Fall Prevention and Management

Last Updated: December 13, 2021

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This tool is designed as a reference to support family physicians, primary care nurse practitioners and other interprofessional team members prevent and manage falls among people aged 65 and older living in the community.

The impact of falls on older adults in Canada3

Falls are the leading cause of injury-related morbidity and mortality among people aged 65 and older living in the community. Also, those who who have experienced recurrent falls (>1 per year) are at an increased risk for morbidity and mortality.1–4 Most falls are, however, preventable. As a crucial component of older adult care, healthcare providers can work in partnership with older adults to implement a variety of interventions to address and reduce their risks for falling.2

20-30% of ≥65 years of age experience a fall each year

85% of injury-related hospitalizations among older adults are caused by falls

50% of all falls causing hospitalization happen at home

95% of all hip fractures are caused by falls

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Initiate universal screening

Timing of universal screening5,6

  • Annually screen all patients 65 years of age and older for falls risk5
  • Other opportunities for screening include:
    • After a hospitalization, ER visit or medical event (e.g., stroke, fracture, delirium, etc.)
    • After a bone mineral density test, decrease in bone density or diagnosis of osteoporosis
    • After a significant change in health status (e.g., weight gain or loss, increased frailty, dementia, etc.)5
    • After a relevant medication change or addition (e.g., CNS medications or hypotensives)

Note: use clinical judgement to determine when these opportunities for screening may also apply to patients <65 years

Talking points5,6
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Talking point

Let patients know that they have not been singled out for this screening and discussion6

“I ask all my patients 65 and over about falls.”

Ensure each patient understands what a fall is6,9

“A fall is when you accidentally end up on the ground, floor or other lower level, including your knees. A fall is a fall with or without injury.”

Link the discussions to what matters to the patient (e.g. independence, activities, goals, involvement)10

“How do you envision your health and/or living situation in the
next few year?”

Identify contributing risk factors and implement interventions

Check for all risk factors outlined below. Implement individualized multifactorial interventions tailored to each patient’s risk factors. See Integrate fall prevention into your practice for tips on integrating fall prevention into practice, leveraging interprofessional teams and community supports and engaging patients and caregivers.

Frailty and falls
  • Adults with frailty are at a higher risk of adverse health events including falls7
  • Evaluating community-dwelling adults for frailty can play a role in preventing recurrent falls8
Talking points
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Talking points

Emphasize that falls (or subsequent falls) are preventable6

“Falls can often be prevented. To find out how we can work
together to prevent falls for you, is it okay if I ask you a few
questions about your health and do an assessment?”

For a detailed list of phrases you might want to try, see Talking about fall prevention with your patients15

Fall risk assessment and interventions2,6,7,22,23

Click on risk factor to view how to assess and interventions
How to assess
  • If the patient has previously experienced a fall, ask about the following (this information can be collected while the patient is in the waiting room or through your EMR prior to the appointment):
    • Circumstances of the fall(s) (e.g. what the patient was doing at the time of the fall, when was the fall, beliefs about their reasons for the
      fall, amount of time spent on the ground and how the patient got up)
    • Symptoms preceding and after the fall (e.g. palpitations, syncope, nausea)
    • Frequency of falls
    • Details of any fall-related physical and psychological injuries
    • Post-fall interventions implemented
    • Any recent ER visits or hospitalizations
    • Any changes in activities of daily living, mobility status or confidence in mobility status
    • Any witnesses to the fall who could provide more detail
Interventions
  • Consider referral to rehabilitation for support for patients recovering from physical, cognitive or communication problems caused by a fall-related injury.
How to assess
  • Ask the patient about their current level of formal or non-formal physical activity.
Interventions
  • Support the patient to choose activities appropriate for their abilities, level of fitness/frailty, mobility and interests, including:2,5,9–14
    • Aerobic physical activities (at least 150 minutes per week, in chunks as short as 10 minutes; this may include everyday activities such as housekeeping, gardening, shopping and walking)
    • Muscle-strengthening activities (at least twice a week)
    • Balance activities (every day)
    • Posture awareness (tuck chin in, draw chest up; every day)
  • Provide the patient with the Too Fit to Fall or Fracture and connect them with a local Seniors Active Living Centre (minimal membership fees) or home and community care coordinator (to arrange connection with a local Exercise and Falls Prevention Program; no membership fees)
How to assess
  • Check for adequate nutrition
    • Ask about food intake (e.g. “What do you eat in a typical day?”)
    • Ask about changes in weight or check current weight against what is in the patient’s ecord. If weight change has occurred, inquire about the cause(s) for the weight change (e.g. changes in appetite, digestion, chewing/swallowing, interest in food, ability to shop or prepare food, food security)
  • Check for adequate hydration
    • Ask about fluid intake (e.g. water, other fluids, caffeine, alcohol)
Interventions
  • Provide education on adequate caloric intake (e.g. recommend nutritional supplement drinks)
  • Consider referral to a home and community care coordinator (public; to arrange local support with healthy eating or to connect with meal delivery or dining programs) or a dietitian (private) if inadequate nutrition and hydration are suspected
How to assess
  • Check for medications and scenarios that have the potential to increase fall risk2,5,15
  • Consider asking the patient’s pharmacist to do a MedsCheck to review the patient’s medications (including medications requiring renal dose adjustment)
  • Have the patient bring in all medications, including non-prescription drugs, vitamins, cannabis products and supplements
  • Ask the patient:
    • “How do you take each of your medications?”
    • “How often do you miss or skip a dose of medication?”
    • “Are there any medications that you wish you could get rid of?”
    • “Are there any medications that you really don’t want to stop?”
    • “Are you having any side effects from your medications?”
  • Check for medications and scenarios that increase fall risk:15-18
    • High-risk medication classes:
      • Antipsychotics
      • Antidepressants
      • Benzodiazepines
      • Anticonvulsants
      • Antispasmodics/muscle relaxants7
      • Opioids
      • Digoxin
      • Loop diuretics
      • Non-selective beta-blockers
      • Antihypertensives as a class*
      • Proton pump inhibitors* (long-term use)
  • Polypharmacy (4+ medications)
  • ≥3 central nervous system medications
  • Medications with high anticholinergic burden
  • Prescribing cascades (i.e. unnecessary medications added to treat medication side effects that then cause side effects of their own,
    prompting even further prescribing)
Interventions

 

*Observational data is conflicting. Use clinical judgment and patient-related decision-making.

How to assess
  • Provide patients with the home safety checklist (could be done in the waiting room or at home and brought to the next appointment)
  • Consider doing a home visit and/or discuss home hazards
Interventions
  • Encourage patients in partnership with any family members and caregivers to make the patient’s home safe by addressing hazards and accessibility issues10,12
  • If the patient lives alone, support them to set up fall alarms and medical alert devices ($25-$70/month19)
  • Consider a referral to a home and community care coordinator (public) or an occupational therapist (private) to support identifying home hazards and accessibility issues
How to assess
  • Check for history of osteoporosis and assess fracture risk using the FRAX tool20
  • Ask about vitamin D and calcium intake from diet and supplements6,20
Interventions
  • Support patients to increase vitamin D intake through supplementation and calcium intake through diet to optimize bone health if current intake is low (calcium supplementation may be explored if a patient is deficient)3,5,9–12
  • Vitamin D intake should be 800-2,000 IU/day6,20
  • Elemental calcium intake should be 500-1,200 mg/day6,20
  • Refer the patient for a bone mineral density test or review existing results if ≤5 years old (≤3 years if previous results demonstrated moderate fracture risk)20
  • Optimize the management of osteoporosis if present20
How to assess

Check the patient’s medical history and screen for conditions that increase their risk for falls, including (these comorbidities may also increase risk in patients <65 years old)6, 21:

  • Brain
    • Dementia
    • Parkinson’s disease
    • Mild cognitive impairment
    • Sleep disorders (e.g. obstructive sleep apnea) or poor sleep
    • Depression
    • Substance use disorder (e.g. alcohol, cannabis, recreational substances)
  • Central circulation
    • Orthostatic hypotension
    • Cardiac system issues (e.g. arrhythmia’s, heart block)
    • Stroke or transient ischemic attackCentral circulation
  • Peripheral Nerve
    • Diabetes
    • Vitamin B12 deficiency
  • Chronic pain
  • Musculoskeletal
    • Arthritis
  • Diagnoses resulting in deconditioning, medication burden and frailty
    • Chronic kidney disease
    • Anemia (e.g. iron deficiency)
    • Chronic obstructive pulmonary disease
    • Urinary incontinence and benign prostatic hyperplasia

 

Interventions
  • Optimize the management of medical conditions (while being mindful of medications that may contribute to the risk for falls)
    • Could this condition be caused or made worse by a medication?
    • Is the condition adequately treated?
    • Are non-pharmacological options optimized?
How to assess
  • Ask the patient about:
    • Whether they live alone
    • Recent losses (e.g. spouse, family member)
    • Roles or responsibilities (e.g. being a caregiver)
    • Recent changes in living arrangements
    • Access to food and housing
  • Look for red flags for elder abuse (See Forms of Abuse for potential signs to look for)
Interventions
How to assess
  • Screen for increased risk of falls using the Timed Up and Go (TUG) test
  • Assess for gait, strength and balance concerns
  • Check or ask if the patient uses a mobility aid
  • Conduct a musculoskeletal examination of the patient’s back and lower extremities, including back flexibility (e.g. how far can the patient bend while sitting or standing)
  • Conduct a neurological examination (i.e. screen for peripheral neuropathy, spinal stenosis and radiculopathy)
  • Consider referring to a home and community care coordinator (public) or physiotherapist (private) for a gait, strength and balance assessment or musculoskeletal examination
Interventions
  • For patients with mobility issues, support them to acquire appropriate mobility aids (see Ontario Assistive Devices Program for more information on coverage for mobility aids)
  • Consider referral to a home and community care coordinator (public; to arrange an occupational therapist or physiotherapist), an occupational therapist (private) or a physiotherapist (private)
  • Ensure that patients with existing mobility aids have the appropriate aid and that it is fitted properly for them:6
    • The height of a cane or a walker should be level with the patient’s wrist crease
    • A cane should be held contralateral to the patient’s weak or painful lower extremity and moved forward at the same time as the weak or painful leg. When using a walker, the patient’s feet should stay between the walker’s back legs or wheels
    • With both devices, the patient’s posture should be upright without leaning forward or to the side
    • For more information on choosing and fitting a mobility aid, see Ambulatory Devices for Chronic Gait Disorders in the Elderly
  • Reserve hip protectors for those at risk of hip fracture (low evidence)11,12,22
How to assess
  • Measure standing and sitting blood pressure (BP) to identify the presence of postural hypotension
  • Ask about dizziness or light-headedness after standing up (may occur without a change to vitals)
Interventions
  • Review blood pressure target and adjust blood pressure medications as needed
  • Provide education on how to identify and manage postural hypotension (see Postural Hypotension)
    • Keep a glass of water at the bedside to drink when waking up
    • Get up gradually from sitting or lying down
    • Perform leg pumps before getting up
  • Consider adding medication (e.g. midodrine, fludrocortisone) if orthostatic hypotension cannot be managed by non-pharmacological methods
How to assess
  • Use the Snellen eye test to assess visual acuity quickly
  • Ask if the patient has had an eye exam in the past year
  • Ask if the patient wears multifocal lenses (increases the risk of falls)
  • Check for patient history or the presence of cataracts
  • Screen for medications that may affect vision (e.g. anticholinergics)
  • Take note of any comorbidities that may impact vision (e.g. macular degeneration, glaucoma)
Interventions
  • Consider a referral to an optometrist for patients with possible or worsening visual acuity issues for a vision assessment, provision or adjustment of prescription or cataract surgery assessment11,12,22 (OHIP coverage for optometry services is currently on hold)
  • If the patient wears multifocal lenses, provide education on depth perception and single vs. multifocal lenses
  • Consider reducing, tapering or discontinuing medications that might affect vision (e.g. anticholinergics)
How to assess
  • Evaluate feet for peripheral neuropathy and peripheral vascular disease
  • Use the Stay On Your Feet checklist to screen for footwear (worn during the appointment and at home) that increases the risk of
    falls
Interventions
  • Encourage patients to purchase appropriate footwear using the Stay On Your Feet checklist
  • After conducting a foot exam, consider a referral to a podiatrist/chiropodist for further assessment and treatment if peripheral neuropathy or peripheral vascular disease is identified11 (OHIP covers a portion of each visit to a registered podiatrist to a designated limit plus contributions to x-rays)22

Integrate falls prevention into your practice

Fitting in fall prevention
  • Display fall prevention-related materials in the office to help start a conversation with patients.
  • Display exercises on waiting room televisions or screens for patients to follow while waiting for their appointments.
  • Conduct a search in your EMR to identify patients aged 65 and older.
  • Set an annual reminder your EMR to screen for risk of falls.
  • Observe balance, gait and home environment first-hand by rooming your patients and conducting home visits, when possible.
  • Fit the falls risk assessment into your practice by:
    • Scheduling a longer appointment
    • Doing the assessment over a series of appointments
    • Incorporating parts of the assessment into existing appointments, including:
      • Assessing feet and footwear during a diabetes visit
      • Discussing calcium and vitamin D intake, nutrition and hydration while reviewing bone mineral density test results
      • Taking orthostatic vitals when renewing blood pressure medications.
Leveraging interprofessional teams and community supports
  • Ask team members, such as nurses, physician assistants, clinic assistants or front of office staff to complete tasks, including:
    • Observing the patient’s gait
    • Taking postural blood pressure
    • Collecting any pre-screening documents or information
    • Checking the patient’s medical record before the appointment
    • Helping the patient remove their shoes.
  • Refer to other interprofessional team members, such as geriatric specialists, physiotherapists, occupational therapists and dietitians to provide specialized care to patients.
  • Consider referring to interdisciplinary programs where available (e.g. fall prevention programs, geriatric day hospitals).
  • Engage a pharmacist to do a medication review with the patient.
Engaging patients and caregivers
  • Empower patients to take an active role in deciding on, documenting and implementing their interventions and monitoring their risk factors (e.g. taking their blood pressure at home, monitoring home hazards).
  • Engage family members or caregivers before the visit to get information and ask them to attend appointments.
  • Share resources that patients and caregivers can review and follow at home.
  • Encourage patients to come in person for the fall risk assessment to allow for a physical exam. Follow-up visits can occur by video or phone if preferred and appropriate.

Supporting resources

Timed Up and Go (TUG) test

Time patient while they:

  1. Stand up from a chair
  2. Walk forward 3 metres
  3. Turn
  4. Walk back to the chair at their normal pace
  5. Sit down again


Patients who take ≥12 seconds to complete the TUG test are at risk for falling.

Gait Assessment6,23

Observe patient walking to identify potential gait disorders:

Frontal gait:

  • Wide based gait with short strides, reduced step height and diminished speed
  • Difficulty picking feet up off the floor (magnetic foot), freezing
  • Common causes: NPH, stroke

Parkinsonian gait:

  • Narrow base with small shuffling steps.
  • Stooped posture, en block turns, may have difficulty initiating steps; reduced arm swing.
  • Common causes: Parkinson’s disease, drug induced parkinsonism

Ataxic gait:

  • Wide based gait; clumsy.
  • Difficulty walking walk heel to toe.
  • May be associated with other cerebellar signs (e.g. dysarthria, nystagmus)
  • Common causes: cerebellar disorder, ETOH

Hemiparetic gait:

  • Legs swing outwards in a semicircle from the hip.
  • Common causes: Stroke

 

Neuropathic gait:

  • Foot drop – will compensate by lifting leg up higher in step.
  • May have other associated signs (e.g. stocking pattern of sensory loss, diminished ankle jerk)
  • Common causes: lower motor neuron causes (e.g. diabetes, ETOH, peroneal nerve palsy, other causes of peripheral neuropathies)

Spastic gait:

  • Narrow base gait with both legs swinging outwards in a semicircle; when severe there is scissoring of gait; toes may turn in and scrape the floor.
  • Common causes: upper motor neuron causes (e.g. cervical spondylosis, B12 deficiency)

Myopathic gait:

  • ‘Waddling’, slow with difficulty rising from chair
  • Common causes: sarcopenia

References

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    Public Health Agency of Canada. Seniors’ falls in Canada: second report [Internet]. Ottawa, ON: Public Health Agency of Canada; 2014 [cited 2021 Jul 13] p. 62. Available from: https://www.phacaspc.gc.ca/ seniors-aines/publications/public/injury-blessure/seniors_falls-chutes_aines/assets/pdf/seniors_fallschutes_aines-eng.pdf

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    World Health Organization. Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity. WHO [Internet]. 2017 [cited 2021 May 31]; Available from: http://www.who.int/nutrition/publications/guidelines/integrated-care-olderpeople/en/

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    Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to prevent falls in older adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018 Apr 24;319(16):1705.

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    Sousa LMM, Marques-Vieira CMA, Caldevilla MNGN de, Henriques CMAD, Severino SSP, Caldeira SMA. Risk for falls among community-dwelling older people: systematic literature review. Rev Gaucha Enferm. 2017 Feb 23;37(4):e55030.

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    Registered Nurses Association of Ontario. Preventing Falls and Reducing Injury from Falls. 2017 [cited 2021 May 31]; Available from: https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries

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    Expert Opinion

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    Chu W, Chang S-F, Ho H-Y. Adverse Health Effects of Frailty: Systematic Review and Meta-Analysis of Middle-Aged and Older Adults With Implications for Evidence-Based Practice. Worldviews Evid Based Nurs. 2021 Aug;18(4):282–9.

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    Cheng M-H, Chang S-F. Frailty as a Risk Factor for Falls Among Community Dwelling People: Evidence From a Meta-Analysis. J Nurs Scholarsh. 2017 Sep;49(5):529–36.

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    US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, et al. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. JAMA. 2018 Apr 24;319(16):1696–704.

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    Crandall M, Duncan T, Mallat A, Greene W, Violano P, Christmas AB, et al. Prevention of fall-related injuries in the elderly: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2016 Jul;81(1):196–206.

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    Rimland JM, Abraha I, Dell’Aquila G, Cruz-Jentoft A, Soiza R, G udmusson A, et al. Effectiveness of nonpharmacological interventions to prevent falls in older people: A systematic overview. The SENATOR project ONTOP series. Laks J, editor. PLOS ONE. 2016 Au g 25;11(8):e0161579.

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    Tricco AC, Thomas SM, Veroniki AA, Hamid JS, Cogo E, Strifler L, et al. Comparisons of interventions for preventing falls in older adults: A systematic review and meta-analysis. JAMA. 2017 Nov7;318(17):1687.

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    Ross R, Chaput J-P, Giangregorio LM, Janssen I, Saunders TJ, Kho ME, et al. Canadian 24-hour movement guidelines for adults aged 18–64 years and adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep. Appl Physiol Nutr Metab. 2020 Oct;45(10 (Suppl. 2)):S57–102.

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    Osteoporosis Canada. Too fit to fall or fracture [Internet]. Available from: http://www.osteoporosis. ca/wp-content/uploads/OC-Too-Fit-to-Fall-or-Fracture.pdf?_ga=2.97543579.548086683.1626124837-215037732.1623783156

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    2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674–94.

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    Seppala LJ, Wermelink AMAT, Vries M de, Ploegmakers KJ, Glind EMM van de, Daams JG, et al. Fall-riskincreasing drugs: A systematic review and meta-analysis: II. Psychotropics. J Am Med Dir Assoc. 2018 Apr 1;19(4):371.e11-371.e17.

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    de Vries M, Seppala LJ, Daams JG, van de Glind EMM, Masud T, van der Velde N, et al. Fall-risk increasing drugs: A systematic review and meta-analysis: I. Cardiovascular Drugs. J Am Med Dir Assoc. 2018 Apr;19(4):371.e1-371.e9.

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    Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others. J Am Med Dir Assoc. 2018 Apr;19(4):372.e1-372.e8.

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    Seniors Bulletin. The best Canadian medical alert devices [Internet]. 2021 [cited 2021 Oct 13]. Available from: https://seniorsbulletin.ca/best-medical-alert-systems-canada/

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    Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary. Can Med Assoc J. 2010 Nov 23;182(17):1864–73.

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    Centre for Effective Practice. Falls prevention discussion guide [internet]. 2016 [cited 2021 Oct 12]. Available from: https://cep.health/clinical-products/falls-preventon/

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    Ontario Ministry of Health. What OHIP covers [Internet]. 2021 [cited 2021 Jul 16]. Available from: https://www.ontario.ca/page/what-ohip-covers#section-6

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    Centre for Family Medicine. Memory Clinic – Gait Assessment [Internet]. [cited 2021 Oct 13]. Available from: https://family-medicine.ca/images/CFFM-Memory-Clinic-Gait-Assessment-form.pdf