25: Falls & Mobility Disorders

As people age, their risk of falling increases. Approximately 30% of people older than the age of 65 years and 50% of people older than age 80 years fall each year. Almost 60% of those with a history of falls in the previous year will suffer from a subsequent fall. Up to 50% of falls result in some type of injury, the most serious of which include hip, head trauma, and cervical spine fractures. Injuries that occur as a result of a falls contribute to a rate of accident-related deaths that rank seventh as a cause of death in the United States. Multiple risk factors account for the increased rate of falls observed in older persons and as such, falls are considered a geriatric syndrome.

One major risk factor for falls includes problems with mobility. As is true with falls, the risk for developing a mobility disorder increases with age. Mobility disorders range from subclinical to obvious and within this range, fall risk is elevated. Because the risk for mobility disorders and falls are increased in older persons, clinicians should be particularly aware of factors important in preventing and treating both. This chapter discusses falls and associated mobility disorders with regards to the background, epidemiology, risk factors, clinical evaluation, prevention, treatment, and prognosis of older persons who may be at risk or who have already developed mobility problems and recurrent falls.

A fall is defined as “inadvertently coming to rest on the ground or other lower level with or without loss of consciousness” (Close, 1999). Most falls do not result in serious physical injury, but those who fall become at increased risk for recurrent falls. In addition, many who experience an initial fall develop a fear of falling that itself can lead to an increased fall risk. Thus, it is particularly important to query about a history of falls when evaluating an older patient so that an appropriate evaluation and recommendations for prevention and treatment can be made before a significant injury occurs.

Mobility disorders refer to any deviation from normal walking. To walk normally, control of balance and posture both at rest and with movement is necessary. Thus, normal gait requires a complex integration of adequate strength, sensation, and coordination. For a normal healthy adult, walking is almost automatic, but in fact, the control of gait and posture is both complex and multifactorial, and a defect at any level can result in mobility problems.

The incidence and health impact of falls vary depending on age, sex, and living status. As stated earlier, the incidence increases with age with about a third of the population older than age 65 years and half of the population older than age 80 years reporting a fall in the previous year. Men and women tend to fall in equal proportions, but women are more likely to suffer from an injury. Similar to those older than age 80 years, approximately 50% of residents in long-term care settings fall each year. Of the 5% to 10% of falls that result in serious injury, the most common complications include major lacerations, head trauma, and fractures.

Fall-related injuries are the major reason that clinicians need to be acutely aware of this widespread problem that affects older patients. Although the majority of falls do not result in serious physical injury, in those age 65 years and older, falls account for 62% of nonfatal injuries leading to U.S. emergency department visits, and approximately 5% lead to hospitalization. Patients who suffer from fall-related injuries are more likely to experience a decline in functional status and an increase in medical service utilization. In addition, they have an increased likelihood of long-term nursing home placement.

Special mention of hip fractures is deserved because they are amongst the most common and costly of fall-related injuries in older adults. More than 90% of all hip fractures occur as a result of a fall. Falls resulting in hip fracture are known to roughly double the 1-year mortality rate compared to matched seniors without hip fractures. The 1-year mortality rate ranges from 12% to 37%, and approximately half of those who fall and fracture a hip are unable to regain the ability to live independently.

Like falls, mobility disorders affect approximately 15% of those age 60 years and older and 80% of those age 85 years and older. One simple measure of mobility is to assess walking speed; in 1 observational study of about 900 older men and women (average age: 75 years; range: 71–82), gait speed averaged 1.2 m/s, and declined approximately 5% over 3 years. In general, slower gait speed is a risk factor for falls among older adults, but there is a U-shaped relationship in that those with faster walking speeds (≥1.3 m/s) also experience an increased rate of falls. Approximately 17% of falls in older persons can be attributed to balance, leg weakness, or gait problems. Of those with mobility problems, the causes are multifactorial in nature, with sensory deficits, myelopathy, and multiple infarcts being among the top 3 categories reported in the literature.

Fall prevention strategies appear to work in both institutional and community settings according to recent comprehensive systematic reviews published by the Cochrane Collaboration. Single and multifactorial intervention randomized controlled trials have been conducted, and while not uniformly in agreement, the preponderance of evidence demonstrate some positive benefit with fall rate declines. In addition, if these fall prevention strategies can be implemented in populations at risk for injurious falls, society on the whole will enjoy cost savings.

Thus, many organizations have taken on falls as a preventable health condition, and resources have been put towards implementing fall prevention programs. In the United States since 2004, the National Council on Aging (NCOA) has been leading the Falls Free Initiative to address the growing public health problem of falls and fall-related injuries among older adults by collaborative leadership. Initially, representatives from 58 national organizations, professional associations, and federal agencies got together to develop a blueprint for reducing falls and fall-related injuries that included 36 strategies. Since its inception, NCOA has developed coalition workgroups, 1 of which was responsible for having the U.S. Senate delegate the first day of fall as National Fall Prevention Awareness Day, initially established in 2009. That same year, the American Geriatrics Society (AGS) and British Geriatrics Society (BGS) expert panel on fall prevention provided updated recommendations that health care providers follow a step-by-step process of decision making and intervention to manage falls among older persons assessed to be at high fall risk (see algorithm, Figure 25–1).

For preventive strategies to be most cost-effective, they should target those who are at highest risk for developing the outcome. Multiple studies have shown that the strongest risk factors for falling include: (a) previous falls; (b) decreased muscle strength; (c) gait and balance impairment; and (d) specific medication use. With the exception of previous falls, theoretically, muscle strength, gait and balance, and medication use could be potentially modifiable risk factors. Other potentially modifiable risk factors include visual impairment, depression, pain, and dizziness. Hard to modify or nonmodifiable fall risk factors are age, female sex, activities of daily living disabilities, low body mass index, urinary incontinence, cognitive impairment, arthritis, and diabetes.

Although advanced age is a risk factor for developing mobility disorders in general, there are no particular risk factors to highlight as the root cause of disabling gait disorders are most often unknown and/or multifactorial in etiology. As an example, weakness leading to mobility problems could stem from upper motor neuron (dysfunction of the cord and/or higher central motor pathways), lower motor neuron (problems with spinal motor neurons or peripheral nervous system), or primary myopathic problems. Some of the most disabling gait disorders result from serious neurologic disease and are beyond the scope of this chapter. However, because each of these diseases are also associated with an increased fall risk, they are listed for completeness: (a) extrapyramidal disorders (eg, Parkinson disease); (b) cerebellar ataxia (eg, cerebrovascular disease); (c) vestibular dysfunction (eg, acoustic neuroma); and (d) frontal lobe dysfunction (eg, normal pressure hydrocephalus).

Besides aging and/or deconditioning leading to muscle weakness and mobility problems, there are other nonneurologic medical problems that can lead to mobility disorders. Examples of these include visual loss, morbid obesity, orthopedic problems, rheumatologic disorders, pain, medications, and cardiorespiratory problems. Thus, in doing a clinical evaluation of an older patient, it is important to keep in mind these underlying systemic medical conditions that can adversely affect mobility, and hence lead to an unwanted fall.

Symptoms & Signs

In the clinical evaluation of a geriatric patient, it is important to keep in mind identified independent risk factors for falling (Table 25–1). In addition, more often than not, falls in older adults are not owing to a single cause, but occur when there is an additional stress, such as an acute illness, new medication, or an environmental hazard, that makes an older person unable to compensate as well as a younger person, and thus more likely to fall. The activity profile of the older person also will affect their risk for falling. Sedentary individuals may have multiple risk factors for falling, but not be at danger because they modify their behavior to avoid the opportunity for falls. More active older adults may be less cautious and therefore be at increased risk for falling, because they may not be able to compensate as well as a younger person to threats against postural stability.

To help prevent falls in older persons, multifactorial risk assessments have been advocated by the AGS/BGS and other organizations. These assessments begin with a basic falls history that inquires whether the patient experienced any fall in the past year. If a fall is reported, important details with regards to the activity that lead to the fall, any prodromal symptoms (eg, lightheadedness, imbalance), and where and when the fall occurred should be obtained. Patients should be asked about the number of falls in the past year, whether any injuries were sustained from any of the falls, and if they suffer from a fear of falling. Finally, patients should be asked if they suffer from any difficulties with walking or balance. All of the above questions are important because a “yes” answer to any would indicate a high likelihood of sustaining a future fall.

When inquiring about a specific fall, if there was an associated loss of consciousness, then orthostatic hypotension, or underlying cardiac or neurologic causes should be considered as precipitating factors. Other chronic medical conditions associated with an increased fall risk should be considered and include cognitive impairment, dementia, chronic musculoskeletal pain, knee osteoarthritis, urinary incontinence, stroke, Parkinson disease, and diabetes. Another crucial part of the medical history for an older person who might be at increased risk for falling includes a functional assessment of the activity of daily living skills, including use of adaptive equipment and mobility aids. In a patient who reports multiple falls, an inquiry into alcohol use is warranted as most patients would not volunteer this information freely, and frequent alcohol consumption could increase fall risk. Finally, physicians should perform an up-to-date and careful review of the patient’s medication list that should include current prescriptions and over-the-counter medications. One large observational study of 4260 older community-dwelling men demonstrated that 82.3% of participants reported inappropriate medication use (eg, polypharmacy, inappropriate medicine consumption, underutilization). And both polypharmacy (≥5 medications) and taking 1 or more potentially inappropriate medications were associated with having had a fall in the past year, highlighting the importance of addressing inappropriate use of medications as modifiable fall risk factor.

Once the history is obtained, clinicians should make sure that orthostatic vital signs, visual acuity, cognitive status, and cardiac system be included in a basic physical exam. Of vital importance is the evaluation of gait and balance. There are quite a few balance and mobility assessments that are effective at assessing fall risk, but are not practical in a busy clinical setting. Such tests include the Performance-Oriented Mobility Assessment (POMA; Table 25–2), Short Physical Performance Battery (SPPB), Berg balance test, and Safety Functional Motion test. However, there are 2 other tests, the Get Up and Go and the Functional Reach tests, that are more frequently used because they each take less than a minute to administer. For the Get Up and Go test, the physician should ask the patient to rise from a standard arm chair (without the use of arms if possible), walk a fixed distance across the room (3 meters), turn, walk back to the chair and sit down. Besides observing the patient for unsteadiness, if it takes >13.5 seconds to complete this task, the patient would be considered to be at increased risk for future falls. The functional reach test requires using a yardstick mounted on a wall at shoulder height. The patient is asked to stand close to the wall at comfortable stance with an outstretched arm with the shoulders perpendicular to the yardstick. The patient is then instructed to extend the arm forward as far as possible without taking a step or losing balance; the functional reach is measured along the yardstick in inches, and if <10 inches in men, there has been reported a 2 times greater risk for falling.

Finally, also important to the physical exam is the examination of the feet and footwear. High-heels, floppy slippers, shoes with slick soles can predispose people to trip and fall. Ill-fitting footwear that is too big, without sufficient grip or too much friction, and/or without proper fixation (untied or loosely tied shoes) will also contribute to increasing someone’s fall risk. When selecting shoes, the upper shoe should be soft and flexible with smooth lining. The toe box should be deep enough to allow for toe wiggle room. The sole should be strong and flexible for good grip. The heel should provide a broad base for stability and be no higher than 4 cm. Finally, the fastening should provide a stable fit with some flexibility to allow for unusually shaped feet or swelling.

Diagnostic Tests

In completing a work up for an older patient with falls or determined to be at increased risk for falling, other than a general medical work up, there is no standard diagnostic evaluation. However, laboratory tests for hemoglobin to rule out clinically significant anemia, a chemistry panel to rule electrolyte disorders, and/or hyper or hypo-osmolar states, thyroid-stimulating hormone (TSH) to rule out hypothyroidism, vitamin B₁₂ level to rule out B₁₂ deficiency (linked to proprioceptive problems), and serum 25-hydroxyvitamin D levels to rule out vitamin D deficiency (linked to falls and fractures) could be considered appropriate. In addition, falling can be a sign of medical illness and it is not uncommon for older patients to present with a fall to the emergency room, and later be diagnosed with an underlying urinary tract infection or pneumonia. A standard urinalysis and chest radiograph might be appropriate depending on the clinical scenario, especially if the patient suffers from significant cognitive impairment or dementia.

Fewer than 10% of falls are caused by a loss of consciousness, but when there is a history of such, a different approach to evaluation and prevention might be indicated. An electrocardiogram to evaluate for significant cardiac pathology should be included; routine Holter monitoring has not been shown to be effective. However, on cardiac exam if a crescendo–decrescendo systolic murmur is appreciated at the right upper sternal border, then echocardiogram would be indicated to rule out clinically significant aortic stenosis that when critical, can present with syncope. Carotid sinus sensitivity has also been linked to falls, and pacemaker placement might be considered in patients who experience carotid sinus massage-induced heart rate pauses of >3 seconds. Contraindications to carotid sinus massage include presence of carotid bruits, recent myocardial or cerebral ischemia, or previous ventricular tachyarrhythmias.

In patients who present with falls who have new or unexplained neurologic findings on examination, imaging with head CT or MRI may be indicated to rule out stroke, mass, normal pressure hydrocephalus, or other structural abnormality. If the patient has significant gait abnormalities, then spine radiographs or even MRI imaging may help exclude cervical spondylosis or lumbar stenosis as a cause of falls. Clinical signs consistent with cervical spinal spondylosis include neck stiffness, deep aching neck, arm and shoulder pain, and possibly stiffness or clumsiness while walking. If the condition is chronically progressive, there may be significant associated muscle atrophy. The hallmark symptom of cervical spondylotic myelopathy is weakness or stiffness in the legs and patients may present with gait instability; characteristically, there should be evidence of hyperreflexia, and a stiff or spastic gait would be expected in advanced cases. Lumbar spinal stenosis usually presents with pain, muscle weakness and tingling of the legs in the L4-S1 distribution with classic symptoms of pseudoclaudication, more recently referred to as neurogenic claudication (pain improves with sitting, worsens with standing or walking).

There are multiple interventions that can be implemented to decrease a patient’s fall risk, and each needs to be tailored to the particular patient’s needs. Overall, a multifactorial approach should be taken as modifiable factors, both intrinsic and extrinsic to the patient, have been shown to decrease fall rates. Of the interventions, medication reduction, physical therapy, and home safety modifications have demonstrated the best efficacy in fall prevention.

Starting with intrinsic modifiable fall risk factors (Table 25–3), visual impairment should be corrected if possible. The evidence supporting treatment of visual problems is not conclusive as a single intervention, but cataracts commonly affect older patients, and correction of vision may not only help to decrease the risk of falls, but improve quality of life. In patients with cardioinhibitory carotid sinus hypersensitivity who experience recurrent falls, dual chamber pacemaker placement is probably indicated. In all patients, but particularly in patients with postural hypotension, careful review of medications should be done. A goal should be to reduce the total number of medications and/or dose of individual medications. Psychoactive medications that include sedative hypnotics, anxiolytics, antidepressants and antipsychotic medications should be minimized and appropriately tapered and withdrawn if possible. If after discontinuation of predisposing medications a patient still has postural hypotension, then recommendations for adequate hydration, advice to slowly change positions, and the addition of a medication such as fludrocortisone may be considered. Finally, there is deemed to be sufficient evidence with regards to vitamin D and reducing the risk of falls that the AGS/BGS guidelines now recommend 800 IU of vitamin D daily for all older adults who are at risk for falling.

Extrinsic modifiable factors include checking the home environment to remove obvious fall hazards and ensuring that proper footwear is worn. In evaluating the home environment, removal of clutter to minimize tripping hazards, making sure there is adequate lighting, and installation of safety measures like shower bars and/or raised toilet seats are helpful to decrease fall risk. In assessing the footwear, foot problems can also be screened for and patients referred for treatment if necessary. Patients should be advised that they should wear well-fitting shoes of low heel height and high surface area.

In addition to reviewing and treating the intrinsic and extrinsic modifiable fall risk factors, patient education and information programs are helpful in falls prevention. For example, simple advice, such as a removal of multifocal lenses while walking or on stairs, can reduce the risk of falls. Perhaps most important is education and recommendations regarding physical activity. Although there is a lot of information available to the general public with regards to proper diet and exercise and good health, many probably do not link this beneficial information directly to fall risk reduction. Therefore, clinicians should make a specified recommendation regarding exercise and fall risk reduction as it has the best-associated evidence for reducing fall rates.

If during the clinical evaluation the patient demonstrates balance or gait instability, referral to physical therapy is warranted. Physical therapy should consist of progressive standing balance and strength exercise, transfer practice, and gait interventions, including use of appropriate assistive devices. Patients should also be trained on how to get up from the floor after a fall. Once mastering of these skills is accomplished, focusing on maintenance and building endurance should be encouraged. For all community-dwelling older patients, clinicians should recommend an individually tailored exercise program to maintain function, possibly increase endurance, and decrease their risk for falls. In the most recent systematic review on the topic, 43 trials tested the effect of exercise on falls. In trials of exercise classes that employed gait training, balance, and strengthening, there was a 17% risk reduction in falling (n = 14 trials, 2364 participants, 95% confidence interval 0.72–0.97). There were 4 trials that examined the effects of Tai Chi on the risk and rate of falls, and the risk reduction was perhaps even more impressive at 37% (95% confidence interval 0.51–0.82).

Separate mention of treatment in acute and long-term care settings is warranted because this patient population clearly would be expected to be at an increased fall risk, and yet studied interventions in these patients have not demonstrated clear benefit. In particular, the use of bedrails, restraints, fall-alert bracelets, and bed alarms have not been shown to decrease fall rates, and may potentially increase fall risk. Even so, the AGS/BGS still provides the recommendation that multifactorial/multicomponent interventions should be considered in the long-term care setting; within this recommendation, exercise programs are also suggested, but to be implemented with caution due to risk of injury in frail persons. The AGS/BGS also recommends that vitamin D supplements of at least 800 IU daily should be provided to older persons residing in long-term care settings with: (a) proven or suspected vitamin D insufficiency (vitamin D 25-OH <30 ng/mL); (b) abnormal gait or balance; and/or (c) an increased risk for falls.

There is significant morbidity and mortality associated with falls in seniors. The prognosis for a single fall is not as severe as for an older person with repeated falls. Those who had fallen one or more times at home in the preceding 3 months were more than 3 times as likely as nonfallers to require institutional care within the subsequent year. Fallers had an overall 3-fold increase in subsequent fracture, with recurrent fallers age 60–74 years having an 8-fold increased risk of subsequent fracture. Additionally, recurrent fallers older than age 60 years had an overall risk of death about twice that of nonfallers. This was not simply a function of subsequent risk of fracture. In fact, recurrent fallers age 60–74 years had a 5-fold increased mortality independent of fracture.

Besides recurrent falls, inability to get up from a fall also portends a poor prognosis. Among 1103 community-dwelling residents in New Haven, Connecticut, there were 313 uninjured fallers, of whom 47% were unable to get up on their own. Even when they were not injured as a result of a fall, those unable to get up without help were more likely to suffer lasting decline in activities of daily living (35% vs. 26%). Not surprisingly, over an average follow-up of 16 months, compared with nonfallers, these individuals were also more likely to be hospitalized.

Older adults who fall also suffer from worse quality of life. Confusion and sadness are 4 times more common in recurrent fallers than nonfallers, and it appears that decisions to enter institutional care are often driven by fear of future falls and being unable to get up, rather than actual demonstrated disability. The negative impact of fear of falling should not be underestimated. Another study reported that compared with falls and fractures, fear of falling had the largest negative effect on health-related quality of life.

Although recurrent falls, inability to get up after a fall, and psychological implications following falls all are associated with poor prognosis, each is potentially modifiable. Careful attention should be made to underlying medical disorders that may contribute to an individual’s fall risk. In 1 randomized controlled trial, a focused history and physical assessment by nurse practitioners following a fall lead to identification of modifiable medical conditions and decreased hospitalization rates over 2 years of follow-up.

In this chapter, we discussed the underlying predisposing risk factors, clinical evaluation, prevention, and treatment of falls in older persons. Although chronologic aging is inevitable, successful aging is not. The astute practitioner who is aware of fall risk factors, takes the time to do a proper assessment, and is knowledgeable about treatment can help our older population avoid falling and its associated ill health consequences.