The document provides a grading rubric for a falls prevention program project consisting of 10 parameters including goals, interventions, training needs, and compliance with rules. It also describes a case of an 84-year-old man who is at risk of falls and discusses potential risk factors, examinations, and treatment options including exercise and managing medications. Clinical practice guidelines for fall prevention recommend multifactorial interventions to address multiple intrinsic and environmental risk factors.

1. Grading rubric for Falls prevention program project
Parameter Points awarded Points Comments
1. Name of program
included
10
2. Location
described (name
and type)
10
3. three evaluation
methods described
10
4. five interventions
stated and
described as to

2. benefit
10
5. Training needed
(patient, staff,
administration, etc.)
10
6. Items needed
10
7. Cost of all
elements of
program
10
8. Goals of the
program
10

3. 9. Paper written
with regards to
grammar,
punctuation,
spelling, etc.
10
10. Complies with
rules of APA
10
Total 100%
Discuss how, as a leader, you can anticipate and overcome
resistance to change in in the military (ARMY).
**Please use 2 APA citation.
FALLS
Andy Geller, MD

4. THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
AGS
MR. C
• 84-year-old man
• Status post quadriceps tendon repair
• Ambulating with cane
• Wife concerned about his risk of falls
Slide 2
MR. C
• Suspected falls since discharge
• Decreased activity level

5. • In chair most of the day
• Soon to get a scooter?
Slide 3
MR. C
• Formerly very active
• Gait unsteadiness
• Former boxer
• Veteran
Slide 4
MR. C:
PAST MEDICAL HISTORY
• Non insulin-dependent diabetes
• Hypertension
• Hypercholesterolemia
• Gout

6. • Obesity
• Insomnia
• Osteoarthritis
Slide 5
MR. C:
MEDICATIONS
• Metformin
• Benazepril
• Amlodipine
• Allopurinol
Slide 6
MR. C:
PHYSICAL EXAMINATION
• BP 175/90, HR 65 (supine); BP 152/85, HR 68
(standing)

7. • Fingerstick blood glucose 380
• Normal heart and lung exams
• Normal abdominal exam (obese contours)
Slide 7
MR. C:
PHYSICAL EXAMINATION
• Visual impairment
• Bilateral sensory loss in feet
• Unchanged manual muscle testing
• Right knee crepitus
• Difficulty arising from seated position
Slide 8
MR. C:
FURTHER HISTORY
• The patient’s wife reports he hasn’t been

8. sleeping well of late
• On further questioning, the patient admits to
feeling “sorry” for his Army buddies, “who are
all gone now…and I don’t have much time left
myself”
Slide 9
QUESTIONS
• Can you identify at least 4 risk factors in this
patient for falling?
• Would a scooter be appropriate for this
patient?
• Can you suggest a different assistive device
for this patient?
Slide 10
Answers: Can you identify at least

9. 4 risk factors in this patient for falling?
• Unsteadiness of gait after quadriceps tendon rupture
• Comorbid arthritis/gout
• Impaired balance due to diabetic neuropathy
• Obesity and deconditioning
• 4+ medications
• Orthostasis
• Decreased visual acuity
• Depressive symptoms
• Possible cognitive impairment due to boxing history
• Abnormal “Get Up and Go” test
• History of prior falls
Slide 11
Answer: Would a scooter
be appropriate for this patient?
• This patient is able to ambulate, and the risks of scooter
use would likely outweigh the benefits

10. • For example, in a recent article in the American Journal of
Cardiology, entitled “Effect of motorized scooters on qual ity
of life and cardiovascular risk,” scooter use was found to be
correlated with increased cardiovascular risk, even as self-
perceived quality of life improved
• The authors concluded that “interventions, such as
scooters, that improve self-perceived quality of life, can
have detrimental long-term effects by increasing
cardiovascular risk, particularly insulin resistance”
Slide 12
Answers: Can you suggest a different
assistive device for this patient?
• Mobility is strongly linked to quality of life. In this
patient, a home safety evaluation would be
appropriate, in conjunction with a multidisciplinary
care team including PT, OT, physiatry, and nursing.
• Based on the evaluation of the multidisciplinary team,
a cane or walker might be selected, both to aid in
stability and maximize mobility.

11. • In the vignette, the type of cane the patient is using is
not specified; however, if it is a single-point cane he
might do better with another type of cane, such as an
offset cane or a 4-pronged cane.
Slide 13
REFERENCES
• The FAB scale, Berg balance scale, and multidirectional reach
test:
http://www.stopfalls.org/service_providers/sp_bm.shtml
• The “Get Up and Go” screen for elderly fall risk assessment:
http://www.aan.com/practice/guideline/uploads/273.pdf
• Lecture on falls: http://www.pogoe.org/km/getdoc/9700
• Peeters G et al. Fall risk: the clinical relevance of falls and
how to integrate
fall risk with fracture risk. Best Pract Res Clin Rheumatol.
2009;23(6):797-
804.
• Practice module, “Assistive Devices for Ambulation in the
Elderly”:
http://www.pogoe.org/AngelUploads/applications/astdevice/Ast
Device.html

12. • Zagol BW, Krasuski RA. Effect of motorized scooters on
quality of life and
cardiovascular risk. Am J Cardiol. 2010;105(5):672-676.
Slide 14
http://www.stopfalls.org/service_providers/sp_bm.shtml
http://www.aan.com/practice/guideline/uploads/273.pdf
http://www.pogoe.org/km/getdoc/9700
http://www.pogoe.org/AngelUploads/applications/ astdevice/Ast
Device.html
ACKNOWLEDGMENTS
• Emory University School of Medicine
• American Geriatrics Society and the John
Hartford Foundation
Slide 15
Visit us at:
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
www.americangeriatrics.org

13. THANK YOU FOR YOUR TIME!
linkedin.com/company/american-geriatrics-
society
Slide 16
FALLS
‹#›
Suggestions for Lecturer
-1-hour to 1½-hour lecture
-Use GRS slides alone or to supplement your own teaching
materials.
-Refer to GRS and Geriatrics at Your Fingertips for further
content.
-Supplement lecture with handouts, eg, “Recommendations from
the AGS Guidelines for the Prevention of Falls” and various
assessment tools, eg, Romberg, Dix-Hallpike, Mini-Cog, and
POMA.
-For strength of evidence (SOE) levels, see related chapter text.
-See GRS8 questions 11, 41, 132, 148, 238, 240, 281, and 324
for case vignettes.
1
OBJECTIVES
Know and understand:
The importance of falls in older people
How to assess and treat falls in an older person

14. ‹#›
2
TOPICS COVERED
Epidemiology of Falls
Causes of Falls
Evaluation and Treatment of Falls
Clinical Guidelines for Preventing Falls
‹#›
3
FALLS
Definition: coming to rest inadvertently on the ground or at a
lower level
One of the most common geriatric syndromes
Most falls are not associated with syncope
Falls literature usually excludes falls associated with loss of
consciousness
‹#›
4
EPIDEMIOLOGY OF FALLS
Each year 30%–40% of community-dwelling people aged ≥65,
and about 50% of residents of long-term-care facilities,

15. experience falls
%
‹#›
5
Community LT Care 30.0 50.0 Community LT Care
10.0
EPIDEMIOLOGY OF FALLS
Annual incidence of falls is close to 60% among those with
history of falls
Complications of falls are the leading cause of death from
injury in people aged ≥65
‹#›
6
MORBIDITY AND MORTALITY
Most falls by older adults result in some injury
10%–15% of falls by older adults result in fracture or other
serious injury
The death rate attributable to falls increases with age
Mortality highest in white men aged ≥85: 180 deaths/100,000
population

16. ‹#›
7
SEQUELAE OF FALLS
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”)
A “long lie” predicts lasting decline in functional status
‹#›
8
COSTS OF FALLS
Indirect cost from fall-related injuries such as hip fractures is
substantial
‹#›
9
CAUSES OF FALLS
BY OLDER ADULTS
Rarely due to a single cause

17. May be due to the accumulated effect of impairments in
multiple domains (similar to other geriatric syndromes)
Complex interaction of:
Intrinsic factors (eg, chronic disease)
Challenges to postural control (eg, changing position)
Mediating factors (eg, risk taking, underlying mobility level)
‹#›
10
CAUSES: INTRINSIC
Age-related decline
Changes in visual function
Proprioceptive system, vestibular system
Chronic disease
Parkinson’s disease
Osteoarthritis
Cognitive impairment
Acute illness
Medication use (see next slide)
‹#›
11
CAUSES: MEDICATION USE
Specific classes, for example:
Benzodiazepines
Other sedatives
Antidepressants
Antipsychotic drugs

18. Cardiac medications
Hypoglycemic agents
Recent medication dosage adjustments
Total number of medications
‹#›
12
FALLS ASSESSMENT
Ask all older adults about falls in past year
Single fall: check for balance or gait disturbance
Recurrent falls or gait or balance disturbance:
Obtain relevant medical history, physical exam, cognitive and
functional assessment
Determine multifactorial falls risk (see next slide)
‹#›
13
FACTORS AFFECTING FALLS RISK
History of falls
Medications
Visual acuity
Gait, balance, and mobility
Muscle strength
Neurologic impairments

19. Heart rate and rhythm
Postural hypotension
Feet and foot wear
Environmental hazards
‹#›
14
PHYSICAL EXAMINATION
Blood pressure and pulse, both supine and standing
Vision screening
Cardiovascular exam
Musculoskeletal exam
Neurologic exam
‹#›
15
See GRS8 chapter entitled “Falls” for further content.
GAIT AND BALANCE EVALUATION
Romberg test
One-
Tandem gait task for 10 feet
Mental status exam (eg, Mini-Cog)
Timed Up and Go test
Berg Balance Test
Performance Oriented Mobility Assessment (POMA)
Functional reach
Appropriateness of footwear

20. ‹#›
16
A useful test of integrated strength and balance is the Timed Up
and Go test, which can be performed with or without timing. It
consists of observation of an individual standing up from a
chair without using the arms to push against the chair, walking
across a room, turning around, walking back, and sitting down
without using the arms. This test can demonstrate muscle
weakness, balance problems, and gait abnormalities.
A test of integrated musculoskeletal function is the Berg
Balance Test. The Berg test includes 14 items of balance,
including timed tandem stance, semi-tandem stance, and the
ability of a person to retrieve an object from the floor. Berg
scores <40 have been associated with an increased risk of falls.
The POMA tests balance and gait through a number of items,
including ability to sit and stand from an armless chair, ability
to maintain standing balance when pulled by an examiner, and
the ability to walk normally and maneuver obstacles. A reliable
cut-point score for predicting falls with the POMA has yet to be
established.
These and related tests are discussed in GRS8 and Geriatrics At
Your Fingertips.
LABORATORY AND
DIAGNOSTIC TESTING
Tests and procedures should be guided by the history & physical
exam: echocardiography, brain imaging, radiographic studies of
spine
Hemoglobin, serum urea nitrogen, creatinine, glucose: can
exclude anemia, dehydration, or hyperglycemia
Holter monitoring: no proven value for routine evaluation
Carotid sinus massage with continuous heart rate and BP
monitoring: can uncover carotid sinus hypersensitivity

21. ‹#›
17
These and related tests are discussed in GRS8 and Geriatrics At
Your Fingertips.
TREATMENT
Most favorable results with health screening followed by
targeted interventions
Aim to reduce intrinsic and environmental risk factors
Interdisciplinary approach to falls prevention is most
efficacious
‹#›
18
.
AGS FALLS PREVENTION
GUIDELINES
Assessment of all older adults and anyone with history of falls
Multifactorial interventions including:
Minimize medications
Initiate individually tailored exercise program
Treat vision impairment
Manage postural hypotension, and heart rate and rhythm
abnormalities
Supplement vitamin D
Manage foot and footwear problems
Modify the home environment

22. ‹#›
19
Cosponsored by the American Geriatrics Society and the
British Geriatrics Society.
Systematic reviews have concluded that there is no evidence
that hip protectors are effective in reducing hip fractures in
studies that randomized individual patients within an institution
or among older adults living at home. However, adherence to
the use of hip protectors was low in these studies, which many
argue could explain the lack of efficacy.
At least a dozen types of hip protectors are commercially
available. Many of these hip protectors have not been tested in
either the laboratory or in clinical trials. Despite the lack of
evidence to date to support the use of hip protectors, it is not
unreasonable to consider their use in patients at high risk of hip
fractures who are willing to use them.
SUMMARY
Falls by older adults are common and usually multifactorial
Falls predict functional decline
Screening and targeted preventive interventions are most
effective
AGS falls prevention guidelines are available and recommend
multifactorial interventions
‹#›
20
CASE 1 (1 of 3)
A 75-year-old woman is brought to the office by her daughter.
The mother has been falling, most often when rising from the

23. toilet or attempting to climb stairs.
History includes sarcopenia and frailty. She has no neurologic
or metabolic abnormalities.
Exercise was recommended at a previous office visit. Despite
the daughter’s efforts, the patient is reluctant to spend time and
energy on the exercise program.
The daughter asks for help prioritizing the exercises. In
particular, she wants to know which exercises are most
important in preventing falls.
‹#›
21
CASE 1 (2 of 3)
Which of the following is most effective for preventing falls?
Strengthening exercise
Aerobic exercise
Balance exercise
Multicomponent exercise
‹#›
22
CASE 1 (3 of 3)
Which of the following is most effective for preventing falls?
Strengthening exercise
Aerobic exercise
Balance exercise
Multicomponent exercise

24. ‹#›
23
ANSWER: C
Exercise is beneficial in frailty, yet it is difficult for frail
individuals to participate in exercise for a host of reasons.
Sarcopenia—loss of muscle with aging—results in a loss of
reserve capacity and an increased sense of effort for a given
exercise intensity. Lactate threshold increases with age, forcing
older adults to exercise at a greater percentage of their maximal
capacity. As the perception of effort increases, older individuals
become more likely to avoid exercise. Graduated exercises
could be prescribed so that an individual participates in the
exercise that will benefit him or her most.
Data from the FICSIT trials (Frailty and Injury: Cooperative
Studies on Intervention Techniques), performed in the early
1990s, found that exercise prevented 10% of falls across
studies, but prevented 20% of falls if balance training was
included. Each type of exercise (strength, aerobic, balance)
could be beneficial, and the multicomponent exercise could
potentially be the most beneficial, yet the case history indicates
that the patient resists multicomponent exercise. For this
patient, balance exercises are the priority, because they have
been found to prevent falls more often than generalized or
strengthening exercise.
CASE 2 (1 of 3)
An 85-year-old man comes to the office because he has fallen 3
times in the past 6 months.
None of the falls involved dizziness or fainting. One fall
occurred while he was walking in his yard; in the other
instances, he tripped inside his house.

25. History includes hypertension without postural changes, gout,
osteoarthritis, and depression.
He takes 5 medications on a regular basis.
‹#›
24
CASE 2 (2 of 3)
Which of his medications is most likely to contribute to his risk
of falls?
Acetaminophen
Allopurinol
Hydrochlorothiazide
Lisinopril
Paroxetine
‹#›
25
CASE 2 (3 of 3)
Which of his medications is most likely to contribute to his risk
of falls?
Acetaminophen
Allopurinol
Hydrochlorothiazide
Lisinopril
Paroxetine

26. ‹#›
26
ANSWER: E
Antidepressant agents, including SSRIs, have been shown to
increase the risk of falls; thus, paroxetine is most likely to
contribute to this patient’s risk. In addition, taking ≥4
medications increases an older adult’s risk of falls; this
patient’s drug regimen includes 5 medications.
Acetaminophen and allopurinol are unlikely to affect blood
pressure, balance, gait, or mental status. Hydrochlorothiazide
and lisinopril reduce blood pressure, and hydrochlorothiazide
may reduce intravascular volume and lead to postural changes
in blood pressure. However, syncope was not a factor in this
patient’s falls, and he does not have postural changes in blood
pressure.
Review of prescription and OTC medications is an important
element of reducing the risk of falls. Medication review should
be done at each visit to ensure that patients are taking
appropriate medications and correct dosages.
CASE 3 (1 of 3)
A 70-year-old woman comes to the office for a routine visit.
History includes hypertension and osteoarthritis.
She mentions that last month she tripped on a high curb and fell
after parking her car.
She has had no other falls.
‹#›
27

27. CASE 3 (2 of 3)
Which of the following is the most appropriate initial step for
evaluating her risk of future falls?
Test visual acuity.
Measure blood pressure for postural changes.
Evaluate gait and balance.
Ask about environmental hazards in her home.
Examine her feet and footwear.
‹#›
28
CASE 3 (3 of 3)
Which of the following is the most appropriate initial step for
evaluating her risk of future falls?
Test visual acuity.
Measure blood pressure for postural changes.
Evaluate gait and balance.
Ask about environmental hazards in her home.
Examine her feet and footwear.
‹#›
29
ANSWER: C
This patient has fallen once. Her gait and balance should be
observed; if no difficulty is seen, formal evaluation of falls risk
is not necessary.
During routine office visits, patients should be asked about any
falls in the past year and should be observed for difficulties

28. with gait and balance. Patients who report no falls do not need
formal risk assessment. If the patient has difficulty with gait
and balance or has had >1 fall, formal risk assessment should be
undertaken. The assessment should include visual acuity
testing; measurement of blood pressure for postural changes;
evaluation of strength, balance, and gait; examination of feet
and footwear; medication review; and home safety evaluation.
GRS8 Slides Editor: Annette Medina-Walpole, MD,
AGSF
GRS8 Chapter Authors: Sarah D. Berry, MD, MPH
Douglas P. Kiel, MD,
MPH
GRS8 Question Writer: Mary B. King, MD
Medical Writers: Beverly A. Caley
Faith
Reidenbach
Managing Editor: Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society
‹#›
Topic
Slide 30