Falls in the elderly
Falls in the Elderly
White House Medical Clinic, Washington, D.C.
Falls are the leading cause of injury-related visits to emergency departments in the United States and the
primary etiology of accidental deaths in persons over the age of 65 years. The mortality rate for falls
increases dramatically with age in both sexes and in all racial and ethnic groups, with falls accounting for
70 percent of accidental deaths in persons 75 years of age and older. Falls can be markers of poor health
and declining function, and they are often associated with significant morbidity. More than 90 percent of
hip fractures occur as a result of falls, with most of these fractures occurring in persons over 70 years of
age. One third of community-dwelling elderly persons and 60 percent of nursing home residents fall each
year. Risk factors for falls in the elderly include increasing age, medication use, cognitive impairment and
sensory deficits. Outpatient evaluation of a patient who has fallen includes a focused history with an
emphasis on medications, a directed physical examination and simple tests of postural control and overall
physical function. Treatment is directed at the underlying cause of the fall and can return the patient to
baseline function. (Am Fam Physician 2000; 61:2159-68,2173-4.)
Elderly patients who have fallen should undergo a thorough evaluation. Determining and treating the
underlying cause of a fall can return patients to baseline function and reduce the risk of recurrent falls.
These measures can have a substantial impact on the morbidity and mortality of falls. The resultant gains
in quality of life for patients and their caregivers are significant.
Epidemiology of Falls in the Elderly
From 1992 through 1995, 147 million injury-related
visits were made to emergency departments in the United CATASTROPHE: A Mnemonic for
States.1 Falls were the leading cause of external injury,
accounting for 24 percent of these visits.1 Emergency
department visits related to falls are more common in
children less than five years of age and adults 65 years of The rightsholder did not grant rights to
reproduce this item in electronic media. For
age and older. Compared with children, elderly persons
the missing item, see the original print version
who fall are 10 times more likely to be hospitalized and
eight times more likely to die as the result of a fall.2
Trauma is the fifth leading cause of death in persons more than 65 years of age,3 and falls are responsible
for 70 percent of accidental deaths in persons 75 years of age and older. The elderly, who represent 12
percent of the population, account for 75 percent of deaths from falls.4 The number of falls increases
progressively with age in both sexes and all racial and ethnic groups.5 The injury rate for falls is highest
among persons 85 years of age and older (e.g., 171 deaths per 100,000 white men in this age group).6
Annually, 1,800 falls directly result in death.7 Approximately 9,500 deaths in older Americans are
Elderly persons who survive a fall experience significant morbidity. Hospital stays are almost twice as
long in elderly patients who are hospitalized after a fall than in elderly patients who are admitted for
another reason.9 Compared with elderly persons who do not fall, those who fall experience greater
functional decline in activities of daily living (ADLs) and in physical and social activities,10 and they are at
greater risk for subsequent institutionalization.11
Falls and concomitant instability can be markers of poor health and declining function.12 In older patients,
a fall may be a nonspecific presenting sign of many acute illnesses, such as pneumonia, urinary tract
infection or myocardial infarction, or it may be the sign of acute exacerbation of a chronic disease.13 About
one third (range: 15 to 44.9 percent) of community-dwelling elderly persons and up to 60 percent of
nursing home residents fall each year; one half of these "fallers" have multiple episodes.14 Major injuries,
including head trauma, soft tissue injuries, fractures and dislocations, occur in 5 to 15 percent of falls in
any given year.15 Fractures account for 75 percent of serious injuries, with hip fractures occurring in 1 to 2
In 1996, more than 250,000 older Americans suffered fractured hips, at a cost in excess of $10 billion.
More than 90 percent of hip fractures are associated with falls, and most of these fractures occur in
persons more than 70 years of age.8 Hip fracture is the leading fall-related injury that results in
hospitalization, with these hospital stays being significantly prolonged and costly.16 It is projected that
more than 340,000 hip fractures will occur in the year 2000, and this incidence is expected to double by
Risk Factors for Falls
Chronic conditions, especially neuromuscular disorders
Medications, especially the use of four or more prescription drugs (see Table 4)
Reduced vision, including age-related changes (i.e., decline in visual acuity, decline in accommodative
capacity, glare intolerance, altered depth perception, presbyopia [near vision], decreased night vision,
Neurologic changes, including age-related changes (i.e., postural instability; slowed reaction time;
diminished sensory awareness for light touch, vibration and temperature; decline of central integration of
visual, vestibular and proprioceptive senses)
Decreased hearing, including age-related changes (i.e., presbycusis [increase in pure tone threshold,
predominantly high frequency], impaired speech discrimination, excessive cerumen accumulation)
Information from Studenski S, Wolter L. Instability and falls. In: Duthie EH Jr, Katz PR, eds. Practice of geriatrics. 3d ed. Philadelphia: Saunders, 1998:199-206, and Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995;43:1214-21.
One fourth of elderly persons who sustain a hip fracture die within six months of the injury. More than 50
percent of older patients who survive hip fractures are discharged to a nursing home, and nearly one half
of these patients are still in a nursing home one year later.18 Hip fracture survivors experience a 10 to 15
percent decrease in life expectancy and a meaningful decline in overall quality of life.
Most falls do not end in death or result in significant physical injury. However, the psychologic impact of
a fall or near fall often results in a fear of falling and increasing self-restriction of activities. The fear of
future falls and subsequent institutionalization often leads to dependence and increasing immobility,
followed by functional deficits and a greater risk of falling.
Accident, environmental hazard, fall from bed
Sedative-hypnotic and anxiolytic drugs (especially
Gait disturbance, balance disorders or weakness,
Central nervous system disorder, syncope, drop
Hypoglycemic agents Any medication that is likely to affect balance
*--Listed in approximate order of occurrence. Adapted with permission from Rubenstein LZ. Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Ambulatory geriatric care. St. Louis: Mosby, 1993: 296-304.
Evaluation of the Elderly Patient Who Falls
Elderly patients with known risk factors for falling should be questioned about falls on a periodic basis.
Specific inquiry is necessary because of the fears many elderly persons harbor about being
institutionalized. Thus, these patients are unlikely to give
If an elderly patient falls more than twice
A single fall is not always a sign of a major problem and an
in a six-month period, an evaluation for treatable causes should be undertaken.
increased risk for subsequent falls. The fall may simply be an
isolated event. However, recurrent falls, defined as more than
two falls in a six-month period, should be evaluated for treatable causes. An immediate evaluation is
required for falls that produce injuries or are associated with a new acute illness, loss of consciousness,
A thorough history is essential to determine the mechanism of falling, specific risk factors for falls,
impairments that contribute to falls and the appropriate diagnostic work-up. Many patients attribute a fall
to "just tripping," but the family physician must determine if the fall occurred because of an
environmental obstacle or another precipitating factor.
The physician should ask about the activity the patient was engaged in just before and at the time of the
fall, especially if the activity involved a positional change. The location of the fall should be ascertained.
It is also important to know whether anyone witnessed the fall and whether the patient sustained any
injuries. The patient and, if applicable, witnesses or caregivers should be asked in detail about previous
falls and whether the falls were the same or different in character. The physician also needs to determine
The mnemonic CATASTROPHE is helpful for recalling the principal items in a functional inquiry (Table
Risk Factor Assessment
The frequency of falling is related to the
The risk of sustaining an injury from a fall depends on the
accumulated effect of multiple disorders superimposed on age-related changes.
individual patient's susceptibility and environmental hazards.
The frequency of falling is related to the accumulated effect of
multiple disorders superimposed on age-related changes. The literature recognizes a myriad of risk factors
for falls (Table 2)
.20,21 The likelihood of falling increases with the number of risk factors.22
The risk factors responsible for a fall can be intrinsic (i.e., age-related physiologic changes, diseases and
medications) or extrinsic (i.e., environmental hazards). It is essential to remember that a single fall may
have multiple causes, and repeated falls may each have a different etiology. Thus, it is critical to evaluate
The Changing Approach to Falls in the Elderly
A = Patient with an accidental fall and no intrinsic or extrinsic risk factors
C = Patient with moderate illness, loss of mobility and some prescription
medications who falls because of an extrinsic factor
D = Severely ill patient with many medications who falls even without extrinsic
E = Elderly patient with numerous age-related changes who falls because of an
Factors that contribute to the risk of falls in the elderly population.
Adapted with permission from Steinweg KK. The changing approach to falls in
t e elderly. Am Fam Physician 1997;56:1815-22,1823.
Normal physical and mental changes related to aging (but not associated with disease)
decrease functional reserve. As a result, elderly patients become more susceptible to falls when they are
Some age-related changes are not necessarily "normal," but they are modifiable. When possible, these
Virtually any acute or chronic disease can cause or contribute to falls. The most common etiologies of
Polypharmacy (four or more prescription medications), the initiation of a new drug treatment in the previous two weeks and
A critical element of the targeted history is a review of
medications, including prescription, over-the-counter, herbal
and illicit drugs. Red flags are polypharmacy (four or more
prescription medications),24 the initiation of a new drug therapy
in the previous two weeks25 and the use of any drug listed in Table 4.
Tricyclic antidepressants and other heterocyclic antidepressants have long been associated with an
increased risk for falls. The selective serotonin reuptake inhibitor (SSRI) antidepressants are largely free
of the side effects of tricyclic antidepressants and have been presumed to be safer for use in persons at
high risk for falling. However, a recent large study of almost 2,500 nursing home residents found little
difference in the rate of falls between patients receiving tricyclic antidepressants and those receiving
SSRIs.26 Thus, the physician needs to maintain a high index of suspicion when reviewing the medications
In a fall, more active persons are likely TABLE 5
to be exposed to high-intensity forces at impact, whereas I HATE FALLING: A Mnemonic for
the risk of injury in less active persons depends more on
their susceptibility (i.e., the presence of fragile bones or
ineffective protective responses).27 Frail elderly persons
tend to fall and injure themselves in the home during the
course of routine activities. Vigorous older persons are
Inflammation of joints (or joint deformity)
more likely to participate in dynamic activities and to fall H
Hypotension (orthostatic blood pressure
and be injured while challenged by environmental
Auditory and visual abnormalities
hazards such as stairs or unfamiliar areas away from
Tremor (Parkinson's disease or other
Equilibrium (balance) problem
A variety of extrinsic factors, such as poor lighting,
unsafe stairways and irregular floor surfaces, are
Arrhythmia, heart block or valvular disease
involved in falls among the elderly. Many of these
Lack of conditioning (generalized
shows how intrinsic and extrinsic factors can
Nutrition (poor; weight loss)
combine to change the likelihood of falling in the elderly G
Adapted with permission from Sloan JP. Mobility failure. In: Protocols in primary care
A mnemonic (I HATE FALLING) can be used to remind geriatrics. New York: Springer, 1997:33-8. the physician of key physical findings in patients who fall or nearly fall (Table 5)
.19 This mnemonic focuses the
physician's attention on common problems that are likely to respond to treatment. Most falls have
multiple causes. Only rarely are all of the causes fully reversible. Nonetheless, a partial positive impact on
one or a few causes often makes a major difference in quality of life for the patients and caregivers.
A home visit is invaluable for assessing modifiable risk factors and determining appropriate interventions.
A home safety checklist can guide the visit and ensure a thorough evaluation (Figure 2)
.23 It is particularly
important to assess caregiver and housing arrangements, environmental hazards, alcohol use and
An algorithm for the evaluation of falls is presented in Figure 3.
Home Safety Checklist
All living spaces
_____ Install grab bars in the bathtub or shower
_____ Remove low furniture and objects on the
_____ Use rubber mats in the bathtub or shower.
_____ Take up floor mats when the bathtub or
_____ Remove cords and wires on the floor.
_____ Check lighting for adequate illumination at
night (especially in the pathway to the bathroom).
_____ Secure carpet or treads on stairs.
_____ Install handrails on stairs and steps.
_____ Eliminate chairs that are too low to sit in and _____ Trim shrubbery along the pathway to the get out of easily.
_____ Avoid floor wax (or use nonskid wax).
_____ Install adequate lighting by doorways and
_____ Ensure that the telephone can be reached
Checklist for evaluating safety during the home visit.
Adapted with permission from Rubenstein LZ. Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K,
e s. Ambulatory geriatric care. St. Louis: Mosby, 1993:296-304.
Balance and Gait Testing.
Postural control is a complex task that involves balance, ambulation capability,
endurance, range of motion, sensation and strength. Several simple tests have exhibited a strong
correlation with a history of falling. These functional balance measures are quantifiable and correlate well
with the ability of older adults to ambulate safely in their environment. The tests can also be used to
measure changes in mobility after interventions have been applied.
One-leg balance is tested by having the patient stand unassisted on one leg for five seconds. The patient
chooses which leg to stand on (based on personal comfort), flexes the opposite knee to allow the foot to
clear the floor and then balances on one leg for as long as possible. The physician uses a watch to time the
patient's one-leg balance.30 This test predicts injurious falls but not all falls.
Evaluation of Falls
Suggested algorithm for the evaluation of falls in the elderly.
The timed "Up & Go" test evaluates gait and balance (Table 6).
31 The patient gets up out of a standard
armchair (seat height of approximately 46 cm [18.4 in.]), walks a distance of 3 m (10 ft.), turns, walks
back to the chair and sits down again. The patient wears regular footwear and, if applicable, uses any
customary walking aid (e.g., cane or walker). No physical assistance is given. The physician uses a
stopwatch or a wristwatch with a second hand to time this activity. A score of 30 seconds or greater
indicates that the patient has impaired mobility and requires assistance (i.e., has a high risk of falling).
This test has been shown to be as valid as sophisticated gait testing.
Timed "Up & Go" Test
Get up out of a standard armchair (seat height of approximately 46 cm [18.4 in.]), walk a distance of 3 m (10 ft.), turn, walk back to the chair and sit down again.
Ambulate with or without assistive device and follow a three-step command.
One practice trial and then three actual trials. The times from the three actual trials are averaged.
Armchair, stopwatch (or wristwatch with a second hand) and a measured path
Adapted with permission from Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.
A simpler alternative is the "Get-Up and Go" test.32 In this test, the patient is seated in an armless chair
placed 3 m (10 ft.) from a wall. The patient stands, walks toward the wall (using a walking aid if one is
typically employed), turns without touching the wall, returns to the chair, turns and sits down. This
activity does not need to be timed. Instead, the physician observes the patient and makes note of any
Interventions to Reduce the Risk of Falls in the Elderly
Behavioral recommendations, such as ankle pumps or hand
systolic blood pressure of >=20 mm clenching and elevation of the head of the bed Hg or to <90 mm Hg on standing
Decrease in the dosage of a medication that may contribute to hypotension; if necessary, discontinuation of the drug or
substitution of another medication Pressure stockings If indicated, fludrocortisone (Florinef), in a dosage of 0.1 mg two or three times daily, to increase blood pressure If indicated, midodrine (ProAmatine), in a dosage of 2.5 to 5 mg three times daily, to increase vascular tone and blood pressure
Education about appropriate use of sedative-hypnotic drugs
Nonpharmacologic treatment of sleep problems, such as sleep restriction Tapering and discontinuation of medications
Environmental hazards for falling or Home safety assessment with appropriate changes, such as tripping
removal of hazards, selection of safer furniture (correct height, more stability) and installation of structures such as grab bars in bathrooms or handrails on stairs
Gait training Use of an appropriate assistive device Balance or strengthening exercises if indicated
Balance exercises and training in transfer skills if indicated
Environmental alterations, such as installation of grab bars or raised toilet seats
Exercises with resistive bands and putty resistance training two or
three times a week, with resistance increased when the patient is
able to complete 10 repetitions through the full range of motion
Adapted with permission from Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7.
In watching patients perform the "Up & Go" test or the "Get-Up and Go" test, the physician should
consider the following questions: How safe does this activity appear for this patient? Are there any tip-
offs to remediable causes of impaired mobility?
Critical Steps in Reducing the
Risk of Falls in the Elderly
Eliminate environmental hazards. Improve home supports. Provide opportunities for socialization and encouragement. Modify medication. Provide balance training. Modify restraints.
Overall physical function should also be assessed. This is
accomplished by evaluating the patient's ADLs and
instrumental activities of daily living (IADLs). An
Adapted with permission from Speechley M,
alternative is the Physical Performance Test (PPT).33 This
Tinetti M. Falls and injuries in frail and vigorous community elderly persons. J Am
performance-based test includes seven usual daily
activities. The patient is asked to write a sentence, lift a
book, put on and take off a jacket, pick up a penny, turn
360 degrees and walk about 15 m (50 ft.). The physician evaluates the performance of these activities to
determine whether the patient is at increased risk for recurrent falls. If a problem is detected, the
physician should institute measures to prevent falls, such as reducing medications (when possible),
improving environmental safety and encouraging exercise that improves balance.
Prevention of Falls
When the cause of a fall is not determined or a patient remains at high risk for falls, referral to a falls
prevention program may be warranted. Recent studies have shown that such programs can reduce the rate
of falls in the elderly. In one study,34 the interactive group had a relative risk of falling of 0.39 compared
with the control group. Interventions included the modification of environmental hazards and the
evaluation and treatment of blood pressure, vision problems and mental status changes, including
depression. Interventions that may be successful in reducing falls are listed in Table 7.
An outpatient assessment using the tools outlined in this article can allow the primary care physician to
identify risk factors quickly and accurately, and to assess the patient who has fallen or nearly fallen.
Critical steps in reducing the risk of falls in the elderly are listed in Table 8.
Members of various family practice departments develop articles for "Problem-Oriented Diagnosis." This
article is one in a series coordinated by the Department of Family Medicine at the Uniformed Services
University of the Health Sciences, Bethesda, Md. Guest editors of the series are Francis G. O'Connor,
LTC, MC, USA, and Jeannette E. South-Paul, COL, MC, USA.
The opinions and assertions contained herein are the private views of the author and are not to be
construed as official or as reflecting the views of the Army Medical Department or the Army Service at
is currently White House physician and deputy director for clinical operations. He is also assistant
professor of family medicine at the Uniformed Services University of the Health Sciences F. Edward
Hébert School of Medicine, Bethesda, Md., where he earned his medical degree. Dr. Fuller completed a
residency in family practice at Hays Army Hospital, Fort Ord, Calif., and a fellowship in geriatric
medicine at American Lake Veterans Affairs Medical Center, Tacoma, Wash.
Address correspondence to George F. Fuller, COL, MC, USA, Old Executive Office Building, Room 105,
17th and Pennsylvania Ave. NW, Washington, DC 20502-0041. Reprints are not available from the
Burt CW, Fingerhut LA. Injury visits to hospital emergency departments: United States, 1992-95. Vital
Runge JW. The cost of injury. Emerg Med Clin North Am 1993;11:241-53.
Weigelt JA. Trauma. In: Advanced trauma life support for doctors: ATLS. 6th ed. Chicago: American
Greenhouse AH. Falls among the elderly. In: Albert ML, Knoefel JE, eds. Clinical neurology of aging. 2d
ed. New York: Oxford University Press, 1994:611-26.
Tibbits GM. Patients who fall: how to predict and prevent injuries. Geriatrics 1996;51:24-8,31.
Sattin RW. Falls among older persons: a public health perspective. Annu Rev Public Health 1992; 13:489-
Dial LK. Falls. In Sadovsky R, ed. Conditions of aging. Baltimore: Williams & Wilkins, 1999:119-26.
Capezuti E. Falls. In: Lavizzo-Mourey RJ, Forciea MA, eds. Geriatric secrets. Philadelphia: Hanley &
Dunn JE, Rudberg MA, Furner SE, Cassel CK. Mortality, disability, and falls in older persons: the role of
underlying disease and disability. Am J Public Health 1992;82:395-400.
Kiel DP, O'Sullivan P, Teno JM, Mor V. Health care utilization and functional status in the aged following
Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls among elderly
Tinetti ME, Inouye SK, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional
dependence. Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-53.
Rabin DW. Falls and gait disorders. In: Abrams WB, Beers MH, Berkow R, eds. The Merck manual of
geriatrics. 2d ed. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 1995:65-78.
Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH. The natural history of functional morbidity in
hospitalized older patients. J Am Geriatr Soc 1990;38:1296-303.
King MB, Tinetti ME. A multifactorial approach to reducing injurious falls. Clin Geriatr Med 1996:
Mahoney JE. Immobility and falls. Clin Geriatr Med 1998;14:699-726.
Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health care utilization and costs in
a Medicare population by fall status. Med Care 1998;36:1174-88.
Coogler CE, Wolf SL. Falls. In: Hazzard WR, et al., eds. Principles of geriatric medicine and gerontology.
4th ed. New York: McGraw-Hill, 1999:1535-46.
Sloan JP. Mobility failure. In: Protocols in primary care geriatrics. 2d ed. New York: Springer, 1997:33-8.
Studenski S, Wolter L. Instability and falls. In: Duthie EH Jr, Katz PR, eds. Practice of geriatrics. 3d ed.
Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in
the community. J Am Geriatr Soc 1995; 43:1214-21.
Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk PT, et al. A multifactorial intervention
to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331:821-7.
Rubenstein LZ. Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Ambulatory geriatric care. St.
Svensson ML, Rundgren A, Larsson M, Oden A, Sund V, Landahl S. Accidents in the institutionalized
elderly: a risk analysis. Aging [Milano] 1991; 3:181-92.
Wells BG, Middleton B, Lawrence G, Lillard D, Safarik J. Factors associated with the elderly falling in
intermediate care facilities. Drug Intell Clin Pharm 1985;19:142-5.
Thapa PB, Gideon P, Cost TW, Milam AB, Ray WA. Antidepressants and the risk of falls among nursing
home residents. N Engl J Med 1998;339:875-82.
Kiel DP. The evaluation of falls in the emergency department. Clin Geriatr Med 1993;9:591-9.
Speechley M, Tinetti M. Falls and injuries in frail and vigorous community elderly persons. J Am Geriatr
Steinweg KK. The changing approach to falls in the elderly. Am Fam Physician 1997;58:1815-23.
Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an
important predictor of injurious falls in older persons. J Am Geriatr Soc 1997;45:735-8.
Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly
persons. J Am Geriatr Soc 1991;39:142-8.
Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the "get-up and go" test. Arch Phys Med
VanSwearingen JM, Paschal KA, Bonino P, Chen TW. Assessing recurrent fall risk of community-
dwelling, frail older veterans using specific tests of mobility and the physical performance test of function. J Gerontol A Biol Sci Med Sci 1998;53: M457-64.
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial
(PROFET): a randomised controlled trial. Lancet 1999;353:93-7.
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