Abstract
Stephanie Anne Studenski, M.D., M.P.H., is Professor of Medicine with a specialty in Geriatrics at the University of Pittsburgh. She is on staff of the Pittsburgh Veterans Administration Geriatric Research, Education and Clinical Center (GRECC). The GRECCs are designed to advance and integrate research, education, and clinical achievements in geriatrics and gerontology into the total VA healthcare system. Dr. Studenski received a degree in nursing before pursuing a master's degree in public health. Her postdoctoral training includes fellowships in rheumatic and genetic diseases and geriatrics from Duke University Medical Center. Jodi Godfrey, M.S., R.D., is a health and wellness specialist in private practice and contributing editor to the Journal.
Falls have always been viewed as a common predilection among frail elderly people, the majority of whom are women. The first representative national estimate of falls among aging adults demonstrates the enormity of the problem, with more than 7 million falls occurring in the United States. 1 Approximately 30% of people over age 65 who are still living in the community fall each year. 2 The majority of people fall indoors, are repeat fallers, and are commonly alone when they fall. Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes. 3
Every 18 seconds, an older adult is treated in an emergency department for a fall, and every 35 minutes someone in this population dies as a result of their injuries. Although one in three older adults falls each year in the United States, falls are not an inevitable part of aging. 4
Although falling may seem like a simple event, it is a complex, multifactorial condition that may lead to fractures and soft tissue and traumatic brain injury and represents the fifth leading cause of death among older adults. 5
The profile has begun to shift to women who are aging successfully and remaining active well into their 80s. Whereas injuries and healthcare use are serious concerns, falling presents other problems for older women, including functional limitations, fear of falling, restricted activity, and social isolation. 6,7 Thus, falls require active management.
In a 2001–2003 survey of U.S. adults, an estimated 3.5 million (9.6%) older adults reported falling at least once in the past 3 months. 1 About 36.2% of all older adults said they were moderately or very afraid of falling, yet slightly fewer than half of seniors mention having fallen to their healthcare provider, and only 60% of those who talk to their physician receive fall prevention information, which means that healthcare providers may be missing many opportunities to provide fall prevention information to older people. 3
As women live longer, remaining active—even athletically vigorous—they represent a completely new subset of the population to consider for fall prevention and management. Dr. Studenski discusses the challenges and opportunities of managing mobility in women who age successfully into their senior years.
The issue of imbalance, which may lead to falls, is not as simple as either an accident or an underlying condition. Many falls are a combination of some kind of environmental threat, such as stubbing a toe or tripping on an uneven surface. In actuality, the patient's feet may not be functioning properly. A clinical conclusion might be that there is a mismatch between the woman's physical capacity and the action or what she is trying to do.
We are living in a world in which a growing number of healthy older women are breaking bones because they are highly athletic. The most familiar data suggest that falls affect vulnerable older adults who have trouble with balance and walking. It is only in the past 10 years or so that there has been an increasing number of women who are aging in relatively good health and remaining active well into their 70s and 80s in the community. In effect, they are highly functioning adults who appear more in line with those in middle life. Our clinical view of falls must change with the times. An increasingly common occurrence relates to these aging women who experience an injurious fall while continuing to pursue old athletic interests, such as skating, skiing, and rollerblading, which often causes bone fractures. These women reflect an emerging pattern of injuries that has not been considered previously in these otherwise healthy, active, elderly women. Because it is a relatively new phenomenon, there is not yet sufficient literature or practice guidelines to direct the management of the active older set.
Suggesting that these women curtail their activity is not necessarily the most beneficial clinical strategy, as staying active is likely the best overall health goal. Rather than suggesting they do less, one should encourage these highly active women to take measures to protect themselves, such as attending to maintenance of bone health and muscle fitness and use of good judgment. This would include avoiding black diamond ski runs and staying clear of fast moving kids (i.e., skating/skiing during school hours and finding other pursuits on weekends and school breaks).
The American Geriatrics Society (AGS) recommends falls screens that identify risk as (1) more than one fall in the last year, (2) one or more falls with injury, (3) self-report of unsteadiness, or (4) unsteadiness on performance testing. The current recommendations essentially require physicians to remember a great deal of new information; these guidelines are being revised. In the meantime, clinicians have sufficient knowledge with which to make an initial assessment of balance impairment that may just be a matter of approaching information in an organized manner. Rarely is there one diagnosis; rather there usually is an accumulation of multiple small and medium physical losses that impair the ability to remain upright and steady. There is a range of systems involved in maintaining balance, but it is enough for practitioners to run through a general screen of three key functions: (1) sensory, (2) central coordination and timing, and (3) effector (muscles and joints).
For many women, discussing a fall seems trivial, especially when they are visiting their physician for a more emergent concern that is the reason for the office visit. Because most patients do not voluntarily mention falling, it is important for clinicians to explicitly ask about falls. Some older adults may actively hide the fact that they are falling and will not volunteer the information unless prompted. The focus of care should be directed at women whose history and physical examination demonstrate problems with walking and balance. The take-away message is to: Ask about falls Conduct simple balance screens by watching patients move: Observe the woman's ability to get onto the examination table, which usually necessitates the use of a stool. Navigating the stool requires balance and agility. Notice if steps become shorter and slower. Notice wobbling or signs of unsteady gait.
Risk factors for falls overlap substantially with risk factors for other geriatric syndromes. 8 We have focused on the aging well, but older age and impairments in cognition, mobility, and function are the best documented risk factors for falls and frailty. 8 Recent research suggests an increased risk in falls among those with such conditions as diabetes, circulatory disorders, and depression. Diabetes affects multiple systems, including vision and sensation in the feet, which affect balance. 9 Therefore, individuals who have chronic diabetes, especially if it is poorly managed or uncontrolled, are at greatest risk. Thus, there is a call to incorporate the prevention and treatment of geriatric disorders into the management of diabetes in the elderly, including that of functional imbalance to reduce risk of falls. 9
Circulatory problems, such as peripheral vascular disease and long-standing uncontrolled hypertension, which would affect reaction time, pose an elevated risk. The data are less clear for arthritis. If the arthritis affects the patient's ability to bend or reduces the person's range of motion markedly, this may contribute to falls. 10
In some women, depression in late life may manifest as psychomotor slowing, which can have a biological impact on reaction time, inhibiting the ability to prevent a fall. 5 More importantly, some common medications used to manage depression have a side effect profile that increases orthostatic hypotension, increasing the risk of falls. Therefore, women who are at risk for falls while on an antidepressant should be monitored closely.
Among otherwise healthy older women, we are just beginning to view balance challenges among the successfully aging, so we do not know enough about the impact of subtle, subclinical changes or symptoms that may require attention. In the clinical setting, these women should remain a strong target for osteoporosis screening and bone care.
There are select factors that may alter fall risk in otherwise active, healthy, older women, such as maintaining muscle mass through appropriate diet and exercise. A major concern among older women is unintentional weight loss. 12 One of the dangers of weight loss is the concomitant loss of lean tissue, which leaves the woman weak and less steady on her feet. These women are likely to benefit from protein supplements to reverse the muscle wasting. Equally relevant is a diet that promotes a healthy body weight and supports musculoskeletal health as well as providing adequate iron and vitamin B12 and sufficient calories to meet energy needs. 13 A diet high in vegetables and fruit and whole grains appears to offer a modest reduction in the rate of falls. 11
Although controversial, it may be that vitamin D supplementation will reduce fall risk, particularly for women who do not spend time outdoors or consume sufficient dairy products. 12,14 This is more certain among women who are at risk for vitamin D deficiency, as supplementation reduces the risk of falls by 20%. 15 The best interpretation of the data suggests that vitamin D does not reduce falls except in people who have vitamin D deficiency, 16 Although there are other valid reasons for women to consider taking supplemental vitamin D. 15
Achieving a healthy weight promotes the right balance of lean muscle and strong bones. The best strategy for maintaining muscle strength is with a regular program of resistance training or a core exercise to provide the physical power and coordination to support vigorous activities. Exercise interventions may target strength, balance, flexibility, and endurance, reducing the risk and rate of falls. Programs that contain two or more of these components show the greatest success in improving balance. Exercise in supervised groups, participating in Tai Chi, and carrying out individually prescribed exercise programs at home are all effective. 16 However, exercise is not effective as a stand-alone treatment to stop falls; a reduction in falls can be achieved, but exercise cannot prevent all falls. 17 Therefore, a regular exercise routine provides an added advantage once any clinical concerns are addressed. It is worth noting that the exercise programs to date are simplistic, and efforts employed to date fall short. One failure of the current process is that patients are sent to physical therapists to regain or improve balance. They get a little better and are told to keep up the exercises at home, but the routine is painfully boring if it is even remembered. The repetition typically causes people to loose interest and quit. There are many novel balance exercises that are under development to be used to tailor treatment programs aimed at the specific conditioning needs of an individual. For example, there are virtual reality environments that would permit a woman to practice balance tasks so to be better prepared to deal with them in the real world.
The overriding goal must be to make exercise more desirable and fun so it will be sustained. One possible approach is the use of video games. The pleasure and play component may sustain motivation and promote participation. The most currently popular video game system is the Wii Fit TM, but other less expensive systems can be equally effective as a mode of interactive video exercise. That said, older women can ask their grandchildren to introduce them to these interactive programs so they can find one that is suitable to their comfort.
Although exercise per se does not offer a stand-alone treatment, it has been shown to reduce the rate of falling by 17% to 35% (Tai Chi). 16 The greatest effect occurs in programs that incorporate a combination of vigorous cardioexercise and the challenge of balance (i.e., yoga or Tai Chi) rather than a walking program. 18,19
Other lifestyle factors
All women should be reminded to keep their glasses prescriptions current, as loss of visual acuity, depth perception, and peripheral vision are common at advancing ages and may hinder their activity. In addition, there are over-the-counter (OTC) medications that are best avoided because they are known to slow reaction time or alter alertness without the person's being aware of this side effect. Such medication include sleep-promoting products and antihistamines. Therefore, clinicians will want to ask about the use of OTC medication. For women engaged in vigorous activity, it may be preferable to suggest that they consider trying behavior modification modalities or be directed to medications that have less sedation as a side effect.
With regard to prescription medications, the effect of changes in medication on the risk of falls has been studied.
16,20
These findings indicate the short-term risk of single and recurring falls is three times higher in the 2 days after a medication change, a factor that should be discussed with patients for whom a change in medication is warranted. Increasing the number of medications used by an older adult increases the risk of falling such that the use of more than four medications increases a patient's risk of falling by 30%.
20
Medications that may increase fall risk include: Antianxiety and antidepressants (increases risk of falls by 1.2–6-fold)
20
Antipsychotics Cardiovascular medications that may cause orthostatic hypotension (i.e., beta-blockers, nitrates, vasodilators, centrally acting agents, diuretics) Pain medication (i.e., opioids)
Gradual withdrawal of psychotropic medication reduced the rate of falls but not the risk of falling. A prescribing modification program for primary care physicians significantly reduced the risk of falling. 16
Regarding footwear, as has been well documented, the right shoe influences balance and the subsequent risk of slips, trips, and falls by altering somatosensory feedback to the foot and ankle and modifying frictional conditions at the shoe/floor interface. 21 Walking indoors barefoot or in socks and walking indoors or outdoors in high-heeled shoes have been shown to increase the risk of falls in older people. Other footwear characteristics, such as heel collar height, sole hardness, and tread and heel geometry, influence the measures of balance and gait. Shoes with elevated heels or soft soles impair walking stability in older people, especially on wet floors, and high-collar shoes of medium sole hardness provide optimal stability on level dry, irregular, and wet floors. 21 Because many older people wear suboptimal shoes, maximizing safe shoe use may offer an effective fall prevention strategy. Based on findings of a systematic literature review, older people should wear shoes with low heels and firm slip-resistant soles both inside and outside the home. 22
Summary
Although multifactorial fall risk assessment and intervention seem a plausible strategy for preventing falls and fall-related injuries in older people, this is not supported by strong research. Current evidence suggests that it may reduce the number of fallers by only a modest amount. Evidence of its effects on other outcomes, such as the rate of falls and injuries, is insufficient. Higher-intensity interventions providing treatments to address risk factors rather than information and referral may be more effective. The costs of implementing these interventions have not been extensively studied; hence, the cost-effectiveness of this type of intervention is questionable. 23
Much discomfort, disability, and healthcare spending due to falls by older people could be averted by more consistently and aggressively addressing fall prevention in clinical practice. 17
Footnotes
Disclosure Statement
No competing financial interests exist.
Patient Resources
Fall Prevention Center of Excellence. Available at