Falls in older adults

• Balance and gait
  • As a result of stroke disease, Parkinsonism, arthritic changes, neuropathy, neuromuscular disease or vestibular disease.
• Visual motor reaction time problems
  • An extended reaction time will delay responses and compensations to standing or walking imbalances, thus increasing the likelihood of falls.
• Medications
  • Polypharmacy is common in older people
  • Sedatives significantly increase the risk of falling
  • Cardiovascular medications can contribute towards falls
• Visual impairment
  • Visual impairments, glaucoma, macular degeneration and retinopathy increase the risk of falling and of hip fractures.[14]
  • Bifocals and trifocals can increase the risk of falling as the lower portion of corrective lenses are optimized for distances approximately 18inches, thus precluding clear vision of one's feet/floor, approximately 4.5 to 5.5 feet below one's eyes.
• Cognitive problems
  • Dementia increases the likelihood of falls
• Cardiovascular causes
  • Orthostatic hypotension
  • Postprandial hypotension
  • Carotid sinus syndrome
  • Neurocardiogenic syncope– the commonest cause of syncope in A&E patients
  • Cardiac arrhythmias
  • Structural heart disease, such as valvular heart disease

Hanging straps with triangular handles in a modern Japanese commuter train

Grab rails on a longer-distance commuter train catering for mainly seated passengers

A staircase with metal handrails

• Poor lighting due to low luminance of existing lights or lamps, so preventing hazard identification and avoidance. Eyesight deteriorates with age, and extra lighting will be needed where seniors move frequently. The power of the bulbs used should be higher than normally accepted, with incandescent bulbs preferred [or LEDs?] especially as they react much more quickly than other types of bulb when switched on. This is vital when entering a room where an obstacle can trip the user for example, especially if not seen in time to prevent the accident.
• Stairs with inadequate handrails, or too steep, encouraging trips and falls. The steps should be spaced widely with low risers, and surfaces should be slip-resistant. Softer surfaces can help limit impact injuries by cushioning loads.
• Doorways with adequate headroom so that the user's head does not hit the lintel. Doorways of low headroom (less than about 2 metres) are common in old houses and cottages for example.
• Rugs/floor surfaces with low friction, causing poor traction and individual instability. All surfaces should have a high friction coefficient with shoe soles.
• Clothing/footwear poorly fitted, shoes of low friction against floor. Rubber soles with ribs normally have a high friction coefficient, so are preferred for most purposes. Clothing should fit the user well, without trailing parts (hems falling below the heel and loose shoe strings) which could snag with obstacles
• Lack of equipment/aids such as walking sticks or walking frames, such as Zimmer frames so as to improve user stability. Grab bars and hanging straps should be supplied plentifully, especially in critical areas where users may be vulnerable.

Improvements to the person's environment such as their home or workplace may help to reduce the risk of falling.[14]

• A review of the current living conditions
• Adding safety devices, such as grab handles, high friction floors, as well as low power lighting at night to the person's home or work environment
• Identify and remove potential hazards

• Regular exercise - lower limb strengthening exercise to increase muscle strength.[18] Other forms of exercise, such as those involving gait, balance, co-ordination and functional tasks, may also help improve balance in older adults.[19]
• A 2014 review concluded that exercise interventions may reduce fear of falling (FOF) in community-dwelling older adults immediately after the intervention, without evidence of long-term effects.[20]
• Monitoring of medications and ongoing medical problems - For example, people with polymyalgia rheumatica often take long-term steroids, leading to osteoporosis. Research in the UK has also suggested that these people would benefit from a falls assessment when first diagnosed, and regular treatment reviews.[21][22]
• Improvements to footwear and utilization of orthotic devices if required.[23]
• Supplementation with vitamin D is not recommended in those without vitamin D deficiency for fall prevention in older adults.[17]

• Hip protectors may decrease risk of hip fractures slightly, although they may slightly increase the risk of a pelvic fracture in older adults living in nursing care facilities. Little or no effect reported on other fractures or falls.[24]
• Treatment for osteoporosis

People who are hospitalized are at risk for falling. A randomized trial showed that use of a tool kit reduced falls in hospitals. Nurses complete a valid fall risk assessment scale. From that, a software package develops customized fall prevention interventions to address patients' specific determinants of fall risk. The kit also has bed posters with brief text and an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.[25]

American Geriatrics society (AGS)/British Geriatrics Society (BGS) recommend that all older adults should be screened for "falls in the past year". Fall history is the strongest risk factor associated with subsequent falls.[26] Older people who have experienced at least one fall in the last 6 months, or who believe that they may fall in the coming months, should be evaluated with the aim of reducing their risk of recurrent falls.[27]

Many health institutions in USA have developed screening questionnaires. Enquiry includes difficulty with walking and balance, medication use to help with sleep/mood, loss of sensation in feet, vision problems, fear of falling, and use of assistive devices for walking.

Older adults who report falls should be asked about their circumstances and frequency to assess risks from gait and balance which may be compromised. A fall risk assessment is done by a clinician to include history, physical exam, functional capability, and environment.[28]