What doctors wish patients knew about preventing falls

Picture a serene morning silence that is broken by the clatter of a coffee cup hitting the floor. For many older adults, such a simple mishap can signal the start of a life-changing event: a fall. These sudden, often unexpected incidents are more than just a slip or a stumble—they represent a significant threat to the health and independence of our aging population. Taking appropriate steps to prevent falls can ensure that older adults continue to live their golden years with the dignity, freedom and joy they deserve.

In the U.S., falls are the leading cause of injury-related morbidity and mortality among older adults. In 2018,  27.5% of community-dwelling adults 65 or older, reported at least one fall in the past year. Meanwhile, 10.2% reported a fall-related injury. In 2021, there were more than 38,000 deaths as a result of fall-related injuries, according to a statement from the US Preventive Services Task Force (USPSTF) published in JAMA^®.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Jason Hill, MD, a hospitalist and innovation officer for Ochsner Health in New Orleans, discusses what patients and families should keep in mind to prevent falls.

Ochsner Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

When it comes to falls, “the probably single most high correlative cause is medications. And very interestingly, what you find is that patients who are older—and when I say older, I mean older than 70—generally have a very high prediction for falls if they’re on certain kinds of medications,” Dr. Hill said, noting that part of Ochsner Health’s fall prevention program is to “deprescribe” medications.

“So, we actually go in and talk to patients and say, ‘Can I reduce the dose or stop this medicine?’” he said. “Because medicines that we’ve been on for many, many years affect us differently as we age and the side effects of those medicines and the complications then start outweighing the benefits that we see from them.

“A lot of times, it’s medications patients have been taking for three decades, so it’s hard to convince them … but the drawbacks are outweighing the benefits,” Dr. Hill added, emphasizing that the No. 1 approach to fall prevention is to analyze medications.

“And there are certain types of medication,” he reiterated. “There’s a list called the Beers List that goes over a lot of medicine that is at risk with older adults. It’s a very expansive list, but if I could identify one medicine that had the highest risk, it’s gabapentin.”

“There’s also a very high correlation with the number of medications being taken and falls. So, particularly around seven medicines or greater tends to correlate with increased fall risk,” Dr. Hill explained. “If you can get under four, that’s awesome. But a lot of people think deprescribing is removing medicines. It’s not necessarily removing medicines. It’s just finding the lowest effective dose.”

“As we get older, we don’t need as much medicine because our kidney clearance goes down, so medicines stick around in our body a little bit more. And our liver doesn’t work as well as it did, so we don’t metabolize medicines as fast as we used to,” he said. “So, trying to find that right, effective dose is probably the most important thing in deprescribing.”

“The second big thing that we found that correlates with falls is what we would think to be obvious,” said Dr. Hill. “Exercise capability and your ability to move around are more important the older we get. So, immobility—particularly immobility of the legs and hips--correlates highly with fall risk.”

“What’s interesting is as we age, our grip strength persists,” he said. “You have probably shaken hands with an older man, and you realize he still has a pretty firm handshake.”

However, due to a number of factors- decreased flexibility as well as decreased strength in the legs, these are the muscles and joints to be most concerned about.

It is also about “balance and coordination, which is what we call proprioception in the medical field. That is the ability to close your eyes and raise your foot, and know where your foot is in space,” Dr. Hill said. “That proprioceptive capability gets lower as you get older and it impacts your lower body more than your upper body, which is why people tend to fall more as they get older.”

What doctors wish patients knew

Subscribe for the answers to the latest questions patients are bringing to the exam room.

Subscribe Now

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 or older who are at increased risk for falls.

Physical activity is important in preventing falls, particularly “lower body strengthening and balance,” Dr. Hill said, noting that Ochsner Health uses an app called Bold, which “helps specifically for that lower strengthening and balance.”

“It does require you to be somewhat proactive because no one is going in and forcing you to go do that,” he said. “But if you wanted to be proactive about your falls, being able to do lower extremity strengthening and balance exercises are important.”

“The third major contributor that we found to falls is chronic pain, which often gets back to the first one because people take medicine for chronic pain that then cause them to fall more,” Dr. Hill said. “But chronic pain—in particular foot pain—tends to be problematic.

“And what we've noticed is that people who have significant amounts of foot pain obviously are not going to walk around as much, which then causes them to get weaker and also causes them to go on medicine to alleviate their pain,” he added. That “then causes side effects and causes them to fall more. So, they're all interrelated.”

“If you don’t have anybody you can turn to or anybody who can help to move you around when you need to get places, we found that those patients tend to fall more and also tend to have greater instances of falls with injury,” Dr. Hill said. “And by that, I mean if they get in a situation where they’re weak or they get sick, they don’t really have anybody to help them out and they try to do things on their own.”

It is important “to understand how you can stay active as you get older and keep not just active physically, but active socially,” he said. “Social activity and social isolation are such huge markers for all things bad in older patients.

“So, being able to make sure that your grandmother or mom is plugged into a day program that has other folks who they can go and hang out with is really important,” Dr. Hill added.

“Falls with injury dovetails very well with a very specific patient population, and that’s patients with osteoporosis or osteopenia,” Dr. Hill said, noting that “the major cause of injury and falls is hip fracture. And if you look at the percent of people who die within six months of hip fracture, it’s almost 50%.

“You would think that if you break a bone, that’s pretty easy to fix and heal. But a lot of the problem with that and why patients have a very high mortality is that the things causing them to fall and break their hip in the first place are things that work actively against them recovering,” he added. “If you’ve gotten to the point where the strongest muscles and the strongest bone in your body is broken, it’s really hard for you to get that back because of all the processes that have happened.”

“Being able to be proactive with osteoporosis and osteopenia are also very important in helping prevent fall injury,” Dr. Hill said.

“Part of our program was actually going through and making sure our patients had things such as grab bars if they needed them in the bathroom or moving big, thick rugs or making sure that you didn’t have cords or trip wires in the middle of your living room,” Dr. Hill said. “Those kinds of things are also very important, but it is hard to quantify what your home risk is without being there.”

“One thing that we noted was if we were able to have someone assess the house and mitigate that risk, it did reduce that person’s risk of falling,” he said. “If a patient already has a cane or a walker or they’re high risk for falls in the general population, you definitely want to make sure the house is walker friendly.”

“Foot pain is a big deal, so you want to make sure that you have comfortable shoes,” Dr. Hill said. But “the big thing for shoes that we found is a lot of people don’t wear shoes around their house.”

“Shoes are really important if you wear them, especially if you have things that can cause you to not have good feeling in your feet,” he said. For example, “diabetic neuropathy. But being able to wear shoes with the appropriately sized orthotic inserts significantly decrease your risk for falls.”

“If you’re having foot pain, visit a podiatrist. They can do orthotic inserts. They can also recommend orthotic shoes,” Dr. Hill said, noting that “many conditions that cause neuropathy and pain are covered by Medicare that you can get the appropriate footwear.”

“But the hardest part is not getting shoes ordered. It’s getting people to wear them. So, order them and wear them,” he said.

“One of the most important things that we found with light that is often under thought of is that well-lit spaces correlate positively with mood,” Dr. Hill said. “And human beings are not designed to be in darkness.”

“Depression causes you to decrease your activity, which causes you to stay in bed, which causes you to get weaker, which then causes you to get more depressed. And it creates a spiral,” he said. “The ability to have a well-lit space, to get out of the house and be interactive with people, all those things that improve mood also decrease your risk of falling.”

For people who “do have a fall, particularly if you have pain or the inability to get back up, you should be assessed by a medical professional immediately,” Dr. Hill said. “If you’re able to get back up and you don’t have significant pain, I would still recommend assessment by a medical professional, especially if you’re an older adult.”

“There are fractures that you can walk on. So, compression fractures of your spine, other things like that are walkable, but can cause significant pain and are able to be mitigated by medical procedures,” he said. “If you have pain in your spine, if you have a compression fracture or a pelvic fracture, even if you can walk, we can still help you.”

After a fall occurs, that is when secondary prevention should occur, meaning “once a thing happens, preventing it from happening again,” Dr. Hill said. “The single most important indicator on if someone is going to fall is if they have already fallen. So, if you’ve already fallen, your chance of falling again is much higher than it was if you have never fallen. Because of that, all of these mitigation factors become way more important.”

“All Apple watches can track falls and family members can track if someone else in their family has fallen,” he said. “I would recommend Apple watches as a wearable that has significant utility in older adults, both for its new Food and Drug Administration approval for atrial fibrillation—which is very common in older adults and quickly becoming what we think to be the No. 1 cause of stroke—and falls. Both of those are significant sources of mortality in older adults.”