Falls are a major health problem for older adults. Various reviews and meta-analyses have estimated that 30% of people over age 65 [4,6,8,10,11,13,14,19,21,22,23] and 50% of people over age 85  who live in the community will fall at least once. The prevalence of falls is even higher in long-term care facilities, occurring in more than 50% of people over age 65 [3,10,23]. Fall-related injuries occur in 10-40% of falls and can range from minor bruises or lacerations to wrist or hip fractures [3,6,10,11,14,22,23]. Falls are the main risk factor for fractures and are even more important than decreased bone mineral density or osteoporosis, as indicated by the fact that 80% of low trauma fractures occur in people who do not have osteoporosis  and 95% of hip fractures result from falls . Overall, significant injuries occur in 4-15% of falls and 23-40% of injury-related deaths in older adults are due to falls [6,10,11,14,23].
Fall Risk Factors
Risk factors for falls can be broken down into two categories: intrinsic and extrinsic [8,10,11,14,15,19,23]. Several well-studied intrinsic risk factors are age, female gender, and previous history of falls [4,10,14,22,23]. Many individual medical conditions, as well as the presence of multiple comorbid illnesses, increase the risk of falls . Three examples that will be discussed are orthostatic hypotension [12,13,21,23], musculoskeletal disease [8,11,15], and visual impairment [5,18,19]. Other medical conditions include low systolic blood pressure, stroke, cognitive impairments, Parkinson’s disease, gait disorders, balance disorders, and other sensory impairments [3,6,8,10,14,15,19,23]. Similarly, many medications, either alone or in combination, increase the risk of falls. Specific medications include benzodiazepines, sedative-hypnotics, antidepressants, anti-hypertensives, anti-arrhythmics, diuretics, and anti-seizure medications [3,6,10,14,22,23].
Orthostatic hypotension (OH) is defined is a drop in systolic blood pressure ≥ 20 mmHg or a drop in diastolic blood pressure ≥ 10 mmHg within three minutes of standing from a supine position. This drop can be accompanied by symptoms included tachycardia, visual changes, dizziness, or syncope [12,13,21]. Similar to falls, the prevalence of OH increases with age and is present in an estimated 5-30% of people over age 65 who live in the community and 50% of people who live in long-term care facilities [12,13,21]. Many medical conditions increase the risk of developing OH. These include hypertension, atherosclerosis, varicose veins, congestive heart failure, chronic kidney disease, diabetes mellitus, Parkinson’s disease, autonomic nervous system disorders, and autoimmune neuropathies [12,13]. Medications such as diuretics, α-blockers, β-blockers, calcium channel blockers, tricyclic antidepressants, anti-histamines, nitrates, acetylcholinesterase inhibitors, and dopamine agonists also increase the risk of OH [12,13]. OH is thought to cause falls through both direct and indirect mechanisms. The direct mechanism is through syncope, which is thought to be related to as many as 10% of falls [21,23]. Syncope can be difficult to diagnose as the cause of a fall because it can involve retrograde amnesia and many falls occur in the absence of witnesses . Indirect mechanisms include poor balance control during presyncope and cognitive impairment due to cerebral hypoperfusion .
Musculoskeletal diseases are a heterogeneous group of diseases that are extremely common in older adults and constitute a major intrinsic risk factor for falls and fall-related injuries. A study of 16,080 Korean adults found a significant association between pre-existing osteoarthritis, osteoporosis, or lower back pain and one-year incidence of fall-related injuries. The presence of multiple musculoskeletal diseases further increased this risk . In Japan, the ROAD study examined the association of baseline physical performance measures and musculoskeletal disease in 1,348 adults with the three-year incidence of falls. The overall incidence of falls was higher in women than men. In men, slower chair stand time was the only independent risk factor for falls. In women, longer 6-meter walking time was a risk factor, as well as knee pain, vertebral fracture, and cognitive impairment. Interestingly, radiographic severity of knee osteoarthritis, lumbar spondylosis, and lower back pain were not significant risk factors for falls in either gender .
Visual impairment is the third most common chronic medical condition in older adults , affecting an estimated 10% of people over age 65 and 20% of people over age 75 . The prevalence of visual impairment increases with age and has been shown to be an independent risk factor for falls and fractures. Impairment can occur in any aspect of vision, including visual acuity, visual fields, contrast sensitivity, depth perception, or color perception [5,19]. It is still unclear which of these factors plays the largest role in fall risk . The most common ophthalmologic diseases causing visual impairment in older adults are presbyopia, cataracts, glaucoma, and age-related macular degeneration (ARMD) [5,19]. Due to the different pathophysiology of these diseases, each one produces a different pattern of visual impairment. Presbyopia, an impairment in the ability to see objects at close range, is corrected by the use of bifocal lenses. These lenses impair depth perception and edge contrast, which increases the risk of falls when walking outside or using stairs . Cataracts, a clouding of the lens, cause generalized blurry vision and glaring of bright lights. This increases the risk of running into objects and limits the ability to drive at night. Glaucoma, an increase in intraocular pressure that can damage the optic nerve, causes a loss of peripheral vision. ARMD, deterioration of the retina, causes loss of central vision, distortion of straight lines, impairment of color vision, and difficulty recognizing faces. These deficits limit activities of daily living and cause problems with balance that contribute to fall risk [5,19]. A study of 3,203 Latin-American adults found a significant association between central visual impairment, peripheral visual impairment, or use of bifocal lenses and the one-year incidence of falls and fall-related injuries . Aside from ophthalmologic diseases, many medications have side effects that can affect vision. These include anticholinergics, α-blockers, anti-arrhythmics, cardiac glycosides, benzodiazepines, selective serotonin reuptake inhibitors, anti-epileptics, phosphodiesterase type 5 inhibitors, and anti-malarials .
Extrinsic risk factors consist of anything in the environment that causes tripping, slipping, or loss of balance. At home, older people can trip over rugs, electrical cords, pets, or other items on the floor. They can slip on stairs, especially if there are no handrails, or in the bathtub. Low toilets or chairs, chairs without armrests, and poor lighting also contribute to the risk for falls at home [10,14,19,23]. Outside, uneven sidewalks, inappropriate footwear, and snow or ice can cause falls [10,14]. In 50-80% of falls, at least one environmental risk factor is reported . Intrinsic risk factors, such as visual or other sensory impairments that affect how an individual interacts with the environment, can increase the risk of falls due to extrinsic risk factors.
Assessing Fall Risk
Due to the prevalence of falls in older adults, the American Geriatrics Society (AGS) recommends screening all older adults for fall risk by asking if they have fallen in the past year and then, if they report a fall, conducting a multifactorial fall risk assessment . One aspect of that assessment that can be performed quickly in the clinical setting is the Timed Up and Go Test (TUGT). This test measures the time it takes for a person to rise from a chair, walk three meters, walk back to the chair, and sit down [1,2,16,20]. The test is usually completed at a comfortable walking speed, but variations exist that ask the person to walk as fast as possible, complete a cognitive task while walking, or walk around various obstacles in the room . The test involves standing up, sitting down, walking, and turning; making it a useful way to evaluate functional mobility [16,20]. However, systematic reviews have found mixed results when examining the relationship between TUGT performance and fall risk. One systematic review found that older adults who experienced a fall were slower when completing the test than those who had not. It also found a significant association between time to complete the TUGT and a history of falls in all retrospective studies but only one prospective study . Furthermore, the cut-off value of the test that separated people who fell from those that did not was very wide, ranging from 10-32.6 seconds [1,2].
A more recent systematic review found that, in most studies, there was a significant association between TUGT time and fall risk in univariate analyses, but found that this association disappeared in 75% of multivariate regression models that accounted for demographics and other fall risk factors. This review also more closely examined the differences in TUGT results between studies performed in the community and studies performed in long-term care facilities. In older adults living in the community, the pooled mean difference in TUGT time between those that fell and those who did not was 0.63 seconds, which was statistically significant but not clinically significant, and the cut-off value of the test that separated people who fell from those that did not ranged from 8.1-16 seconds. In older adults living in a long-term care facility, the pooled mean difference in TUGT time was 3.59 seconds and the cut-off value of the test ranged from 13-32.6 seconds, possibly indicating that the test is better at predicting fall risk in lower-functioning populations . Interestingly, a study of 183 Swedish adults living in long-term care facilities found that both a history of falls and the staff’s global rating of fall risk were better predictors of future falls than the TUGT . Given these mixed results, it is still recommended to use the TUGT to screen for gait and balance disorders  but to look more broadly at the clinical picture when making decisions about an individual patient’s fall risk .
Given the prevalence of falls and fall-related injuries, many different fall prevention strategies have been developed. Guides for conducting home safety assessments to identify and modify extrinsic risk factors are readily available , but the evidence that these interventions are effective is mixed. One review found that alone these interventions do not significantly reduce falls . Other reviews have found that high-risk populations, consisting of individuals with many intrinsic risk factors and a previous history of falling, benefit from environmental modifications but low-risk populations do not [6,10,14,22]. Despite this somewhat mixed evidence, it is a Grade A recommendation from the AGS to assess the home environment and mitigate hazardous factors in the home in order to reduce fall risk .
Some intrinsic risk factors, such as age, gender, and history of previous falls, cannot be modified . Therefore, interventions have targeted other intrinsic risk factors, including medication reduction, vitamin D supplementation, correcting visual impairment, and exercise [3,4,5,6,10,14,22]. Reducing the number of medications, especially psychotropic medications, can significantly decrease the risk of falls [6,10,14,22]. However, the benefit is limited by compliance. 47% of individuals who stopped taking a psychotropic medication restarted the medication within one month [14,22]. The effect of vitamin D supplementation on risk of falls is mixed. One review found no risk reduction , others only found a significant risk reduction in individuals who were vitamin D deficient at baseline [6,10], and another only found a significant risk reduction in individuals who live in long-term care facilities . Based on this evidence, it is a Grade A recommendation from the AGS to supplement vitamin D in all individuals who are proven to be vitamin D deficient . Multiple reviews have found that visual assessment alone is not effective in reducing fall risk [5,14,22]. However, the effect of interventions to correct visual impairment is mixed. For example, several studies have shown a reduced risk of falls after a patient’s first cataract surgery, but not after subsequent cataract surgery on the other eye [6,10,22].
In all reviews of community-based interventions, the best single intervention to prevent falls was exercise [4,5,6,10,14,19]. Exercise was the only intervention that both reduced the number of people who fall as well as the rate of falls in those who do . The most important components of exercise were improving balance and muscle strength. These components could either be trained in separate exercise modalities or trained together in a single exercise, such as Thai Chi [10,14,22]. Other important components of exercise included flexibility and endurance. As a result, it is a Grade A recommendation from the AGS to offer an exercise program that targets strength, gait, and balance as an intervention to reduce falls . One alternative to traditional exercises is functional-based training, which was shown to significantly reduce the risk of falls in high-risk populations . All types of exercise that effectively reduced the risk of falls also reduced the risk of fractures . However, not all types of exercise were effective. Neither walking nor muscle-strengthening exercise reduced the risk of falls when these interventions were used in isolation [6,10,14]. No type of exercise was as effective in long-term care facilities as it was in the community [3,10].
Given the vast number of intrinsic and extrinsic risk factors, as well as their complex interactions that lead to falls in each individual, it is not surprising that all reviews, as well as the AGS guidelines, recommend a multifactorial approach to fall prevention [3,4,6,10,14,17,19,22,23]. A multifactorial fall prevention program should include physical exercise, especially balance and strength training, and modifications of as many risk factors as possible. Additionally, patients and their families must be involved in the decision-making process about their care. Patient education about the risk of falls and why each part of the fall prevention program is being implemented should improve compliance, which in turn should lead to better outcomes.
Joseph Plaksin is a 4th year medical student at NYU School of Medicine
Peer reviewed by Sathya Maheswaran, MD, Medicine, NYU Langone Medical Center
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