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Falls & Gait Disorders in Elderly

For further information, see CMDT Part 4-04: Management of Common Geriatric Problems

Key Features

Essentials of Diagnosis

  • Falls in older people are rarely due to a single cause

  • Medications are a common and potentially reversible cause of falls in older adults

General Considerations

  • With age, balance mechanisms can become compromised, reaction time slows, and postural sway increases

  • These changes predispose the older person to a fall when challenged by an additional insult to any of these systems

  • Effective intervention entails a comprehensive assessment of the patient's intrinsic deficits (usually diseases and medications), the activity engaged in at the time of the fall, and environmental obstacles

  • Intrinsic deficits are those that impair

    • Sensory input

    • Judgment

    • Blood pressure regulation

    • Reaction time

    • Balance and gait

  • Dizziness may be closely related to the deficits associated with falls and gait abnormalities

  • Medications (eg, benzodiazepines, sedative-hypnotics, cardiac medications, antidepressants, neuroleptics) and polypharmacy have been associated with increased risk of falls

  • Postural hypotension, including postprandial

  • Acute medical illness (pneumonia, myocardial infarction)

  • Other contributing factors

    • Urinary urgency

    • Peripheral edema

    • Insomnia

    • Use of multifocal lenses

    • Footwear

  • See Table 4–2

Table 4–2.Fall risk factors, targeted interventions, and best evidence for fall prevention.
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Table 4–2. Fall risk factors, targeted interventions, and best evidence for fall prevention.
To Consider for All Patients  
Exercise or physical therapy Tai Chi, gait training, balance training, strength training
Multifactorial intervention Home safety assessment, medication review, review of specific conditions (below), advice on appropriate footwear, vision check, adaptive aids as appropriate, physical therapy or exercise as appropriate
Condition Targeted Intervention
Postural hypotension (> 20 mm Hg drop in systolic blood pressure, or systolic blood pressure < 90 mm Hg) Behavioral recommendations, such as hand clenching, elevation of head of bed; discontinuation or substitution of high-risk medications
Use of benzodiazepine or sedative/hypnotic agent Education about sleep hygiene; discontinuation or substitution of medications
Use of multiple prescription medications Review of medications with a focus on discontinuation (deprescribing)
Environmental hazards Removal or mitigation of hazards; installation of safety equipment (eg, grab bars)
Gait impairment Gait training, assistive devices, balance or strengthening exercises
Impairment in transfer or balance Balance exercises, training in transfers, environmental alterations (eg, grab bars)
Impairment in leg or arm muscle strength or limb range of motion Exercise with resistance bands or putty, with graduated increases in resistance
Vision impairment Cataract surgery or other interventions as appropriate (eg, corrective lenses)
Inability to get up after a fall Medic-alert system, physical therapy training for strategies
High-risk footwear Education on appropriate footwear (eg, avoid slippers, high heels)

Demographics

  • Falls are the leading cause of nonfatal injuries in older persons

  • Complications from falls are the leading cause of death from injury in persons over age 65

  • About one-third of people over 65 fall each year, and ...

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