A 76-year-old woman comes to the office for follow-up after being seen in the emergency department for a fall. While walking to the bathroom at night, the patient tripped on her cane, which she uses intermittently for long-standing knee osteoarthritis, and fell to the floor. She was unable to rise for several minutes following the fall. Evaluation in the emergency department revealed no fracture. Before this episode, the patient had sustained 2 similar falls at home in the past year, one while going downstairs and the other while walking outside. Each time, she did not sustain any major injuries or seek care from a medical provider. The patient lives alone and has a caregiver who assists her with daily meal preparation and grocery shopping. Medical history also includes hypertension, for which she takes an ACE inhibitor. Blood pressure is 142/87 mm Hg sitting and 141/79 mm Hg standing. Pulse is 83/min. The patient is alert and fully oriented. Muscle strength is globally decreased in the upper and lower extremities. Gait is slow but without evidence of ataxia or a limp. Examination of the heart and lungs is normal. Which of the following should be performed next to reduce this patient's risk for falls?
Falls in older adults | |
Overview |
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Risk factors |
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Outpatient prevention |
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Inpatient prevention |
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*Ask the patient to rise from a chair & walk briskly to the end of the room. Time & patient difficulty in this test predict the risk of falling. CVD = cardiovascular disease; T2DM = type 2 diabetes mellitus. | |
Falls are a major cause of injury in older adults (eg, age >65), resulting in injury, prolonged immobilization, and functional decline. This patient has multiple fall risk factors, including prior history of a fall, decreased muscle strength, and history of a chronic condition (eg, hypertension, osteoarthritis).
All patients who have fallen should undergo a multifactorial risk assessment that includes screening for sensory disturbances, a major underlying contributor to fall risk in the elderly population. For example, age-related declines in proprioception affect balance, leaving patients with increased reliance on visual input. As a result, diminished visual acuity can substantially elevate overall fall risk. In addition, age-related eye conditions (eg, macular degeneration, cataracts) can reduce dark adaptation, increasing risk for falls in low-light conditions. Therefore, all patients who sustain a fall should have visual acuity screening with a dilated eye examination and receive appropriate corrective eyewear or prevention interventions (eg, surgical treatment of cataracts, nutritional supplementation for macular degeneration).
In patients who have sustained previous falls, supervised balance and strength training and a home safety assessment (typically performed by an occupational therapist) are also recommended to further reduce risk for subsequent falls.
(Choices A and B) Holter monitoring is rarely indicated in average-risk elderly patients who sustain falls in the absence of concerning symptoms (eg, history of palpitations, frequent syncope). Carotid artery stenosis is also not a typical cause of falls. Sensory function (eg, balance, vision) should be tested first.
(Choice C) Although vasodilators (eg, calcium channel blockers) may increase fall risk in some patients, discontinuation of this patient's ACE inhibitor is not recommended given her hypertension and lack of orthostasis.
(Choice D) Assistive devices (eg, canes, scooters, walkers) may be needed in select cases. However, the specific type of device should be identified only after multifactorial assessment (eg, physical therapy evaluation, home safety assessment) is completed. Use of assistive devices without adequate training or assessment has been linked to increased risks (eg, tripping over the device, muscle atrophy from disuse).
(Choice E) This patient may eventually require increased assistance if she experiences further functional declines or falls. However, preservation of independence is often highly desired by patients, and attempts should first be made to screen for correctable contributors to fall risk.
Educational objective:
Age-related declines in proprioception lead to increased reliance on visual input, and diminished visual acuity can substantially elevate fall risk in dark settings. Patients who sustain falls should undergo a multifactorial fall risk assessment that includes screening and correction of deficits in balance, strength, and vision.