Falls in older adults: a practical approach

Falls are a major problem in public health since they are an important cause of morbidity and mortality. To evaluate the risk of fall and prescribe preventive interventions may be a challenging task.

Objectives:

The objectives of this study are to summarize the most relevant information on the topic “falls in the elderly” and to give a critical view and practical clinical approach on this topic.

Methods:

In March 2022, a search of Pubmed database was performed, using the terms “fall elderly”, fall prevention”, “fall risk”, with the following parameters: five years, review, systematic review, meta-analysis, practice guidelines.

Results:

There are several risk factors for falls that can be grouped in different areas (psychosocial, demographic, medical, medication, behavioral, environmental). The clinical evaluation of an older adult prone to falls must include identification of risk factors through history and examination and identification of risk of falls through an assessment tool such as gait velocity, functional reach test, timed up and go, Berg balance test, and miniBEST test. Fall prevention strategies can be single or multiple, and physical activity is the most cited. Technology can be used to detect and prevent falls.

Conclusion:

A systematic approach to the older patient in risk of falls is feasible and may impact fall prevention.

Keywords:
Accidental Falls; Aged

WHO³	Lord et al⁵	Kim et al⁶
Biological risk factors	Psychosocial and demographic	General characteristics
Age Race Gender chronic illnesses (eg, neurologic diseases, arthritis, cancer) physical, sensory, cognitive, and affective declines	Advanced age Female gender Living alone History of falls Inadivity ADL limitations	Sex Increased age Living alone Low income
	Balance and mobility	Physical function
	Impaired stability when standing Impaired stability when leaning and reaching Inadequate responses to external perturbations Slow voluntary stepping Impaired gait and mobility Impaired ability in standing up Impaired ability with transfers	Low vision Mobility/balance/gait deficit Impaired ADL Musculoskeletal function Cardiac function Neurological function Inappropriate footwear Use of assistive devices
	Sensory and neuromuscular
	Visual acuity Visual contrast sensitivity Visual field dependence Reduced peripheral sensation Reduced vestibular function Muscle weakness Poor reaction time
	Medical	Disease factor
	Impaired cognition Depression Abnormal neurological signs Stroke Incontinence Acute illness Parkinson 's disease Vestibular disorders Arthritis Foot problems Dizziness	Stroke Dementia Parkinson’s Dizziness Cardiovascular Hypotension Respiratory Peripheral neuropathy Diabetes Chronic pain Arthritis Osteoporosis Incontinence
Behavioral risk factors		Behavior factor
Multiple medications lack of exercise excess alcohol usage inappropriate footwear inattention, multitasking hurrying		Inadequate diet History of previous falls Fear of falling Lack of exercise Excess alcohol intake
	Medication	Medication
	Psychoactive drugs Antihypertensive Use of four or more medications	Psychoactive drugs Cardiovascular drugs Multiple medication use
Environmental	Environmental	Environmental
narrow steps slippery surfaces of stairs looser rugs and insufficient lighting	Poor footwear Inappropriate spectacles	Brightness of light Carpet Slipperiness Support of community
Socioeconomic risk factors
low income low education inadequate housing lack of social interaction limited access to health and social care lack of community resources

Single measure tools
Test	Purpose	Instructions	Interpretation	Cut-off for falls
Functional reach test²¹	Measures the maximum distance a person can reach forward while standing in a fixed position	The patient is instructed to stand next to a wall and position the arm that is closer to the wall (but not touching) at 90 degrees of shoulder flexion with a closed fist. The assessor Instructs the patient to “Reach as far as you can forward without taking a step.” The location of the 3rd metacarpal is recorded at beginning and ending position, and the scores are the difference between these values. Three trials are done, final score is the average value of the best 2 results.	Smaller distances = worse performance	< 18,5cm²²
Gait velocity²⁴	Measures the walking speed in a comfortable, natural speed	A distance of 3-10 meters is measured, with or without an addition distance for acceleration and deceleration. Individual is timed once the foot touches the initial path and is stopped once it reached the end of the path (without the acceleration and deceleration distance). Two trials are measured	Higher gait velocity = better functional mobility Normal functional mobility = gait speed > 1,0m/sec	<0,7m/s²⁶ <1,0 m/s²⁰
Berg Balance Scale²⁷	Assesses balance	14 items, that include static and dynamic balance tasks Each item points 0-4 Total scale score 0-56	Higher scores = better performance	45-49 points²⁹
Timed up and Go (TUG)³⁰	Assesses balance, mobility, walking ability	The patient sits on a standard armchair, and is instructed to stand up, walk on a comfortable speed along a l3 meters line, turn around at the line, walk back to the chair, and sit down. The test ends when the patient’s buttocks touch the seat.	Shorter time = better performance	>11 sec²⁰ >13 sec¹⁸
miniBEST test³¹	Assesses balance, mobility, walking ability	14 items, that include dynamic balance tasks, walking tasks and TUG. Each item point 0-2 Total score 0-28	Higher scores = better performance	>19 points³³ 17-25 points³² (age dependent)

Intervention
Exercises (supervised, unsupervised, or both)	gait; balance and functional training; strength/resistance exercises; flexibility exercises; 3D training (e.g. Tai Chi); general physical activity; endurance training or others.
Medication (review and target)	vitamin D and calcium supplementation.
Medication (review and target)	medication withdrawal, dose reduction or increase, substitution or provision (antihypertensives, cardiovascular agents, drugs used in diabetes, anti-parkinson drugs, anti-dementia drugs, antidepressants, antipsychotic/neuroleptic drugs, anxiolytics/hypnotics/sedatives, other)
Surgery	cataract extraction, pacemaker provision, podiatric surgery or others.
Management of urinary incontinence	e.g. assisted toileting, bladder retraining, prompted voiding, pelvic floor exercises, antispasmodics
Fluid or nutrition therapy	Fluid therapy to restore the volume and composition of the body fluids to normal with respect to water- electrolyte balance. Nutrition therapy to improve health status of an individual by adjusting the quantities, qualities, and methods of nutrient intake.
Psychological individual or group	Cognitive (behavioural) interventions and others.
Environment/Assistive technology	Furnishings and adaptations to homes and other premises, aids for personal mobility, aids for communication, information and signalling, body worn aids for personal care and protection, social environment.
Social environment	staff ratio, staff training, service model, telephone support, caregiver training, home care services, others.
Knowledge	pamphlets, information, booklets/sheets, videos, lectures.

Risk factor		Intervention
Non-modifiable conditions	Age Female gender	Raising awareness of the increased risk of falls
Medical conditions	Chronic diseases	Improving the individualized management of chronic diseases
	Depression	Improving the individualized management of depression Exercises
	Pain	Improving the individualized management of pain
	Impaired cognition	Improving the individualized management of impaired cognition Cognitive training, computerized version of cognitive training Exercises
	Visual impairment	Treatment with corrective lenses or surgery Exercises
	Balance impairment	Gait; balance and functional training; strength/resistance exercises; flexibility exercises; 3D training (e.g. Tai Chi); general physical activity; endurance training or others.
Medication	Polipharmacy	Medication review (withdrawal, dose reduction or increase, substitution, provision): anti-hypertensives, cardiac effects, hypoglycemic medications, skeletal muscle relaxants, antihistamine medications and mainly psychoactive drugs
Medication	Supplementation	Vitamin D plus calcium
Behavioral	Living alone History of falls ADL limitations	Raising awareness of the increased risk of falls Possible change of living arrangements Aids for walking assistance: walking-sticks, walking-frames, wheelchairs
Behavioral	Inactivity	Exercise, education
Environmental	Narrow steps	Advise for the use of appropriate footwear
	Slippery surfaces of stairs	Installation of safety features, correction or removal of hazards
	Looser rugs	Correction or removal
	Insufficient lighting	Correction of ambient lighting

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[1] Correspondence:
Cristiana Borges Pereira; Email: cbpereira@live.com.