Copyright © 2015 Wolters Kluwer Health, Inc. All Rights Reserved. Fall Prevention in Older Adults Fall Prevention in Older Adults

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Abstract: Falls in older adults are a major public health concern and can often have fatal results. Practitioners need to be aware of assessment and diagnostic techniques to prevent falls in older adults.

By Scott J. Saccomano, PhD, RN, GNP-BC and Lucille R. Ferrara, EdD, MBA, RN, FNP-BC

ne of the major public health concerns of older adults is falls. Falls are deﬁ ned as an unintentional loss of balance that results in a posi- O tion change and contact with the ground.1 Practitioners who work with older adults must know and understand the implications of falls and work to improve the quality of life for the older adult who has fallen.

■ Epidemiology Approximately one third of individuals over the age of 65 fall each year, rising to 50% by the age of 80.2-6 Falls in older adults are the leading cause of nonfatal and fatal injuries. In 2012, EDs treated almost 2.5 million older adults who had suffered nonfatal falls resulting in 722,000 hospitalizations.7 The CDC reported that in 2012, the adjusted medical cost of falls was approximately 30 billion dollars. As the population ages, the number of falls is ex- pected to increase as well as the cost of treating them.8 Over the last 10 years, death rates from falls have risen dramatically with almost 23,000 fall-related deaths in 2011. Men have a higher death rate from falls than women, and older White men are almost three times more likely to die from a fall than older Black men.8

■ Pathophysiology of falls The origin of falls is multifactorial. While hazardous behavior may cause falls, walking, stepping, or position changes cause the majority of falls. Lower extremity weakness, balance disorders, postural hypotension, central nervous system diseases, abnormalities in cognition and sensation, and unsafe environments all contribute to falls.9

Keywords: fall assessment, fall prevention, fall risk, falls, fear of falling, geriatrics, mobility, older adults www.tnpj.com The Nurse Practitioner • June 2015 41

During the normal aging process, visual impairment ■ History and physical exam and ocular disease increase. Glare intolerance and slow Is the fall an isolated event? If not, is there a pattern to adaptation to changes in light level are normal and related the falls? If there is a pattern to the falls, how often and to the aging process.10 when do the falls occur, and are the falls increasing in Peripheral and central vestibular function as well as frequency? Is there a particular triggering factor or event sensory cues help to maintain balance. Age-related changes to the fall? Was any alcohol consumed? What caused the in the inner ear and changes in transmission signals from fall? What activity was the patient doing at the time of the periphery cause disequilibrium and unsteadiness in the fall? older adults.11 Depression and acute changes in mental status Patients who are arising from bed or off a toilet may also contribute to falls in older adults. Other factors that can do so quickly, thus, inadvertently causing orthostatic hy- lead to falls include medications, especially sedating drugs, potension. Did the fall involve exertion, change of position BP changes, and imbalances in fl uid and electrolytes.12,13 of the head (looking up then down)? Patients who are Changes in the aging cardiovascular system impair nor- reaching up or extending their neck can cause vertebro- mal homeostatic mechanisms of BP control and perfusion, basilar insuffi ciency, thereby decreasing blood fl ow to the leading to hypotension and an inability to maintain proper brain, causing dizziness or blackouts. Micturition syncope, balance. Balance and gait are affected by joint disease and which can affect older adult males especially at night, musculoskeletal changes as well as environmental factors, occurs after rapid urination that causes a sudden drop in BP resulting in syncope.9,31 The level of consciousness should Chronic illness such as hypertension, kidney be asked about. Was there any loss of disease, diabetes mellitus, and arteriosclerosis consciousness? Does the patient re- member falling? Sudden “blackouts” or increase the patient’s risk for falls. falling can be caused by underlying car- diac or neurologic disorders and require further investigation. The patient such as scattered rugs, loose electric cords, and clutter. Fear should be asked if there was a warning or associated symp- of falling after a fall has occurred is common among older toms before the fall (palpitations, shortness of breath, diz- adults because they have lost their self-confi dence and feel ziness, chest pain, vertigo, dizziness).32 Did the patient have that they are losing control over their lives.14 Fear of falling a loss of balance? Patients may state they felt weak, dizzy, or produces additional cautious behaviors as well as diminished faint prior to falling; these symptoms require a more in- activity and ambulation, which may put the older adult at depth evaluation. What was the patient status after the fall? risk for future falls.15 Continued weakness, disorientation, incontinence, and a bitten tongue can indicate neurologic dysfunction and re- ■ Conditions for fall predisposition quire further evaluation. Disorders that are common in older adults, such as muscu- Witnesses are important in the evaluation of a witnessed loskeletal diseases, are often the cause of falls and fall-related fall, as they can report the circumstances before, during, and injuries. Osteoarthritis, osteoporosis, and low back pain have after a fall. This is important in describing fall behaviors, a signifi cant association to fall-related injuries.16 Neuro- such as tonic-clonic movements, mental status, and level of logic conditions in older adults that can increase fall risk consciousness. include gait and balance disorders, sensory impairments, Patients reporting a history of tripping and falling stroke, Parkinson disease, and cognition impairments. Car- should be further assessed. Are there visual defects present? diovascular risk factors for falls include orthostatic hypoten- Has the patient had a recent eye exam? Does the patient sion, which is a common medical condition in older adults. have blurred vision, or is vision loss present? Patients who Chronic illness such as hypertension, kidney disease, diabe- present with visual disturbances, such as presbyopia, cat- tes mellitus, and arteriosclerosis also place the patient at risk aracts, glaucoma, and age-related macular degenera- for orthostatic hypotension, which increases the fall risk.17,18 tion, should be followed for appropriate evaluation and Additional risk factors for falls include medications, espe- treatment.14,27 cially the use of multiple medications known to increase the Components of the physical exam should include risk of falls, alcohol abuse, visual disturbances, foot prob- vital signs—particularly postural vital signs—and cardio- lems, coordination and balance impairment, and urinary vascular/neurologic evaluations. The cardiovascular ex- incontinence.19-30 (See Risk factors for falls.) amination should include an assessment of pulses for

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irregularities in rhythm or an abnormal rate—especially atrial fi brillation or bradycardia. The recording of BP in Risk factors for falls12,14,17-30 lying, sitting, and standing positions is critical, especially if there is evidence of postural hypotension in the history. Aging–Falls increase with age and increasing frailty A drop of 20 mm Hg in the systolic pressure with standing Gender–Women are more likely to have a nonfatal fall, is noteworthy, as a 20 mm Hg drop can cause changes in while men who suffer a fall are approximately 50% more likely to have a fatal fall balance, leading to falls. Carotid bruits should be assessed Medications–Common medications in older adults, such for. Auscultation of the heart can provide evidence of as diuretics, beta-blockers, antidepressants, nitrates, murmurs, such as aortic stenosis, regurgitation, mitral angiotensin-converting enzyme inhibitors, and antihista- stenosis, or regurgitation.14,33 mines, are thought to precipitate orthostatic hypotension The neurologic examination includes assessment of and cause falls as a result of syncopal adverse reactions. Benzodiazepines, psychotropics, and sedatives can muscle wasting, muscle strength, tone, and a sensory sys- cause confusion, leading to falls. tem assessment—especially if neuropathies are suspected. Polypharmacy–Using four or more medications causing Muscle wasting can be seen in diseases of disuse, such as interactions and adverse reactions are likely to cause arthritis. Mobility and gait testing are quick and easy and falls. Even using one medication known to cause falls can predict the risk of falls. The ‘timed up and go” test is can increase risk a timed test that is the modifi ed version of the “get up and Alcohol abuse–can cause instability from acute intoxica- go” test; it entails regular footwear and any regular walk- tion. Alcohol abusers can be predisposed to falls secondary to polyneuropathy, Wernicke encephalopathy, and ing aid where the patient rises from a seated position in a Korsakoff syndrome chair with their arms folded across the chest, ambulates Diabetes–related neuropathy can predispose one to 10 feet, then turns around to return to the chair to sit balance impairments, motor weakness, and loss of sen- down. The ease of gait, mobility, balance, position, change, sation, leading to lower extremity weakness, which can and turning is evaluated. Patients taking longer than cause frequent tripping and inability to navigate stairs and rise from a seated position 30 seconds to complete the test are considered function- ally dependent.34 Visual disturbances–Increased falls related to visual disturbances is becoming more common. Visual distur- Another performance test for gait and balance and fall bances, such as presbyopia, cataracts, glaucoma, and risk is The Tinetti Performance Oriented Mobility Assess- age-related macular degeneration, are associated with ment (POMA). The Tinetti POMA measures 16 items increased tripping, slips, and falls (9 items of balance and 7 items of gait) in older adults with Coordination and balance–impairments related to chang- three-point ordinal scores ranging from 0 to 2; the higher es in musculoskeletal impairments, resulting in disorders of gait and lower extremity weakness score indicates independence, a score of less than 19 is an Foot problems–Older adults with deformities of toes, individual at high risk for falls, 19 to 24 medium risk for bunions, callus nail deformities (even improper foot- 35,36 falls, and 25 to 28 low risk for falls. wear) can cause increased pain when ambulating and can lead to balance diffi culties and falls ■ Fall prevention in the older adult Urinary incontinence–Falls from urinary incontinence are Patient history and physical exam are key in the formula- a direct result from trying to do two things at once; urine tion of differential diagnosis specifi c to fall risk and pre- is to be held before being expelled at the bathroom vention. A thorough and comprehensive history and Depression–Coupled with the use of antidepressive medication, diminished physical functioning, and cognitive physical exam should be performed to provide a baseline defi cits, depression is known to increase the risk of falls assessment of neurologic and cognitive function, visual in older adults and hearing acuity, musculoskeletal strength and stability, as well as cardiopulmonary stamina. Questionable or sug- gestive fi ndings will then guide the provider’s choice for the provider in determining the underlying cause associ- further study. ated with a fall or detect potential conditions that may in- Metabolic studies. Metabolic factors should be consid- crease the patient’s propensity to fall. ered, such as infection, polypharmacy, hypoglycemia, and Medicare or other third-party insurance carriers may dehydration. Routine lab testing for the older adult is typi- not always cover some of these baseline blood tests. The cally obtained during the annual physical exam or in some complete blood cell count, baseline metabolic panel, thyroid cases depending more frequently upon medication regimen studies, and hemoglobin A1C offer a solid foundation. Ane- and other comorbidities, such as hyperlipidemia, cardiovas- mia, impaired kidney function, electrolyte imbalances, cular disease, or diabetes. Baseline testing can greatly assist thyroid disease, and diabetes are easily detected with these www.tnpj.com The Nurse Practitioner • June 2015 43

simple lab studies, and when appropriately corrected, can an easy and relatively safe exam with low radiation expo- signifi cantly aid in fall prevention.34 sure that greatly assists in the calculation of bone den- Assessment of balance. Another factor associated sity loss. Results can provide a useful guide for nurse with falls is imbalance disturbances that can range from practitioners when considering pharmacologic treatment benign positional vertigo (BPV) to more complex neu- for osteoporosis as well as other interventions, such as rologic disorders, such as Parkinson disease. Simple strength training exercise, nutritional supplementation, screening exams, such as the single leg stance test and the and therapy.38 “timed up and go test,” establish a baseline for impaired Cognitive assessment. There is a signifi cant correlation balance and justifi cation for further investigation with between falls and dementia. Creating a safe environment other testing.34 for all patients—especially those with dementia—is central Cardiovascular assessment. Impaired balance can be to their overall care. Assessing the older adult at baseline attributed to cardiovascular conditions, including dysrhyth- and monitoring at least annually (or more frequently if mias (such as atrial fi brillation) and vasculopathies (such warranted) aids in early detection of dementia. The Mini as carotid artery atherosclerosis). A simple baseline ECG Mental State Exam (MMSE) is a simple and convenient can detect dysrhythmias, but when symptoms such as syn- tool to use when performing a baseline assessment as well cope are present, Holter monitoring—either a 24-hour study as for trending progressive cognitive impairment.34 The or longer event monitoring (30 days)—may be required to MMSE is a standardized test that has sound reliability and validity; it evaluates registration, attention and calculation, recall, language, Arthritis accounts for approximately 15% to simple commands, and orientation. 20% of falls in adults over the age of 45 due The maximum score is 30. A score of 26 or above is considered to limitations in mobility. normal. If the older adult scores below 26, further evaluation by a neurologist is recommended to differentiate the capture more complex dysrhythmias that are transient or degree and type of dementia that may be present. Another paroxysmal. Doppler studies provide a baseline vascular tool that is used to detect mild cognitive impairment is the evaluation and can also be used to monitor and track the Montreal Cognitive Assessment (MoCA). The MoCA is also progression of documented vasculopathies, such as carotid a 30-point tool that assesses attention and concentration, artery occlusion.34,37 executive functions, memory, language, visuoconstruc- Visual and hearing assessment. Many falls occur in tional skills, conceptual thinking, calculations, and orienta- the patient’s home during the night when there is less light. tion. A score of 26 or above in the MoCA is also considered A routine eye exam and hearing screening will help to normal. Again, older adults scoring below 26 should be complete the comprehensive evaluation for fall prevention. evaluated further.39 An annual eye exam is recommended, especially if the Bowel and bladder assessment. A comprehensive patient has diabetes or documented retinopathy, cataracts, history with regard to the patient’s bowel and bladder or other visual pathology. Patients should also be cautioned habits is essential. Questions should focus on overall bow- with regard to certain lens types, such as bifocals, as these el and bladder habits, bladder continence, the presence of types of lenses may alter depth perception and increase the constipation, the use of laxatives and diuretics, and any chance of falls.34 other over-the-counter (OTC) medications the patient Musculoskeletal assessment. During the musculo- may use. Urinary incontinence poses a major risk factor skeletal assessment, arthritic changes in the joints and for falls. These falls frequently occur due to the patient’s limitations in mobility are detected. Arthritis accounts attempting to get to the bathroom quickly to avoid an for approximately 15% to 20% of falls in adults over the incontinent episode. In addition, wet bathroom fl oors due age of 45 due to decreased strength and limitations in to urinary incontinence increase the risk of slipping. Con- mobility.38 In addition to the musculoskeletal physical stipation on the other hand also presents fall risk for the assessment of the older adult patient, the provider must older adult who may use various laxatives and other aids also consider the direct correlation of osteoporosis to to alleviate constipation. Some laxatives may increase falls in older adults due to loss of bone density experi- episodes of diarrhea that in turn increases the incidence enced from the effects of osteoporosis. Dual X-ray ab- of dehydration, which may also increase dizziness and sorptiometry (also known as the DXA or DEXA scan) is syncope.34

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Fall assessment tools. In addition to the above discussed fall assessment, there are a number of tools that Useful provider websites have been developed for the assessment of falls in the Fall assessment tools older adult (see Useful provider websites). The CDC has An algorithm for falls risk assessment and interventions published a pocket guide for providers, which contains an https://www.wehealny.org/services/ipa/fi les/MAW/ algorithm for fall assessment as well as a fall checklist for algorithm_fall_risk_assessment.pdf providers and their patients to use for additional fall risk A fall risk checklist screening (www.cdc.gov/homeandrecreationalsafety/pdf/ http://www.cdc.gov/homeandrecreationalsafety/pdf/ steadi/pocket_guide_preventing-falls.pdf). The Morse Fall steadi-2015.04/Check_for_Safety_brochure-a.pdf Scale (1989) is another tool that was developed by J.M. Common screening and assessment tools Morse for the rapid evaluation of fall risk for patients who http://www.fallpreventiontaskforce.org/resourcetools/ are either hospitalized or in long-term care.40,41 The Morse screening-assessment-tools Fall Scale assesses six parameters for falls, history of falls, NICHE fall assessment: secondary diagnoses, ambulatory aids, current I.V., gait, http://www.nicheprogram.org/niche_encyclopedia- assessment-fall_risk_assessment transference, and mental status. Other assessment and screening tools can also be found on the website created by the Ohio Department of Health (http://www.healthy. orthopedist that the patient is taking a sleep aid, the ortho- ohio.gov/vipp/falls/fallsolder.aspx). pedist prescribes oxycodone and acetaminophen for pain. The combination of the two drugs has the potential to ■ Pharmacology increase somnolence and gait imbalance due to sedation, The pharmacy intervention for falls focuses on supple- which in turn increases fall potential. Reviewing the pa- mentation for bone health and careful review of current tient’s medications regularly can signifi cantly decrease the medication regimens. Falls often occur after a fracture due incidence of polypharmacy. Comprehensive medication to osteoporosis and most commonly affect the hip and reconciliation should include having the patient physi- spine. Increasing the strength of the bones—specifi cally cally bring all of their medications with them to the pro- the longer bones—will decrease the chance of fracture- vider visit.43 related falls. Vitamin D, bisphosphonates, raloxifene, denosumab, or teriparatide may be used for the treatment ■ Nonpharmacologic measures of osteoporosis.34,37 Central to fall prevention are the nonpharmacologic in- Many older adults experience decreased appetite and terventions that should be considered and discussed with eat less. Vitamin supplementation is recommended, and the the older adult and his or her caregivers. When evaluating use of most OTC multivitamins is suffi cient. Iron supple- the risk factors for falls, safety is of paramount concern. mentation can also be included if the patient is found to Creating a safe environment. Proper lighting, espe- have iron defi ciency. cially during the evening and nighttime, will increase Cognitive impairment and metabolic changes increase the risk of falls. That being said, medication reconcili- Age-related changes in the inner ear and ation should be performed at every transmission signal changes from the visit to ensure proper medication use, evaluation for polypharmacy, medica- periphery cause unsteadiness in older adults. tion adherence, and evaluation of adverse events.42,43 It is not uncommon for older adult patients to have more than one provider, visibility—especially for those older adults with diminished specifi cally those providers in specialty, such as cardiology, visual acuity and in some cases, impairment. Ensuring that neurology, urology, pulmonology, and orthopedics. Each fl ooring is secure, such as carpeting and tiles, will decrease of these providers may prescribe disease-specifi c medica- the chance of tripping or slipping. Cautioning patients with tion and frequently, duplication or over prescribing of a regard to walking when there is ice, snow, or other wet specifi c drug class can occur. A good example is as follows: surfaces outside should be part of the safety conversation the patient is seen by the neurologist who prescribes low- and instructions. dose zaleplon for sleep. The patient is also being seen by an Many older adults drive, and this also poses a major orthopedist for a recent wrist fracture. Unbeknownst to the safety risk. The National Highway Safety Commission www.tnpj.com The Nurse Practitioner • June 2015 45

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27. Reed-Jones RJ, Solis GR, Lawson KA, Loya AM, Cude-Islas D, Berger CS. Vi- 39. Smith T, Gildeh N, Holmes C. The Montreal Cognitive Assessment: validity sion and falls: a multidisciplinary review of the contributions of visual im- and utility in a memory clinic setting. Can J Psychiatry. 2007;52(5):329-332. pairment to falls among older adults. Maturitas. 2013;75(1):22-28. 40. Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall- 28. Leveille SG, Jones RN, Kiley DK, et al. Chronic musculoskeletal pain and prone patient. Canadian Journal on Aging. 1989;8:366-377. the occurrence of falls in an older population. JAMA. 2009;302(20):2214- 41. Schwendimann R, De Geest S, Milisen K. Evaluation of the Morse Fall Scale 2221. in hospitalised patients. Age Ageing. 2006;35(3):311-313. 29. Chaiwanichsiri D, Janchai S, Tantisiriwat N. Foot disorders and falls in older 42. Agashivala N, Wu WK. Effects of potentially inappropriate psychoactive med- persons. Gerontology. 2009;55(3):296-302. ications on falls in US nursing home residents: analysis of the 2004 National 30. Foley AL, Loharuka S, Barrett JA, et al. Association between the geriatric gi- Nursing Home Survey Database. Drugs Aging. 2009;26(10):853-860. ants of urinary incontinence and falls in older people using data from the 43. Kojima T, Akishita M, Nakamura T, et al. Association of polypharmacy with Leicestershire MRC Incontinence Study. Age Ageing. 2012;41(1):35-40. fall risk among geriatric outpatients. Geriatr Gerontol Int. 2011;11(4):438-444. 31. Sherman C. Determining the cause of fainting spells. Clinical Advisor. 44. Maciaszek J, Osi_ski W. The effects of Tai Chi on Body Balance in Elderly 2007;10(3):87-92. People—a review of studies from the early 21st century. Am J Chin Med. 32. Brignole M. Distinguishing syncopal from non-syncopal causes of fall in 2010;38(2):219-229. older people. Age Ageing. 2006;35(suppl 2):ii46-ii50. 45. Li F, Harmer P, Stock R, et al. Implementing an evidence-based fall prevention 33. American Geriatrics Society, British Geriatrics Society 2010. AGS/BGS clini- program in an outpatient clinical setting. J Am Geriatr Soc. 2013;61(12):2142- cal practice guideline: prevention of falls in older persons. New York, NY: 2149. American Geriatrics Society; 2011. 46. Johnson CS. The association between nutritional risk and falls among frail 34. Waldron N, Hill AM, Barker A. Falls prevention in older adults—assessment elderly. J Nutr Health Aging. 2003;7(4):247-250. and management. Aust Fam Physician. 2012;41(12):930-935. 35. Salzman B. Gait and balance disorders in older adults. Am Fam Physician. Scott J. Saccomano is an assistant professor at Herbert H. Lehman College, De- 2010;82(1):61-68. partment of Nursing, Bronx, N.Y. 36. Tinetti ME. Performance-oriented assessment of mobility problems in elderly Lucille R. Ferrara is an associate professor, director Family Nurse Practitioner patients. J Am Geriatr Soc. 1986;34(2):119-126. Program at Pace University, College of Health Professions, Pleasantville, N.Y. 37. Campbell AJ, Robertson MC. Fall prevention: single or multiple interventions? Single interventions for fall prevention. J Am Geriatr Soc. 2013;61(2):281-287. The authors and planners have disclosed no potential conﬂ icts of interest, ﬁ nan- 38. Barbour KE, Stevens JA, Helmick CG, et al. Falls and fall injuries among cial or otherwise. adults with arthritis—United States, 2012. MMWR Morb Mortal Wkly Rep. 2014;63(17):379-383. DOI-10.1097/01.NPR.0000465117.19783.ee

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