Guideline sources The following summarized guidelines for the evaluation and management of falls in the elderly are prepared by our editorial team based on guidelines from the World Falls Guidelines (WFG 2022), the American College of Obstetricians and Gynecologists (ACOG 2021), the U.S. Preventive Services Task Force (USPSTF 2018), the Danish Health Authority (DHA 2018), the Eastern Association for the Surgery of Trauma (EAST 2016), and the Osteoporosis Canada Foundation (OC 2010). 1 2 3 4 5 6 7 7 8 8 Definition Falls in the elderly is an accidental event due to loss of center of gravity and imbalance that results in an increased risk of traumatic injuries and hospitalizations. 7 Epidemiology Falls in the elderly can be caused due to intrinsic (sight disorders, hearing disorders, balance deficit, alterations in CNS, musculoskeletal alterations; neurological, cardiovascular, endocrine, psychiatric, and iatrogenic pathologies) and extrinsic (environmental factors such as obstacles, inadequate footwear) predisposing factors. 8 https://web.pathway.md/diseases/recCny4SfSOLQBKqV 1/8 6/29/23, 4:01 AM Falls in the elderly Pathway Disease course Clinical manifestations of falls in the elderly include pain, bruising, lacerations, fractures (mostly upper extremity and hip fractures), and intracranial bleeding in severe cases. Falls in the elderly increase the risk of hospitalizations and morbidity. 7 Prognosis and risk of recurrence Falls-related mortality in adults with 65, 75, and 85 years of age is 50 per 100,000, 150 per 100,000 and 5,252 per 100,000 individuals, respectively. 8 Guidelines 1. Screening and diagnosis Indications for screening: As per WFG 2022 guidelines, ask about falls when interacting with older adults, as they often will not be spontaneously reported. B Show 2 more As per ACOG 2021 guidelines, assess the risk of falls in postmenopausal patients with low bone mineral density or osteoporosis. E 2. Classification and risk stratification Risk prediction, general principles: As per WFG 2022 guidelines, obtain multiprofessional, multifactorial assessment in community-dwelling older adults identified to be at high risk of falling, to guide tailored interventions. A Show 5 more As per EAST 2016 guidelines, perform risk stratifaction with targeted, comprehensive fall risk-reduction strategies tailored to high risk groups. A Risk prediction (screening for environmental hazards): identify individual's environmental hazards where they live and assess their capacities and behaviors in relation to them as part of a multifactorial falls risk assessment. A Risk prediction (cardiovascular assessment): obtain a cardiovascular assessment, initially including cardiac history, auscultation, lying and standing orthostatic BP, and surface 12-lead ECG, as part of a multifactorial falls risk assessment. A Show 2 more Risk prediction (assessment of gait and balance): assess gait and balance as part of the risk assessment of falls. A Risk prediction (assessment of dizziness): assess for dizziness symptoms and obtain follow- up assessment as necessary to identify cardiovascular, neurological and/or vestibular causes. E Risk prediction (assessment of vision and hearing): https://web.pathway.md/diseases/recCny4SfSOLQBKqV 2/8 6/29/23, 4:01 AM Falls in the elderly Pathway Assess for vision impairment as part of a multifactorial falls risk assessment, measure visual acuity and examine for other visual impairments, such as hemianopia and neglect where appropriate. E Assess for hearing impairment as part of a multifactorial falls risk assessment, measure and examine for hearing impairments and refer to a specialist where appropriate. E Risk prediction (assessment of urinary symptoms): assess for urinary symptoms as part of a multifactorial falls risk assessment. E Risk prediction (assessment of pain): assess for pain as part of a multifactorial falls risk assessment, followed as indicated by a comprehensive pain assessment. E Risk prediction (assessment of mental health): Obtain assessment of cognition as part of a multifactorial falls risk assessment in older adults. A Assess for depressive symptoms as part of a multifactorial falls risk assessment, followed by further mental state assessment if necessary and referral to a specialist where appropriate. E Risk prediction (assessment of nutritional status): assess nutritional status, including vitamin D intake, as part of a multifactorial falls risk assessment, followed by supplementation where appropriate. E 3. Diagnostic investigations Clinical history: As per WFG 2022 guidelines, ask older adults presenting with a fall or related injury about the details of the event and its consequences, previous falls, transient loss of consciousness, or dizziness, and any preexisting impairment of mobility or concerns about falling causing limitation of usual activities. E As per EAST 2016 guidelines, consider obtaining screening for frailty in elderly patients with falls. C 4. Medical management Management of cardiovascular issues: Manage orthostatic hypotension as a component of a multidomain intervention. B Offer the same intervention for cardiovascular disorders identified during assessment for risk of falls as for similar conditions associated with syncope, in addition to other interventions based on the multifactorial falls risk assessment. A Management of vestibular issues: consider managing vestibular issues as part of the multifactorial approach. E Management of impaired vision: consider managing impaired vision as part of the multifactorial approach. E Management of pain: consider providing adequate pain control as part of the multifactorial approach. E https://web.pathway.md/diseases/recCny4SfSOLQBKqV 3/8 6/29/23, 4:01 AM Falls in the elderly Pathway Management of patient concerns: offer exercise, CBT, and/or occupational therapy as part of a multidisciplinary approach to reduce concerns about falling in community-dwelling older adults. A 5. Inpatient care Inpatient assessment: obtain a multifactorial falls risk assessment in all hospitalized patients aged > 65 years. Do not use scored falls risk screening tools in hospitals for multifactorial falls risk assessment in older adults. B Show 2 more Inpatient prevention strategies: Deliver a tailored education on falls prevention in all hospitalized older adults ( 65 years of age) and other high-risk groups. B Implement personalized single or multidomain falls prevention strategies in acute B or subacute care A based on identified risk factors, behaviors, or situations in all hospitalized older adults or younger persons at risk of falls. A 6. Specific circumstances Patients in care homes: do not obtain falls risk screening to identify care home residents at risk for falls since all residents should be deemed at high risk of falls. D Show 7 more Patients with Parkinson's disease: consider obtaining a falls risk assessment, including a self- report 3-risk factor assessment tool including a history of falls in the previous year, freezing of gait in the past month, and slow gait speed, in older patients with Parkinson's disease. B Show 3 more Patients with hip fracture: offer an individualized and progressive exercise program to improve mobility, including standing up, balance, walking, and climbing stairs, as a fall prevention strategy in older adults after sustaining a hip fracture. A Commence such programs in the hospital B and continue in the community. B 7. Patient education General counseling: advise on how to maintain safe mobility and optimize physical functioning in older patients at low risk of falls, taking into consideration the individual's circumstances, priorities, preferences, and resources. Reinforce health promotion/prevention messaging relevant to falls and fracture risks, including physical activity, lifestyle habits, and nutrition, including vitamin D intake. E 8. Preventative measures General principles: incorporate the individual's values and preferences in the care plan developed to prevent falls and related injuries. A Include both the individual's and their https://web.pathway.md/diseases/recCny4SfSOLQBKqV 4/8 6/29/23, 4:01 AM Falls in the elderly Pathway caregivers' perspectives when creating fall prevention care plans for older adults with cognitive impairment. B Environmental modifications: As per WFG 2022 guidelines, provide counseling for modifications of the physical home environment for fall hazards as part of a multidomain falls prevention intervention. A As per ACOG 2021 guidelines, offer fall prevention strategies, including environmental assessment and modification, in patients at risk of falls. E As per DHA 2018 guidelines, consider offering changes to improve the safety in the home environment of elderly adults at risk of falls living at home. C As per EAST 2016 guidelines, consider offering physical environment modification to prevent falls in frail elderly people. C Exercise interventions: As per WFG 2022 guidelines, offer an exercise program based on an individual assessment. E Show 6 more As per ACOG 2021 guidelines, offer fall prevention strategies, including weight-bearing and muscle-strengthening exercises, in patients at risk of falls. E As per DHA 2018 guidelines: Consider offering balance training in elderly adults at risk of falls living at home or in institutional care. C Consider offering movement concepts, such as Tai Chi, yoga, dance, or dance-like training in elderly adults at risk of falls living at home. C Updated evidence: Treadmill balance training in older adults In community-dwelling adults 65 years of age and were able to walk without a walking aid, perturbation-based balance training was not superior to treadmill walking training with respect to a daily-life fall rates in the past 12 months. Jens Eg N rgaard et al. JAMA Netw Open. 2023 Apr 3. As per USPSTF 2018 guidelines, offer exercise interventions to prevent falls in community- dwelling 65 years old adults at increased risk for falls. B As per EAST 2016 guidelines, consider offering evidence-based exercise programs for frail elderly individuals. C As per OC 2010 guidelines, consider offering exercises focusing on balance, such as Tai Chi, or on balance and gait training in individuals at risk of falls. B Multifactorial interventions: As per WFG 2022 guidelines, offer multidomain interventions, informed by a multiprofessional, multifactorial falls risk assessment, in community-dwelling older adults at high risk of falls. A https://web.pathway.md/diseases/recCny4SfSOLQBKqV 5/8 6/29/23, 4:01 AM Falls in the elderly Pathway As per ACOG 2021 guidelines, offer fall prevention strategies, including individualized multifactorial interventions such as vision assessment and treatment, balance training, and environmental assessment and modification, in patients at risk of falls. E As per USPSTF 2018 guidelines, offer multifactorial interventions to prevent falls in selective groups of 65 years old community-dwelling individuals at increased risk for falls. B Hip protectors: As per EAST 2016 guidelines, consider offering hip protectors in frail elderly individuals in the appropriate environment. C As per OC 2010 guidelines, consider offering hip protectors in older adults at high risk for fracture residing in long-term care facilities. C Vestibular rehabilitation: consider offering vestibular rehabilitation in elderly patients with diagnosed vestibular dysfunction. C Vitamin D/calcium supplementation: As per USPSTF 2018 guidelines, do not use vitamin D supplements for the prevention of falls in community-dwelling 65 years old adults. D As per EAST 2016 guidelines, consider offering vitamin D and calcium supplementation for the prevention of fall-related injuries in frail elderly individuals. C Medication review: As per WFG 2022 guidelines: Assess for fall history and the risk of falls before prescribing potential fall risk-increasing drugs in older adults. A Obtain a medication review and deprescribe fall risk-increasing drugs as part of multidomain fall prevention interventions. A Use a validated, structured screening and assessment tool to identify fall risk-increasing drugs when conducting a general medication review or medication review targeted to fall prevention. B As per DHA 2018 guidelines: Discontinue benzodiazepines in elderly adults in case of > 4 weeks of use, since benzodiazepines increase the risk of falls. B Keep selective serotonin receptor inhibitors only upon due consideration and only if non- pharmacological treatment has been ineffective, in > 65 years old adults with moderate depression, since selective serotonin receptor inhibitors may increase the risk of falling and the effect on depression and quality of life is likely to be negligible. B Clinical findings Symptoms Past medical history Dizziness Dementia Gait disturbance Depression Lightheadedness Diabetes mellitus Loss of balance Diabetic neuropathy Loss of consciousness Epilepsy https://web.pathway.md/diseases/recCny4SfSOLQBKqV 6/8 6/29/23, 4:01 AM Falls in the elderly Pathway Loss of sensation HF Muscle weakness Orthostatic hypotension Palpitations Osteoporosis Urinary incontinence Parkinson's disease Vasovagal syncope Rheumatoid arthritis Stroke Medication history Visual disorder Vitamin D deficiency Polypharmacy Psychotropic medications Vital signs Anthropomorphic exam Bradycardia Hypotension Frailty Neurological exam Musculoskeletal exam Cognitive impairment Abnormal timed Up and Go test Peripheral neuropathy ECG findings Integument exam Cardiac arrhythmias Studies 2023 Treadmill balance training in older adults In community-dwelling adults 65 years of age and were able to walk without a walking aid, perturbation-based balance training was not superior to treadmill walking training with respect to a daily-life fall rates in the past 12 months. Jens Eg N rgaard et al. JAMA Netw Open. 2023 Apr 3. References 1. US Preventive Services Task Force, Grossman DC, Curry SJ et al. Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Apr 24;319 16 1696 1704. Open 2. Manuel Montero-Odasso, Nathalie van der Velde, Finbarr C Martin et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022 Sep 2;51 9):afac205. Open 3. Papaioannou A, Morin S, Cheung AM et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182 17 1864 73. Open 4. Crandall M, Duncan T, Mallat A et al. Prevention of fall-related injuries in the elderly: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2016 Jul;81 1 196 206. Open 5. Danish Health Authority. National clinical guideline for the prevention of falls in elderly people: Quick guide. Sundhedsstyrelsen. 2018 Apr. Open https://web.pathway.md/diseases/recCny4SfSOLQBKqV 7/8 6/29/23, 4:01 AM Falls in the elderly Pathway 6. American College of Obstetricians and Gynecologists Committee on Clinical Practice Guidelines Gynecology. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138 3 494 506. Open 7. Suleiman I. Sharif, Alaa B. Al-Harbi, Alaa M. Al-Shihabi et al. Falls in the elderly: assessment of prevalence and risk factors. Pharm Pract Granada). 2018 Jul-Sep; 16 3 1206. Open 8. Pietro Pasquetti, Lorenzo Apicella, Giuseppe Mangone. Pathogenesis and treatment of falls in elderly. 2014 Sep;11 3 222 5.2014 Sep;11 3 222 5. Open 9. Carpenter CR. Evidence-based emergency medicine/rational clinical examination abstract. Will my patient fall?. Ann Emerg Med. 2009 Mar;53 3 398 400. Open 10. American Academy of Neurology. Choosing Wisely AAN recommendations. Choosing Wisely. 2014. Open 11. American Physical Therapy Association. Choosing Wisely APTA recommendations. Choosing Wisely. 2014. Open 12. Society for Post-Acute and Long-Term Care Medicine. Choosing Wisely AMDA recommendations. Choosing Wisely. 2015. Open 13. Pietro Pasquetti, Lorenzo Apicella, and Giuseppe Mangone. Pathogenesis and treatment of falls in elderly. Clin Cases Miner Bone Metab. 2014 Sep-Dec; 11 3 222 225. Open 14. Jens Eg N rgaard, Stig Andersen, Jesper Ryg et al. Effect of Treadmill Perturbation-Based Balance Training on Fall Rates in Community-Dwelling Older Adults: A Randomized Clinical Trial. JAMA Netw Open. 2023 Apr 3;6 4):e238422. Open https://web.pathway.md/diseases/recCny4SfSOLQBKqV 8/8