Falls & Gait Disorders

About one-third of people over age 65 fall each year, and the frequency of falls increases markedly with advancing age. About 10% of falls result in serious injuries such as fractures, soft tissue injuries, and traumatic brain injuries. Complications from falls are the leading cause of death from injury in persons over age 65. Hip fractures are common precursors to functional impairment, nursing home placement, and death. Furthermore, fear of falling may lead some elders to restrict their activities.

Every older person should be asked about falls; many will not volunteer such information. Assessment of patients who fall should include postural blood pressure and pulse, thorough cardiac examination, evaluations of strength, range of motion, cognition, and proprioception, and examination of feet and footwear. A thorough gait assessment should be performed in all older people. Gait and balance can be readily assessed by the “Up and Go Test,” in which the patient is asked to stand up from a sitting position without use of hands, walk 10 feet, turn around, walk back, and sit down. Patients who take < 10 seconds are usually normal, patients who take longer than 30 seconds tend to need assistance with many mobility tasks, and those in between tend to vary widely with respect to gait, balance, and function. The ability to recognize common patterns of gait disorders
is an extremely useful clinical skill to develop. Examples of gait abnormalities and their causes are listed in Table 4–3.

Causes of Falls

Balance and ambulation require a complex interplay of cognitive, neuromuscular, and cardiovascular function. With age, balance mechanisms can become compromised and postural sway increases. These changes predispose the older person to a fall when challenged by an additional insult to any of these systems.

A fall may be the clinical manifestation of an occult problem, such as pneumonia or myocardial infarction, but much more commonly falls are due to the interaction between an impaired patient and an environmental risk factor. Falls in older people are rarely due to a single cause, and 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, and balance and gait. Dizziness may be closely related to the deficits associated with falls and gait abnormalities. While it may be impossible to isolate a sole “cause” or a “cure” for falls, gait abnormalities, or dizziness, it is often possible to identify and ameliorate some of the underlying contributory conditions and improve the patient’s overall function.

As for most geriatric conditions, medication use is one of the most common, significant, and reversible causes of falling. A meta-analysis found that sedative/hypnotics, antidepressants, and benzodiazepines were the classes of drugs most likely to be associated with falling. The use of multiple medications simultaneously has also been associated with an increased fall risk. Other often overlooked but treatable contributors include postural hypotension (including postprandial, which peaks 30–60 minutes after a meal), insomnia, use of multifocal lenses, and urinary urgency.

Since most falls occur in or around the home, a visit by a visiting nurse, physical therapist, or health care provider reaps substantial benefits in identifying environmental obstacles and is generally reimbursed by third-party payers, including Medicare.

Complications of Falls


wrist, hip, and vertebrae. There is a high mortality rate (approximately 20% in 1 year) in elderly women with hip fractures, particularly if they were debilitated prior to the time of the fracture.

Fear of falling again is a common, serious, but treatable factor in the elderly person’s loss of confidence and independence. Referral to a physical therapist for gait training with special devices is often all that is required.

Chronic subdural hematoma is an easily overlooked complication of falls that must be considered in any elderly patient presenting with new neurologic symptoms or signs. Headache or known history of trauma may both be absent.

Patients who are unable to get up from a fall are at risk for dehydration, electrolyte imbalance, pressure sores, rhabdomyolysis, and hypothermia.

Prevention & Management

The risk of falling and consequent injury, disability, and potential institutionalization can be reduced by modifying those factors outlined in Table 4–4. Emphasis is placed on treating all contributory medical conditions (eg, cataracts), minimizing environmental hazards, and eliminating medications
where the harms may outweigh the benefits particularly those that induce orthostasis and parkinsonism (eg, a-blockers, nitrates, antipsychotics). Also important are strength, balance, and gait training as well as screening and treatment for osteoporosis, if present. Falls and fractures may be prevented by prescribing vitamin D at a dose of 800 international units daily or higher.

Assistive devices, such as canes and walkers, are useful for many older adults but are often used incorrectly. Canes should be used on the “good” side. The height of walkers and canes should generally be about the level of the wrist. Physical therapists are invaluable in assessing the need for an assistive device, selecting the best device, and training a patient in its correct use.

Early surgery for patients with cataracts may reduce falls, but eyeglasses, particularly bifocal or graduated lenses, may actually increase the risk of falls, particularly in the early weeks of use. Patients should be counseled about the need to take extra care when new eyeglasses are being used (eg, to look down to use the lens above the bifocal when going up or down stairs).

Patients with repeated falls are often reassured by the availability of phones at floor level, a portable phone, or a lightweight radio call system. Their therapy should also include training in techniques for arising after a fall. The clinical utility of anatomically designed external hip protectors in reducing fractures is currently uncertain.

When to Refer

Patients with a recent history of falls should be referred for physical therapy, eye examination, and home safety evaluation.

When to Admit

If the patient has new falls that are unexplained, particularly in combination with a change in the physical examination, hospitalization should be considered.

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