Current Geriatric Diagnosis & Treatment, 1st Edition
Section III - Common Disorders in the Elderly
12. Falls & Mobility Disorders
Jane Mahoney MD
ESSENTIALS OF DIAGNOSIS
- Older adults who report > 1 fall in the past year or a single fall with injury or gait and balance problems are at increased risk for future falls and injuries.
- Falls and mobility disorders result from disease in 1 or more organ systems related to balance: sensory input (visual, vestibular, and proprioceptive), central (neurological) processing, and effector output (neuromuscular and musculoskeletal).
- Transient cerebral hypoperfusion may result in a syncopal fall; loss of consciousness may not be reported because of amnesia for the event.
- Acute factors (infectious, toxic, metabolic, ischemic, or iatrogenic) may contribute to falls and mobility disorders.
- Medications, particularly psychotropic drugs, increase the risk for falls.
Approximately 30% of people over the age of 65 fall each year. The incidence increases with age. In general, the rate of falls is higher in hospital and immediate post-hospital settings, compared to a general community setting. The incidence of falls is higher in the nursing home than in the community. Up to 50% of falls result in some injury. Approximately 10% of falls require hospitalization because of injuries sustained, including bone and hip fractures. Persistent pain and mobility limitation are common after a fall-related injury. Almost 50% of patients seen in an emergency room for a fall injury will have continued pain and mobility limitation 2 mo after the fall. In about 3% of falls, the older adult lies on the floor for at least 20 min. Falls are associated with increased risk for nursing home placement, functional decline, and fear of falling.
Risk factors include vision impairment, muscle weakness, peripheral neuropathy, balance and gait abnormalities, use of psychotropic medications, impaired cognition, foot problems, lower extremity arthritis, neurological diagnoses such as stroke and Parkinson's disease, orthostatic hypotension, and recent hospitalization. Risk factors for injury with a fall include older age, low body mass index, previous fracture, low bone mineral density, and loss of consciousness (LOC).
In the nursing home, risk factors for falls include use of psychotropic medications, a fall in the past 180 days, recent decline in function, male gender, history of wandering, use of a cane or walker, independence in transferring or wheelchair use, and impaired cognition. Patients who are nonambulatory are generally at lower risk. In the hospital setting, risk factors include impaired cognition, weakness, urinary incontinence, mobility impairment, multiple comorbidities, and use of psychotropic medications. Fall rates are highest among patients in geriatric psychiatry, rehabilitation, geriatric medical, and neurology units.
Vigorous older adults more often tend to fall as the result of environmental hazard and more often when engaged in vigorous activities, which displace the center of gravity. Frail older adults tend to fall with only minimal environmental hazard or minimal risk activities. Vigorous older adults may be at greater risk for injury, particularly if the fall is from a height or results from an activity that rapidly displaces the center of gravity, either of which may increase the momentum at impact.
- MOBILITY DISORDERS
The onset of mobility impairment may be catastrophic (eg, after cerebrovascular accident or hip fracture) or chronic, related to progression of disease and sedentary lifestyle. In chronic progression of mobility impairment, patients report difficulty with mobility before the development of actual dependency in activities of daily living (ADLs; including bathing, toileting, dressing, transferring) and instrumental ADLs (including housework, shopping, laundry, yard work). In this preclinical stage, patients have minor abnormalities in performance tests of balance, gait, and lower extremity muscle function. Poorer performance on these tests predicts future disability.
Risk factors for impaired mobility include decreased cognition, depression, arthritis, obesity, vision impairment, and other comorbidities. Impaired cognition is associated with impaired mobility even after adjusting for comorbidities.
Blaum CS et al: Log cognitive performance, comorbid disease, and task-specific disability: findings from a nationally representative survey. J Gerontol Med Sci 2002;57A:M523. [PMID: 12110069] (This study demonstrates, in a national sample of older adults, that low cognitive performance is associated with impaired mobility, even after adjusting for multiple comorbidities.)
Brauer et al: The interacting effects of cognitive demand and recovery on postural stability in balance-impaired elderly persons. J Gerontol Med Sci 2001;56A:M489. [PMID: 11487601] (Balance-impaired older adults had difficulty maintaining balance in response to a perturbation while simultaneously performing a cognitive task. In contrast, healthy older adults were able to maintain balance and simultaneously perform a cognitive task.)
Kannus P et al: Fall-induced injuries and deaths among older adults. JAMA 1999;281:1895. [PMID: 10349892] (This analysis of the Finnish National Hospital Discharge Register found that yearly age-adjusted fall-related injury incidence more than doubled from 1970 to 1995 for both men and women.)
Leipzig et al: Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 1999;47:30. [PMID: 9920227] (This study provides a review and meta-analysis of data linking neuroleptics, sedative-hypnotics, and antidepressants to falls, with increased risk for those taking > 1 psychotropic drug.)
Leipzig et al: Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47:40. [PMID: 9920228] (This review and meta-analysis shows an association of digoxin, type Ia antiarrhythmics, and diuretics with falls. The authors point out that the association is weak, and existing studies have only minimally adjusted for confounders.)
Accidental falls are due to a combination of extrinsic (environmental), intrinsic (organ system abnormalities contributing to postural control), and situational (risk taking) factors. Extrinsic factors include environmental hazards, such as loose rugs, clutter, poor lighting, and improper footwear, such as loose, floppy slippers.
Intrinsic factors include abnormalities in any of the organ systems that contribute to postural control. Postural control is composed of 3 linked components: sensory input, central processing, and effector output. Sensory input for balance comes from visual, vestibular, and somatosensory input. Central nervous system movement pathways involve sensory cortex, frontal and motor cortex, brainstem, basal ganglia, and cerebellum. Effector output involves upper and lower motor neurons, muscles, and joints. Any pathology affecting any of these components of postural control will increase the risk for falls.
Approximately 10% falls are due to acute causes. These include cerebral hypoperfusion states and acute toxic, metabolic, endocrine, infectious, and ischemic changes. Psychotropic medications and alcohol may lead to transient alterations in alertness and attention and increase the risk of falls. Acute disease states increase the risk for falls, especially when they are superimposed on chronic conditions affecting postural control. Balance impairment often contributes to falls and may be acute (posterior circulation TIA or CVA), subacute (labyrinthitis, benign positional vertigo), or chronic (peripheral neuropathy, cerebellar dysfunction).
Situational factors may involve risk-taking behaviors, such as failure to use a prescribed ambulatory device or not wearing eyeglasses, and so on. All 3 types of factors are potentially remediable with intervention.
- MOBILITY DISORDERS
The pathogenesis of mobility disorders can also be seen as extrinsic, intrinsic, and situational. Extrinsic causes include unsafe home or outdoor environment (eg, throw rugs or ice on sidewalks) that may limit mobility. Intrinsic causes include any disease that impairs balance, as described previously in the Falls section. The pathogenesis of mobility impairment is broader than that of balance impairment. A number of diseases may negatively affect mobility without impairing balance. These include any diseases causing pain or difficulty with walking, such as arthritis, claudication, lumbar spinal stenosis, and obesity. Fear of falling, anxiety, and depression may also contribute to mobility curtailment.
Situational factors include use of adaptive aids and other modifiers to enhance mobility. For example, provision of a 4-wheeled walker may allow a mobility-impaired individual to resume outdoor walking. Alternatively, lack of an appropriate adaptive aid (bath bench, walker) may lead to unnecessary curtailment of mobility.
Woolacott MH: Systems contributing to balance disorders in older adults. J Gerontol Med Sci 2000;55A:M424. [PMID: 10952363] (This brief, excellent review of research on balance control in older adults summarizes findings on changes in motor and sensory systems that contribute to balance impairment. It also summarizes recent research showing an association between attentional demands and balance.)
An algorithm defining the guidelines issued by the American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention is presented in Figure 12-1. Among high-risk, community-dwelling older adults, a strong, consistent reduction in rate of falls has been demonstrated from the implementation of multifactorial interventions (Table 12-1).
In nursing homes and assisted-living facilities, multidisciplinary programs comprising both facility-wide
and resident-specific fall prevention strategies have been shown to reduce falls. Facility-wide strategies include staff education and environmental modifications. Individual interventions for high-risk older adults include balance and strength exercises, issuance or repair of ambulation aids, multifactorial medical interventions including medication reduction, and post-fall problem-solving conferences. Individual interventions without staff education do not appear to be successful in reducing fall in the long-term care setting. Physical therapy as a single intervention has not been shown to prevent falls in the nursing home.
Figure 12-1. Algorithm summarizing the assessment and management of falls. From American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention: Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2002;49:666. Used with permission.
In the acute care setting, fall prevention programs have included staff education, identification of high-risk inpatients, use of bed alarms, increased toileting, medication review, and environmental modification. Uncontrolled studies of unit-based intervention programs have shown decreases in rate of falls compared with preintervention. However, randomized, controlled trials are lacking.
Table 12-1. Components of a multifactorial falls and mobility evaluation.
There is no evidence that restraint use decreases falls. Restraint reduction in nursing homes has not been followed by increased rates of fall injury. Use of 4 side rails should be considered a restraint, is not an effective fall reduction measure, and may increase fall-related injury because of unsafe (head-first) bed exits.
- CORRECTION OF VISION DEFICITS
Correction of unilateral vision loss should be encouraged to enhance mobility, particularly if the fall is related to tripping or change in depth. Maximal lighting in the home with reduction in glare should be encouraged. Consideration should be given to switching from bifocal to distance lenses, particularly if a fall has occurred on a stair, ramp, or curb. Older adults with poor neck flexion may be more likely to have problems with inaccurate depth perception related to bifocals because they may be unable to flex the neck sufficiently to look at the feet through the upper, distant lenses.
- TREATMENT OF CARDIOVASCULAR ABNORMALITIES
Consideration should be given to further evaluation and treatment for carotid sinus syndrome in the case of otherwise unexplained falls, even in the absence of a history of syncope. Use of a pacemaker in older adults with unexplained falls and cardioinhibitory carotid
sinus syndrome has been shown to decrease falls. Treatment of symptomatic orthostatic hypotension should be considered when circumstances of the fall suggest this as a cause. If an asymptomatic finding of orthostasis is noted on exam, treatment is less likely to be beneficial.
- DECREASED PSYCHOTROPIC MEDICATIONS
As a single intervention, psychotropic medication reduction has been shown to reduce falls. Patients should be encouraged to decrease their use of sleep aids, including over-the-counter medications containing diphenhydramine or other sedating antihistamines. If a sedative-hypnotic is needed, a short-acting agent is preferred, and the dose should be started at about half of the usual starting adult dose. However, short-acting benzodiazepines, as well as the nonbenzodiazepine agent zolpidem have been associated with falls.
Antidepressants are associated with falls in a dose-dependent manner. Antidepressant and antipsychotic medication dose should be titrated downward if possible. Use of first-generation tricyclic antidepressants should be avoided.
- VITAMIN D REPLACEMENT
Vitamin D replacement for those who are deficient has been shown to decrease falls and improve body sway. Vitamin D supplementation has also been shown to improve functional status. Although a recommendation of 800 IU Vitamin D/day for older adults is reasonable, some patients may require higher doses to achieve a desired level of 25-OH vitamin D of > 32 ng/mL.
- IMPLEMENTATION OF EXERCISE PROGRAM
Exercise is efficacious in preventing falls for both high- and low-risk older adults. For high-risk older adults (those with previous falls or multiple fall risk factors), the 2 positive randomized trials of exercise as a sole intervention both used individualized, progressive exercise programs of at least 3 mo duration. In low-risk older adult, group-based rather than individualized exercise has been shown to be effective. One positive study used tai chi ch'uan, and the other positive study used weekly exercise classes incorporating balance training supplemented by daily home exercises.
A meta-analysis of the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) found an overall significant falls reduction associated with exercise; the most pronounced reduction was from those interventions that included balance exercises. The Guidelines for the Prevention of Falls in Older Persons recommends that older adults with recurrent falls be offered long-term exercise that includes balance training.
For older adults with a history of falls and specific gait and balance abnormalities on exam, a physical therapist should be consulted to establish an individualized exercise program. Although strengthening or aerobic conditioning exercises may be prescribed, therapy should also include balance exercises, which should progress over time. Sensory integration can be improved by balance exercises. Therapy of several months durations is more likely to be beneficial than therapy of shorter duration. For more fit older adults, tai chi or another group exercise program that incorporates standing balance exercises should be recommended for a goal of fall prevention. There is no evidence that exercises in the seated position will decrease falls.
Exercise treatment for mobility impairment is similar to that for falls. Exercise has been shown to reduce the progression of functional decline among older adults with moderate physical frailty. A physical therapist should be consulted if mobility impairment is severe and is associated with marked muscle weakness or aerobic deconditioning. To improve mobility, individualized treatment may focus on strengthening, aerobic training, or both. Strengthening and aerobic training have been shown to improve function and movement speed in patients with knee osteoarthritis. In the absence of cardiac signs and symptoms, a cardiac evaluation using a submaximal treadmill is generally not needed before beginning a reconditioning or strengthening program.
If mobility impairment is only mild to moderate, then patients can and should be encouraged to begin community exercise programs (either strengthening or aerobic) and do not need individualized physical therapy first. A walking program should be instituted. Walking has been shown to improve endurance and quality of life for patients with osteoarthritis and peripheral vascular disease.
- USE OF ASSISTIVE DEVICES
The use of an assistive device may decrease fear of falling and improve mobility. Patients who have sensory loss (visual, vestibular, or proprioceptive) as their primary cause for falls or mobility impairment may benefit from the use of a cane, which decreases sway for patients with neuropathy or vestibular loss. A cane may be particularly helpful at night, when visual cues are not available to help stabilize balance. For patients with somatosensory loss, a cane or walking stick should be used outdoors or on uneven ground.
Other ambulation aids include 4-prong canes; hemiwalkers; 2-wheeled, 3-wheeled, and 4-wheeled walkers (often with a seat); and standard walkers (4 legs, no wheels). In general, the least restrictive device that provides for safe ambulation should be used. A hemiwalker is often useful in the setting of CVA. The 3-wheeled walker provides more stability than a cane without significantly limiting dexterity of movement. However,
the back wheels are out of the line of vision and may be prone to hit obstacles when used by patients with poor visuospatial skills or cognitive impairment. For patients with more marked mobility impairment, a 4-wheeled walker, which is heavier and more stable, may be preferred. A walker seat can be helpful for patients with limited endurance. Although a standard walker, with or without front wheels, is most stable, it also provides the least maneuverability. Decisions regarding the best type of walker should take into account cognitive status and in-home and out-of-home needs. Patients should be able to walk, turn, and maneuver around obstacles with the ambulation aid. Patients with severe cognitive impairment may not be able to use any assistive device appropriately. Those with severe cerebellar ataxia or brainstem CVAs may also not do well with any assistive device. For such patients, the best way to enhance mobility may be a scooter. Medicare will cover the cost of a standard walker only.
- HOME SAFETY
Home assessment is advisable as part of a multifactorial intervention. It may be covered by Medicare in some cases and should be performed by a trained occupational or physical therapist. There are also a number of home safety checklists that patients may self-administer. The home safety assessment ideally should be tailored to match the specific deficits of the individual. Table 12-2 provides more detailed information on matching the home safety intervention to the individual.
Table 12-2. Home and behavioral adaptations for specific deficits related to falls.
- USE OF APPROPRIATE FOOTWEAR
Foot position awareness and balance improve with the use of firm, thin-soled shoes and low, rather than high, heels. Balance is also better with the use of footwear compared with going barefoot. Older adults with poor foot clearance or a history of tripping falls should avoid crepe-soled shoes (such as tennis shoes). Loose-fitting slippers or sandals should be avoided.
- USE OF MEDICAL ALARMS & LIFELINES
Older adults at high risk for falls can be advised to use a medical alarm or lifeline bracelet or necklace when they are home alone. These systems usually work by connecting to a 24-h dispatch center that notifies a designated person or emergency medical system when activated. They are not usually covered by Medicare or supplemental insurance and cost approximately $30 or more per month. These devices do not work outside the home.
- BEHAVIOR MODIFICATION
Patients should be informed of their specific fall risk factors and the particular types of maneuvers or activities that increase risk. In addition, patients should be
informed of the need for increased attention to mobility tasks. Although education alone, without multifactorial assessment and intervention, appears to be of no benefit in preventing falls, it is an important part of individualized falls prevention.
- USE OF HIP PROTECTORS
The most cost-effective hip fracture prevention for the long-term care setting is a hip protector pad. In the nursing home setting, the risk of hip fractures is reduced by up to 60% with the use of hip protector pads. Use of hip protectors has been shown to decrease fear of falling among community-living adults. Although compliance may be problematic and may limit use, hip protectors should be offered to older adults who are at significant risk of falling. Use should be strongly encouraged for institutionalized older adults with recurrent falls or prior hip fracture.
- BONE MINERAL DENSITY MONITORING
Older adults at high risk for falls should undergo evaluation and treatment for osteoporosis. Treatment should be strongly considered when the T score is below -1.5.
American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention: Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:179. [PMID: 11380764] (Provides recommendations for falls prevention and grades intervention strategies according to the quality of supporting evidence.)
Close J et al: Prevention of falls in the elderly trial (PROFET): A randomized controlled trial. Lancet 1999;353:93. [PMID: 10023893] (Assesses the efficacy of a multifactorial intervention to prevent falls targeted to patients aged 65 and older who had presented to an emergency room after a fall.)
Day L et al: Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:128. [PMID: 12130606] (Analyzes success of interventions, eg, exercise, home hazard management, and vision correction, in decreasing falls among primarily low-risk older adults. Although exercise alone was effective, home hazard management and vision correction provided additional benefit.)
Gill TM et al: A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med 2002;347:1068. [PMID: 12362007]. (Study demonstrates that intervention of home modifications plus exercise prescribed by a physical therapist reduced the progression of functional decline.)
Gillespie LD et al: Interventions for preventing falls in elderly people (Cochrane Review). Cochrane Database Syst Rev 2001;3:CD000340. [PMID: 11686957] (Review analyzed pooled odds ratios to categorize interventions that are likely to be beneficial and those that are of unknown effectiveness.)
Jensen J et al: Fall and injury prevention in older people living in residential care facilities: A cluster randomized trial. Ann Intern Med 2002;136:733. [PMID: 12020141] (A multifactorial fall prevention program was found to reduce falls and fractures among older adults living in assisted-living facilities.)
Kannus P et al: Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 2000;343:1506. [PMID: 11087879] (Use of hip protectors was found to reduce the risk of hip fracture among ambulatory, high-risk older adults.)
Kenny RA et al: Carotid sinus syndrome: A modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). J Am Coll Cardiol 2001;38:1491. [PMID: 11691528] (Use of a pacemaker was found to reduce the risk of falls among nonaccidental fallers who were found to have cardioinhibitory carotid sinus hypersensitivity on examination.)
Parker MJ et al: Hip protectors for preventing hip fractures in the elderly (Cochrane Review). Cochrane Database Syst Rev 2001;2:CD001255. [PMID:11405982]. (Review of 7 trials of hip protectors for older adults at high risk for hip fracture in nursing homes and assisted living facilities.)
Pate RR et al: Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402. [PMID: 7823386] (Summary of evidence-based consensus process and statement regarding recommendations for physical activity endorsed by the Centers for Disease Control and Prevention and the American College of Sports Medicine.)
Pfeifer M et al: Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women. J Bone Miner Res 2000;15:1113. [PMID: 10841179] (Among older women with low vitamin D status, calcium plus 400 IU vitamin D daily for 8 weeks, compared with calcium alone, improved vitamin D status, decreased PTH, decreased body sway, and decreased the mean number of falls over 1 year follow-up.)
Province MA et al: The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273:1341. [PMID: 7715058] (This preplanned meta-analysis found an adjusted significant falls incidence ratio of 0.90 for FICSIT interventions that included exercise and of 0.83 for interventions including balance exercises.)
The clinical findings for falls and mobility disorders are similar. Table 12-1 details components of falls and mobility evaluation.
- SYMPTOMS & SIGNS
Although vertigo classically corresponds to vestibular abnormalities, dysequilibrium, or sense of imbalance, is a nonspecific symptom that may indicate sensory loss or CNS abnormality. Light-headedness classically is associated with disorders relating to decreased cerebral perfusion, such as with orthostatic hypotension or other cardiovascular abnormality.
- PATIENT HISTORY
Patient histories for falls and mobility disorders are similar. The history should evaluate the types of maneuvers (indoors and outdoors) that are difficult and the reason
for the difficulty (eg, poor vision, pain, shortness of breath, imbalance). With mobility disorders, it is particularly important to evaluate for the presence of back or lower extremity pain with walking or other maneuvers.
The history should elicit circumstances of the fall, including environment, direction, activity engaged in at the time of the fall, time of day and relation to medications, and presence or absence of associated symptoms. Pertinent environmental circumstances include location, floor surface, lighting, and presence of environmental hazard, if any. Information about the environment can directly lead to modification of extrinsic and situational risk factors (eg, discontinued use of an unsteady chair, improving lighting).
Direction of the fall may provide a clue to the underlying pathophysiological mechanism. Forward falls typically indicate a trip. Tripping falls may be due to impaired depth perception, which may occur from either unilateral or bilateral vision loss. A tripping fall may also be due to hemineglect or poor foot clearance. Backward falls may be due to a slip. Backward falls with little or no environmental component may indicate CNS disease, including cerebellar, brainstem, or basal ganglia disease.
Activity at the time of the fall provides information about cause and prevention. For example, a fall that occurs with head turning may be related to vestibular disease, cervical arthritis, spondylosis, or a vascular cause, such as vertebrobasilar insufficiency or carotid sinus syndrome. A fall while rising from a chair may be related to muscle weakness or CNS or peripheral nervous system disease. A fall while descending or ascending stairs may be related to problems with balance, proprioception, decreased vision, muscle weakness, or orthopedic problems causing pain.
Time of day and relation to meals, medication, or alcohol is also important. For example, a fall occurring 30 min after a meal may raise suspicion of postprandial hypotension. Other situational factors about the fall are relevant because they directly lead to recommendations for behavior modification. Was the person using an assistive device at the time of the fall? What type of shoe was the patient wearing? Was the patient wearing glasses? Thick-soled, rubber or crepe-soled shoes may contribute to a trip, particularly indoors and among those with poor foot clearance. Bifocals may contribute to tripping falls, particularly for older adults who have limited neck flexion.
The history should also assess whether there were competing attentional demands at the time of the fall. Postural control worsens when a competing attentional task is given. Was the person rushing to answer the telephone or door? Was the patient carrying laundry while going upstairs?
Questions should be directed toward associated symptoms of vertigo, dysequilibrium, light-headedness, presence of other neurological symptoms, and presence of joint or leg pain or instability. Although vertigo classically corresponds to vestibular abnormalities, dysequilibrium, or sense of imbalance, is a nonspecific symptom that may indicate sensory loss or CNS abnormality. Light-headedness classically is associated with disorders relating to decreased cerebral perfusion, such as with orthostatic hypotension or other cardiovascular abnormality.
The history should also elicit any symptoms suggestive of acute contributors to the fall (eg, infectious, ischemic, toxic, metabolic, neurological). A fall may be the first sign of infection, worsened congestive heart failure, or metabolic derangement such as hypoglycemia or hyponatremia. For example, frequent falls at night in a diabetic should raise suspicion for nocturnal hypo- or hyperglycemia.
Patients should be questioned about their fear of falling. Individuals who have unnecessarily avoided or curtailed activities may benefit from a new or different assistive device or from task modification to allow resumption of the activity.
- MEDICATION REVIEW
- Psychotropic medications—Patients should be questioned regarding use of psychotropic medications. New medication, change in dosage, high dosage (for geriatric population), and use of > 1 psychotropic agent are associated with increased risk for hip fractures. Substantial evidence links neuroleptics, benzodiazepines, and antidepressants with falls and fractures.
- Neuroleptics—High-potency agents may contribute to falls related to extrapyramidal side effects, whereas low-potency agents may increase fall risk as a result of sedating and anticholinergic side effects. Fall risk related to atypical antipsychotics (risperidone, olanzepine) has not been well evaluated, but it is likely that these agents also contribute to falls through extrapyramidal and anticholinergic pathways.
- Benzodiazepines—Both long- and short-acting benzodiazepines increase the risk for falls and fractures, again in a dose-dependent manner. Zolpidem use may also be associated with hip fracture. Sedative-hypnotics may exert their effect by impairing attention or alertness. It is prudent to consider that any medication carrying a caution regarding driving may increase the risk for falls, particularly if prescribed to an older adult who is already at an increased risk for falls.
- Antidepressants—Although first-generation tricyclic antidepressants are of particular concern, other medications such as trazadone (in doses used for antidepressant effect) and selective serotonin reuptake inhibitors
have also been implicated. Newer antidepressants have not been well evaluated in regard to falls, but patients should be prescribed the lowest dose possible.
Depression itself may increase the risk for falls. A link between falls and depression is plausible because depression may lead to impaired concentration, decreased sleep, and psychomotor retardation, all of which may increase risk.
- Cardiovascular medications—Digoxin, type IA antiarrhythmics, and diuretics may be weakly associated with falls. Other cardiac medications, including antihypertensives, angiotensin-converting enzyme inhibitors, calcium channel blockers, and nitrates, have not been linked. However, it is reasonable to evaluate antihypertensive and cardiac medications in the setting of a fall that appears related to orthostasis or postprandial hypotension.
- Analgesics—The use of narcotic or other analgesics is not strongly linked to falls. However, new or recently increased doses of narcotics should be considered as potential contributing factors if circumstances are suggestive.
- Other medications—Ataxia and sedation may be noted at higher doses of all antiseizure medications. It is particularly important to evaluate for cerebellar side effects when prescribing these agents for neuropathic pain. Because patients with neuropathy are already at increased risk for falls, any upward titration of neuropathic pain medications should proceed with careful monitoring to ensure that risk does not increase further.
Although support for a link between anticholinergic antihistamines (eg, diphenhydramine) and falls is not strong, use of diphenhydramine may lead to impaired driving performance and symptoms of delirium.
- PHYSICAL EXAMINATION
Although disorders related to sensory input and CNS processing clearly affect falls and mobility, particular attention should be paid to the musculoskeletal system. The back, legs, and feet should be assessed for biomechanical, muscular, and arthritic changes affecting gait, such as decreased joint range of motion (ROM), changes in joint alignment, leg-length discrepancy, and muscle weakness.
- Vision assessment—Specific visual deficits related to falls and mobility impairment include poor distant vision (unilateral or bilateral), reduced contrast sensitivity, decreased depth perception, decreased visual field, and posterior subcapsular cataract. The visual examination should include assessment of visual fields by confrontation, assessment of distant vision in each eye with and without distance lenses, and fundoscopic exam. Even unilateral vision impairment may affect depth perception and cause falls. If a cataract is impairing vision unilaterally, strong consideration should be given to its extraction, particularly if falls appear to be related to impaired depth perception.
- Vestibular function assessment—Vestibular dysfunction, either peripheral or central, may be associated with classic symptoms of vertigo or with a nonspecific dizziness or dysequilibrium. Oscillopsia (a sensation that the environment is moving upon walking or moving the head) may be present. Patients may rely more on vision for maintaining balance, with increased unsteadiness in the dark. Patients may also complain of decreased balance or dizziness in crowded shopping areas or with highly patterned floor surfaces, when visual input becomes conflicting. They may also rely more on somatosensory input and display decreased balance with uneven surfaces.
Symptoms of vestibular dysfunction should prompt a more in-depth examination, including the head-thrust test, dynamic visual acuity, Dix-Hallpike maneuver, Romberg test, and march-in-place (Fukuda) test.
In the head-thrust test, the patient is instructed to look at the examiner's nose while the examiner rapidly moves the patient's head to the right and left. A positive test is noted if small, rapid eye movements are elicited.
Dynamic visual acuity assesses distant vision on the Snellen chart with slow passive head movements (2-Hz frequency). A drop of more than 3 lines in visual acuity with head movement is suggestive of dysfunction in the vestibular pathways.
The Dix-Hallpike maneuver may help with the diagnosis of benign positional vertigo. Nystagmus and vertigo that lasts for 10-30 s and is brought on within a few seconds of rapidly positioning the patient from seated to supine with the head turned 45° is a positive response.
Unilateral peripheral vestibular hypofunction is also suggested by abnormal rotation while the patient marches in place with eyes closed and arms held out straight ahead. More than 45° rotation during 30 s of marching is abnormal.
None of these tests is very sensitive for vestibular abnormality. If clinical suspicion is high, referral to an otolaryngologist for further, more sensitive testing may be warranted.
Even if no reversible cause of disease is found, most patients with vestibular dysfunction can benefit from vestibular rehabilitation exercises. They may also benefit from the use of an ambulation aid, which improves somatosensory input. Extra caution is required in the dark. In general, meclizine and sedative-hypnotics should be avoided because of the potential for adverse effects, including falls.
- Cardiovascular assessment—The cardiovascular exam should include assessment of heart rate and
rhythm as well as lying and standing (after 1 and 3 min) heart rate and blood pressure (BP). Symptoms or signs consistent with a cardiovascular cause should prompt additional evaluation. For example, presyncopal symptoms associated with prolonged standing may suggest need for delayed monitoring of standing BP. Presyncopal symptoms 30 min after a meal may suggest the need for postprandial BP monitoring. Presyncopal symptoms associated with head turning may suggest carotid sinus syndrome or vertebrobasilar insufficiency. If the history is suggestive, an electrocardiogram (ECG) may be of benefit even if the pulse is regular.
Caution should be used in ascribing orthostatic hypotension as a cause of the fall because epidemiological evidence linking orthostatic hypotension to falls is not strong. To establish orthostatic hypotension as the cause, in general, the fall should have occurred in circumstances consistent with orthostasis (eg, shortly after arising from a chair), symptoms of orthostasis should have been present at the time of the fall, and symptoms of light-headedness should be reproducible on exam.
Syncope as the cause for a fall may be underdiagnosed. Frequently with a fall there is no corroborating witness. In the absence of a witness, a patient's denial of syncope does not rule it out. In fact, a substantial proportion of patients who have syncope during carotid sinus massage will deny LOC when asked immediately afterward. Therefore, a history of multiple, otherwise unexplained falls should lead to consideration of more in-depth cardiac evaluation, including carotid sinus massage.
- Lower extremity assessment—Varus or valgus deformities, leg-length discrepancy, and ligamentous laxity may contribute to gait impairment and falls. Arthritis may contribute to falls and impaired mobility either directly as a result of pain or indirectly because of proprioceptive loss, decreased joint ROM, or weakness in surrounding muscles. Foot deformities are associated with increased risk for falls and with gait and mobility disorders.
The lower extremity should be assessed for the presence of joint deformities, joint ROM, and pain with active and passive ROM. Feet should be examined for excess pronation or supination, painful calluses or corns, fallen metatarsals, and other biomechanical abnormalities. Orthotic devices and appropriate footwear can alleviate biomechanical deformities. The use of an assistive device may decrease joint loading. Referral to physical therapy for strengthening and endurance exercise is an integral part of treatment.
- Neurological assessment—The neurological assessment should include light touch, joint position sense and vibration, muscle strength and tone, reflexes, and cortical, extrapyramidal, and cerebellar function. Further diagnostic evaluation should be guided by findings from the neurological exam and the gait and balance exam (see later discussion).
- Cognition assessment—Dementia has been strongly associated with falls through mechanisms of decreased judgment, slowed reaction time, and apraxia. Patients with Lewy body dementia have prominent extrapyramidal signs and a marked propensity to fall, which may be increased further by the use of antipsychotics. Evaluation of executive and visuospatial functioning is particularly important. The Mini-Mental State Examination and the Clock-Drawing Test are valuable in this regard.
- Gait & balance assessment—The purposes of the gait and balance exam are 3-fold: to help determine the cause of the fall by reproducing the circumstances that evoke instability; to help determine the pathological mechanisms resulting in the gait/balance abnormality; and to help counsel patients regarding risk for falls.
The Get Up and Go Test is a simple, validated test of gait and balance. The patient is instructed to rise from a chair with armrests, walk 10 feet, turn around, walk back, and sit down using any usual ambulation aids and walking at a normal pace. The maneuver should be timed; a time of > 14 s is associated with increased risk for falls. Qualitative evaluation is also important. Imbalance, hesitancy, and lack of fluidity with chair rise, walking, turning, or sitting down are considered abnormal.
The specific gait pattern should be noted. A mildly slowed gait speed with decreased but symmetric stride length is common with older age and is not, in itself, abnormal. A broad-based gait is abnormal but nonspecific. It may be seen as an adaptation to loss of sensory input or fear of falling. It may also be seen with cerebellar disorders. A shuffling gait with decreased arm swing and tendency to festination is classic for Parkinson's disease. A related gait may be seen with frontal gait disorders, including normal pressure hydrocephalus, cerebrovascular disease, and frontal masses. There may be difficulty initiating gait, with short steps and a “magnetic gait” appearance (ie, feet appear glued to floor). Abnormally slow gait speed with short steps is also noted with high-grade cerebral white matter changes on computed tomography (CT) or magnetic resonance imaging (MRI).
A spastic gait with circumduction of the leg at the hip may be related to stroke or cervical spinal stenosis. A characteristic waddling gait and Trendelenburg's sign are seen with proximal motor weakness. Steppage gait and foot slap are seen with distal motor weakness (eg, distal motor neuropathy). Cerebellar ataxia is characterized by broad-based gait with asymmetry of step length and lack of a straight path. Irregularity of cadence and
step length may be heightened with turns or rapid walking. Finally, antalgic gait is characterized by shortened stance phase on the affected side.
Gait assessment should include stepping over obstacles (eg, shoe or shoe box). Individuals with vision impairment or poor foot clearance may slow gait speed considerably when trying to step over objects, may not clear the object with the foot, or may lose balance when trying to step over. This aspect of gait testing is particularly contributory if a person has suffered a tripping fall.
It is also helpful to retest gait while diverting the person's attention, in particular when circumstances of the fall suggest the person was trying to do more than 1 task at a time. Persons with increased fall risk may perform well on gait assessment as long as their attention is focused specifically on the task, but they may show gait slowing or balance impairment when their attention is diverted. Attentional aspects can be tested in the office by asking the person to walk a short distance, turn around, and return while carrying a full glass of water, performing serial subtractions, or listing animal names. Stepping over objects can also be tested while the person does a mental task. If obvious slowing or worsening of gait or balance is noted, the individual should be cautioned regarding the need to focus attention while walking and avoid competing attentional demands.
Finally, it can be helpful to ask the person to walk as fast as possible. Patients with cerebellar ataxia may become more ataxic at rapid speed. Patients with periventricular white matter changes or other frontal gait syndromes may be unable to speed up when asked.
Other performance-based tests may help with diagnosis. Patients should be asked to rise from a chair without armrests. An inability to rise from the chair is abnormal and suggests proximal muscle weakness or impaired postural control resulting from proprioceptive, visual, or CNS abnormalities. The ability to withstand a light nudge on the sternum may be impaired with Parkinson's disease and other CNS disorders. Needing to step backward when nudged on the sternum or beginning to fall are considered abnormal and may be indicative of propensity to backward falling.
The Romberg test assesses somatosensory and vestibular input. Patients with cerebellar ataxia may be unable to put their feet together to perform the test. For those who are able to place their feet together, increased sway with the eyes closed indicates proprioceptive or vestibular abnormality. If the Romberg test is positive, the patient should be educated regarding the need for extra caution in circumstances in which visual input is limited (eg, in dim light or when the eyes are closed in the shower).
Other functional balance tests include neck turning while standing, reaching up to barely just rise on the toes, and bending over to pick up an object from the floor. Dizziness or imbalance with neck turn may indicate cervical proprioceptive loss, vestibular dysfunction, or central neurological balance disorder. Patients should be counseled regarding the need to modify head and neck movements. Difficulty reaching while on tiptoes may lead to the recommendation to move kitchen items down from top shelves. Patients with difficulty bending may benefit from the use of a reacher.
For mobility disorders, gait abnormalities associated with biomechanical, muscular, or arthritic changes include antalgic gait, decreased step length, unequal step length, and Trendelenberg gait. Adverse effects on mobility may be at least partially alleviated by appropriate orthotic devices for foot, ankle, or knee; assistive devices for ambulation; pain medication; exercise; and orthopedic surgery.
- LABORATORY FINDINGS
No specific routine laboratory tests are indicated as part of an evaluation for falls. However, hypothyroidism may manifest as falls without other findings on history and physical exam; therefore, a thyroid-stimulating hormone test should be strongly considered.
Selection of additional laboratory tests should be directed by history and physical exam findings. A metabolic panel may be helpful when there is suspicion of acute or subacute change in health status contributing to the fall. Anemia has been noted as a risk factor for falls; a hematocrit should be obtained if there are suggestive symptoms. Falling may also be an early symptom of Addison's disease; morning cortisol testing may be considered if other signs and symptoms are suggestive. If cognitive loss or loss of proprioception and vibration is present, the vitamin B12 level should be obtained and a rapid plasma reagin test or Venereal Disease Research Laboratories test considered.
Vitamin D deficiency is common in frail older adults, and low 25-OH vitamin D levels are associated with decreased muscle strength and falls. Because signs and symptoms are often nonspecific, assessment of 25-OH vitamin D level should be strongly considered. A level of < 32 ng/mL is abnormal.
- IMAGING STUDIES
Imaging studies are not considered part of the routine evaluation for falls but should be prompted by specific signs and symptoms. Head CT and MRI may be indicated if there are new or unexplained neurological findings. A rapid progression in gait impairment with a frontal gait with or without symptoms of dementia and urinary incontinence should prompt evaluation for normal pressure hydrocephalus. Slow gait speed and falls have been strongly linked with MRI findings of high-grade periventricular white matter changes, which are presumptively ischemic. Lesions have been linked to
nocturnal hypotension, orthostatic hypotension, and postprandial hypotension. There is no specific treatment.
MRI of the cervical or lumbar spine is indicated if signs and symptoms suggest cervical or lumbar spinal stenosis. Findings of cervical spinal stenosis include lower extremity proprioceptive and vibratory sense loss along with lower extremity weakness, hyperreflexia, and spasticity. Upper extremity radicular symptoms and signs may be present. Lumbar spinal stenosis may produce weakness in muscles innervated by L4-S1 and classically presents with symptoms of pseudoclaudication.
- SPECIAL TESTS
Special tests may be helpful if organ system abnormalities are found on exam. Electronystagmography and dynamic posturography may help distinguish central versus peripheral vestibular disease and its effect on balance. Sensory or motor loss in the lower extremity may indicate abnormalities in peripheral nerves, spinal cord, or brain. Electromyography, nerve conduction velocity, and somatosensory evoked potential may help delineate the specific disease.
There should be a low threshold for further cardiac testing given the overlap between syncope and falls. Carotid sinus massage should be strongly considered in the setting of unexplained recurrent falls, with or without a history of LOC, if there is no contraindication. Continuous ECG and BP monitoring is indicated. Tilt table testing may be considered, again even in the absence of history of LOC. Holter monitoring may be helpful if there are specific signs or symptoms suggesting arrhythmia as a cause. Similarly, echocardiogram may also be considered if other markers suggest that the fall is due to decreased blood flow to the brain.
More specialized balance testing may be available through physical therapy. Testing may include the sensory organization test or computerized balance platform testing, both of which help evaluate the vestibular, visual, and sensory contributions to balance. Tests of motor control, automatic postural responses, muscle activation, and dynamic weight shifting may also be performed. Although not necessary as a routine evaluation, these evaluations may help when the cause of symptoms of dizziness, dysequilibrium, or balance impairment is unclear. They also may help guide treatment by allowing prescription of specific exercises to improve sensory integration and dynamic balance.
The first step in investigating the cause of a fall is to determine whether consciousness was maintained or lost during the event. If consciousness was lost, the differential shifts to seizure and syncope; further evaluation should follow for these causes. There is growing recognition, however, that lack of patient report of LOC does not rule out syncope. Whenever possible, a witness should be interviewed to ascertain state of consciousness. In the absence of a witness, syncope must remain in the differential if a fall is otherwise unexplained.
A fall not resulting from syncope, seizure, or overwhelming environmental hazard is typically related to deficits in multiple organ systems related to balance. The evaluation should focus on the search for reversible causes; evaluation of medications; prescription for physical therapy for individualized balance and strengthening program and for evaluation for assistive device; evaluation of home safety; and patient education to modify unsafe behaviors. Table 12-3 lists reversible causes for falls.
- MOBILITY DISORDERS
The approach to evaluation of mobility disorders is similar to that for falls. Mobility disorders are typically multifactorial, and evaluation should ascertain which factors are potentially reversible. Certain conditions may play more of a role in mobility impairment than they do in falls. Obesity, pain (particularly arthritic), decreased joint ROM, deconditioning, and depression contribute substantially to mobility impairment.
Complications of falls and mobility disorders include fear of falling, social isolation, depression, and ADL dependency. Mobility impairment may be associated with functional incontinence, accelerated deconditioning, and poor quality of sleep.
Although injuries associated with falling are most frequently minor, even minor injuries may result in further mobility restriction. Severe injury occurs infrequently but markedly increases the risk of complications. Hip fracture is associated with a sharp increase in ADL dependency, which is often permanent, and with increased risk for permanent institutionalization. Half of all hospitalizations for fall-related injury result in nursing home placement.
Treatment of falls and mobility disorders is largely based on the detection and treatment of underlying reversible causes and on implementation of preventive measures after an event has occurred to decrease repeat incidents and fear of falling.
Multifactorial interventions have resulted in a 40% decrease in fall rate. Reduction in fall rates from exercise
alone varies from 20-50% depending on the target population and type of exercise provided.
Table 12-3. Potentially treatable causes of falls, associated falls history, and gait abnormality.
The prognosis for any individual patient depends on the ability to detect and treat underlying factors related to falls and on patient adherence with exercise and the use of assistive device and other behavioral modifications. Patients with cognitive impairment and a history of falls and those with certain central balance disorders (eg, Parkinson's disease, brainstem CVAs, cerebellar ataxia) have a poor prognosis because of their decreased ability to compensate.
The prognosis related to treatment of mobility disorders also depends on the ability to identify and treat reversible underlying factors. Deconditioning may be readily reversed by exercise. Both resistance and aerobic exercise increase functional ability for patients with knee osteoarthritis. Both resistance and balance exercises have been shown to increase levels of physical activity. The use of an assistive device has been shown to increase mobility. Thus, prognosis is good for gains in mobility with a multifactorial intervention strategy incorporating exercise and modification of other intrinsic and situational factors.
- Multifactorial intervention is effective in decreasing falls in community, nursing home, and assisted-living settings.
- Psychotropic medication reduction is likely effective in decreasing falls among community-dwelling older adults. As part of a multicomponent intervention, it is likely effective in decreasing falls among institutionalized older adults as well.
- Exercise, particularly balance training, should be offered as part of a multifactorial intervention for high-risk older adults. For low-risk older adults, group-based balance exercises are likely effective as a single intervention to prevent falls.
- Hip protector pads are highly protective against hip fractures.
RELEVANT WORLD WIDE WEB SITES
American Physical Therapy Association Section on Geriatrics: http://www.geriatricspt.org (Information and resources about physical therapy for clinicians and patients.)
Center for Injury Prevention Policy and Practice, Injury Prevention Literature Update: http://www.safetylit.org. (Provides weekly update with abstracts of new injury prevention literature.)
Centers for Disease Control and Prevention: http://www.cdc.gov. (Links to National Center for Injury Prevention, providing injury morbidity and mortality data, and National Center for Chronic Disease Prevention and Health Promotion, providing information on benefits of exercise.)
National Guideline Clearinghouse: http://www.guideline.gov. (Compendium of published guidelines, including guidelines on exercise and fall prevention.)
National Resource Center on Aging and Injury: http://www.olderadultinjury.org. (Contains resources for older adults and families on injury prevention, and has excellent links to data on unintentional injury.)
President's Council on Physical Fitness and Sports: http://www.fitness.gov. (Links to excellent fact sheets and reports on physical activity and health.)