Keeping Older Adults Safe from Falls

America is aging.

Falls are the leading cause of death and injury among older adults in the United States. According to the Centers for Disease Control (CDC), one out of four adults 65 and older will fall annually in the U.S. The CDC encourages healthcare providers (HCPs) to utilize the Stopping Elderly Accidents, Deaths, & Injuries (STEADI) initiative in their practices.

A 2019 outcome evaluation found that the STEADI program effectively reduced fall-related hospitalizations. It also found that older adults with a fall risk and a fall plan of care (FPOC) were 0.6 times less likely to have a fall-related hospitalization than those with a fall risk and without an FPOC.

Recommended course: Brace for the Falls of an Aging Nation

Three core elements for implementation

To facilitate the STEADI initiative, healthcare providers need to:

• Screen all older adult clients for fall risk
• Assess modifiable risk factors
• Intervene to reduce identified risks by implementing clinical and community strategies

Screening for fall risk

Identifying an older adult’s fall risk is an essential first step for fall prevention. The CDC recommends screening patients using a screen such as the 12-question tool, Stay Independent, or by asking the following questions:

• Do you feel unsteady when standing or walking?
• Do you worry about falling?
• Have you fallen in the past year?

A clinically significant score on the Stay Independent screener or an affirmative answer to any screening question warrants an assessment of modifiable fall risk factors.

If a client does not demonstrate a fall risk based on screening, the CDC suggests that the older adult client receive education as a preventative measure, be reassessed yearly or when a fall does occur, and receive a referral for a community exercise or fall prevention program.

Assessing modifiable fall risk factors

The type of healthcare setting and the HCP’s scope of practice will determine how the HCP assesses the clients’ modifiable risks. An interdisciplinary approach can be used to gather fall risk information.

If an older adult client is identified as having a fall risk, the CDC lists four functional assessments to aid in determining modifiable fall risk factors.

• 30-second sit-to-stand test to assess leg strength and endurance
• 4 Stage balance test to assess balance
• Timed Up and Go (TUG) test to assess mobility
• Measure orthostatic blood pressure to assess

The CDC also provides additional ways to assess modifiable factors. These include:

• Asking the client about medications that can contribute to their fall risk
• Asking the client about potential household hazards such as throw rugs, pets, and bathroom surfaces
• Identifying co-morbidities such as osteoporosis
• Assessing feet and footwear
• Determining visual acuity
• Determining Vitamin D intake

Assessing grip strength

Grip strength peaks between 30 and 40 years old before declining. A 2021 study found a clinical significance between poor hand strength and older women. Women with impaired balance and poor handgrip strength were found to have a higher fall risk.

HCPs can objectively evaluate a client’s grip strength with a dynamometer to determine how it compares to their client’s age group’s normative data. This quantitative data can be reviewed and gathered at various intervals as determined by the HCP.

Function-based assessments

Assessing modifiable risk factors can be achieved by having the client perform an activity of daily living or vocational task to determine which factors contribute to the client’s fall risk.

Functional assessments allow HCPs to give valuable feedback to the client about safety and body mechanics when engaged in a functional task with high fall-risk potential.

Reducing identified risks

Client education and referrals to other HCP specialists are essential fall risk reduction and prevention strategies. Creating an FPOC and implementing a multi-faceted program therapeutic intervention are additional effective strategies to mitigate fall risk.

The National Institute on Aging (NIA) divides exercises into four categories:

• Strength
• Endurance
• Balance
• Flexibility

However, a comprehensive therapeutic program will include all four areas as a means to reduce fall risk. An effective therapeutic program can consist of therapeutic exercises and function-based activities.

Increasing muscle mass and maintaining strength

After age 30, muscle mass decreases by 3-8% per decade. After age 60, the decline is even higher. Clients can gain muscle mass by lifting weights the recommended amount of two days per week. An appropriate strength program should be implemented to mitigate fall risk due to generalized weakness. Recommendation two of the APTA Choosing Wisely campaign says, “Don’t prescribe under-dosed strength training programs for older adults. Instead, match exercise frequency, intensity, and duration to the individual’s abilities and goals.”

Yoga and Tai Chi

A 2021 article published in Advances in Geriatric Medicine and Research cites the physical benefits of yoga for older adults. Some of these benefits are:

• Increased mobility
• Increased flexibility
• Protection against cognitive decline
• Increased strength
• Increased balance

Like yoga, Tai Chi produces the same benefits for fall risk reduction. Both are easy on the joints for older adults with co-morbidities that cause joint pain.

Function-based treatments

Therapeutic programs should be tailored to the client's unique needs, strengths, and desired outcomes. The first tenet of AOTA’s Choosing Wisely initiative states, “Don’t provide intervention activities that are nonpurposeful.”

Purposeful interventions can include having the client complete the following activities: 

• Grocery shopping 
• Laundry 
• Yardwork 
• Cooking 
• Cleaning 
• Showering 
• Pet care 

Function-based treatments that use purposeful activities have many benefits, such as: 

• Increasing patient engagement 
• Facilitating dynamic movements that recruit the supporting muscles 
• Increasing endurance 
• Improving overall motor performance 

Promoting wellness in clients 65 and older 

The CDC’s STEADI initiative provides a plan for HCPs to support fall risk prevention. Client and HCP education regarding fall risk mitigation and a client-centered therapeutic intervention can reduce the adverse effects of falls for older adults.