Falls in the older patient, multifactorial assessment, gait/balance, polypharmacy, post-falls workup

Definition / Overview

• A fall is defined as an event resulting in a person coming to rest inadvertently on the ground, floor, or other lower level.
• Falls in older Australians (typically defined as aged 65 years and over) represent a major public health concern, being the leading cause of injury-related hospitalisation and death in this demographic.
• Approximately one in three community-dwelling Australians aged over 65 years experiences at least one fall annually, with this proportion increasing to one in two for those aged over 80 years.
• The approach to falls in older patients requires a comprehensive multifactorial assessment that addresses intrinsic factors (age-related physiological changes, chronic diseases, cognitive impairment), extrinsic factors (environmental hazards, inappropriate footwear, poor lighting), and situational factors (activity being undertaken at time of fall, time of day).
• Falls are rarely due to a single cause. Clinical Pearl: The presence of four or more risk factors increases falls risk 10-fold compared to one risk factor alone.
• In Australia, falls prevention is supported by national and state-based programs.
• The Stay On Your Feet program operates across multiple states (WA, SA, NT) and provides community education, home hazard assessment, and exercise programs.
• HealthDirect and state health departments provide accessible resources for falls prevention aligned with National Safety and Quality Health Service (NSQHS) Standards.

Pathophysiology

• Falls in older adults result from the complex interaction between age-related physiological decline and acute or chronic pathological processes.
• Understanding these mechanisms is essential for targeted assessment and intervention.

Age-related changes

• Normal ageing affects multiple systems critical to maintaining balance and mobility.
• Visual changes include reduced acuity, impaired depth perception, decreased contrast sensitivity, and narrowed visual fields.
• Vestibular function declines, with loss of hair cells in the semicircular canals and reduced central processing of vestibular input.
• Proprioceptive feedback diminishes due to peripheral neuropathy and reduced joint position sense.
• Musculoskeletal changes include sarcopenia (loss of muscle mass and strength), reduced bone density, joint stiffness, and altered gait patterns.
• Cardiovascular ageing contributes through reduced baroreceptor sensitivity, predisposing to orthostatic hypotension.

Intrinsic factors

• Intrinsic factors encompass patient-specific medical conditions and physiological states.
• Neurological conditions (stroke, Parkinson's disease, peripheral neuropathy, cervical myelopathy, normal pressure hydrocephalus) impair motor control, sensation, or cognition.
• Cardiovascular causes include arrhythmias (particularly atrial fibrillation), valvular disease (especially aortic stenosis), carotid sinus hypersensitivity, and postural hypotension.
• Metabolic derangements (hypoglycaemia, hyponatraemia, anaemia, vitamin B12 deficiency) affect consciousness and muscle function.
• Acute illness (urinary tract infection, pneumonia, dehydration) commonly precipitates falls through delirium or general deconditioning.
• Visual impairment from cataracts, macular degeneration, or glaucoma substantially increases falls risk.
• Cognitive impairment and dementia affect risk assessment, attention, and executive function required for safe mobility.
• Depression associates with reduced activity, psychomotor slowing, and medication effects.
• Foot problems (bunions, calluses, ulcers, inappropriate footwear) alter gait mechanics.

Extrinsic factors

• Environmental hazards contribute to approximately half of all falls in community-dwelling older adults.
• These include poor lighting, loose rugs, cluttered pathways, uneven surfaces, lack of grab rails in bathrooms, inappropriate bed height, inadequate footwear, and pets underfoot.
• Home hazards are modifiable through occupational therapy assessment and targeted interventions.

Medications and polypharmacy

• Polypharmacy (typically defined as five or more regular medications) independently increases falls risk through multiple mechanisms: altered pharmacokinetics and pharmacodynamics in older adults, increased drug interactions, medication side effects (sedation, dizziness, confusion), and orthostatic hypotension.
• High-risk medication classes include benzodiazepines and other sedative-hypnotics, antipsychotics, antidepressants (particularly tricyclics), anticonvulsants, antihypertensives (particularly alpha-blockers), anticholinergics, opioids, and non-steroidal anti-inflammatory drugs.

Clinical Features

History

• A comprehensive falls history begins with detailed circumstances of the fall(s).
• Document: exact time and date, location (home, outdoors, institution), activity being performed, witnesses present, whether the patient remembers the fall, presence of prodromal symptoms (dizziness, palpitations, chest pain, weakness), loss of consciousness, injuries sustained, ability to get up independently, and duration on ground before help arrived.
• Ascertain falls frequency over the past 12 months.
• A single fall may be incidental, whereas recurrent falls (two or more in 12 months) mandate comprehensive assessment.
• Ask specifically about fear of falling, as this often leads to activity restriction and further deconditioning.
• Red Flag: Loss of consciousness during a fall suggests syncope and requires urgent cardiovascular assessment including ECG, 24-hour Holter monitoring, and echocardiography.
• Document preceding symptoms (palpitations, chest pain) and post-ictal features (confusion, incontinence, tongue-biting).
• Medication review is critical.
• List all medications including dose, frequency, recent changes, over-the-counter preparations, and herbal supplements.
• Calculate the number of regular medications.
• Specifically ask about compliance, confusion with medications, and whether the patient manages their own medications independently.

Systems review targets known risk factors: cardiovascular symptoms (chest pain, palpitations, dyspnoea), neurological symptoms (weakness, numbness, tremor, memory problems), visual changes, dizziness (characterise as vertigo, pre-syncope, disequilibrium, or light-headedness), urinary urgency or incontinence, musculoskeletal pain limiting mobility, and mood symptoms.

• Functional assessment documents baseline mobility: walking aid use, ability to perform activities of daily living (ADLs), instrumental ADLs, usual exercise level, and social supports.
• Assess home environment: stairs, bathroom configuration, lighting, rugs, and recent changes.

Examination

• Physical examination must be thorough and systematic.
• Commence with vital signs including lying and standing blood pressure (measure after lying supine for 5 minutes, then at 1 and 3 minutes after standing).
• Orthostatic hypotension is defined as a drop of 20 mmHg systolic or 10 mmHg diastolic.
• Document heart rate response.
• Cardiovascular examination identifies arrhythmias (irregular pulse), murmurs (especially aortic stenosis), and signs of heart failure.
• Neurological examination assesses cognition (use standardised screening such as Montreal Cognitive Assessment or Mini-Mental State Examination), cranial nerves (particularly visual acuity and fields), tone (rigidity, spasticity), power in all limbs (proximal and distal), reflexes, sensation (including proprioception and vibration sense), coordination (finger-nose testing, heel-shin testing), and gait.
• Musculoskeletal examination documents joint range of motion, deformities, muscle bulk and strength, and foot problems.
• Vision screening includes acuity (Snellen chart or near vision card), visual fields (confrontation testing), and assessment for cataracts.

Gait and Balance Assessment

• Formal gait and balance assessment forms the cornerstone of falls evaluation.
• Observe the patient walking: assess posture, arm swing, step length and height, stride width, turning, and need for aids.
• Abnormal gait patterns provide diagnostic clues (parkinsonian shuffling, hemiplegic, high-stepping, ataxic, antalgic).
• Timed Up and Go (TUG) test is validated, quick, and widely used.
• The patient sits in a standard chair with arms, stands, walks 3 metres, turns, walks back, and sits down.
• Normal completion is under 10 seconds. 11-20 seconds indicates moderate mobility impairment and falls risk.
• Over 20 seconds indicates high falls risk and need for mobility aids.
• Over 30 seconds suggests severe mobility impairment requiring further assessment. Clinical Pearl: Document whether the patient uses their arms to rise from the chair, as this indicates proximal lower limb weakness.
• Berg Balance Scale is a 14-item assessment of static and dynamic balance (sitting unsupported, standing unsupported, transfers, reaching forward, picking up objects, turning 360 degrees, standing on one foot).
• Each item scored 0-4, maximum 56 points.
• Scores below 45 indicate high falls risk.
• The Berg is time-consuming (15-20 minutes) but provides detailed functional information useful for physiotherapy planning.

Other useful bedside tests include: single-leg stance time (inability to stand on one leg for 5 seconds indicates increased falls risk), functional reach test (inability to reach forward more than 15 cm while standing indicates poor balance), and assessment of sit-to-stand ability.

Investigations

Baseline investigations

• All patients presenting with falls require a structured investigation protocol.
• Blood tests should include: full blood count (anaemia), electrolytes, urea and creatinine (renal function, dehydration), glucose (hypoglycaemia), calcium (hypercalcaemia causing confusion or weakness), thyroid function tests (hypothyroidism or thyrotoxicosis), and vitamin B12 (if peripheral neuropathy or cognitive impairment).
• Consider vitamin D if osteoporosis risk present.
• 12-lead ECG is mandatory for all falls patients.
• Look for arrhythmias (atrial fibrillation, heart block, ventricular ectopy), ischaemic changes, prolonged QT interval, and pre-excitation syndromes.
• Consider 24-hour Holter monitoring if syncope occurred or palpitations reported.
• Lying and standing blood pressure measured formally as described above.
• If orthostatic hypotension detected, review medications and consider autonomic function testing if severe or unexplained.

Imaging

• Hip X-rays (AP pelvis and lateral hip) are essential if the patient cannot weight-bear post-fall, has hip pain, or hip tenderness on examination.
• Occult fractures require urgent orthopaedic review.
• If X-ray negative but clinical suspicion high, proceed to MRI hip (more sensitive than CT for subtle fractures).
• CT head is indicated for: patients on anticoagulation (warfarin, DOACs, antiplatelets including aspirin and clopidogrel), syncope with head strike, witnessed loss of consciousness, confusion or altered mental state post-fall, focal neurological signs, scalp haematoma or boggy swelling, or persistent headache.
• The threshold for CT should be low in anticoagulated patients given high risk of subdural haematoma. Red Flag: Any patient on warfarin who has fallen and struck their head requires CT head within 8 hours, even if asymptomatic.
• ECG monitoring (Holter or event recorder) for 24-48 hours if cardiac cause suspected.
• Consider implantable loop recorder if recurrent unexplained syncope.

Echocardiography if murmur detected, heart failure symptoms, or structural heart disease suspected.

• Bone density scan (DEXA) should be arranged for osteoporosis assessment in all patients with fragility fractures.
• MBS item 12306 covers DEXA for women aged 70+ or men aged 70+ with fracture history or other risk factors.

Specialist referrals

• Refer to geriatrician or falls clinic for complex multifactorial falls, recurrent unexplained falls, or polypharmacy requiring specialist medication review.
• Physiotherapy for gait and balance retraining is beneficial.
• Occupational therapy for home assessment and environmental modification reduces falls by up to 20%.
• Ophthalmology if significant visual impairment requiring intervention.
• Cardiology if syncope, arrhythmia, or structural heart disease.
• Neurology if gait disorder, peripheral neuropathy, or parkinsonian features.

Management

Multifactorial intervention

• Evidence supports multifactorial intervention tailored to individual risk factors.
• Single interventions are less effective.
• The NHMRC guidelines (2009, updated by ACSQHC) recommend addressing all identified risk factors through a coordinated multidisciplinary approach.

Medication review and deprescribing

• Comprehensive medication review is essential.
• Use tools such as the Beers Criteria (adapted for Australian practice) or STOPP/START criteria to identify potentially inappropriate medications.
• Target high-risk drugs first: benzodiazepines (taper slowly to avoid withdrawal), sedating antidepressants (consider switching mirtazapine to SSRI), first-generation antihistamines (cease), anticholinergics (review need, consider alternatives), and multiple antihypertensives (consider reducing if postural drop present). Clinical Pearl: Deprescribing benzodiazepines in older adults reduces falls risk by 66% but requires slow taper over 6-8 weeks to avoid withdrawal seizures.
• Consider Home Medicines Review (HMR, MBS item 900) for complex patients with polypharmacy.
• A pharmacist conducts home visit and provides comprehensive report.
• Residential Medication Management Review (RMMR, MBS item 903) serves similar function for residential aged care.

Exercise programs

• Structured exercise programs reduce falls by 20-30%.
• Programs should include balance training, strength training, and gait training performed at least twice weekly for minimum 12 weeks.
• Group programs improve adherence.
• Examples include tai chi (strong evidence base), yoga, and physiotherapist-led exercise programs.
• The Stay On Your Feet program coordinates exercise classes in many Australian communities.

Environmental modification

Occupational therapy home assessment identifies hazards and recommends modifications: removing loose rugs, improving lighting (especially night lights for nocturnal bathroom trips), installing grab rails in bathrooms (especially shower and toilet), ensuring adequate stair railings, removing clutter, securing electrical cords, non-slip mats in shower, and appropriate footwear (non-slip soles, good ankle support, properly fitted).

Vision correction

• Refer to optometrist or ophthalmologist for vision assessment and correction.
• Cataract surgery reduces falls risk if significant visual impairment.
• Single-lens distance glasses are safer than multifocals for outdoor use.

Cardiovascular interventions

Treat identified cardiac causes: anticoagulation for atrial fibrillation (consider falls risk versus stroke risk using HAS-BLED score), pacemaker for symptomatic bradycardia or heart block, medication adjustment for orthostatic hypotension (dose reduction or switching agents), and compression stockings or midodrine for severe postural hypotension resistant to other measures.

Management of specific conditions

• Parkinson's disease: optimise levodopa dosing, refer to neurologist, consider physiotherapy for gait training.
• Osteoporosis: calcium and vitamin D supplementation (MBS item 66833 for 25-hydroxyvitamin D testing if specific indications met), bisphosphonate therapy if T-score below -2.5, consider denosumab if bisphosphonates contraindicated.
• Vitamin D: if deficient (<50 nmol/L), supplement with 3000-5000 IU daily for 6-12 weeks then 1000-2000 IU daily maintenance.

Hip protectors

• External hip protectors reduce hip fractures by 50% in high-risk residential aged care populations but compliance is poor (uncomfortable, difficulty with toileting).
• Consider for very high-risk patients with previous hip fracture.

Alarm systems and assistive technology

• Personal alarm systems (pendants or watches) enable rapid response if fall occurs and patient cannot get up.
• Subsidised through some state programs and Department of Veterans' Affairs.
• Consider smart home technology (motion sensors, automatic lighting) for high-risk patients.

Australian programs

• Stay On Your Feet is the major falls prevention program across WA, SA, and NT.
• Provides community education, exercise classes, home safety checklists, and health professional training.
• Other states have equivalent programs: Life Saving Falls Prevention (NSW), Stepping On (Victoria, evidence-based 7-week program), and Stand Up (Queensland).
• RACGP resources include the Falls Prevention Quality Improvement Toolkit.
• Aged care facilities must have falls prevention strategies under Aged Care Quality Standards.

Red Flags

• Red Flag: Syncope with fall requires urgent assessment to exclude life-threatening cardiac causes (arrhythmia, aortic stenosis, pulmonary embolism, myocardial infarction).
• Admit for telemetry if cause unclear.
• Red Flag: Recurrent unexplained falls in absence of obvious environmental hazards suggests serious underlying pathology (cardiac arrhythmia, seizure disorder, transient ischaemic attacks, occult malignancy causing metabolic derangement or cachexia).
• Warrants comprehensive assessment and possible admission.
• Red Flag: Inability to weight-bear post-fall necessitates imaging to exclude hip fracture (including occult fracture).
• Do not discharge home until fracture excluded and patient safely mobile.
• Red Flag: Anticoagulated patient with head strike requires CT head even if neurologically intact.
• Delayed presentation of subdural haematoma can occur 24-72 hours post-injury.
• Red Flag: New confusion post-fall may indicate head injury, hip fracture (pain causing delirium), or intercurrent illness precipitating fall (urinary tract infection, pneumonia).
• Requires full assessment including CT head and septic screen.
• Red Flag: Multiple falls in residential aged care may indicate suboptimal care, inadequate supervision, or unrecognised medical deterioration.
• Consider Aged Care Quality and Safety Commission notification if concerns about care standards.

Australian Context

• Falls represent the leading cause of injury hospitalisation in Australians aged 65 and over, with approximately 125,000 hospitalisations annually.
• The economic burden exceeds $2 billion per year including healthcare costs and productivity losses.
• Hip fractures, predominantly caused by falls, have high mortality (20% die within 12 months) and morbidity (50% lose independent living status).
• Medicare provides coverage for falls-related services: a GP chronic condition management plan (GPCCMP, MBS item 965) can include direct referral to MBS allied health for physiotherapy (10960) and occupational therapy (10958), up to 5 individual allied health services per calendar year in total (10 for Aboriginal and Torres Strait Islander patients).
• Comprehensive geriatric assessment is rebated through various items including health assessments for patients aged 75+ (MBS item 701, $218.90), assessment in residential aged care facilities, and case conferences (MBS items 735-739).
• State-based variations exist in falls prevention programs and community services.
• NSW operates the Staying Active and On Your Feet program through local health districts.
• Victoria funds Strength and Balance Exercise programs through councils.
• Queensland's Health and Wellbeing Queensland coordinates falls prevention.
• Tasmania's Stay Strong, Stay Steady program provides structured exercise classes.
• Aboriginal and Torres Strait Islander peoples experience falls-related hospitalisations at 1.6 times the rate of non-Indigenous Australians, with higher mortality.
• Cultural factors, remote location, and reduced access to allied health contribute.
• The Aboriginal Medical Services (AMS) network provides culturally appropriate falls assessment and prevention in many communities.
• The Royal Flying Doctor Service (RFDS) and state-based retrieval services (CareFlight, NETS-Victoria, Retrieval Services Queensland) retrieve patients with serious fall-related injuries from remote locations.
• Rural patients face challenges accessing specialist falls clinics and allied health services.
• Residential aged care facilities must comply with Aged Care Quality Standards including Standard 3 (Personal Care and Clinical Care) requiring falls risk assessment and prevention strategies.
• The Aged Care Quality and Safety Commission oversees compliance.
• Mandatory reporting of falls causing major injury or requiring transfer to hospital is required.
• Private health insurance covers some allied health services (physiotherapy, exercise physiology) but significant out-of-pocket costs often limit access.
• NDIS may fund equipment and modifications for younger patients with disability contributing to falls risk.

Key Points

1. High-Yield: Falls in older adults are almost always multifactorial. Comprehensive assessment must address intrinsic (medical, physiological), extrinsic (environmental), and situational factors. Single-cause attribution misses opportunities for intervention and prevention.

2. High-Yield: Polypharmacy is a major modifiable risk factor. Systematically review all medications, particularly benzodiazepines, anticholinergics, antihypertensives, and sedatives. Deprescribing high-risk medications reduces falls by up to 66% for benzodiazepines.

3. Timed Up and Go test and lying-standing blood pressure are essential bedside assessments. TUG over 12 seconds indicates high falls risk requiring intervention. Orthostatic hypotension (20 mmHg systolic or 10 mmHg diastolic drop) is common and treatable.

4. Post-falls workup must include: ECG (all patients), lying-standing BP, bloods (FBC, UEC, glucose, B12), hip X-ray if not weight-bearing, and CT head if anticoagulated, head strike, or syncope. Low threshold for imaging in high-risk scenarios.

5. Multifactorial intervention is evidence-based and reduces falls by 30-40%. Combine medication review, structured exercise programs (twice weekly minimum), home hazard assessment and modification, vision correction, and treatment of underlying medical conditions.

6. Exercise programs must include balance and strength training performed at least twice weekly for 12+ weeks. Tai chi, group exercise, and physiotherapist-led programs all show benefit. Stay On Your Feet and equivalent state programs coordinate community exercise.

7. Anticoagulated patients who fall and strike their head require CT within 8 hours even if asymptomatic, due to high risk of delayed subdural haematoma. Do not defer imaging based on absence of symptoms.

8. Australian Medicare and state programs support falls prevention: a GPCCMP (MBS item 965) enables direct referral to MBS allied health, MBS item 701 (health assessment 75+), Home Medicines Review (MBS 900), and state-based community programs (Stay On Your Feet, Stepping On, Stand Up) provide accessible resources.