Falls are a leading cause of injury and hospitalization, particularly among older adults. Identifying patients at high risk is the first critical step in implementing effective prevention strategies. A comprehensive risk assessment considers a patient's individual health status and external influences. Risk factors are typically categorized as intrinsic, arising from a patient's own physical and mental health, and extrinsic, related to the patient's environment and care.
Intrinsic Risk Factors: Patient-Specific Contributors to Fall Risk
These factors originate within the individual and are often tied to the aging process or specific medical conditions. When a patient has multiple intrinsic risk factors, their likelihood of falling increases exponentially.
Age and Previous Falls
Advanced age is a primary and non-modifiable risk factor, with the risk of falling doubling for those aged 75 or older. Furthermore, a patient who has fallen once has twice the chance of falling again. This creates a dangerous cycle, as the fear of falling can lead to reduced activity, which then causes muscle weakness and further increases fall risk.
Medical Conditions
Several chronic and acute medical conditions can compromise a patient's stability and increase fall risk. Neurological and cardiovascular diseases are particularly significant. A history of stroke, Parkinson's disease, and dementia is strongly associated with an increased risk of falling due to impairments in balance, gait, and cognition. Cardiovascular issues like arrhythmias, heart failure, and orthostatic hypotension (a sudden drop in blood pressure upon standing) can cause dizziness, fainting, and falls. Other conditions include diabetes (causing peripheral neuropathy and affecting sensation in the feet), arthritis (leading to pain and gait problems), and urinary incontinence (causing a rushed trip to the bathroom).
Mobility and Sensory Impairments
Loss of muscle mass and strength, known as sarcopenia, is a major contributor to falls. Weakness, especially in the lower body, and problems with gait and balance make it harder to maintain or regain stability. Sensory impairments also play a critical role. Poor vision, including cataracts and glaucoma, can make it difficult to see hazards. Additionally, impaired sensation in the feet due to conditions like peripheral neuropathy can affect proprioception, the body's sense of its position in space.
Extrinsic Risk Factors: External Influences on Patient Safety
These factors relate to the patient's environment and external circumstances. They can often be modified or controlled with proper assessment and intervention.
Medication Use (Polypharmacy)
Taking four or more medications, a condition known as polypharmacy, is a major risk factor. Numerous drug classes can increase fall risk due to side effects like drowsiness, dizziness, or confusion. High-risk medications include:
- Psychoactive drugs: Benzodiazepines, sedatives, and antidepressants.
- Cardiovascular medications: Diuretics, antihypertensives, and antiarrhythmics.
- Pain relievers: Opioids and certain NSAIDs.
Environmental Hazards
Unsafe environments are a common cause of falls, accounting for 30-50% of falls in older adults. Hazards include:
- Clutter, loose rugs, and electrical cords in walkways.
- Poor lighting, especially in hallways, stairways, and bathrooms.
- Wet or slippery floors.
- Lack of grab bars in bathrooms and handrails on stairways.
- Unstable furniture or assistive devices.
Inappropriate Footwear and Clothing
Unsuitable footwear can significantly increase the risk of tripping and slipping. High heels, floppy slippers, slick soles, and even walking in socks can be hazardous. Ill-fitting or improperly used assistive devices like canes or walkers can also increase risk.
Comparison of Intrinsic and Extrinsic Risk Factors
Understanding the interplay between intrinsic and extrinsic factors is essential for creating a comprehensive prevention plan. A high-risk patient often has a combination of both.
| Feature | Intrinsic Risk Factors | Extrinsic Risk Factors |
|---|---|---|
| Origin | Inside the patient (medical, physical, cognitive) | Outside the patient (environment, medications, footwear) |
| Examples | Advanced age, Parkinson's, stroke, sarcopenia, visual impairment, cognitive decline, fear of falling | Polypharmacy, psychoactive drugs, home hazards, poor lighting, slippery floors, improper footwear |
| Modifiability | Often less modifiable (e.g., chronic disease), but manageable with treatment and therapy | Highly modifiable through lifestyle changes, environmental adjustments, and medication review |
| Intervention | Physical therapy, disease management, vision correction, balance exercises (e.g., Tai Chi) | Medication adjustment, home safety modifications (grab bars, lighting), proper footwear, assistive devices |
Preventing Falls in High-Risk Patients
Effective prevention requires a multifactorial approach. For patients with a history of falls, balance impairment, gait problems, or significant medication use, a full risk assessment is recommended. Based on this, a tailored intervention plan can be developed, which may include:
- Targeted Exercise: Programs focusing on strength, balance, and gait training, such as the Otago Exercise Program or Tai Chi, can significantly reduce fall risk.
- Medication Management: Regular review of all medications by a healthcare provider or pharmacist is crucial. High-risk medications should be minimized or replaced where possible.
- Home Safety Modifications: An occupational therapist can perform a home evaluation to recommend and install grab bars, improve lighting, and remove tripping hazards.
- Vision Correction and Foot Care: Ensuring current prescriptions are worn and using appropriate, non-skid footwear can help.
- Healthcare Setting Strategies: In hospitals and nursing homes, strategies include regular monitoring, identifying high-risk patients, and ensuring staff communication is clear.
Conclusion
Identifying which patients are high risk for falls involves recognizing a complex combination of intrinsic and extrinsic factors. Older adults, especially those with a history of falls, neurological conditions like stroke and dementia, or cardiovascular issues, are particularly vulnerable. When combined with factors like polypharmacy and an unsafe environment, the risk is significantly elevated. Proactive, multifactorial interventions addressing both the patient's health and their surroundings are the most effective way to reduce falls, prevent serious injuries, and improve overall quality of life. An excellent resource for fall prevention is the Centers for Disease Control and Prevention's 'Stopping Elderly Accidents, Deaths, and Injuries (STEADI)' toolkit.
