Safeguarding seniors: Identifying fall risks in your elderly patients

By Naveed Saleh, MD, MS | Medically reviewed by Anita Chandrasekaran, MD, MPH
Published May 19, 2023

Key Takeaways

  • Falls occur frequently in the elderly and result in increased morbidity and mortality, decreased quality of life, fear of falling, and, in severe cases, brain injury or the need for surgery.

  • Patients aged 65 years or older should be screened and assessed for fall risk.

  • The best intervention to prevent falls is exercise. Vitamin D supplementation appears to provide no benefit in preventing falls in patients aged 65 years or older who do not have osteoporosis or vitamin D deficiency.

Unfortunately, falls are frequent in patients aged 65 years or older. All the good work done to try to keep a person healthy as they age can be undermined by one common occurrence: a fall. About one-third of older persons living at home, and half of those living in nursing homes, fall at least once a year.[]

Causes of falls

The complex nature of falls is discussed in Falls and Fall Prevention in the Elderly.[]

Normal gait requires the coordination of neural input from many areas of the brain, including the cerebellum, cerebral cortex, brain stem, and basal ganglia. The cerebellum relays signals to the cerebral cortex and brainstem to regulate gait. Regulation involves muscle tone and the sensory processing of vision, hearing, and proprioception. 

In the elderly, these functions diminish, and the deficits are compounded by the comorbidities of age and the use of medications, thus further predisposing older people to falls. 

Gait changes with age can be obvious to the eye, as older individuals tend to walk slower and take shorter steps, as well as exhibiting diminished lower-limb strength. Factors that can lead to a fall include neurocognitive decline, adverse drug reactions, acute illness, and tripping on an irregular surface. 

The term sarcopenia refers to the loss of muscle mass, function, and strength. It is an important determinant of falls and is related to food decline, lengthy hospital stays, prolonged illness, and drugs such as steroids. Older adults experience a decrease in mass volume and coordination, as well as physiologic changes, such as a loss of white fibers.

In assessing an individual’s risk for a fall, each additional factor further adds to the risk.

A person with zero risk factors has a 1-year risk of fall of 8%, whereas the risk is 78% for a person with four risk factors. 

The most important risk factors, ranked by evidence basis, are a history of falls, compromised balance, decreased muscle strength, vision problems, and polypharmacy.

Fall complications

The repercussions of fall are numerous, with recurrent falls resulting in increased morbidity and mortality. Recurrent falls can also lead to premature admission to a nursing home and decreased functionality. 

Traumatic brain injury and subdural hematoma can also result. Other consequences of falls include the need for surgery, fear of falling, and impaired quality of life. Bone fractures and soft-tissue injury are major complications of fall that require surgical repair. 

Preventing falls in the first place, through early intervention, is a key strategy.

Fall-risk assessment

The CDC and the American Geriatric Society suggest yearly fall screening in patients aged 65 years or older. Based on the screening, an assessment may be necessary. Patients with dizziness, syncope, or arrhythmias likely need a fall assessment.

One commonly used assessment tool is STEADI (ie, Stopping Elderly Accidents, Deaths, and Injuries). STEADI has components for screening, assessing, and counseling patients on interventions to decrease their fall risk. 

For screening, the patient is asked questions like, “Have you fallen during the past year?” and “Do you feel unsteady when standing or walking?”

The fall assessment involves tests of strength, gait, and balance. For instance, Timed Up-and-Go (TUG) assesses mobility. For this test, the patient starts from a sitting position, stands up, and walks about 10 feet at their regular pace, and then sits again in the chair. The physician times the process, and if it takes 12 seconds or more, the patient is at a higher risk of a fall.

Interventions for those at high risk

Following the screening and assessment, patients at an increased risk of fall should be counseled on potential interventions to decrease that risk. Falls and Fall Prevention in the Elderly describes the range of interventions that can be helpful.

Interventions for fall prevention include home exercise, home-safety precautions, diet modification, changing medication doses, vision checks, proper footwear, and balance training. 

Patients should also have emergency contacts readily available. Devices such as Life Alert are also very helpful.

Many of these interventions are multidisciplinary in nature. For instance, a podiatrist can help with footwear, an ophthalmologist can perform a vision screen, and an occupational therapist can tour the home on the lookout for poor lighting, wayward cords, or unsecured rugs.

To help prevent fall risk, the US Preventive Services Task Force (USPSTF) issued recommendations for community-dwelling adults aged 65 years or older without osteoporosis or vitamin D deficiency.[] The task force found that exercise reduces fall risk by a moderate amount (grade B recommendation), whereas multifactorial interventions exhibit a small net benefit that depend on the individual patient (grade C recommendation). The USPSTF does not recommend vitamin D supplementation in this patient population, stating “adequate evidence that vitamin D supplementation has no net benefit for preventing falls in older adults.”

Understandably, many older adults are scared of exercising for fear of falling. As noted in Falls and Fall Prevention in the Elderly, up to 70% of patients with a recent fall voice fears of falling, with 50% consequently limiting or avoiding exercise or social activity. This fear sets up a vicious cycle that further increases fall risk. 

The National Institute on Aging has addressed the problem of falls.[] 

"Many older adults fear falling even if they haven’t fallen before."

National Institute on Aging

This fear can result in avoiding activities such as walking, shopping, or partaking in social activities. Keep in mind, however, that staying active is important to keeping the body healthy and actually helps to prevent falls. The Institute’s advice is not to let a fear of fall preclude physical activity.

What this means for you

Yearly falls occur in about one-third of elderly individuals living at home. Falls are dangerous and contribute to morbidity and mortality. Physicians should screen and assess adults aged 65 years or older for fall risk. The best intervention for seniors at risk is exercise, but keep in mind that patients who have a history of falls may fear physical activity.

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