Aetiology

The causes of falls may be inter-related and multifactorial. Overall health may be more important than age in preventing falls and injury.[9]

Neuropsychiatric

  • Visual impairment: manifestations such as blurred vision, loss of peripheral vision, or diplopia.

  • Peripheral neuropathy: may be accompanied by a history of diabetes, neurodegenerative disease, or spinal stenosis.

  • Vestibular dysfunction, particularly benign paroxysmal positional vertigo: may manifest itself as dizziness, vertigo or imbalance.[13][14]

  • Hearing impairment.[15]

  • Gait and balance disturbance: possible history of lumbar disc disease, peripheral neuropathy, arthritis or prior injury/fracture; specific abnormalities in gait or movement (shuffling gait, tremors, bradykinesia) may suggest underlying disorder such as Parkinson's disease.[16][17]

  • Fear of falling itself can increase the risk of falls.[18][19][20]

  • Cognitive or mood impairment: includes dementia, depression, or delirium; behavioural disturbances, functional impairments, and the use of neuroleptics.[21][22][23][24]​​ Cognitive impairment may also contribute to balance and motor dysfunction, particularly when associated with physical frailty.[25][26]

  • Seizure disorder: may be due to vascular disease, infection, neurodegenerative disorder, or malignancy.

  • Subdural haematoma: suggested by head trauma (higher risk when in the presence of anticoagulation).

  • Stroke or transient ischaemic attack: focal neurological symptoms of non-transient or transient duration, respectively.

Cardiovascular

  • Syncope: a transient loss of consciousness due to transient global cerebral hypoperfusion; for example, cardiac syncope caused by tachyarrhythmias or bradycardia, or vasovagal syncope caused by an abnormal or exaggerated autonomic response (e.g., emotion, valsalva, micturition [rarely]).[27][28]

  • Orthostatic hypotension: suggested by onset of symptoms with positional change from supine or seated to standing.

  • Carotid sinus syndrome: may be elicited by activities such as facial shaving (with coincident pressure on carotid sinus).[29]

  • Post-prandial hypotension: event based on history of observed fall coincident with meal times.[30]

Musculoskeletal

  • Joint buckling/instability/poor mechanical mobility: may be due to prior injury or arthritis.

  • Foot problems: particularly foot pain, hallux valgus, and lesser toe deformity.[31]

  • Deconditioning: insufficient exercise and prolonged periods of immobility leading to reduced muscle tone and function.

  • Sarcopaenia/osteosarcopaenia/frailty: muscle weakness, muscle and/or bone mass loss, and associated arthritic conditions.[32][33][34][35][36][37]

  • Obesity: particularly sarcopenic obesity.[38][39]

Toxic/environmental

  • Medications:[40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63]

    • Especially benzodiazepines, antidepressants, anxiolytics, antipsychotics, opioids, sedatives and hypnotics (e.g., zolpidem), sildenafil

    • Others associated with an increased risk of orthostatic hypotension, including alpha-blockers, anti-hypertensives, diuretics, beta-blockers, bromocriptine, levodopa

    • Non-steroidal anti-inflammatory drugs

    • Diabetes medications (e.g., insulin, thiazolidinediones), and associated hypoglycaemia

    • Highly anticholinergic medications such as first-generation antihistamines (e.g., diphenhydramine), muscle relaxants, antimuscarinic drugs used for treatment of urinary incontinence, and vasodilators

    • Cholecalciferol (at high doses)

  • Polypharmacy: use of five or more medications increases the risk of falls by approximately 30% in community-dwelling people, and by at least a factor of 4 in nursing-home patients.[64][65]

  • Substance misuse: including alcohol (chronic misuse or acute intoxication), marijuana, or other recreational psychoactive substances.

  • Environmental hazards such as loose rugs or tiles, poor lighting, uneven floors, presence of clutter; recent use of a cane or walker, or living alone: these factors are of increased importance with age.[66]

Fall-risk assessment

The presence of certain factors is associated with greater probability of future falls.[67][68][69]​ Evidence suggests that identifying the following characteristics in at-risk people can be useful when implementing falls prevention strategies:[15][20][34][40][41][64][67][70][71][72][73][74][75][76][77][78][79][80][81][82][83]

  • Motor problems: gait or balance impairment, muscle weakness, and associated arthritic conditions

  • Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment, hearing loss

  • Cognitive or mood impairment: dementia, depression, delirium

  • Orthostatic hypotension

  • Polypharmacy or certain medications (particularly psychotropic medications and opioids)

  • Impairment of activities of daily living

  • Environmental hazards (e.g., loose rugs, poor lighting, clutter)

  • Urinary symptoms attributable to medical conditions, bladder or prostate issues, or medications

  • Fear of falling

  • Additional factors such as age, or comorbid illnesses and frailty.

Given the significant association between medications and falls risk, review of medications and deprescribing in appropriate circumstances can lower this risk.[84][85]

Fall-prevention strategies

Components of many fall-prevention programmes include addressing the risk factors (including chronic diseases, patient behaviours, medications, sensory impairment [balance, hearing, and vision], and home environmental hazards and advocating exercise (including strength and balance training), with interventions as deemed necessary.[86][87]

The Task Force on global guidelines for falls in older adults has sought to stratify risk for falls in older adults living in the community to help determine the appropriate preventative interventions and treatments.[88][89]​​​ Key recommendations include:[88][89]

  • Advising older adults on falls prevention and physical activity.

  • Opportunistic case finding for falls risk for community-dwelling older adults.

  • Offering a comprehensive multifactorial falls risk assessment with a view to co-designing and implementing personalised multidomain interventions.

Exercise interventions to prevent falls

The US Preventive Services Task Force (USPSTF) recommends exercise interventions to prevent falls in community-dwelling adults ≥65 years who are at increased risk for falls.[90]​​​[91]​​

One 2019 Cochrane review concluded with high certainty that exercise (primarily involving balance and functional exercises) reduces the rate of falls, and the number of community-dwelling older people experiencing falls.[92]​ Exercise programmes that reduce falls comprise multiple exercise categories (typically balance and functional exercises, plus resistance exercises) and Tai Chi.[92][93]​​ The effectiveness of resistance exercise alone, dance, or walking remained uncertain.[92]

Calcium and vitamin D for fall prevention and primary prevention of fracture in community-dwelling and institutionalised adults

The USPSTF has concluded that there is insufficient evidence to assess the balance of risks versus the benefits of daily vitamin D >400 IU and calcium >1g for the primary prevention of fractures in post-menopausal women.[90]​ Furthermore, the USPSTF concluded that there is insufficient evidence to assess the balance of risks versus benefits of vitamin D and calcium supplementation, alone or in combination, for the primary prevention of fractures in community-dwelling asymptomatic men and premenopausal women.[90][94]

Meta-analyses of vitamin D supplementation (alone or with calcium) in mixed populations of community-dwelling individuals and institutionalised patients have not shown benefit in terms of reduction of falls.[95][96]​​​ However, in one Cochrane review of studies conducted in care facilities and hospitals, vitamin D supplementation was found to probably reduce the number, but not the risk, of falls in care homes (moderate-quality evidence).[97] In a subsequent meta-analysis, low dose vitamin D supplementation (800-1000 IU daily) in older persons was associated with lower risk of falls; supplementation in older persons with vitamin D deficiency conferred some benefit in falls prevention.[98]

The role of vitamin D supplementation in falls risk and falls prevention continues to evolve. Shared decisions with patients regarding risks and benefits of vitamin D should be undertaken when considering this specific intervention.

Multiple component interventions

The USPSTF recommends that clinicians individualise the decision to offer multifactorial interventions (that include an initial assessment of modifiable risk factors for falls and subsequent customised interventions) to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls.[90][91]

One Cochrane systematic review found that multi-factorial interventions may reduce falls in older people in the community compared with usual care or attention control.[99] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] [Evidence C]​​​ The review also found that multiple component interventions (offering the same component interventions to all people without taking into account any assessment of risk of falls; most of which include exercise) may reduce the number of falls, and the risk of falling, compared with usual care or attention control in older people living in the community.[99] Subsequent analyses have also supported the value of multi-component interventions in reducing falls risk.[100][101]

Several guidelines have examined the implementation of interventions to prevent falls:

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