Modifiable and unmodifiable fall risk factors Modifiable risk factors can be altered through changes in lifestyle, improved health, or therapeutic interventions. First, addressing modifiable risk factors can have a more immediate effect on the overall chance of future falls. Environmental risk factors for falls are extrinsic factors that are typically modifiable and should be among the first areas addressed in fall prevention. Environmental fall risk factors can be categorized as hazards inside the home or outside of the home in the community. Although frailer, less active older adults are more likely to fall inside their home where they spend the majority of their time, more active older adults tend to fall outside the home where fall hazards are less predictable and many times outside of the control of the older adult. Therefore, examples of community fall risk hazards, such as uneven flooring or steps, slippery sidewalks or faulty handrails, as well as fall risk factors in the home environment, should be assessed, modified, and eliminated if possible as part of a multifactorial fall prevention program. Unmodifiable or irreversible fall risk factors are characteristics of an older adult that cannot be changed or influenced. These can include factors such as the following:
● Age : Especially over 80; one in three adults over 65 years of age fall once per year, whereas adults over 85 years of age fall four to five times more often than their peers 65 to 69 years of age (Bird et al., 2013). ● Sex : Women fall more than men in every age category; they sustain more injuries, especially fractures, seek more medical attention, and stay in the hospital longer than men (Stevens & Sogolow, 2005). ● Illness : Some chronic illnesses are irreversible, such as diabetes mellitus, Parkinson’s disease, alcoholism (Renfro et al., 2016). ● Ethnicity : African Americans are 24% less likely to have initial or recurrent falls than non-Hispanic whites, but when they do fall they are more likely to fall indoors (Nicklett & Taylor, 2014). ● History of falls : The best predictor of future falls is if a fall resulted in an injury or if the older adult has sustained two or more falls (Carpenter et al., 2014). Table 2 lists modifiable and unmodifiable risk factors for falling (adapted from CDC/STEADI, 2014; Renfro et al., 2016).
Table 2: Modifiable and Unmodifiable Risk Factors Modifiable Factors
Unmodifiable Factors
• Age >65 years. • History of falls. • Sex: women > men. • Poor sensation in feet/legs. • Ethnicity: White/Asian > African American > Hispanic. • Impaired cognition. • Most chronic diseases. • Financial limitations for safety equipment.
• Dizziness or vestibular deficits. • Problems with feet and/or shoes.
• Poor vision. • Lower extremity weakness. • Difficulties with gait and balance. • Postural hypotension. • Fear of falling that limits activity. • Polypharmacy (≥4 drugs per day). • Use of psychoactive medications. ADL = Activities of daily living. Note . From Western Schools, 2019. Medications and fall risk
• Home hazards. • Incontinence. • Frailty, low weight. • Depression. • Impaired ADLs.
Community-dwelling older adults who are in higher fall risk categories (>65 years of age and a history of at least one fall in the past year) are more likely to be injured if they fall at home in the bathroom, whereas more active older adults tend to fall in the community (Stevens, Mahoney, & Ehrenreich, 2014). Knowing the circumstances and factors that contribute to falls is crucial in designing an effective intervention plan for future fall prevention. Thus, a therapist assessing older adults for fall risk should be aware of the many intrinsic, extrinsic, and modifiable factors that influence the likelihood of falling. But they should also be aware of the typical age-related changes in body systems that contribute to increased fall risk. In summary, there are multiple factors that have been identified as influential on fall risk in older community-dwelling adults (as many as 20). This may seem overwhelming to any therapist who endeavors to screen, then assess, and intervene in the fall epidemic. Fortunately, comprehensive screening tools already exist and will be discussed later in the course.
Polypharmacy (taking four or more medications daily) is a common occurrence with older adults. An older adult who is on four or more medications of any kind has a higher than normal risk for falls (Ziere et al., 2006, Milos, et al, 2014). Common medications taken by older adults that increase risk for falls include benzodiazepines (34% increase in fall risk), antidepressants (54% increase in fall risk), antihypertensives and antipsychotics (24% increase in fall risk; Woolcott et al., 2009). Reducing analgesics and anticonvulsant medications can decrease fall risk by 66% (Woolcott et al., 2009). Polypharmacy has been shown to increase fall risk, although some authors believe that one of the four medications has to belong to one of the medication categories identified as high risk for falls (i.e., antipsychotics; Hartikainen, Lonnroos, & Louhivuori, 2007; Ziere et al., 2006). Fall risk also may be increased during the first 2 weeks of medication use as the medication level adjusts or changes based on patient response (Gleason et al., 2010).
TYPICAL AGE-RELATED CHANGES THAT CONTRIBUTE TO FALLS
fit are more likely to be mobile in the community, where they may encounter extrinsic factors for falls that challenge them to the point of falling. Less active older adults tend to have more intrinsic health changes that prevent community engagement, thus they are more likely to fall in their home. Almost every system in the body is negatively affected by the natural aging processes, with the exception of vocabulary, which typically increases with age. This section focuses on the numerous physical changes that result from the aging process, with an
Many of the intrinsic fall risk factors previously identified are a result of typical age-related declines in optimal physical and mental function in older adults. With advancing age, intrinsic rather than extrinsic risk factors are more likely to cause falls. For example, a fall in an older adult who is institutionalized will typically involve factors such as incontinence, lower extremity weakness, or sensory loss, whereas a community-dwelling older adult is more likely to have an extrinsic factor involved like a slippery floor or an uneven walkway. Older adults who are more
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