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 • 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. • Dizziness or vestibular deficits. • Problems with feet and/or shoes. • Home hazards. • Incontinence. • Frailty, low weight. • Depression. • Impaired ADLs. • 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.
ADL = Activities of daily living. Note . From Western Schools, 2019. Medications and fall risk
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).
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.
TYPICAL AGE-RELATED CHANGES THAT CONTRIBUTE TO FALLS
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 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 Neurologic changes Changes in postural control that can lead to falls in an older adult population, in both the central and peripheral nervous systems, can be either attributed to typical decline due to aging and/or the presence of disease. As mentioned earlier, the presence of chronic disease can increase fall risk, but when coupled with typical neurologic changes due to aging, this risk multiplies. Changes in postural control Although the overall population of older adults is a very heterogeneous group with a wide variety of aging consequences, there are specific changes in older adults that impact postural control (Shumway-Cook & Woollacott, 2017). Some of these include: ● Delay in ankle, hip, stepping strategies.
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 emphasis on the neurologic and musculoskeletal changes that effect fall risk. These changes will be discussed by the system primarily involved in maintaining upright posture. Other bodily systems, such as the cardiopulmonary and endocrine systems, also experience age-related changes, but do not have as significant an effect on fall risk as the neurologic and musculoskeletal systems, thus the emphasis on the latter two systems. Screening and assessment of these systems will be covered in later sections. ● Balance strategies activated out of sequence, or in an inefficient or ineffective manor. ● Increased sway in quiet stance with impairments in at least two sensory systems, and especially when relying on vestibular inputs only. ● Slower adaptation to new environments (lighting, surface, visual stimulation). ● Decreased anticipatory postural abilities during functional tasks. ● Difficulty dual-tasking during mobility. With aging, motor control becomes more reliant on central mechanisms, especially prefrontal and basal ganglia (Seidler et al., 2010), making dual-tasking increasingly difficult. Older adults engage these central nervous system (CNS) structures
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