Falls, a common and serious problem for the elderly, are associated with significant mortality, morbidity, decreased independent functioning, and premature admission to nursing homes.¹ The incidence and severity of complications related to falls increase steadily after age 60.¹ In 2001, more than 1.6 million seniors were treated in EDs for fall-related injuries.² Unintentional injury is the eighth leading cause of death in the elderly with two-thirds of these unintentional injuries resulting from falls.¹

About one-third of those older than 65 years of age fall each year, and almost half of those older than age 72 who live in the community experience falls.³ Hospitals and nursing homes have a fall incident rate almost three times higher than those living in the community — one study reported an incidence of 1.5 falls per bed annually for persons age 65 years and older.² While 20% of falls require medical attention, less than 10% result in fractures.⁴ Of this subset, individuals who sustain hip fractures are at greatest risk for such complications as immobility, disability, and death. Almost 50% of older persons who sustain a serious fall-induced injury never fully recover, and many lose independence for life.⁵

Physical therapists encounter the elderly across all practice settings. This broad exposure to the aging population allows therapists the opportunity to play a significant role in fall prevention by performing thorough fall risk assessments and developing individualized intervention plans. In-depth knowledge of fall risk factors, fall prevention measures, and post-fall assessment tools are essential for all clinicians.

Where Falls Occur

Falls occur everywhere — in one’s home, in the community, and in healthcare institutions.

Falls in the Community: For example, falls in the home usually take place in the bedroom, bathroom, living room, and on the stairs, most frequently while descending. These mishaps most commonly occur during routine activities of daily living. In a study that compared falls in the elderly at home and in the community, one group of investigators found that older persons who fell in and around their own homes were more likely to have their falls caused by factors such as frailty or unsteady gait.⁶

Decreased proprioception and quadricep muscle strength diminish the lateral stability necessary for transfers and activities of daily living.⁶ They also discovered that falls that occurred away from home were primarily due to environmental causes, such as uneven ground or poor lighting. The researchers concluded that both frail and vigorous elderly persons are at risk, and that the risk for falls increases even for the vigorous elderly when they are away from familiar surroundings.⁷

Falls in Healthcare Settings: Falls in the acute care hospital setting have been reported at a rate of 2.6 falls for every 1,000 bed days, but they may vary with patient populations.⁸ They can also be linked to medications, illness severity, and the use of physical and chemical restraints. Research has shown that restraints do not decrease the number of falls or protect a person from injury. In fact, the risk for serious injury may actually increase when restraints are used.^9,10,11 Restraints further promote immobility and lead to muscle wasting, diminished bone density, and pulmonary atelectasis. They are also demoralizing and can interfere with sensory stimulation, leading to disorientation and confusion.

In long-term care settings like nursing homes, falls account for 40% of all admissions.¹² Residents with the greatest risk of falling include those with gait or balance instability, polypharmacy, orthostatic hypotension, dementia/delirium, and other comorbidities.¹³ The rate of fall-related injury is 10% to 25% in this setting, most commonly from fractures and lacerations.¹

The Culprits Within

Falls in the elderly are typically multifactorial, owing to a combination of intrinsic (internal) or extrinsic (environmental) causes. Normal, age related physiological changes in sensory, neurological, cognitive, and musculoskeletal functions are intrinsic factors that predispose the elderly to falls. Some normal age-related changes linked to falls include visual impairment, dementia, depression, anxiety, and reduced righting reflexes.

Neurological diseases, such as stroke with hemiparesis, Parkinson’s disease, dementia, seizures, peripheral neuropathies, and vestibular dysfunction can impair mobility and also predispose the elderly to falls. The effects of musculoskeletal disorders, including arthritic conditions that weaken muscles, bones, or joints,⁶ along with metabolic conditions of hypothyroidism, hypoglycemia, electrolyte imbalances, and diabetes, also increase the risk for falls. The most common intrinsic cardiovascular age-related risk factor is orthostatic hypotension. Orthostasis is a transient reduction in the systolic blood pressure of at least 20 mmHg that occurs when a person assumes an upright position after sitting or lying down. Certain drugs, such as antihypertensive or diuretic medications, and disorders of vascular volume depletion (e.g., diarrhea, dehydration, and gastrointestinal bleeding) cause orthostasis. Hypotension reduces brain blood flow, predisposing an individual to dizziness or fainting. Syncopal syndromes, such as cardiac syncope associated with cardiac dysrhythmias, postmicturition syncope, cough syncope following paroxysmal coughing, and carotid syncope related to carotid sinus hypersensitivty,¹⁴ can also trigger fall-inducing hypotensive episodes.

Research has demonstrated that the risk for falls increases when the older person is taking more than four medications.¹⁵ Sedatives, antidepressants, anxiolytics, and long-acting psychotropic agents are among the most commonly prescribed drugs for the elderly population. Their adverse effects can include confusion and sedation. Diuretics and antihypertensives often produce postural hypotension and fatigue. Other agents, such as aspirin, aminoglycosides, alcohol, and tobacco can negatively affect balance and vestibular function, resulting in falls.

Finally, the elderly’s state of mind can play an important part in falls. Any condition that impairs safe judgment can lead to a high-risk situation for an older adult. Fear, anxiety, depression, delirium, and dementia can interfere with the ability to accurately assess the environment for hazards.

And an unwillingness to accept physical limitations and reluctance to seek assistance with certain tasks may also lead to accidents.  Consider the elderly man on a ladder outdoors — in the snow — preparing to fix the house gutters. Normal age-related changes like poor vision, decreased strength, limited range of motion, slowed reaction time, diminished balance, and hazardous weather conditions set the stage for catastrophic injury as a result of falling from a height.

The daily living space of the elderly often presents extrinsic safety hazards. Slippery floors, poor lighting, loose rugs, cluttered pathways, inclement weather and uneven walking surfaces are prescriptions for danger. Daily activities commonly associated with falls are transfers on and off beds or chairs and trips to the bathroom.¹⁶ Fall prevention strategies can be determined once these high-risk conditions in the home setting have been assessed. Educating patients about these hazards is an important measure for primary prevention.

Fall Consequences

Serious physical consequences of falling can include fatality and or fractures. Fractures typically involve one or more of the following bones: the pelvis, hip, femur, vertebrae, humerus, hand, forearm, or ankle.¹⁷ Falls are also the second leading cause of spinal cord and traumatic brain injury among older persons.¹⁷ Thirty percent to 50% of individuals who fall sustain soft tissue injuries, such as hematomas, sprains, and dislocations. Additionally, the elderly patient whose mobility is restricted during recovery from a fall is at risk for life-threatening complications of immobility, such as pneumonia, pulmonary embolism, and sepsis.

The psychological and social consequences of falls can also be devastating to patients and their families. Falls commonly trigger fear, anxiety, and depression in the elderly. Loss of confidence experienced after a fall can be catastrophic. Fear of repeated falls can diminish a person’s self-confidence in his or her ability to maintain safe mobility skills leading to self-imposed restriction on functional activities.¹ In one study, serious falls produced feelings of confinement, helplessness, aging, and affected socialization and function.¹⁸ Patients may become unwilling to perform routine activities of daily living or participate in rehabilitation due to kinesiophobia. Loss of independence due to immobility produces social isolation, dependency, and even institutionalization.¹⁹ Consider the following case example and efforts of the team approach.

Case Example

Mrs. Cane is a 72-year-old widow who lives with her daughter. Although she enjoys good health, her medical history includes osteoporosis and chronic constipation for which she takes various bowel preparations and multivitamins. She recently fractured her left humerus after a fall while getting out of bed. She was admitted to a nursing home for rehabilitation after her accident, but is responding poorly to attempts at skilled intervention. The physical therapist reports that Mrs. Cane is uncooperative, and refuses to participate in an exercise and gait-training regime. She is also unwilling to ambulate to the bathroom or go to the dining room for meals. She expresses fear of further falls while attempting to transfer out of bed. She refuses antidepressant medication and rebuffs any reassurance or offers of assistance made by the staff. Mrs. Cane has become deconditioned and has developed pressure ulcers, muscle atrophy, and urosepsis as a result of her diminished mobility.

Team Approach

At a multidisciplinary meeting, the patient care team developed a treatment strategy to include bedside physical therapy treatments and nursing intervention for bed positioning, muscle strengthening, transfer training, and improved cardiovascular endurance. The aid of a psychologist was enlisted to help the patient work through her fear of recurrent falls.

A dietitian was also called in to visit Mrs. Cane daily and encourage her to eat a well-balanced diet, including nutritional supplements. Although Mrs. Cane had to remain in the nursing home, she recovered the ability to ambulate in the halls with a walker and supervision. She now smiles and jokes with the staff and enjoys her daughter’s visits.

Case Discussion

Functional losses, such as those experienced by Mrs. Cane, are a significant consequence of falls. They can be a direct result of fall-induced injuries or be psychological in origin. Restricted mobility is associated with muscle weakness, incontinence, compromised skin integrity, pressure ulcers, dehydration, impaired appetite and malnutrition, and a generalized debilitated state.

Evaluating Falls

A comprehensive physical therapy fall evaluation includes a post-fall injury assessment and investigation of the cause of the fall. This includes a systematic appraisal of intrinsic risk factors obtained from the medical history and patient records. A fall is often the first indication of an acute underlying condition, such as infection, transient ischemic attack, or cardiac diseases so it is vital to perform a thorough medical history review and assessment.

An exacerbation of a chronic disease, such as congestive heart failure, can also precipitate an accident. Almost 10% of falls in the community and 25% in institutions are related to an acute illness.²⁰ Fall assessments should also include evaluation of extrinsic factors such as the proper use and condition of assistive devices and braces. Type and condition of footwear must also be considered.

Often, one fall predisposes a patient to more falls. Assessment should focus on identifying fall predictors such as recent changes in cardiovascular, pulmonary, musculoskeletal, or mental status. These findings, combined with a review of the patient’s records for preexisting conditions, medication use, and previous history of falls can yield important information for future fall prevention.

Therapists should assess the location of the fall for modifiable environmental hazards and determine the activity the patient was engaged in at the time of the fall, for example, hurrying to the bathroom after taking a diuretic, standing up quickly, or while negotiating stairs without a railing. If the fall occurred in an institution, incident reports can track an individual’s fall history and the effectiveness of past intervention measures.

The Joint Commission Develops National Patient Safety Goal Related to Patient Falls

The issue of patient falls was selected by The Joint Commission as one of their National Patient Safety Goals for 2005. While not focusing specifically on the elderly, the goal considers all patients who, for reasons discussed below, are at risk for falling. National Patient Safety Goals are developed from recommendations made in The Joint Commission’s patient safety newsletter, Sentinel Event Alert. Aggregated information from the sentinel event database forms the derivation of National Patient Safety Goals.²¹ Falls accounted for approximately 4.6% of the sentinel events reviewed by The Joint Commission through the end of 2003. The goal related to patient falls is applicable to assisted living facilities, critical access hospitals, home care organizations, hospitals, and long-term care facilities. All accredited entities were expected to be in compliance with goal requirements by January 1, 2005.²²

The National Patient Safety Goal relating to falls states that organizations should reduce the risk of patient harm resulting from falls. The compliance requirement mandates organizations to assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks.

A thorough assessment identifies patients at risk for falls and allows a proactive approach. An assessment tool listing fall risks, including previous history of falls, cognitive impairment, impaired balance or mobility, musculoskeletal problems, chronic diseases, nutritional problems, and use of multiple medications, allows therapists to evaluate a patient’s fall potential and take appropriate action based upon the results. The Joint Commission is especially focused on the effect the patient’s medications will have on the assessed risk for falling.

Compliance measures and risk reduction strategies advocated in The Joint Commission's National Patient Safety Goals include installing bed alarms, offering fall prevention education to appropriate patients/residents, using low beds for those at risk for falls, ensuring adequate staffing is in place, and educating staff on fall prevention strategies and risk reduction measures. Creating a fall prevention committee to look at fall statistics, determine trends and patterns in falls, and evaluate and modify current policy based on the analysis is also advocated.²²

Implementation of a risk-oriented fall assessment tool, following through on actions dictated by assessment results, and initiating applicable risk reduction measures will help an organization successfully comply with the goal requirements.

Prevention Measures

The approach to prevention is multidisciplinary, including input from nursing, medicine, nutrition, social work, and physical/occupational therapy staff. Preventive measures seek to minimize risk of falling while also maintaining functional independence and mobility. Long-term care institutions formally assess patients’ functional status and the related nursing care needs through the Minimum Data Set (MDS). The MDS is mandated by the Centers for Medicare and Medicaid (formerly Healthcare Finance Administration [HCFA]) and is enforced by state health departments. It addresses fall risk and triggers a plan of care that is initiated upon admission for every patient. It is then routinely reviewed and revised. Additionally, many acute-care and long-term care institutions have risk management departments that also monitor fall incidents and prevention strategies. All members of the multidisciplinary team need to be vigilant in identifying and reporting any unsafe conditions that they notice within their facilities. Patients who demonstrate unsteady gait or experience difficulty making transfers should be identified and referred for evaluation by a physical or occupational therapist, who can further guide other team members in how to properly use assistive devices and reinforce instructions to the patient.

For the older person living at home, an assessment can identify environmental risks, and it offers the opportunity to educate the patient and his or her family about ways to improve home safety. Well-defined safety measures can promote self-confidence and reduce the fear of falls. One study found that home visits by professionals reduced falls by both modifying the environment and encouraging safer behavior in high-risk elders.²³ Safety measures include use of items such as nonskid rugs, handrails on stairs, grab bars near toilets and in bathtubs/shower stalls, and proper lighting conditions among others. Elders should be instructed to reduce clutter on the floor and tuck electrical or phone cords out of the way. They should also be advised to follow medication dosages closely and take all medications as directed. Moving commonly used items from high shelves to lower cabinets may help reduce the chance of falling while reaching or climbing.

Comprehensive prevention regimens should also include assessment and treatment of any underlying chronic or acute conditions with periodic reviews of medications, physical function, and mental status changes. Caregivers need to be aware of changes in patients’ nutritional and functional status as well as the use of medications that could prompt an increase in the risk of falls. In particular, staff must be attuned to subtle changes in patients’ vigor, social interactions, and ability to communicate – areas in which alterations could indicate functional decline.²³

Therapists can play a vital role in developing a patient’s self-efficacy – that is, confidence in the ability to perform daily activities without fear of falling. Self-efficacy, described in the Frailty and Injuries: Cooperative Study of Intervention Techniques (FICSIT) trials, is an important consideration in fall prediction and prevention.²⁴ Elders should be encouraged to discuss their concerns or fears of falling with the healthcare team. Caregivers can approach these fears through cognitive-behavioral interventions, including relaxation techniques and fall prevention strategies.²⁵ Regular exercise can improve balance and strength which has also been shown to be effective in preventing falls.

Safety education for those at risk of falls as well as their family members is critical in preventing falls and injuries. The elderly should be instructed to transfer slowly when getting out of bed and to sit on the side of the bed for a couple minutes before standing. Advise elders to notify their healthcare provider if their hearing, vision, or physical abilities deteriorate in any way. Also, advise them to avoid alcohol and sedatives and to notify their provider if their medications make them feel ill or weak. Healthcare professionals should routinely review their patients’ medications with them to ensure that drugs are being taken as prescribed, that certain medications and doses remain appropriate, and to consider the effects or interactions any over-the-counter medications may have if taken with the prescribed medication.

The American Geriatric Society recommends that healthcare professionals ask all older persons if they’ve experienced a fall.¹ A single incident should trigger a “Get Up and Go Test” (see sidebar) or Tinetti Assessment. These tests are reliable and generate objective scores predicting the risk of future falls.

Get Up and Go

The American Geriatric Society recommends that all older persons who report a single fall should be assessed using the “Get Up and Go Test.”¹ The test is used to identify intrinsic risk factors, such as lower extremity weakness, gait disorders, and poor vision and can be performed by ambulatory persons in any practice setting.²

Follow this procedure:^1,2

1. Seat the older person in a straight-backed chair and observe how he or she is seated. Look for slumping posture or leaning towards one side.
2. Ask the older person to stand. Is the motion smooth, does it take more than one try; does the person need to use his or her hands to push up off the seat? This maneuver assesses leg muscle strength.
3. Ask the person to remain standing with his or her eyes open and as still as possible. Then instruct the individual to stand with his or her eyes closed. Is the person able to stand without swaying?
4. Instruct the person to open his or her eyes and walk 10 feet, then turn and walk back to the chair. Observe the person’s gait, speed, and balance. If the person is impaired, you’ll observe a broad-based gait, small steps while turning, staggering, or limping.
5. Upon returning to the chair, instruct the person to turn and sit. Is the person’s motion smooth or does the person fall into the chair?

An alternative test is to time the get up and go action. Time the person doing the procedure three times and then calculate an average time. An average time of 30 seconds or more indicates impaired mobility while a 10 second to 19 second average time indicates almost complete independence.²

These scores can be used to track the effectiveness of skilled intervention strategies, revise treatment plans, and set new patient goals. Further assessment is needed if a problem is identified during testing.¹ A more thorough fall evaluation by a qualified clinician, such as a geriatrician, should be done if a patient seeks medical attention after a fall, reports more than one fall in a year, and/or has a gait and/or balance problem.¹ A collaborative effort by healthcare professionals, the older adult, and family members is key to identifying risk, developing and initiating an individualized fall prevention plan, evaluating the effectiveness of the plan, and revising it as needed. Preventing a fall is the best way of avoiding what could be a life-changing event.

Most falls in the elderly are predictable, preventable, and not due solely to the aging process. In spite of this data, many elderly people attribute their falls to the inevitable process of aging.²⁶ Fear of institutionalization and losing independence contribute to underreporting of falls. The FICSIT trials concluded that interventions aimed at those with the highest risk of falls could reduce their occurrence and improve the targeted elderly person’s quality of life.²³ Physical therapists and other healthcare professionals need to recognize those at risk and the many intrinsic and extrinsic factors that add to their danger.

Sidebar References:

1. Guidelines for the prevention of falls in older persons. American Geriatrics Society website. Available at: www.americangeriatrics.org/products/positionpapers/Falls.pdf. Accessed November 15, 2006.

2. Kimbell S. Before the fall. Nurs. 2001;31(8):44-45.

Web Resources

American Geriatric Society
The Empire State Building
350 Fifth Avenue, Suite 801
New York, NY 10118
Phone: (212) 308-1414
Fax: (212) 832-8646
www.americangeriatrics.org

National Institute on Aging
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD 20892
Phone: (301) 496-1752
www.nia.nih.gov