Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults

Abstract

ImportanceFalls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.ObservationsFalls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.Conclusions and RelevanceMore than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.

Factors Associated with Falls in Community-Dwelling Older Adults: A Subgroup Analysis from a Telemergency Service

“…These characteristics are highly prevalent in older populations and their interaction accounts for the risk of falls [ 21 , 22 , 23 ]. The abovementioned characteristics also contribute to a frailty phenotype [ 24 ] that acts as an additive risk factor for falls [ 25 ].…”

“…In conclusion, fall-detection technologies have shown a broader use in real world context. As falls result from the combination of intrinsic and extrinsic factors, the combination of new technologies with other types of interventions could be an effective strategy in reducing not only falls, but promoting an independent living [ 24 ]. Technology could help healthcare professionals performing a broader evaluation of the fall-risk factors of the person.…”

Preventing Falls in Older Persons

“…The fall prevention exercise programs in the USPSTF review most commonly included gait, balance, and functional training (30/37 studies reviewed), and many programs included strength and resistance training (25 studies); flexibility training and endurance training were seen less frequently . In general, functional exercises that focus on movements performed in daily activities and balance appear to be more effective for fall prevention than walking or resistance training alone …”

“…For example, in a large trial, only one-third of patients were willing to identify actions to reduce use of medications that increase fall risk, especially hypnotics . Interestingly, interventions such as exercise that have been demonstrated effective when delivered as single interventions under research conditions have not led to effectiveness when delivered as parts of multifactorial interventions in pragmatic trials, perhaps because implementation is more challenging as interventions become more complex and multifaceted.…”

Risk Assessment and Prevention of Falls

“…To the Editor The comprehensive review of risk assessment and prevention of falls by Dr Colón-Emeric and colleagues did not mention one important, common, and modifiable risk factor: alcohol use. The relationship between alcohol intoxication and falls is self-evident, whereas the effect of smaller amounts of consumption has been less studied and with inconsistent results.…”