Preventing Falls in Older Persons LAINIE VAN VOAST MONCADA, MD, and L. GLEN MIRE, MD, Louisiana State University School of Medicine, University Hospital and Clinics, Lafayette, Louisiana

The American Society and British Geriatrics Society recommend that all adults older than 65 years be screened annually for a history of falls or balance impairment. The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend exercise or physical therapy and supplementation to prevent falls in community-dwelling older adults who are at increased risk of falls. Although the U.S. Preventive Services Task Force and American Academy of Family Physicians do not recommend routine multifactorial intervention to prevent falls in all community-dwelling older adults, they state that it may be appropriate in individual cases. The Centers for Control and Prevention developed an algorithm to aid in the implementation of the American Geriatrics Society/British Geriatrics Society guideline. The algorithm suggests assessment and multifactorial intervention for those who have had two or more falls or one fall-related injury. Multifactorial interventions should include exercise, particularly balance, strength, and gait training; vitamin D supplementation with or without calcium; management of medications, especially psychoactive medications; home environment modification; and management of postural hypotension, vision problems, foot problems, and footwear. These interventions effectively decrease falls in the com- munity, hospital, and nursing home settings. is reimbursed as part of the Medicare Annual Wellness Visit. (Am Fam Physician. 2017;96(4):240-247. Copyright © 2017 American Academy of Family Physicians.) ▲ See related editorial alls are the leading cause of fatal and (Figure 19) and the Stages of Change Model on page 220. nonfatal injuries in persons older (Table 110). Fall prevention is reimbursed as More online than 65 years.1 In a survey, 37.5% of part of the Medicare Annual Wellness Visit. at http://www. fallers responded that they required aafp.org/afp. Fmedical treatment or activity restriction.2 Risk Factors CME This clinical content Fall injuries result in 2.8 million emergency There are many risk factors for falls, some conforms to AAFP criteria department visits annually,1 and 25% of of which are modifiable(Table 2).6,11-16 The for continuing medical education (CME). See falls cause serious injuries, such as fractures strongest modifiable risk factors are balance CME Quiz on page 222. or traumatic brain injury.3 The risk of falls impairment, gait impairment, muscle weak- Author disclosure: No rel- and resulting serious injury increases with ness, and medication use. Fear of can evant financial affiliations. age. Injuries, such as , and falls result in a downward cascade of events lead- ▲ Patient information: are risk factors for placement in a nursing ing to social isolation and loss of function, A handout on this topic, home,4 where the fall risk is nearly three as well as more falls.17 Approximately 60% of written by the authors of 18 this article, is available times that of persons living in the commu- falls are the result of multiple factors. 5 at http://www.aafp.org/ nity. A history of falls is associated with afp/2017/0815/p240-s1. a two- to sixfold increased risk of a future Assessment html. fall.6 Noninjurious falls are a harbinger of All persons older than 65 years should be potentially life-threatening events and are asked annually about whether they have fallen, an opportunity for physicians to intervene. the number of falls they have had and if they Many of the recommendations in this caused injury, and whether they have difficulty article are based on the American Geriatrics with walking or balance.7 The CDC STEADI Society/British Geriatrics Society (AGS/BGS) initiative encourages physicians to screen for clinical practice guideline for the prevention fall risk by asking these questions and about of falls in older persons.7 The Centers for Dis- fear of falling, or by administering the Stay ease Control and Prevention (CDC) devel- Independent self–risk assessment brochure.8 It oped the Stopping Elderly Accidents, Deaths, is important for physicians to elicit a falls his- and Injuries (STEADI) toolkit for physicians tory because, in one study, only 36% of men based on the AGS/BGS guideline.8 The tool- and 50% of women who fell in the previous kit includes resources such as an algorithm year talked to their physician about falls.19 A for fall risk assessment and interventions gait, strength, and balance evaluation should

240Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American AcademyVolume of Family 96, Physicians. Number For 4 the◆ August private, 15,noncom 2017- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Fall Risk Assessment and Interventions in Older Adults Patient completes checklist in the Stay Independent brochure (http://www.cdc.gov/steadi/patient.html, click the Brochures tab)

Screen for falls and/or fall risk Key questions: Fell in past year? If yes ask: How many times did you fall and were you injured? Feels unsteady when standing or walking? Worries about falling?

No to all key questions Yes to any key questions

Evaluate gait, strength, and balance Recommended test: Timed Up and Go Optional: 30-Second Chair Stand and 4-Stage Balance tests

No gait, strength, or Gait, strength, or balance problems* balance problem

Low risk: individualized fall interventions ≥ 2 falls 1 fall 0 falls Educate patient Vitamin D with or without calcium Refer for strength and balance exercise (community exercise or fall prevention program) Injury No injury

Conduct multifactorial risk assessment Moderate risk: individualized Review Stay Independent brochure fall interventions Falls history Educate patient Physical examination including: Review and modify medications Postural dizziness/postural hypotension Vitamin D with or without calcium Medication review Refer to a physical therapist to improve gait, strength, and Cognitive screen balance or to a community fall Feet and footwear prevention program Use of assistive devices Visual acuity assessment

High risk: individualized fall Follow up with high-risk interventions patients within 30 days Educate patient Review care plan Vitamin D with or without calcium Assess and encourage fall Refer to physical therapist to improve risk reduction behaviors gait, strength, and balance Discuss and address Manage and monitor hypotension barriers to adherence Modify medications Transition to maintenance exercise program when Address foot problems the patient is ready Optimize vision Optimize home safety

*—Consider additional risk assessment (e.g., medication review, cognitive screen, syncope).

Figure 1. Algorithm for fall risk assessment and interventions in older adults. Adapted from Centers for Disease Control and Prevention. Algorithm for fall risk assessment and interventions. http://www. cdc.gov/steadi/pdf/algorithm_2015-04-a.pdf. Accessed May 5, 2016. Preventing Falls in Older Persons

be performed if a patient answers positively to Table 1. Stages of Change Model for Fall Prevention any of the screening questions. The Timed Up and Go (TUG) test, 30-Second Chair Stand Precontemplation stage: The patient is not thinking about change and does test, and 4-Stage Balance test are quick and not feel that anything can be done to prevent falls. easy to administer. These tests are shown in Physician’s response: Offer the patient education about the benefits of making online instructional videos at https://www. a change. youtube.com/playlist?list=PLWqeMose​ Contemplation stage: The patient is weighing the benefits of a behavior change to prevent falls (e.g., home modification) vs. the cost. Z2MwwznjB-TF​rq​4dt​HX8hPsSE. The TUG Physician’s response: Offer encouragement and specific suggestions for change. test is recommended as the primary measure Involve family for support. of functional assessment. It involves tim- Preparation stage: The patient begins to consider making a change to prevent falls. ing the patient as he or she rises from a chair Physician’s response: Help patient set specific goals and create action plan. with armrests, walks 10 feet (with an assistive Action stage: The patient is ready to make a behavior change to prevent falls. device if applicable), turns, walks back to the Physician’s response: Make referrals and provide support with follow-up. chair, and sits.8 Maintenance stage: The patient continues the new behavior (e.g., exercise) A multifactorial fall risk assessment should for at least six months. be performed for all high-risk persons who Physician’s response: Offer praise and encouragement to continue. require 12 or more seconds to complete the TUG test and report two or more falls or one NOTE: The Stages of Change Model can be used to facilitate conversations with 8,9 patients and assist with their acceptance of fall prevention strategies such as exercise, fall-related injury. The assessment should home modifications, and medication changes. include circumstances and frequency of Information from reference 10. falls, associated symptoms, injuries, medi- cations (prescription and over-the-counter),

Table 2. Risk Factors for Falls in Older Persons

Potentially modifiable Potentially modifiable (continued) Nonmodifiable Cardiac Neurologic Age older than 80 years Cardiac Delirium Congestive heart failure Dizziness or vertigo Cognitive impairment/ Hypertension Parkinson disease and other Female sex Environmental hazards movement disorders History of cerebrovascular accident/transient Medication use (see Table 3; risk is ischemic attack higher when four or more medications Psychological History of falling are used simultaneously) Depression History of fractures Metabolic Fear of falling Recently discharged from the hospital (within Diabetes mellitus Sensory impairment one month) Low body mass index Auditory impairment White race Vitamin D deficiency Multifocal lens Musculoskeletal Balance impairment Other Foot problems Acute illness Gait impairment Anemia Impaired activities of daily living Cancer Limited activity Inappropriate footwear Lower extremity muscle weakness Nocturia Musculoskeletal pain Obstructive sleep apnea Use of an assistive device Postural hypotension Urinary incontinence

Adapted with permission from Moncada LV. Management of falls in older persons: a prescription for prevention. Am Fam Physician. 2011;84 (11):1267- 1268, with additional information from references 6, and 11 through 15.

242 American Family Physician www.aafp.org/afp Volume 96, Number 4 ◆ August 15, 2017 Preventing Falls in Older Persons BEST PRACTICES IN GERIATRIC MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation Sponsoring organization other relevant acute or chronic medical Do not let older adults lie in bed or only get up to American Academy problems, activities of daily living and use a chair during their hospital stay. of Nursing of assistive devices, and fear of falling.7 The Do not use physical restraints with an older American Academy hospitalized patient. of Nursing physical examination should include evalua- Do not use benzodiazepines or other sedative- American Geriatrics tion of muscle strength; cognitive examina- hypnotics in older adults as a first choice for Society tion; cardiovascular examination, including insomnia, agitation, or delirium. postural dizziness/postural hypotension; Do not prescribe a medication without conducting American Geriatrics assessment of visual acuity; and examina- a drug regimen review. Society tion of the feet and footwear.7 An environ- Do not prescribe under-dosed strength training American Physical programs for older adults. Instead, match the Therapy Association mental assessment, including home safety, frequency, intensity, and duration of exercise to 7 is also recommended. Checklists for home the individual’s abilities and goals. safety and risk factors for falling (Stay Inde- pendent brochure) are available at http:// Source: For more information on the Choosing Wisely Campaign, see http://www. choosingwisely.org. For supporting citations and to search Choosing Wisely recom- www.cdc.gov/steadi/patient.html (click the mendations relevant to primary care, see http://www.aafp.org/afp/recommenda Brochures tab). Any person seeking medical tions/search.htm. attention immediately after a fall should be evaluated for underlying acute illness. with or without calcium; management of Multifactorial vs. Single Interventions medications; home environment modifica- In each setting (community, hospital, and tion; and management of postural hypo- nursing home), assessment with correspond- tension, vision problems, foot problems, ing individualized multifactorial interven- and footwear.7 These patients should follow tion involving a combination of components up within 30 days. A Cochrane review con- (e.g., exercise, medication reduction) reduces cluded that assessment and multifactorial fall rates.20-22 Studies vary widely on which interventions in community-dwelling older components were used. Single interven- adults reduce the number of falls by 24%.20 tions such as exercise alone are also effective These strategies can also reduce hip and (without a complete multifactorial assess- other fractures, head injuries, use of medical ment) in falls prevention.20 services related to falls,25 and death.26 eTable A includes tips for implement- Community Setting ing interventions for fall prevention in MULTIFACTORIAL INTERVENTIONS community-dwelling older adults. eTable B The U.S. Preventive Services Task Force is a falls prevention electronic medical record (USPSTF) and American Academy of Family template. All components on the template are Physicians do not recommend routine mul- based on the evidence discussed in this article. tifactorial intervention in all community- dwelling older adults at risk of falling, but SINGLE INTERVENTIONS they state that multifactorial assessment Exercise or Physical Therapy. The USPSTF and management may be appropriate in and the American Academy of Family Phy- individual cases.23,24 The CDC advises that sicians conclude that exercise or physical moderate-risk patients (those with gait, therapy alone has moderate net benefit in strength, or balance impairment and a his- preventing falls.23,24 All older adults who are tory of zero or one noninjurious fall) receive at risk of falling should be offered physical vitamin D supplementation with or without therapy or an exercise program incorporat- calcium, a medication review, and a referral ing balance, gait, and strength training.7 A to physical therapy or a community fall pre- Cochrane review found that the number vention program.9 of fallers was reduced by 15% to 29% with High-risk patients should receive a multifac- group exercise containing multiple compo- torial intervention, including an exercise pro- nents, individual home-based exercise, or tai gram with muscle strengthening and gait and chi.20 In most studies, the exercise program balance training; vitamin D supplementation was a minimum of 12 weeks with 30- to

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90-minute sessions one to three times per initiated or increased shortly before a fall week.20 In a meta-analysis, fall prevention should be considered a possible cause. exercise programs reduced falls resulting in Home Safety. The physician should moni- fracture by 61% and reduced falls resulting tor progress toward improving home safety,7 in the need for medical care by 43%.27 Exer- which may be done with the assistance of a cise interventions have also been effective in home health agency. Training patients about reducing the fall rate in cognitively impaired proper use of assistive devices for mobility is older adults.28 an important part of improving safety. Home Vitamin D. The evidence supporting vita- safety modification interventions reduce min D supplementation to reduce the risk of falls and are most effective in patients who falls in community-dwelling adults is mixed. have a high risk of falls or who have severe Although the USPSTF, American Academy visual impairment and when delivered by an of Family Physicians, and AGS recommend occupational therapist.20 vitamin D, a Cochrane review did not find Vision Correction. Falls are reduced when benefit.20,23,24,29 The USPSTF recommends regular wearers of multifocal glasses who vitamin D supplementation in older adults routinely participate in outdoor activities are at increased fall risk.23 The recommended given single lens glasses.34 Patients who use dietary allowance of vitamin D is 800 IU multifocal glasses may benefit from wearing per day 30; however, the AGS recommends single lens glasses for activities such as walk-

vitamin D3 plus calcium supplements that ing or climbing . The risk of injurious include at least 1,000 IU of vitamin D per day falls increases after a first-eye cataract sur- for older persons to reduce fall risk.29 gery. Second-eye cataract surgery decreases Medication Review. Patients and caregiv- fall risk, although fall risk remains above ers must be educated about increased fall risk baseline.35 Delays in second-eye cataract sur- with and certain medications, gery should be minimized. especially benzodiazepines, opioids, and Foot Care. Podiatry intervention involv- sleep medications (Table 311,31). In one study, ing routine podiatry care, home-based withdrawal of psychotropics reduced the fall foot and ankle exercises, foot orthoses, and rate by 66%.32 Another study showed that advice about footwear reduces the fall rate in educating family physicians about their pre- community-dwelling older adults with dis- scribing practices can reduce falls by 39%.33 abling foot pain.36 Older persons should be When possible, physicians should limit high- advised that walking in shoes with low heels risk medications and the total number of and a high surface contact area may reduce medications used. Any medication that was the risk of falls.7 Pacemakers. Carotid sinus hypersensitivity should be considered when a patient has unex- Table 3. Medications Associated with Falls plained recurrent falls. Pacemakers reduce falls and syncope in patients with this syndrome.20,37 Anticonvulsants* Digoxin Antidepressants (tricyclic Diuretics Hospital Setting antidepressants and selective Laxatives MULTIFACTORIAL INTERVENTIONS serotonin reuptake inhibitors)* Opioids* Multifactorial interventions have been effec- Antihypertensives Nonbenzodiazepine, benzodiazepine tive in the extended-care and rehabilitation Antiparkinsonian drugs receptor agonist hypnotics* hospital settings.21 A systematic review sug- Antipsychotics (typical and atypical)* Nonsteroidal anti-inflammatory drugs gested that multicomponent interventions Benzodiazepines (short- and long- Sedatives and hypnotics* may also reduce fall rates in U.S. acute care acting)* hospitals, but the pooled risk reduction was 38 *—These medications are on the 2015 Beers Criteria list for potentially inappropriate not statistically significant. This review medication use in older adults who have a history of falls or fractures.31 included several successful individual tri- Information from references 11 and 31. als in which fall risk was reduced by up to 30%. Components included a standardized

244 American Family Physician www.aafp.org/afp Volume 96, Number 4 ◆ August 15, 2017 Preventing Falls in Older Persons SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References assessment to identify risk factors, such as Community-dwelling older persons at low to B 7, 8, 20, delirium, for which patient-specific care moderate risk of falls should participate in an 23, 29 exercise program or physical therapy and take plans could be developed; patient and staff vitamin D supplements. education; alert signs; safety and toileting Community-dwelling older persons at high risk of C 8, 20, 23 rounds; bed and chair alarms; footwear falls should receive a multifactorial risk assessment advice; and medication review.38,39 There is and intervention tailored to their needs. little evidence that low beds and bed alarms Older persons at risk of falls who are hospitalized B 21, 38, 39, 40 in an acute setting or for an extended time in a 42 reduce falls. Improved bed alarms and subacute setting should receive a multifactorial wearable movement sensors are currently risk assessment and intervention tailored to being developed, but the evidence for their their needs. ability to prevent falls is inconsistent.41 Nursing home residents at risk of falls should B 22 The Agency for Healthcare Research and receive a multifactorial risk assessment and intervention tailored to their needs that are Quality has developed a toolkit to assist in administered by a multidisciplinary team. the implementation of interdisciplinary The following components should be included in multifactorial interventions best practices for fall prevention in hos- for falls in older persons: pitals (available at http://www.ahrq.gov/ Exercise, particularly balance, strength, and gait A 7, 8, 22 sites/default/files/publications/files/fall​px​ training 42 toolkit_0.pdf). The Centers for Medicare Vitamin D3 supplementation of at least 800 IU B 7, 8, 29 and Medicaid Services has designated falls daily Withdrawal or minimization of psychoactive and B 7, 8, 22, 39 occurring during hospitalization as pre- other medications ventable; therefore, any additional cost of Adaptation or modification of the home B 7, 8, 22 care or increased length of stay because of environment for those who have fallen or have resulting fracture or brain injury is the hos- visual impairment pital’s responsibility. Physicians must be Management of foot problems and footwear B 7, 8, 22, 39 diligent about avoiding restraints whenever Management of postural hypotension B 7, 8, 22 possible because they increase the risk of Dual chamber cardiac pacing should be considered B 6, 20, 37 43 in patients with carotid sinus hypersensitivity injurious falls. who experience unexplained recurrent falls. SINGLE INTERVENTIONS A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- Although data are limited, supervised exer- quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence cise in the extended-care hospital setting has rating system, go to http://www.aafp.org/afpsort. been shown to decrease fall risk.21

Nursing Home Setting A meta-analysis concluded that exercise MULTIFACTORIAL INTERVENTIONS intervention to prevent falls is most effective Multidisciplinary team administration of if balance exercise is combined with other multifactorial assessment and intervention types of exercise, usually resistance training, in nursing homes reduces falls by 33% and and performed two to three times per week the number of recurrent fallers by 21%.22 for more than six months.45 Exercise inter- The individualized interventions contained ventions have demonstrated effectiveness many similar components to the interven- in preventing falls in cognitively impaired tions provided for community-dwelling per- older adults who are in the nursing home sons but also included staff education. Falls settings.28 and fall-related injuries were not increased Vitamin D. Vitamin D supplementation when nursing homes implemented interven- decreases the number of falls in long-term tions to reduce the use of restraints such as care residents.21 The Institute of Medi- belts and full-enclosure bed rails.44 cine recommends that persons older than 70 years (including those who are institu- SINGLE INTERVENTIONS tionalized) receive 800 IU of vitamin D3 Exercise. The effectiveness of exercise pro- daily, 30 and the AGS recommends at least 21,22 29 grams in long-term care is controversial. 1,000 IU of vitamin D3 daily.

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Interventions to Reduce Fall-Related 3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls Injuries among elderly persons living in the community. N Engl J Med. 1988;​319(26):1701-1707​ . Bisphosphonates are recommended for 4. Tinetti ME, Williams CS. Falls, injuries due to falls, and patients with to reduce frac- the risk of admission to a nursing home. N Engl J Med. tures from falls.46 A Cochrane review found 1997;​337(18):​1279-1284. 5. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the that vitamin D plus calcium supplementa- nursing home. Ann Intern Med. 1994;121(6):​ 442-451​ . tion resulted in nine fewer hip fractures per 6. Tinetti ME, Kumar C. The patient who falls:​ “It’s always 1,000 institutionalized older adults per year,47 a trade-off”. JAMA. 2010;​303(3):258-266​ . 7. Panel on Prevention of Falls in Older Persons, American but the USPSTF concludes that the evidence Geriatrics Society and British Geriatrics Society. Sum- is insufficient for the use of vitamin D for the mary of the updated American Geriatrics Society/British primary prevention of fractures in noninsti- Geriatrics Society clinical practice guideline for preven- 48 tion of falls in older persons. J Am Geriatr Soc. 2011;​ tutionalized adults. Hip protectors may 59(1):148-157​ . reduce hip fractures but may also slightly 8. Centers for Disease Control and Prevention. STEADI increase the risk of pelvic fractures.49 materials for health care providers. http:​//www.cdc.gov/ New sensors, such as wristwatches, cam- steadi/materials.html. Accessed May 5, 2016. 9. Centers for Disease Control and Prevention. Algorithm eras, microphones, and floor sensors, are for fall risk assessment and interventions. http:​//www. being developed to detect falls quickly in var- cdc.gov/steadi/pdf/algorithm_2015-04-a.pdf. Accessed ious settings, but trials have been small and May 5, 2016. 50 10. Centers for Disease Control and Prevention. Talking about inconclusive. Personal emergency response fall prevention with your patients. http:​//www.cdc.gov/ systems decrease hospitalization and may be steadi/pdf/talking_about_fall_prevention_with_your_ considered for community-dwelling older patients-a.pdf. Accessed May 5, 2016. adults.51 11. Bloch F, Thibaud M, Tournoux-Facon C, et al. Estima- tion of the risk factors for falls in the elderly: ​can meta- This article updates previous articles on this topic by Van analysis provide a valid answer? Geriatr Gerontol Int. Voast Moncada,16 Rao,52 and Fuller.53 2013;13(2):​ ​250-263. 12. Mahoney J, Sager M, Dunham NC, Johnson J. Risk of Data Sources: An Ovid Medline search was completed falls after hospital discharge. J Am Geriatr Soc. 1994;​ using the term accidental falls. The search included meta- 42(3):269-274​ . analyses, randomized controlled trials, clinical trials, and 13. Stenhagen M, Ekström H, Nordell E, Elmståhl S. Falls in reviews. Also searched were the Agency for Healthcare the general elderly population:​ a 3- and 6-year prospec- Research and Quality evidence reports, the Cochrane tive study of risk factors using data from the longitudinal database, the National Guideline Clearinghouse data- population study ‘Good ageing in Skane’. BMC Geriatr. base, the U.S. Preventive Services Task Force website, and 2013;13:​ 81.​ Essential Evidence Plus. Search dates: March 30, 2016, 14. LeFevre ML. Screening for vitamin D deficiency in adults: ​ and December 6, 2016. U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;​162(2):​133-140. 15. Onen F, Higgins S, Onen SH. Falling-asleep-related The Authors injured falls in the elderly. J Am Med Dir Assoc. 2009;​ LAINIE VAN VOAST MONCADA, MD, is a clinical associate 10(3):207-210​ . professor in the Department of Family Medicine at Louisi- 16. Moncada LV. Management of falls in older persons:​ ana State University School of Medicine, University Hospi- a prescription for prevention. Am Fam Physician. 2011;​ tal and Clinics in Lafayette. 84 (11):1267-1276​ . 17. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry L. GLEN MIRE, MD, is a clinical associate professor in the PJ. Fear of falling and restriction of mobility in elderly Department of Family Medicine at Louisiana State Univer- fallers. Age Ageing. 1997;​26(3):189-193​ . sity School of Medicine, University Hospital and Clinics. 18. Campbell AJ, Robertson MC. Implementation of multi- factorial interventions for fall and fracture prevention. Address correspondence to Lainie Van Voast Moncada, Age Ageing. 2006;​35(suppl 2):​ii60-ii64. MD, University Hospital and Clinics, 2390 West Congress 19. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro St., Lafayette, LA 70506 (e-mail: [email protected]). E, Adler G. Gender differences in seeking care for falls Reprints are not available from the authors. in the aged Medicare population. Am J Prev Med. 2012;​ 43(1):​59-62. REFERENCES 20. Gillespie LD, Robertson MC, Gillespie WJ, et al. Inter- ventions for preventing falls in older people living in 1. Centers for Disease Control and Prevention. National Cen- the community. Cochrane Database Syst Rev. 2012;​(9):​ ter for Injury Prevention and Control (WISQARS). http:​// CD007146. www.cdc.gov/injury/wisqars/. Accessed March 13, 2016. 21. Cameron ID, Gillespie LD, Robertson MC, et al. Inter- 2. Bergen G, Stevens MR, Burns ER. Falls and fall injuries ventions for preventing falls in older people in care facil- among adults aged ≥65 Years—United States, 2014. ities and hospitals. Cochrane Database Syst Rev. 2012;​ MMWR Morb Mortal Wkly Rep. 2016;65(37):993-998. (12):CD005465.​

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Clin Geriatr Med. 2002;​18(2):141-158​ . tive impairment:​ a systematic review and meta-analysis. 44. Gulpers MJ, Bleijlevens MH, Ambergen T, Capezuti E, J Am Med Dir Assoc. 2015;​16(2):149-154​ . van Rossum E, Hamers JP. Belt restraint reduction in 29. American Geriatrics Society Workgroup on Vitamin D nursing homes: ​effects of a multicomponent interven- Supplementation for Older Adults. Recommendations tion program. J Am Geriatr Soc. 2011;​59 (11):2029-2036​ . abstracted from the American Geriatrics Society con- sensus statement on vitamin D for prevention of falls 45. Silva RB, Eslick GD, Duque G. Exercise for falls and frac- and their consequences. J Am Geriatr Soc. 2014;​62(1):​ ture prevention in long term care facilities: ​a systematic 147-152. review and meta-analysis. J Am Med Dir Assoc. 2013;​ 14(9):​685-689.e2. 30. Ross AC, Taylor CL, Yaktine AL, Cook HD; ​Institute of Medicine. Dietary Reference Intakes for Calcium and 46. Florence R, Allen S, Benedict L, et al. Diagnosis and Vitamin D. Washington, DC:​ National Academies Press;​ treatment of osteoporosis. Institute for Clinical Systems 2011:363.​ Improvement. Updated July 2013. https://www.icsi.org/_​ asset/vnw0c3/osteo.pdf. Accessed October 31, 2016. 31. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 47. Avenell A, Mak JC, O’Connell D. Vitamin D and vitamin D updated Beers Criteria for potentially inappropriate analogues for preventing fractures in post-menopausal medication use in older adults. J Am Geriatr Soc. 2015;​ women and older men. Cochrane Database Syst Rev. 63 (11):2227-2246​ . 2014;(4):​ CD000227.​ 32. Campbell AJ, Robertson MC, Gardner MM, Norton RN, 48. Moyer VA. Vitamin D and calcium supplementation to Buchner DM. Psychotropic medication withdrawal and prevent fractures in adults:​ U.S. Preventive Services Task a home-based exercise program to prevent falls:​ a ran- Force recommendation statement. Ann Intern Med. domized, controlled trial. J Am Geriatr Soc. 1999;​47(7):​ 2013;158(9):​ 691-696​ . 850-853. 49. Santesso N, Carrasco-Labra A, Brignardello-Petersen R. 33. Pit SW, Byles JE, Henry DA, Holt L, Hansen V, Bowman Hip protectors for preventing hip fractures in older peo- DA. A Quality Use of Medicines program for general ple. Cochrane Database Syst Rev. 2014;(3):​ CD001255.​ practitioners and older people: ​a cluster randomised 50. Chaudhuri S, Thompson H, Demiris G. Fall detection controlled trial. Med J Aust. 2007;​187(1):​23-30. devices and their use with older adults: ​a systematic 34. Haran MJ, Cameron ID, Ivers RQ, et al. Effect on falls of review. J Geriatr Phys Ther. 2014;​37(4):​178-196. providing single lens distance vision glasses to multifo- 51. Roush RE, Teasdale TA, Murphy JN, Kirk MS. Impact cal glasses wearers:​ VISIBLE randomised controlled trial. of a personal emergency response system on hospital BMJ. 2010;340:​ c2265.​ utilization by community-residing elders. South Med J. 35. Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of 1995;​88(9):917-922​ . first- and second-eye cataract surgery on injurious falls 52. Rao SS. Prevention of falls in older patients. Am Fam that require hospitalisation: ​a whole-population study. Physician. 2005;​72(1):​81-88. Age Ageing. 2014;​43(3):341-346​ . 53. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;​ 36. Spink MJ, Menz HB, Fotoohabadi MR, et al. Effectiveness 61(7):2159-2174​ . of a multifaceted podiatry intervention to prevent falls

August 15, 2017 ◆ Volume 96, Number 4 www.aafp.org/afp American Family Physician 247 Preventing Falls in Older Persons

eTable A. Tips for Implementing Fall Prevention Interventions for Community-Dwelling Older Adults

1. Screen all persons older than 65 years annually for history of falls, frequency of falls, and difficulty with gait and balance as recommended by the American Geriatrics Society and British Geriatrics Society.A1 Also, solicit any history of fear of falling.A2 Consider screening at the same time every year, such as during the season of fall or at the Medicare Annual Wellness Visit. 2. Train medical assistants or nursing staff to automatically document postural blood pressure and pulse, Timed Up and Go (and possibly 30-Second Chair Stand and 4-Stage Balance) test results, visual acuity, functional history, and activities-of-daily-living findings, as well as conduct a cognitive screen, such as a three-item recall, for any patient with a recent fall or history of falls. 3. Assign office staff to identify group exercise programs and/or tai chi programs with strength, gait, and balance components. The local Council on Aging, hospitals, YMCAs, and senior centers may offer these programs. The Tai Ji Quan: Moving for Better Balance tai chi program* (http://tjqmbb.org) reduces the risk of recurrent falls by 55%.A3 The Stepping On program* (https://wihealthyaging.org/national-stepping-on_1), which teaches fall prevention strategies, decreases the risk of falls by 30%.A3 4. Assign office staff to identify outpatient programs that specialize in physical therapy for falls or balance impairment. The Otago Exercise Program* (https://www.med.unc.edu/aging/cgec/exercise-program) is an individually tailored home exercise program administered by a trained physical therapist that reduces the risk of falls by 35%.A3 5. Assign office staff to identify home health companies that provide home safety evaluations and follow up for adherence to recommendations. 6. Assign office staff to identify companies that provide home safety modification, such as installation of grab bars in the bathroom. Find National Association of Homebuilders–certified aging-in-place specialists at http://www.nahb.org/en/find/directory-designee.aspx. Contact the local Council on Aging for resources. 7. Input resources from numbers 4 to 6 into the fall prevention EMR template (eTable B) for high-risk fallers. 8. Input patient education materials into the fall prevention EMR template (eTable B) for high-risk fallers. Examples: http://www.cdc.gov/steadi/patient.html and http://health.gov/dietaryguidelines/2015/guidelines/appendix-11/

9. Recommend vitamin D3 supplementation (minimum of 800 IU daily) with or without calcium to all older adults at risk of falling. 10. Refer older adults who are at low risk of falling to a community exercise or fall prevention program (see number 3). Refer older adults who are at moderate risk of falling to a community fall prevention exercise program or physical therapy for fall prevention (see number 4) and review or modify their medications. 11. Complete the fall prevention EMR template (eTable B) for high-risk older adults who have impairment on gait or balance evaluation and report two or more falls or one fall causing injury.

EMR = electronic medical record. *—Evidence based and recommended by the Centers for Disease Control and Prevention. Adapted with permission from Moncada LV. Management of falls in older persons: a prescription for prevention. Am Fam Physician. 2011;84 (11):1274, with additional information from: A1. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59 (1):148-157. A2. Centers for Disease Control and Prevention. STEADI materials for healthcare providers. http://www.cdc.gov/steadi/materials.html. Accessed May 5, 2016. A3. Stevens JA, Burns E. A CDC compendium of effective fall interventions: what works for community-dwelling older adults. 3rd ed. Atlanta, Ga.: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2015.

DownloadedAugust 15, from2017 the ◆ VolumeAmerican 96, Family Number Physician 4 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American Academy of FamilyAmerican Physicians. Family For the Physician private, non 247A- commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Preventing Falls in Older Persons

eTable B. Falls Prevention Electronic Medical Record Template: Multifactorial Assessment and Intervention for Community-Dwelling High-Risk Fallers

Chief problem Social history Assessment History of a fall History of alcohol use ICD-10 codes History Physical examination R26.2 for difficulty in walking, not Number of falls in the past year Visual acuity elsewhere classified Feeling of unsteadiness when Left eye with glasses R26.81 for unsteadiness on feet standing or walking Right eye with glasses R29.6 for repeated falls Fear of falling Bilateral eyes with glasses Z91.81 for history of falling Injuries due to a fall Use of multifocal glasses Plan for those at high risk of falling Environmental hazards Postural blood pressure and pulse Referral to a physical therapist for gait, strength, and balance training Dizziness Cardiovascular examination Vitamin D supplementation (minimum of Syncope Musculoskeletal strength 3 800 IU daily) with or without calcium Assistive devices needed Gait and use of assistive device List of how medications were reviewed and Assistive device used at the time Number of seconds for Timed Up and Go modified of the fall test with assistive device (12 or more Referral to occupational therapist for home Assistance needed with seconds indicates a high risk of falling) safety evaluation transferring, bathing, dressing, 4-Stage Balance test (inability to hold Postural hypotension treatment or toileting first three stages for 10 seconds or Review of systems more without assistive device indicates Referral to ophthalmologist or optometrist Vision problems increased risk of falling) Advice to wear single lens glasses for outdoor activities, walking, or climbing stairs Date of the most recent Number of seconds with feet side by side eye examination by an Number of seconds in semitandem stance Referral to a podiatrist ophthalmologist or optometrist Number of seconds in tandem stance Recommendation to wear footwear with a low heel and high surface contact area Urinary or fecal incontinence Number of seconds standing on one foot Bone density scan (dual energy x-ray Acute or chronic musculoskeletal Number of stands in 30-Second Chair absorptiometry) problems Stand test 25-hydroxyvitamin D measurement History of osteoporosis Below-average scores (number of Foot pain stands) by age and sex: Osteoporosis treatment Footwear worn at the time of 60 to 64 years: < 14 men, < 12 women Personal emergency response system the fall 65 to 69 years: < 12 men, < 11 women Complete blood count, chemistry panel, urinalysis, or chest radiography (if patient Acute or chronic neurologic 70 to 74 years: < 12 men, < 10 women problems may have underlying acute or subacute 75 to 79 years: < 11 men, < 10 women illness) History of acute or chronic 80 to 84 years: < 10 men, < 9 women cognitive impairment List of patient education materials 85 to 89 years: < 8 men and women distributed (e.g., http://www.cdc.gov/ Medications Feet examination steadi/patient.html, http://health.gov/ Current medications, including Footwear dietaryguidelines/2015/guidelines/​ over-the-counter, herbal, and appendix-11/) psychoactive medications Neurologic examination Follow-up visit scheduled for one month to Cognitive examination (number of items New medications or recent encourage fall risk reduction behaviors, recalled at three minutes) dosage changes assess adherence, and address any barriers to the care plan

ICD-10 = International Classification of , 10th ed. Information from: Centers for Disease Control and Prevention. STEADI materials for healthcare providers. http://www.cdc.gov/steadi/materials.html. Accessed May 5, 2016. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59 (1):148-157.

247BDownloaded American from Family the American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American AcademyVolume of Family96, Number Physicians. 4 ◆ For August the private, 15, 2017 non- commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.