2016

1. FALLS IN OLDER ADULTS:
RISK ASSESSMENT AND
INTERVENTIONS
NEILA SHUMAKER M.D., UNIVERSITY OF NEVADA RENO SCHOOL OF MEDICINE
MERCE VENERACION, PT, CCI, SAN DIEGO PACE PROGRAM
KATRINA SOTO
JEREMY NELSON, MPT, EXCEL HOME HEALTH

2. NOT THIS KIND OF FALLS

3. NOR THIS KIND: ROCK FALL ON NEW
ZEALAND BEACH, WITNESSED BY
DAUGHTER AT GEOLOGY SITE

4. OBJECTIVES
• Recognize the importance of falls in older people
• Learn causes of geriatric falls
• Assess and manage fall risk

5. FALL DEFINITION: COMING TO REST
INADVERTENTLY ON THE GROUND OR
AT A LOWER LEVEL
• A fall is one of the most common events threatening the independence of older adults
• Most falls are not associated with loss of consciousness
• Falls are associated with:
 Decline in functional status
 Nursing home placement
 Increased use of medical services
 Fear of falling
• Half of those who fall are unable to get up without help (“long lie”) – this is a predictor of
lasting decline in functional status

6. COMPLICATIONS OF FALLS ARE THE
LEADING CAUSE OF DEATH FROM
INJURY IN PEOPLE AGED ≥65 YEARS
• 1 in 3 adults ≥ 65 years reports falling each year - one-half
of those > 80 years, one-half of nursing-home residents,
nearly 60% of those with a history of falls
• Most falls by older adults result in some injury
• 5%–10% of falls by older adults result in fracture or more
serious soft-tissue injury or head trauma
• Mortality is highest in white men aged ≥85. WHY DO YOU
THINK THAT IS?

7. COST OF FALLS – TO ELDERS,
CARERS, SOCIETY
•  Emergency department visits and hospitalizations; longer
length of stay
•  Indirect costs from fall-related injuries such as hip
fractures
• Costs of moving from independent living to institutional
setting
• Caregiver may stop working to take care of elder

8. FALLS ARE RARELY DUE TO A
SINGLE CAUSE
• Causes of falls are almost always multifactorial - due to
the accumulated effect of multiple impairments
(similar to other geriatric syndromes)
• Causes of falls are a complex interaction of:
Intrinsic factors (eg, chronic disease)
Challenges to postural control (eg, changing
position)
Mediating factors (eg, risk taking, situational
hazards)

9. FALLS CLINICAL GUIDELINES
• Ask all older adults about falls in the past year
• Single fall: check for balance or gait disturbance
• Recurrent falls or gait or balance disturbance:
 Pursue a multifactorial falls risk assessment
 For a summary of the recommendations of the expert panel on falls prevention
assembled by AGS and BGS, see www.americangeriatrics.org

10. PREHISTORIC FALLS WARNING SIGN:
FALLING MAN PETROGLYPH, GOLD
BUTTE AREA, SOUTHERN NEVADA

11. PREHISTORIC FALLS PREVENTION:
WALKING MAN PETROGLYPH, GOLD
BUTTE AREA, SOUTHERN NEVADA

12. CHALLENGE: ASSESSING FALLS
RISK IN THE HOME ENVIRONMENT
FROM YOUR OFFICE

13. INTRINSIC RISK FACTORS – FALL RISK
GOES UP WITH THE NUMBER OF
FACTORS
• Older age
• Cognitive impairment
• Female gender
• Past history of a fall
• Leg weakness or gait
problems
• Foot disorders
• Balance problems
• Hypovitaminosis D
• Pain
• Parkinson’s disease
• Stroke
• Arthritis

14. CHALLENGE: UNDERLYING HEALTH OF
BONE STRUCTURE IN THE ELDERLY

15. MEDICATIONS AND FALLS
• Specific classes, for example:
 Benzodiazepines
 Other sedatives
 Antidepressants
 Antipsychotic drugs
 Cardiac medications
 Hypoglycemic agents
• Recent medication dosage adjustments
• Total number of medications

16. FALLS HISTORY
• History of falls
• Activity at time of
fall(s)
• Prodromal
symptoms
• Location and time
of fall(s)
• Medication history
(new, changed,
high-risk meds)
• Lighting
• Floor coverings
• Railings
• Door threshholds
• Furniture
• Footwear

17. EVALUATION AFTER A FALL
• Evaluate for acute, subacute illness with history, general
exam, labs
• Do orthostatic BP, supine and standing
• Perform Dix-Hallpike maneuver if history suggests
vestibular component
• Visual acuity screen
• Examine neck, back, legs, feet for pain, deformities,
decreased range of motion, contractures, leg-length
discrepancy – measure the distance from the anterior
superior iliac spine to the medial malleolus

18. FALLS NEUROLOGIC EXAM
• Assess strength, tone, sensation (including proprioception),
coordination (including cerebellar function), station, and
gait
• Use a gait assessment tool (eg, timed Get Up and Go) to
determine a comfortable gait speed
• Perform the Romberg test to assess postural control and
whether the proprioceptive and vestibular systems are
functional
• Perform a cognitive screen such as the Cognistat or MoCA

19. FALLS INTERVENTIONS
• Multi-component interventions such as home safety assessment and
modifications, physical and occupational therapy, balance training
such as Tai Chi, vision correction and proper footwear have been
shown to be effective in some trials
• In the nursing-home setting, vitamin D supplementation has been
shown to decrease falls risk. Multicomponent interventions should be
considered in this setting as well
• Hip protectors have not been consistently shown to reduce hip
fractures in community dwelling or institutionalized older adults, and
most of the commercially available products have never been used in
clinical trials

20. GAIT DISORDERS PREDICT
FUNCTIONAL DECLINE
• Gait disorders are common and a predictor of functional decline in
older adults
• Age-related gait changes such as slowed speed are most apparent
after age 75 or 80; the prevalence of walking limitations in community
dwellers over 80 can be over 50%
• Age over 85, three or more chronic conditions at baseline, and the
occurrence of stroke, hip fracture, or cancer predict loss of walking
ability
• Community-dwelling older adults with gait disorders, particularly
neurologically abnormal gaits, are at higher risk of institutionalization
and death

21. SOME GAIT DISORDERS
• Antalgic gait - Pain-induced limp with shortened stance phase of gait on
painful side
• Trendelenburg gait - Shift of the trunk over affected hip, which drops due to
hip abductor weakness
• Circumduction - Outward swing of leg in semicircle from the hip
• Equinovarus - Excessive plantar flexion and inversion of the ankle
• Scissoring - Hip adduction such that the knees cross in front of each other with
each step
• Foot drop, Steppage gait - Loss of ankle dorsiflexion due to weakness of ankle
dorsiflexors
• Propulsion, Retropulsion, Festination, Freezing, Turn en bloc - Tendency to fall
forward or backward, accelerate, stop or slow suddenly, or move whole body
while turning – characteristic of Parkinsonism

22. PERIPHERAL SENSORY AND MOTOR
CAUSES OF GAIT DYSFUNCTION
• Peripheral neuropathy, proprioceptive deficits – loss of touch,
position sense – gait may be wide-based, unsteady, steppage
gait
• Vestibular disorders – disequilibrium (balance impairment) –
“drunken” gait - abnormal Romberg test
• Visual impairment – tentative gait
• Arthritis, other pain and decreased motion of hip, knee, or spine –
antalgic gait, Trendelenburg gait, stooped posture, thoracic
kyphosis
• Focal weakness of muscle and nerve groups – proximal muscle
weakness, distal muscle weakness, exaggerated lumbar lordosis
(secondary to pelvic girdle weakness), waddling and steppage
gaits

23. HIGHER SENSORIMOTOR GAIT
DISORDERS
• Cerebellar ataxia - poor trunk control, incoordination or other
cerebellar signs – gait is wide-based with increased trunk sway,
irregular stepping, staggering, especially on turns
• Parkinsonism – cardinal signs are rigidity, bradykinesia, tremor,
stooped posture – gait has small shuffling steps, hesitation,
festination, propulsion, retropulsion, turning en bloc, absent arm
swing, freezing
• Hemiplegia or hemiparesis - arm and leg weakness, spasticity,
equinovarus, genu recurvatum, leg circumduction, loss of arm
swing, foot drag or scrape
• Paraplegia or paraparesis - leg weakness, spasticity, bilateral leg
circumduction, scraping feet, possibly also scissoring

24. COGNITIVE AND WHITE MATTER
GAIT DISORDERS
• Frontal lobe disease, dementia, normal-pressure
hydrocephalus – cognitive impairment, weakness,
spasticity, urinary incontinence – may have “magnetic”
gait as though feet are glued to the floor
• Dementia (Alzheimer disease, vascular) – mid- to late-
stage dementia, may have fear of falling, cautious gait
with normal to widened base, shorter stride, slower, en
bloc turns

25. FALLS TESTS OF INTEGRATED
MUSCULOSKELETAL FUNCTION
Functional reach test – distance reached along a yardstick at shoulder
height; less than six inches is abnormal
Up and Go test (with or without timing) – rise from chair w/o using arm
walk about 3 meters, turn, return to chair, sit down w/o using arms – ov
15 seconds to complete suggests increased fall risk
Berg Balance Test – 14 balance items including tandem, semi-tandem
stance. Score under 40 associated with increased fall risk
Performance-Oriented Mobility Assessment (POMA) – combines many
items from other tests

26. FUNCTIONAL GAIT ASSESSMENT
• Comfortable gait speed and related endurance
measures (such as 6-minute walk) are powerful
predictors of falls, disability, hospitalization,
institutionalization, and mortality
• Usual gait speed is tested from a standing start over a
distance of 4 m
 Speed of 0.6 m/s has been proposed as cut point for
dysmobility
 Speeds of >1.0-1.2 m/s are associated with better functional
outcomes and increased life expectancy

27. FALLS WARNING SIGN

28. CURRENT FALLS PREVENTION

29. FALLS PREVENTION!