Home | About | Events | Contact | Advisory Board | Writer’s Guidelines | Reprints | Organizations | Advertising
July/August 2024
July/August 2024 Issue Fall Risk: Repeated Fall Risk in Older Adults Falls are the leading cause of preventable injury for adults 65 years of age and older.1,2 But annually, one in four older adults, totaling more than 14 million, report falling. According to the CDC, falls are also the leading cause of injury-related death for older adults, and the death rate associated with falling increased 41% from 2012 to 2021. Repeated falls are common in the older adult population; after one fall, the risk of another fall doubles.1 And, approximately 40% of community-dwelling older adults experience two or more falls in the same year.3 Over the last 10 years, there have been significant national, state, and local efforts to implement fall prevention programs, such as those promoted by the CDC and the National Council on Aging. Many older adults may have accessed such fall prevention programs in their local communities. However, despite these evidence-based fall prevention programs and the well-publicized fall-related statistics in older adults, physicians working with older adults may not be adequately addressing fall prevention for various reasons. Less than half of older adults who fall tell their physicians.1 Fall prevention may not be addressed at medical appointments focused on other health issues. And, physicians may provide general fall prevention guidance, such as recommending exercise programs and regularly checking vision. Research published in the last several years has shown that attention to fall risk and more targeted fall prevention efforts are needed from medical care providers, including in the primary care and emergency settings.2,4,5 A 2016 retrospective analysis found that approximately 80% to 90% of primary care providers routinely addressed fall-related risk factors such as patient gait/balance issues and vitamin D levels; however, risk factors related to multiple medication use (polypharmacy) and home safety were addressed by less than 25% of providers. And physicians performed a comprehensive fall risk assessment, as is recommended by evidence-based fall prevention programs, for less than 50% of older adults at high risk for repeated falls.4 A 2018 study led by CDC researchers surveyed approximately 1,200 US primary care providers about fall prevention approaches with older adult patients. Only 52% of surveyed providers recommended general exercise programs, and less than 15% recommended tai chi, a proven low cost and effective method of reducing falls.5 In a January 2024 publication, researchers evaluated follow-up and fall prevention strategies for approximately 1,500 patients aged 65 years and older who visited the emergency departments (EDs) of two university-affiliated community hospitals in Florida due to head trauma from a ground-level fall.6 Annually, there are three million older adult ED visits for fall-related injuries,1 making the ED an important intervention setting for fall prevention efforts. Researchers contacted patients via phone 14 days after ED discharge and asked if they followed up with their primary care physicians since the ED visit, whether their physician assessed the reason for the fall, and if they or their physician started any fall prevention interventions as a result. Fall prevention recommendations were then categorized, and clinical characteristics for patients with and without fall-related follow-up were analyzed.6 Their analysis revealed that only 60% of older ED patients with a fall-related head injury pursued follow-up with their physicians; 72% of those reported receiving a fall assessment, but only 56% initiated a fall prevention strategy. The most common fall prevention intervention was physical therapy prescribed by their physicians. The researchers called the fall prevention follow-up “suboptimal” given that almost one-third of patients who had a follow-up visit with their primary care physician did not receive a fall risk assessment and more than 40% did not receive any fall prevention strategy.6 Fall prevention follow-up for older adults with fall-related injuries is essential to reduce the risk of repeat falls and associated morbidity and mortality. In a second publication, some of the same researchers analyzed risk factors for repeat falls in approximately 2,100 older adults seen in the EDs of the same two Florida hospitals for fall-related head injuries. Within two weeks of the initial ED visit, 14% of patients returned for another ED visit due to a complaint related to the initial fall (58.5%), a new medical issue (23%), or a new injury (18.5%). Of the patients who returned to the ED due to a new injury, 96% had injured themselves in a second fall. Patients who had dementia or a previous stroke were at significantly greater risk of having a second fall requiring an ED visit.7 The researchers suggested the following for older patients at risk for repeat falls7: • identifying older patients at high risk for repeat falls and ED visits based on risk factors; Recurrent Fall Risk Factors • diagnosed psychiatric condition, including depression/anxiety; Determining the risk of repeat falls for older adults requires a comprehensive fall risk assessment, in particular to ascertain whether they have multiple risk factors. “I believe there are common causes, but there may not be a ‘most common cause’ due to the variation of fall risks and how risks interact with each other and can have a cumulative effect,” says Emily Nabors, MS Gerontology, senior program specialist at the Center for Healthy Aging at the National Council on Aging. She notes that mobility/functional disabilities from an initial fall, medications, and fear of falling are some common factors that increase fall risk. Injuries from an initial fall may affect gait, balance, strength, and endurance. Also, if the injury affected their ability to perform daily activities, such as bathing and getting dressed, there’s a greater risk of falling during these activities, Nabors explains. In addition, particular types of medications contribute to fall risk. “If, after a person falls, they are prescribed additional medications, there’s a greater chance of interactions and side effects, such as dizziness, drowsiness, and confusion, that could increase fall risks,” she states. For example, many medications commonly taken by older adults for chronic conditions such as hypertension and heart disease are considered “fall risk-increasing drugs.” When older adults are then prescribed antidepressants, sedatives, or hypnotics (eg, benzodiazepines) to treat depression or anxiety, or an opioid pain medication to treat a fall-related injury, the combination of medications creates an additive risk of falling.8,9 Fear of falling, which can manifest after an initial fall or near fall, can have a substantial impact on repeat fall risk. “Fear of falling can cause an older adult to limit their activities out of fear that they may fall again. Yet, limiting activity can then lead to decreased activity levels and depression from reduced social activity, both of which increase fall risk,” Nabors notes. Repeat Fall Prevention Efforts Additional ongoing state and local fall prevention coalitions are also available to address repeat falls by giving older adults access to diverse experts, service providers, and community members that provide fall prevention programs, education, and referrals within the older adult’s community. “Some partners include emergency medical services [EMS] and fire departments, since it is not uncommon for first responders to devote more resources to fall-related calls. “EMS and other first responders work to reduce future falls by providing educational materials and referrals to local services for frequent fallers who call for assistance,” Nabors explains. Local hospitals and medical centers may also provide evidence-based fall prevention programs that include education, physical activity, medication management, and home assessments and safety modifications for older adults at risk for falls, she adds. Advice for Geriatric Care Professionals • Ask patients if they have fallen, almost fallen, or are worried about falling. • Use free and easily accessible resources to educate and engage patients about fall risk and prevention (see sidebar). • Learn about the multiple factors contributing to falls to address an individual’s fall risk. Most older adults have a varied range of fall risks, Nabors notes, including medications, balance or vision problems, home hazards, and health issues. • Use the CDC’s STEADI Toolkit (www.cdc.gov/steadi/index.html). • Learn about locally available evidence-based fall prevention programs and resources for referrals, including physical and occupational therapists, pharmacists, ophthalmologists, and podiatrists. • Get involved with fall prevention coalitions, especially during Falls Prevention Awareness Week (September 23-27, 2024). — Jennifer Van Pelt, MA, is a freelance writer and health care researcher located in the Lancaster, Pennsylvania, area.
National Council on Aging Resources • 6 Steps to Help Prevent Falls in Older Adults infographic (www.ncoa.org/article/6-steps-to-help-prevent-falls-in-older-adults) and video (www.ncoa.org/article/video-6-steps-to-prevent-a-fall) • National Falls Prevention Resource Center for Professionals (www.ncoa.org/professionals/health/center-for-healthy-aging/national-falls-prevention-resource-center) • Find an Evidence-Based Fall Prevention Program (www.ncoa.org/evidence-based-programs) • National Falls Prevention Awareness Week (www.ncoa.org/professionals/health/center-for-healthy-aging/national-falls-prevention-resource-center/falls-prevention-awareness-week)
References 2. Cox DD, Subramony R, Supat B, Brennan JJ, Hsia RY, Castillo EM. Geriatric falls: patient characteristics associated with emergency department revisits. West J Emerg Med. 2022;23(5):734-738. 3. Choi NG, Marti CN, Choi BY, Kunik MM. Recurrent falls over three years among older adults age 70+: associations with physical and mental health status, exercise, and hospital stay. J Appl Gerontol. 2023;42(5):1089-1100. 4. Phelan EA, Aerts S, Dowler D, Eckstrom E, Casey CM. Adoption of evidence-based fall prevention practices in primary care for older adults with a history of falls [published correction appears in Front Public Health. 2016;4:255]. Front Public Health. 2016;4:190. 5. Burns ER, Haddad YK, Parker EM. Primary care providers' discussion of fall prevention approaches with their older adult patients—DocStyles, 2014. Prev Med Rep. 2018;9:149-152. 6. Shih RD, Solano JJ, Engstrom G, et al. Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall. Am J Emerg Med. 2024;75:29-32. 7. Alter SM, Knopp BW, Solano JJ, Hughes PG, Clayton LM, Shih RD. Repeat fall risk in geriatric patients after fall-induced head trauma. Cureus. 2023;15(9):e45056. 8. Ming Y, Zecevic A. Medications & polypharmacy influence on recurrent fallers in community: a systematic review. Can Geriatr J. 2018;21(1):14-25. 9. Ie K, Chou E, Boyce RD, Albert SM. Fall risk-increasing drugs, polypharmacy, and falls among low-income community-dwelling older adults. Innov Aging. 2021;5(1):igab001. |
