Managing falls in the older adult

Contributed by:

Vivian Ewa, MBBS, CCFP (COE), FCFP, MMedEd, FRCP Edin., CHE - View bio 

Case

JD is a 72-year-old woman who lives alone in her own home. She presents to you in clinic with a history of frequent falls and in the last three months has fallen three times. Her last fall was a week ago and she presented in the emergency department (ED) with bruising of her left leg and left hip pain. No fracture was seen.

JD’s past medical history is significant for hypertension, type 2 diabetes mellitus, coronary artery disease, dyslipidemia, chronic low back pain, insomnia and depression. Her current medications include hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, bisoprolol 5 mg twice daily, atorvastatin 20 mg daily, perindopril 8 mg daily, ASA 81 mg daily, metformin 500 mg twice daily, lorazepam 1 mg as needed at night and acetaminophen extended release 650 mg as needed every six hours. 

Background

Falls are common in older adults and can result in injuries, increased ED visits and hospitalizations.¹ Falls among older adults are a public health issue in Canada. In 2017-2018 about 5.8% of Canadians aged 65 years and above, living in a household residence reported at least one fall-related injury in the last 12 months.² Between 2010/2011 to 2019/2020, the number of falls-related ED visits in Ontario and Alberta rose by 47%.² Women had a higher rate of fall-related ED visits compared to men.² A prior history of falls predicts the likelihood of another fall. The odds ratio (OR) of falls in a community-dwelling older adult with a history of falls is 2.9³ and opportunistic case-finding in these individuals starts with inquiring about any falls in the last 12 months. A single fall in the last year is a strong predictor for future falls.^4,5 

Risk factors for falls are usually multifactorial and require a multiprong approach to assessment and evaluation. Risk factors range from intrinsic factors (e.g., sensory impairment, cognitive impairment, gait, balance and mobility issues and chronic medical conditions), extrinsic factors (e.g., medications) and environmental factors (e.g., poor lighting, uneven surfaces and loose rugs).

The initial assessment includes history of falls and medication review; a neurological exam; cardiovascular exam (i.e., heart rate, rhythm and postural blood pressures); an assessment of the patient’s gait, balance and mobility; a neurological and motor examination; a feet and footwear review; and finally, an environmental assessment.

The patient’s history of falls should include the time of day it occurred, the activity during the fall and the location, the patient's footwear at the time and the lighting in their environment. Other symptoms should be included in the history, such as dizziness, loss of consciousness and mobility concerns. It is also important to include a comprehensive medication review, including those that are over-the-counter, to identify any that may pose an increased risk for falls, such as sedatives, hypnotics and antipsychotics.³ An initial gait and balance assessment in the office can include one the following commonly used tools: the Time Up and Go test (TUG),⁶ Chair Stand Test (CST)⁷ and a Short Physical Performance Battery (SPPB).⁸ A referral to physiotherapy for comprehensive gait, balance and mobility assessment is strongly recommended to determine risk for further falls.⁹  A home environment assessment by occupational therapy will identify risk for falls and provide recommendations for additional equipment, such as a raised toilet seat and grab bars in the bathroom. An additional railing for the stairs can also help reduce the risk for falls.

Management of falls involves identifying risk factors and implementing strategies to address them. 

Back to case

JD’s falls occur mostly at midday and usually on rising from her recliner chair in the living room. She has also had one fall in the kitchen while preparing lunch. She mobilizes independently without a gait aid and reports episodes of dizziness on rising from a sitting position. Her last eye exam was more than four years ago, and she has declined using hearing aids. She reports difficulties with short-term memory recall but otherwise is independent with activities of daily living. Pertinent findings on her physical examination include a heart rate of 52 beats per minute and lying blood pressure 110/70 mmHg with a standing blood pressure after one minute of 85/60 mmHg. She is symptomatic for postural drop. Her neurological exam is unremarkable. Her motor system exam revealed medial compartment tenderness in her left knee. Her gait is antalgic with a tendency to limp on the left. Her cognitive testing using the MOCA reveals a score of 28/30, losing two points on memory recall. Pertinent investigations showed a low serum potassium of 3.0 and a mildly elevated creatinine of 112. 12-lead ECG showed sinus bradycardia with a heart rate of 50. An X-ray of her left knee was consistent with osteoarthritis.

Management of JD includes adjusting her bisoprolol dose due to bradycardia. Her low potassium is secondary to HCTZ and given postural hypotension, you reduce her dose of HCTZ to 12.5 mg with a plan to deprescribe if her blood pressure continues to be on the low side. She will benefit from scheduled acetaminophen for her knee osteoarthritis, which may also help with sleep at night. You discuss and provide her with information on non-pharmacological approaches for insomnia and wean her off lorazepam.¹⁰ You explore her mood symptoms and maximize non-pharmacological approaches to managing them prior to considering antidepressant therapy.

You request a physiotherapy referral for in-home exercises to improve gait, balance and mobility as exercise therapy can reduce the risk of falls by 13% in community dwelling older adults.¹¹ You request a home care referral for an environmental assessment and home equipment to address environmental risk factors. You address other risk factors such as referral for hearing and visual assessment. You refer JD for a bone density scan and start osteoporosis therapy, if indicated.¹² You start JD on oral vitamin D 1,000 units daily as it can help reduce the risk of falls; a recent systematic review showed a falls risk reduction of about 13% when doses of 700 units or more of Vitamin D are used in community dwelling older adults with NNT of 17.¹³

Conclusion

Falls and falls-related injuries are common in older adults and can cause significant morbidity, mortality and increased health-related costs. Identifying and managing older adults at risk using a personalized multipronged interdisciplinary approach is key to reducing falls and associated morbidity and mortality.

References

1. James SL, Lucchesi LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, et al. The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Inj Prev. 2020;26(Supp 1):i3-i11.
2. Surveillance report on falls among older adults in Canada  [Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/surveillance-report-falls-older-adults-canada.html.
3. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010;21(5):658-68.
4. Burns ER, Lee R, Hodge SE, Pineau VJ, Welch B, Zhu M. Validation and comparison of fall screening tools for predicting future falls among older adults. Arch Gerontol Geriatr. 2022;101:104713.
5. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? Jama. 2007;297(1):77-86.
6. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903.
7. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls. A prospective study. Jama. 1989;261(18):2663-8.
8. Kwon S, Perera S, Pahor M, Katula JA, King AC, Groessl EJ, et al. What is a meaningful change in physical performance? Findings from a clinical trial in older adults (the LIFE-P study). J Nutr Health Aging. 2009;13(6):538-44.
9. Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age and ageing. 2022;51(9).
10. Other resources | Sleepwell 2024 [Available from: https://mysleepwell.ca/other-resources/.
11. Poulton G, Funderburke Matney B, Williams T, Hulkower S, Stigleman S. Exercise to Reduce Falls in Older Adults. American family physician. 2020;101(1):42-3.
12. Morin SN, Feldman S, Funnell L, Giangregorio L, Kim S, McDonald-Blumer H, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2023;195(39):E1333-e48.
13. Wei FL, Li T, Gao QY, Huang Y, Zhou CP, Wang W, et al. Association Between Vitamin D Supplementation and Fall Prevention. Front Endocrinol (Lausanne). 2022;13:919839.