Prevention of Falls in Community-Dwelling Older Adults

Abstract

A 79-year-old woman presents for her annual wellness visit. She reports having fallen 9 months ago and again a few weeks ago. She does not remember the details of the first fall, but for the second fall, she notes having tripped over uneven pavement while walking outside of her home. Despite some difficulty, she was able to get up unassisted and did not seek medical attention; she recalls having taken an overthe-counter "sleep aid" the night before. She said she has no fear of falling, dizziness, or loss of consciousness. Office staff perform a Timed Up and Go test, and it takes her 15 seconds to complete the test (≥12 seconds indicates an increased risk of falls). How would you evaluate this patient and manage the risk of future falls? The Clinic a l Problem F alls, defined as "an unexpected event in which the participants come to rest on the ground, floor, or lower level," 1 occur at least once annually in 29% of community-dwelling adults 65 years or older-a rate of 0.67 falls per person per year. 2 Population-based studies suggest that 10% of older adults fall at least twice annually 3 ; patients regularly visiting clinician offices are presumed to be more likely to belong to this high-risk group, given the prevalence of diseases and impairments that increase the risk of falling. After falling, a quarter of older adults restrict their activity for at least a day or seek medical attention. 2 More serious injuries, such as fractures, joint dislocations, sprains or strains, and concussions, occur in approximately 10% of falls. 4 Rhabdomyolysis due to muscle ischemia can develop in persons who are unable to get up after a fall and are "found down" after a long period. After a fall, a fear of falling develops in 21 to 39% of those who previously had no such fear; persons who fear falling may restrict their activity and have a reduced quality of life. 5 In aggregate, fall injuries lead to 2.8 million emergency department visits and 800,000 hospital stays in the United States annually, 2 with total health care costs of $49.5 billion. 6 Most falls result from a combination of intrinsic risks (e.g., balance impairment) and extrinsic risks (e.g., trip or slip). Given the many contributors to the risk of falls, 7 focusing on the factors that are the final common pathways to falls and are those most commonly evaluated in randomized trials leads to a core set of risk factors (Table 1). 3,29 Deficits in gait and balance are the most prominent predisposing risk factors at the population level. Medications (including over-the-counter drugs), alcohol, visual deficits, impairments in cognition and mood, and environ-From the Geriatric Research, Education, and Clinical Center and the Center for the

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