaired coordination (wheeled walkers can be dangerous for patients who cannot control them properly). Physical therapists can help fit or size the devices and teach patients how to use them.
Medical management
Medications that can increase the risk of falls should be stopped, or the dosage should be adjusted to the lowest effective dose (see table Some Medications That Contribute to Risk of Falls). Patients should be evaluated for osteoporosis and, if osteoporosis is diagnosed, treated to reduce risk of fractures from any future falls.
If any other specific disorder is identified as a risk factor, targeted interventions are required. For example, medications and physical therapy may reduce risk for patients with Parkinson disease. Pain management, physical therapy, and sometimes joint replacement surgery may reduce risk for patients with arthritis. A change to appropriate lenses (single lenses rather than bifocals or trifocals) or surgery, particularly for removal of cataracts, may help patients with visual impairment.
Environmental and situational management
Correcting environmental hazards in the home may reduce the risk of falls (see table Home Assessment Checklist). Environmental hazards that commonly increase fall risk, (eg, throw rugs, inadequate lighting, lack of grab bars and handrails, unstable furniture, clutter), should be mitigated or eliminated (6).
Patients should also be advised on how to reduce risk due to situational factors. For example, footwear should have flat heels, some ankle support, and firm, nonskid midsoles. Many patients with chronic limited mobility (eg, caused by severe arthritis or paresis) benefit from combined medical, rehabilitative, and environmental strategies. Wheelchair adaptations (eg, removable foot plates to reduce tripping during transfers, antitip bars to prevent backward tipping), removable belts, and wedge seating may prevent falls in patients with poor sitting balance or severe weakness when they are sitting or transferring.
Restraints may lead to more falls and other complications and should generally not be used. Surveillance by a caregiver or companion is more effective. Motion detectors may be used, but a caregiver must be present to respond promptly to the triggered alarm.
Hip protectors (padding sewn into special undergarments) have been shown to reduce hip fractures in high-risk patients in nursing facilities, but are less effective in older adults living in the community. Furthermore, many patients are reluctant to wear protectors indefinitely. Compliant flooring (eg, firm rubber) can help dissipate the impact force, but a floor that is too compliant (eg, soft foam) may destabilize patients.
Patients should also be taught what to do if they fall and cannot get up when they are alone. Useful techniques include turning from the supine position to the prone position, getting on all fours, crawling to a strong support surface, and pulling up. The following can decrease time on the floor after a fall:
Having frequent contact with family members or friends
A phone that can be reached from the floor
A remote alarm
A wearable alert device
Newer technologies (eg,smartwatches, mobile medical alert systems, in-home motion sensors) can automatically detect falls and trigger a call for help. Voice-activated smart speakers and AI (artificial intelligence) camera systems may be used to monitor seniors and alert caregivers about potential falls. Combining human contact, wearable devices, and in-home monitoring can optimize the likelihood of a timely response to a fall.
Prevention references
1. U.S. Preventive Services Task Force (USPSTF): Final Recommendation Statement: Falls Prevention in Community-Dwelling Older Adults: Interventions. Accessed 10/8/23.
2. Allen NE, Sherrington C, Paul SS, Canning CG: Balance and falls in Parkinson's disease: A meta-analysis of the effect of exercise and motor training. Mov Disord 26 (9),1605–1615, 2011. doi.org/10.1002/mds.23790
3. Sherrington C, Fairhall N, Wallbank G, et al: Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med 54 (15):885–891, 2020. doi: 10.1136/bjsports-2019-101512. Epub 2019 Dec 2. PMID: 31792067.
4. Thanapluetiwong S, Chewcharat A, Takkavatakarn K, et alMedicine (Baltimore) 99 (34):e21506, 2020. doi: 10.1097/MD.0000000000021506. PMID: 32846760; PMCID: PMC7447507.
5, U.S. Preventive Services Task Force (USPSTF): Interventions to Prevent Falls in Community-Dwelling Older Adults. JAMA 319 (16):1696–1704, 2018. doi:10.1001/jama.2018.3097
6. Gill T, Williams CS, Robison JT, Tinetti MEGill T, Williams CS, Robison JT, Tinetti ME: A population-based study of environmental hazards in the homes of older persons. Am J Public Health, 89 (4), 553–556, 1999. doi.org/10.2105/ajph.89.4.553
Key Points
Each year in the United States, about one in four adults age ≥ 65 report a fall each year, for a total of about 14 millions falls.
Not all falls result in an injury, but about 37% of adults who fall report an injury that required medical treatment or restricted activity for at least one day.
Causes are multifactorial and include age-related functional declines (eg, reduced vision, slowed reaction time, muscle weakness), chronic illnesses that impair balance and mobility (eg, Parkinson disease, arthritis, dementia), adverse effects of medications, and environmental hazards.
Use validated tools such as the Timed Up and Go test to determine the need for fuller assessment of predisposing intrinsic, extrinsic, and situational factors.
To the extent possible, optimize treatment of comorbidities and contributing conditions, modify or eliminate causative medications, and correct environmental hazards.
Emphasize the need to eliminate environmental hazards that commonly increase fall risk (eg, throw rugs, inadequate lighting, lack of grab bars and handrails, unstable furniture, clutter).
Use multifactorial interventions for patients who have fallen more than once or have abnormalities in initial gait or impaired balance; interventions include referral for physical therapy and exercise programs, which are most effective when tailored and continued for ≥ 3 months.
High-risk disorders such as Parkinson disease often require targeted treatment (eg, physical therapy, assistive devices) to reduce fall risk.
Teach patients techniques to get up after a fall, especially when they are alone, and the importance of having a phone or emergency alert device accessible from the floor.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Cochrane: Interventions for preventing falls in older people living in the community: Podcast, transcript, and full article can be accessed from this web site; the effects of these interventions is also assessed.
American Family Physician: Preventing falls in older persons: This article discusses what preventive strategies for various populations of older adults (eg, community-dwelling older adults, those who have fallen). It provides an algorithm for fall risk assessment and interventions in older adults and links to patient information.
Centers for Disease Control and Prevention: STEADI (Stopping Elderly Accidents, Deaths, & Injuries): This web site includes materials for health care practitioners to help them screen, assess, and intervene to reduce fall risk by giving older adults interventions tailored to their needs.
