Risk Assessment and Prevention Strategies for Falls in Older Adults

Globally, falls are a major public health problem. Although most fall-related injuries are non-fatal, an estimated 424,000 fatal falls occur each year, making it the second leading cause of unintentional injury death after road traffic injuries.¹ 

Across all age groups, both genders are at risk for falls. In some countries, it has been noted that males are more likely to die from a fall, while females suffer more non-fatal falls. Possible explanations for the greater number of fall-related deaths among males may include higher levels of risk-taking behaviors and hazards within occupations.¹

Age is one of the key risk factors for falls. Falls are the leading cause of unintentional injury and death in the older population. In the United States, 20–30% of older people who fall experience moderate to severe injuries such as bruises, hip fractures, or head trauma. This risk level may be, in part, due to physical, sensory, and cognitive changes associated with aging in combination with environments that are not adapted for an aging population.¹ 

Additionally, the possibility of falls can present a quality of life burden to older adults. A growing number of older adults fear falling and, as a result, limit their activities and social engagements in an attempt to control their fall risk. This can result in further physical decline, depression, social isolation, and feelings of helplessness. However, falling is not an inevitable result of aging. Through practical lifestyle adjustments, evidence-based falls prevention programs, and clinical-community partnerships, the number of falls among seniors can be substantially reduced.²

To gain a better clinical understanding of falls in older adults, specifically in the long-term care setting, Annals of Long-Term Care: Clinical Care and Aging spoke with Laurence Z Rubenstein, MD, MPH, Professor and Chairman of the Donald W Reynolds Department of Geriatric Medicine at the University of Oklahoma College of Medicine. 

Can you speak to the seriousness of fall-related injuries in the geriatric population?

Falls are a key geriatric syndrome. In the United States, accidental and incidental injuries are the fifth leading cause of death in older adults, and falls comprise two-thirds of those. Overall, almost three-quarters of all fall-related deaths occur in the population of adults aged 65 years and older, which currently comprises only about 13% of the total population.³ So, it’s a very disproportionate problem in the geriatric arena. Of course, falls occur at every age, especially in kids and athletes, but kids and athletes usually don’t get injured; it’s older people that have a higher likelihood of injury. About 20–25% of falls in the older adult population require some kind of medical attention. Approximately 5–10% of these falls result in a fracture.³ And of course, some of these, like hip fractures, can be devastating to the older adult population, with between one-quarter and two-fifths not surviving the year following a fracture. Head injuries are also a major cause of mortality. So, these are major problems. 

Some more statistics for you: about 8% of the population over 70 years of age will visit the emergency room each year for falls; for people over 65 years of age, about 5% of all hospitalizations are related to falls; and about 1 in 6 restricted activity days are related to falls. Falls are also a major cause of disability and of nursing home admission.³ Depending on which study you look at, falls and dementia are neck and neck as the main reason older people lose their independence and end up in a nursing facility. 

Then, inside nursing facilities, falls are a major cause of litigation and lawsuits, which can be devastating to the bottom lines of these facilities. So, we know from a multitude of studies that we can prevent between 50% and 60% of falls, but you certainly can’t prevent all falls, especially in nursing home settings where residents are often frail. But you can minimize your chance of falls, and you can defend yourself against costly lawsuits by having community standards for fall prevention in place. 

Are there risk assessments for falls?

Every nursing home probably has some kind of fall risk assessment standard on admission into a facility. There are actually a lot of validated instruments that can be used in that way, for example, the Morse Fall Risk Scale or Oliver’s STRATIFY scale have been well-validated fall-risk instruments for institutional settings.⁴ Some nursing homes have their own that they compiled from other validated scales, and there are some that just adopt a published scale in its entirety. But it’s very important not to just do the risk assessment; you have to come up with an individualized fall prevention plan that tries to address those risks.  

What strategies are there to aid in the prevention of falls? 

There are a lot of interventions and preventive approaches that you can take. The first would be to do the risk assessment. The major fall risks include things such as muscle weakness, prior falls, problems with balance or gait, vision or joint instability, depression, cognitive deficit, or being on medications that have a psychotropic or psychoactive side effect. Such drugs don’t have to be antipsychotics or antidepressants; many other drugs can cause confusion or disorientation and can contribute to falls. 

So, first you find out if a person has any of these risk factors, and then you try to deal with them through individualized treatments or adjustments in medication. For example, you can treat balance or gait problems with physical therapy or ambulatory devices or by focusing on what the specific problem is. If it is painful arthritis, you try to treat that and make sure that they have any needed assistive devices. Some of the patients for whom it is most difficult to prevent falls are those with dementia who are still able to get up and around on their own, because they have lost some of their judgment and they tend to get up unpredictably. They often forget to use the call button when they need assistance, which makes them particularly challenging.

When you can’t really reverse the risk factors, you need to come up with plans to mitigate the possibility of falls through injury control or modification techniques such as hip protectors or impact-absorbing flooring. Even though devices like that don’t prevent or stop falls, they can prevent hip fractures. You don’t have to reduce impact force dramatically. Some of the studies I have seen on the different types of hip protectors have shown that a protector that can reduce the impact by maybe just 30% can reduce the likelihood of hip fractures by over 80%. So there seems to be a threshold phenomenon. And I think the same could be true of impact-reducing flooring; you don’t need a mattress on the floor, but some new flooring types that can reduce impact 25 to 35% might produce a significant reduction of injury. These types of flooring, however, are still being tested.  

Other things that can improve the risk of falls are balance and exercise programs. Research has shown that having older adults participate in programs led by people who are experienced and know what they’re doing can lead to improved balance and strength as well as reduced fall risk. Most of those studies have been performed in the home or in independent living settings and usually include programs like tai chi or similar exercises that include balance, strength, and endurance training.^5-7 A lot of senior centers offer these programs, normally 2 or 3 days per week for 40–60 minutes at a time, during which participants do some stretching, some strengthening exercises, some balance training, and then some endurance exercises. 

Exercise programs in nursing homes have shown more equivocal results, perhaps because of the greater levels of frailty and cognitive impairment among nursing home residents. One study—a large multi-site nursing home study—split the population into higher and lower cognitive status using the mean mental status score. And they showed that the exercise program significantly reduced the rate of falls for the half of participants with higher cognitive functioning, whereas the half with lower cognitive functioning showed no difference. However, part of the program was to use hip protectors, and these reduced the rate of hip fractures in the lower cognitive functioning group but not in the higher cognitive functioning group. They concluded that you need a certain cognitive ability to really benefit from the exercises. But hip protectors were more readily accepted by the patients with more severe dementia because they didn’t resist as much—people with higher cognitive functioning were kind of put off by the hassle of wearing the hip protector. So, that was a really interesting study.⁸

Now, another thing I would add is environmental assessment and modification. It is important in the nursing home facility to have some form of risk mitigation strategy in place. There should be adequate handrails and lighting in the hallways, the bathrooms, and the bedrooms. And then if you can do things like install impact-absorbing flooring, that’s even better. You can also have nursing education that deals with awareness for some of the hazards of falls, teach residents how to use call buttons, lock wheelchairs, and just make sure that assistance is provided when needed. So, all of these things can be effective in significantly reducing falls in both the community and nursing home settings. 

Are there any situations in which falls are more likely to occur? 

Standing up after meals and after using the toilet are situations of high fall risk. You need to ensure there are adequate grab bars available to people who are a little bit unsteady. You can also have seats in the shower and make sure that assistance is nearby in case someone needs help. Getting out of bed has been shown to be another high-risk activity. Partial bedrails can be helpful, but full bedrails have been shown to be harmful. Although bedrails can be helpful for preventing people from rolling out of bed, they can actually cause more injuries from people trying to climb over them. So, full bedrails have been pretty much eliminated from routine use. Half bedrails are still widely used and can be helpful. They can help reduce the risk of falling out of bed—although this is uncommon—and also provide a handrail that somebody can grab onto while standing up.

Are there approaches older adults themselves can take to reduce the risk of falling? 

Well, some of the keys things are staying active, such as by getting involved in a regular community exercise program. It’s good to be involved in a group because then you’re more likely to continue doing it—it’s easier to find excuses not to exercise if you’re on your own—plus it’s good to have supervision. So, I would recommend group exercise programs, especially in facilities. 

Also, be aware of any risk factors that you as a senior might have. If your hearing, vision, or balance is impaired, you should be aware of it and make sure to compensate for it without trying to walk around like you would when you were 40 years old. If you do have a balance problem, make sure it gets proper assessment. And if necessary, use assistive devices. 

What other information should long-term care providers know about falls?

There are all kinds of new gadgets on the horizon to help older adults. For example, there are vibrating platforms for people who don’t really enjoy exercise that can provide a kind of passive strengthening. It’s too soon to really advocate for anything like that, but there have been some preliminary studies suggesting that they may be useful. Also, supplemental vitamin D has been shown to reduce falls in several European studies.⁹ This was discovered inadvertently while studying the effect of vitamin D on improving bone health and reducing osteoporosis. They found out that vitamin D not only improved bone function and structure but also reduced falls. In the United States, there isn’t as much of a vitamin D deficiency, so it might not be as helpful here, but vitamin D and calcium supplementation is so cheap and potentially beneficial that it is probably worth using routinely, unless there is a contraindication. Most of my patients are on vitamin D and calcium deposits as part of their daily regimen. These are very inexpensive and have virtually no negative side effects. 

1. World Health Organization. Falls: Fact sheet N¬∞344. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs344/en/. Accessed February 11, 2016. 

2. National Council on Aging. Falls Prevention Facts. National Council on Aging Web site. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/. Accessed February 11, 2016.

3. Rubenstein LZ.  Falls in older people: epidemiology, risk factors, & strategies for prevention. Age and Aging. 2006;35(supp 2):ii37-41.

4. Perell KL, Nelson A, Goldman RL, Luther SL, Lewis NP, Rubenstein LZ.  Fall risk assessment measures: an analytic review.  J Gerontol A Biol Sci Med Sci. 2001;56(12):M761-M766.

5. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomized clinical trials. BMJ. 2004;328(7441):680-687.

6. Kenny RA, Rubenstein LZ, Tinetti ME, et al. 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.

7. Rubenstein LZ, Ganz DA. Falls and their prevention. Clin Geriatr Med. 2010;26(4):xiii-xiv.

8. Jensen J, Nyberg L, Gustafson Y, Lundin-Olsson L. Fall and injury prevention in residential care‚Äîeffects in residents with higher and lower levels of cognition. J Am Geriatr Soc. 2003;51(5):627-635.

9. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465. doi: 10.1002/14651858.CD005465.pub3.