A risk factor is something that increases a person’s risk or susceptibility for falling. Determining fall risk and making a timely referral to a healthcare professional familiar with assessment and treatment is recommended by a number of professional organizations. The complex nature of the deficits related to fall risk requires close case management and coordination of services (Moyer, 2012). The risk of falling increases dramatically with a number of risk factors. Prevention is difficult because falls are complex events caused by a combination of physiologic impairments, disabilities, and environmental hazards.

In her seminal study of risk factors associated with falls in older adults, Mary Tinetti studied multiple-modifiable risk factors and the effects of multifactorial interventions on the risk of falling among community-dwelling older adults. Tinetti’s research has shown that as the number of risk factors rise so does the risk of falling. The following risk factors were examined in the Tinetti study:

• postural hypotension
• use of sedatives
• use of at least four prescription medications
• impairment in arm or leg strength or range of motion
• balance
• ability to move safely from bed to chair or to the bathtub or toilet (transfer skills)
• gait (Tinetti, 1994)

Researchers noted that a patient’s ability to compensate for loss of function declines sharply as the number of risk factors increases (Tinetti, 1994).

Other studies have focused on these common risk factors associated with falls (Shumway-Cook and Woollocott, 2016):

• Muscle weakness
• History of falls
• Gait deficit
• Balance deficit
• Use of assistive device
• Visual deficit
• Arthritis
• Impaired ADLs
• Depression
• Cognitive impairment
• Age >80 years

In the Veterans Affairs (VA) system, in addition to the factors listed above, these risk factors trigger a fall risk assessment:

• Agitation/delirium
• Medication timing and dosing
• Frequent toileting
• Impaired vision, inappropriate use of assistive devices or footwear
• Psychotropics, digoxin, type 1A anti-arrhythmics, diuretics (thiazides > loop diuretics)
• Antihistamines/benzodiazepines
• Antidepressants: tricyclics higher risk than SSRI but SSRIs have risk as well, high level of phenytoin; low-dose amitriptyline affects gait
• Drugs treating nocturia

Studies of risk factor assessment have used a large and varied list of risk factors for falls, which makes it difficult to pinpoint effective solutions. When determining to whom these recommendations apply, primary care clinicians can reasonably consider a small number of risk factors to identify older adults who are at increased risk for falls. Age is strongly related to risk for falls. Studies most commonly used a history of falls to identify increased risk for future falls; history of falls is generally considered together or sequentially with other key risk factors, particularly impairments in mobility, gait, and balance (USPSTF, 2018). 

A pragmatic approach to identifying persons at high risk for falls, consistent with the enrollment criteria for intervention trials, would be to assess for a history of falls or for problems in physical functioning and limited mobility. Clinicians could also use assessments of gait and mobility, such as the Timed Up and Go test (USPSTF, 2018).

4.1 Polypharmacy

Polypharmacy is the use of multiple medications at one time, including over-the-counter (OTC) medications, dietary supplements, and herbal remedies. It is the use of multiple medications in which the therapeutic benefits may be outweighed by harm, such as increased adverse events and poor health outcomes (Young et al., 2021).

Polypharmacy includes prescribing more medications than are clinically indicated, using inappropriate medications, and using the correct medication for an inappropriate length of time. Polypharmacy, especially excessive polypharmacy, have been shown to be important risk factors for falling, and several studies have shown an increased fall risk associated with diuretics, type 1a anti-arrhythmics, digoxin, and psychotropic agents.

An older man on multiple medications participating in a medication review. Medications that increase his risk of falling are of particular interest. Source: National Institutes of Health.

Half of longterm care residents fall annually, a proportion that is two to three times that of community-dwelling people. Polypharmacy and several drug classes, such as psychotropics, opioids, and anticholinergics, have been shown to increase the risk of falls. Despite it being very common, polypharmacy lacks a universal definition (Roitto et al., 2023). 

Older adults living in longterm care are prone to polypharmacy (and excessive polypharmacy) due to multimorbidity. Although falls and mortality have been associated with polypharmacy in longterm care, evidence on the number of medications that currently predict adverse outcomes is inconclusive. Some studies suggest that the use of two or more fall risk-increasing drugs are an independent risk factor for falls rather than polypharmacy alone, while others have found polypharmacy is an independent risk factor, even after adjustments for drugs known to increase fall risk. It may be equally important to stop counting medications and instead concentrate on identifying unnecessary medications, defined as a medication that have no indication, are ineffective, or are a therapeutic duplication (Roitto et al., 2023).

In a study of older adults living in longterm care settings in the United Kingdom:

• fall risk rose exponentially in people using more than 10 medications 
• people with polypharmacy are significantly more likely to be prescribed anticholinergic drugs
• the highest incidence rate ratio for falls was found for opioid use
• the lowest survival rate was in the excessive polypharmacy group (Roitto et al., 2023)

The risk of falls can increases significantly in the days following a medication change. A study by researchers at Johns Hopkins University looked at the effect of medication changes on the risk of falls among residents of three nursing homes. The study looked at medication changes that occurred 1 to 9 days before a fall, including the risk of falling after a start, stop, or dose change in medications. The results indicated that the short-term risk of single and recurring falls may triple within two days after a medication change.

To address these issues, the National Council on Aging (NCOA) Falls-Free National Action Plan encourages healthcare professionals to support policies that increase awareness of polypharmacy and fall risk. The goal is to “increase the number of older adults who have annual medication reviews conducted by healthcare providers or pharmacists and ensure this review includes an adequate focus on falls and fall-related injury prevention, with the goal of reducing or eliminating medications that increase fall risk.”

To accomplish this goal, NCOA recommends that clinicians regularly review each patient’s medications for potential interactions and side effects that may increase fall risk and, where possible, reduce or eliminate medications or select alternatives. Reducing the number and types of medications, particularly tranquilizers, sleeping pills, and anti-anxiety drugs, can be an effective fall prevention strategy when used alone or as part of a multi-component intervention.

4.2 Depression, Antidepressants, and Falls

Depression is common and treatable in older adults and outcomes improve with effective antidepressant therapy. Older people who fall are more likely to be depressed compared with those who do not fall. Several studies have suggested that some classes of medications, such as antidepressants and sedatives show significant association with recurrent falls of community-dwelling older adults. Since inappropriate prescription is common among elderly people, reduction or withdrawal of certain classes of medications might be a feasible and effective way to decrease the risk of recurrent falling (Ming and Zecevic, 2018).

4.3 Cognitive Decline

In the past, the relationship between age-associated declines in cognitive function, increased fall risk, and reduced mobility were viewed as distinct and separate. It is now well-known that individuals with dementia are vulnerable to a decline in physical functioning and basic activities of daily living and people with Alzheimer's disease have a higher frequency of falls. Today, cognitive impairment is well established as an independent risk factor for falling. Even very early disturbances in cognitive function have been associated with slower gait and gait instability (Suzuki et al., 2023). 

Several studies have examined the role of specific cognitive domains on fall risk. Lower scores on cognitive screening tests such as the Mini-Mental State Examination and the Montreal Cognitive Assessment were associated with an increased risk of falls. Lower scores on tests of attention, executive function, memory, and visual-spatial function have all been reported to be associated with an increased risk of falls in both cognitively intact and cognitively impaired individuals.

Difficulty with dual-task walking, a measure of divided attention and executive function in which individuals are given a secondary mental task while walking, has consistently been shown to be associated with an increased risk of falls. Impaired cognition may cause these problems because of a limited ability to perform either task or problems in allocating attention efficiently between the two tasks (Shumway-Cook and Woollocott, 2016).

The vestibular system senses head movement and orientation in space, and vestibular sensory input plays a critical role in postural control and balance. Emerging evidence suggests that vestibular loss is disproportionately prevalent among individuals with mild cognitive impairment as well as in people with dementia due to Alzheimer's disease. Earlier studies have indicated that vestibular loss can cause hippocampal atrophy and impaired spatial memory in humans. A Baltimore Longitudinal Study of Aging found that poorer vestibular function was associated with significantly reduced hippocampal volume (Suzuki et al., 2023).

4.4 Cardiovascular Disorders

Adults with cardiovascular disease are at high risk of falling. Cardiovascular causes can be from syndromes such as orthostatic hypotension, syncope, or carotid sinus hypersensitivity. The cause can also be structural and can include abnormalities such as cardiac arrhythmias, valvular stenosis, cardiomyopathies, and myocardial infarctions.

The prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record–based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards (Denfeld et al., 2022).

Adults with heart failure and arrhythmias have an especially high risk of falls likely because of diminished cardiac output, polypharmacy, or interaction with other comorbid conditions. Among adults with heart failure, the fall rate was 43% compared with fall rates of ~30% for people with other chronic diseases. Studies demonstrate a higher prevalence of falls in patients with atrial fibrillation compared with those without atrial fibrillation and a higher prevalence of nonaccidental falls than accidental falls (Denfeld et al., 2022).

Although racial, ethnic, and sex differences in fall rates have not been studied in cardiovascular disease, there are notable differences in the general population. The Health and Retirement Study found that Black individuals had significantly lower odds of experiencing a fall than non-Hispanic White individuals. Other studies have also demonstrated racial differences, with White individuals having higher rates of falls outside the home and differences in fall injuries compared with Black individuals. Similarly, Asian Americans are significantly less likely to fall than non-Hispanic White individuals. Women have higher rates of falls than men and have higher rates of falls that resulted in injury or required a medical visit and hospitalization (Denfeld et al., 2022).

4.5 Restraints and Fall Risk

Because unsafe behaviors such as wandering, aggressive behaviors, and falls are common among older adults in certain healthcare settings, it may seem like a good idea to restrain people to prevent falls. However, use of physical restraints has come under intense scrutiny because they can cause agitation, confusion, deconditioning, pressure ulcers, strangulation, adverse psychological effects, and even death. They affect a person’s sense of well-being, causing feelings of low self-worth, depression, humiliation, and anger. 

In the United States, the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established a resident’s right to be free of the use of restraints in nursing homes when used for the purpose of discipline or convenience and when not required to treat the resident’s medical symptoms. Related regulations also specify that uncooperativeness, restlessness, wandering, or unsociability are not sufficient reasons to justify the use of antipsychotic medications (Agens, 2010).

4.51 Physical Restraints

A physical restraint is defined by the Centers for Medicare and Medicaid Services (CMS) as “any manual method, physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.” Physical restraints can include belts, mittens, vests, bedrails, geriatric chairs, and other devices (Staggs et al., 2016).

Restraints have been used in nursing homes and hospitals both as safety devices and as falls prevention tools. Physical restraints such as bedrails, belts in beds or chairs, and geriatric chairs with fixed tables are commonly used in general hospital settings in many countries despite their unclear effectiveness and potential risks for harm (Abraham et al., 2020). Several studies have shown no statistically significant difference in falls compared with historical controls when bedrails are removed.

Over the past 20 years, alongside the ongoing ethical debate, several studies have demonstrated both the direct and indirect negative effects of physical restraints. Pressure ulcers, strangulation, muscle, nerve, or vascular injuries, decreased mobility, falls, physiological illness, and prolonged length of stay have all been reported as consequences, with some studies also documenting a direct association with death. Although available evidence has emphasized the lack of effectiveness in promoting safety, such as in avoiding falls, the physical restraint is still widely used mainly for safety purposes (Palese et al., 2021).

Despite evidence that restraints can increase the likelihood of a fall, a Hong Kong study (Lai, 2007) found nurses were resistant to the notion of removing patients’ restraints and how (or whether) it relates to fall risk. The study involved focus-group interviews with nurses in rehabilitation facilities and explored the perspective of the nursing staff with regard to the use of physical restraints, and their perception of the means available to reduce it. The nurses’ responses highlight the ambivalence many medical professionals feel when tasked with the responsibility of preventing falls among high-risk older adults:

I am not worried about having to write an incident report (if a patient fell). Probably we would have to face the family. That is to say, they placed their relative under our care in the hospital, but then we allowed him or her to get hurt. They may put the responsibility on us. That is, they will blame us. It is not as simple as writing a statement. We will feel the burden. (Lai, 2007)

In regards to staffing:

In fact, really . . . we feel that there is nothing much we can do . . . in many situations, one member of staff has to look after two-and-a-half to three cubicles; one cubicle has eight beds, and there is one nurse and one healthcare aide looking after five cubicles of patients. Well, each of us has our work to do. Both the healthcare organization and I have the responsibility to prevent falls. For the sake of patients’ safety, well, we have to prevent them from falling, so we have to do everything . . . we can. (Lai, 2007)

In regards to pressure from the hospital organization to perform:

In fact the management is very important. . . . For example, when the ward manager comes around the unit and asks us to take off the restraints, even if we feel inside that this one cannot do without a restraint, we still need to try. The work that you have to do after a patient falls is considerable. Even if it is only a minor fall, the work that follows takes at least an extra hour. . . . You have to get the patient up, reassure him, get him back into bed, do your observations, and ask them about what happened. Then, if the patient needs treatment, you call the doctor. Probably you will have to arrange for the patient to have an x-ray, and then you will have to report it—you will have to write up a statement, update the patient’s record . . . and then you will have to inform the family, etc. (Lai, 2007)

Reducing falls in high-risk older adults takes a commitment on the part of the healthcare organization to provide training, staffing, equipment (and equipment storage areas). It also takes a commitment on the part of individual healthcare workers and family members to educate themselves about fall-risk reduction strategies. When a facility is dedicated to ongoing training and education, the use of physical restraints can be significantly and safely reduced.

Environmental and equipment modifications can make a big difference. Keeping hallways free of equipment and obstacles and installing rails in hallways can have a dramatic impact. But because of the need to store wheelchairs and other equipment in facilities that lack storage space, all sorts of equipment is often left in hallways, creating a fall hazard and preventing clients from using any rails that may have already been installed. The liberal use of grab bars in bedrooms, bathrooms, and showers can reduce the danger of falls in these potentially danger areas. Floor-to-ceiling transfer poles installed next to a bed or chair provide a simple and effective safety feature for clients with poor balance. 

For clients using wheelchair, lowering the seat to allow a client to self-propel provides a good opportunity for exercise and wandering. Offering pressure relief cushions and adapting wheelchairs to improve posture and support are essential. Providing comfortable alternative seating in activity rooms and hallways, along with a grab bar or safety pole allows a client to move about safely. Other safety features can include:

• Install half-rails on beds.
• Lower beds—place mattress on floor if necessary
• Remove wheels from beds and chairs.
• Install carpeting to reduce injury from falls.
• Use undergarments with pads over the hips to reduce injuries from falls.

4.52 Chemical Restraints

A chemical restraint is the use of any medications to subdue, sedate, or restrain an individual. Chemical restraints are intended to restrict the freedom of movement of a patient—usually in acute, emergency, or psychiatric settings. Legally, a chemical restraint can be prescribed for dangerous, uncontrolled, aggressive, or violent behavior, but it must be used for the shortest time possible. As with physical restraints, chemical restraints have been shown to increase falls in older adults (Agens, 2010).

Atypical antipsychotics were approved by Food and Drug Administration (FDA) in the 1990s exclusively for the treatment of schizophrenia. Soon after, these medications became the new standard of care for behavioral and psychological symptoms of dementia. A 2022 report from the Office of the Inspector General (OIS) stated that psychotropic drugs were prescribed to about 80% of nursing home residents between 2011 and 2019. Higher use of psychotropic drugs, including antipsychotics, anticonvulsants, mood stabilizers, and central nervous system agents was associated with nursing homes that have certain characteristics. Nursing homes with lower ratios of registered nurse staff to residents were associated with higher use of psychotropic drugs. Nursing homes with higher percentages of residents with low-income subsidies were also associated with higher use of psychotropic drugs (OIS, 2022).

Although an off-label use, antipsychotic medications in particular are often used in older patients to control unwanted behaviors such as hitting, yelling, and cursing. They become, in effect, a chemical restraint and have been shown to increase falls and patient deaths (Agens, 2010).

An increased risk of mortality in older adults prompted the Food and Drug Administration to mandate a “black box” label on atypical antipsychotic medications stating that they are not approved to treat behavioral issues associated with dementia. Research suggests that conventional antipsychotics are just as likely to cause death, if not more so (Agens, 2010).

Given the risks, if antipsychotic medications are used at all, they should be prescribed as part of a documented informed-consent process. Education of patients, family members, and staff about the harms of restraints is a good first step in a plan to avoid or eliminate their use (Agens, 2010).