---

Health Education in Geriatrics: Falls & Fall Prevention

---

1. Why Falls Matter - Epidemiology

• ~30% of adults over 65 fall at least once per year; incidence rises with age
• Up to 10% of falls result in serious injury (hip fractures, head trauma, lacerations)
• Falls are the leading cause of injury-related deaths in people over 65
• Hip fractures account for >300,000 hospitalizations per year in the US, with a 1-year mortality rate of up to 33%
• Direct medical costs exceed $19 billion annually (in the US alone)
• By 2050, worldwide hip fractures are projected to rise to 6.26 million per year

- Textbook of Family Medicine 9e, p. 62

---

2. Risk Factors - Intrinsic vs. Extrinsic

Intrinsic Risk Factors (Patient-Related)

Extrinsic Risk Factors (Environmental & Medication-Related)

• Benzodiazepines and sedative-hypnotics
• Tricyclic antidepressants and SSRIs
• Antihypertensives and diuretics
• Neuroleptics/antipsychotics
• Narcotic analgesics
• Antihistamines and anticonvulsants
• Class 1A antiarrhythmics

Key point: Taking 4 or more prescription drugs is itself an independent risk factor for falls.

• Loose rugs, poor lighting, slippery floors
• Stairs without handrails
• Poorly fitting shoes or footwear
• Uneven pavements, low toilet seats, no grab bars

- Textbook of Family Medicine 9e, p. 62-63; Goldman-Cecil Medicine

---

3. Screening - Who Needs Assessment?

Three Key Screening Questions (AGS/BGS Guidelines):

1. Two or more falls in the prior 12 months?
2. Presents with an acute fall?
3. Difficulty with walking or balance?

The two strongest predictors of future falls are: (1) a history of previous falls, and (2) a reported abnormality in gait or balance.

---

4. Clinical Assessment - The Falls Workup

History

• Circumstances of fall(s): activity, time of day, symptoms beforehand
• Medication review (complete list including OTC and supplements)
• Medical history: cardiac, neurologic, musculoskeletal, psychiatric conditions
• Functional status and ADLs
• Home environment assessment

Physical Examination

The "Get Up and Go" Test (TUG)

• Patient stands from a seated chair, walks ~10 feet (3 m), turns around, walks back, sits down
• Normal: completed within 10 seconds
• Watch for: pushing off chair to rise (weak legs), shuffling gait, poor step height, decreased stride length, wide-based stance, slow multi-point turning

- Textbook of Family Medicine 9e, p. 63; Cummings Otolaryngology

Investigations (when clinically indicated)

• Labs: CBC, BMP, glucose (if metabolic cause suspected)
• Cardiac: Holter monitor or event monitor if syncope suspected; echo if murmur present
• Neuroimaging (MRI/CT): Only if focal neurological signs are present

---

5. The Falls Prevention Guideline - A Clinical Algorithm

---

6. Management - Multifactorial Interventions

A. Medication Review (First Priority)

• Reduce the total number of medications when possible
• Taper or discontinue sedating drugs (benzodiazepines, sleep aids, opioids)
• Adjust antihypertensives/diuretics if orthostatic hypotension is present
• Review each medication's fall-risk profile

B. Exercise Programs (Strongest Evidence)

• Programs targeting at least 2 of 3 components for a minimum of 12 weeks show the most benefit (SOR: A):
  • Strengthening (resistance training)
  • Balance training (Tai Chi is particularly effective)
  • Aerobic/endurance training
• The 2025 APTA Geriatrics Clinical Practice Guideline gives multicomponent exercise a strong recommendation (Level I evidence) as the most important intervention

C. Environmental Modification

• Home safety assessment by an occupational therapist (SOR: A for community-dwelling elderly)
• Install grab bars in bathrooms, handrails on stairs
• Remove loose rugs and clutter
• Improve lighting
• Encourage appropriate footwear

D. Sensory Corrections

• Treat vision impairment (including cataracts)
• Hearing aids where applicable
• Correct peripheral neuropathy causes where possible

E. Manage Specific Conditions

• Treat orthostatic hypotension
• Manage cardiac arrhythmias
• Manage foot and footwear problems
• Manage Parkinson's disease, osteoporosis, and other contributing conditions

F. Vitamin D

• Routine vitamin D supplementation to reduce falls has inconclusive evidence and recent trials show no benefit in vitamin D-replete individuals
• Still recommended if the patient has osteopenia or osteoporosis, or documented vitamin D deficiency

G. Physical Restraints - Do NOT Use

• Physical restraints do not reduce fall risk and are associated with increased injury risk - their use has been appropriately and dramatically reduced since the 1980s

- Textbook of Family Medicine 9e, p. 64; Goldman-Cecil Medicine; World Falls Guidelines 2022

---

7. Post-Fall Syndrome - The Psychological Dimension

• Post-fall anxiety syndrome develops in many elderly patients after a fall - even without injury
• Patients restrict their own activity out of fear of falling again
• This leads to: deconditioning → muscle weakness → worse balance → increased fall risk
• Can progress to depression and social isolation
• Management includes psychological support, graded return to activity, and balance retraining

---

8. Key Clinical Pearls for Students

---

9. Recent Evidence Update (PubMed, 2023-2026)

---

Summary Table: Falls in the Elderly