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:

• Muscle weakness
• History of falls
• Gait deficit
• Balance deficit
• Use of assistive device
• Visual deficit
• Arthritis
• Impaired ADLs
• Depression
• Cognitive impairment
• Age >80 years (Shumway-Cook and Woollocott, 2016)

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

A Taiwanese study involving 1377 community-dwelling adults 65 and older looked at co-morbidities, cognitive impairment, neuromuscular impairment, balance and gait disorder, depression, functional decline, higher use of medication, and environmental hazards. They noted that many older adults neither recognize risk factors for falls nor report falls to their physicians. Risk factors for falls only become evident after injuries and disability has occurred (Lin et al., 2011).

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).

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 concomitant 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 is an important risk factor for falling, and several studies have shown an increased fall risk in users of diuretics, type 1a anti-arrhythmics, digoxin, and psychotropic agents.

Due to concurrent prescription of several drugs, the risk of inappropriate drug combinations is increased in older adults. In addition, medication metabolism is affected by age-related changes, which increase both drug half-life and drug free fraction. Coexisting illnesses can also interact with medications. For all these reasons, older adults are at higher risk of experiencing adverse drug effects (Berdot et al., 2009).

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.

Polypharmacy has been discussed extensively and at length in the scientific literature, but the concept still lacks a clearly accepted definition. Attempts to establish a cut-off value for the number of drugs used, which might make it easier to identify risk, have not always been successful. In a study that looked at polypharmacy and falls in nursing home residents in Varese, Italy, polypharmacy was not found to be a risk factor for fall-related injuries. Injuries were associated with the use of multiple drugs (7 or more), but only when a fall-risk-increasing drug (antiarrhythmic or anti-Parkinson drug) was part of the patient’s therapeutic regimen. Multiple medications or particular medication classes were not clearly associated with injurious falls. In particular, digoxin, type 1a antiarrhythmics, and diuretic use were associated with falls in older adults (Baranzini et al., 2009).

The risk of falls can increases significantly in the days following a medication change. Researchers at Johns Hopkins University studied the effect of medication changes on the risk of falls among residents of three nursing homes who fell during 2002–2003. 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 (CDC, 2012a).

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.

Depression, Antidepressants, and Falls

Depression is common and treatable in older adults and outcomes improve with effective antidepressant therapy, which could lead to a decrease in the morbidity associated with falls. Older people who fall are twice as likely to be depressed compared with those who do not fall (Kerse, 2008). However, antidepressant use can also increase the risk of falls, both for those in the community and in residential care (Kerse et al., 2008).

A cross-sectional survey of Australians aged 60 and over investigated the association between depressive symptoms, medication use, falls, and fall-related injury. Both depression and the treatment for depression were independently associated with an increased risk of falls. Selective serotonin reuptake inhibitor (SSRI) use was associated with the highest risk of falls and injurious falls of all psychotropic agents (Kerse et al., 2008).

Cognitive Decline

The understanding of the relationship between age-associated declines in cognitive function and reduced mobility is evolving. For a long time, these two common geriatric symptoms were viewed as distinct and separate. An increased fall risk in older adults was typically considered to be unrelated to age-associated changes in cognitive function. New research gives us reason to suspect that falls are affected by cognitive function even in the absence of dementia (Mirelman et al., 2012).

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 (Buracchio et al., 2011). 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 (Buracchio et al., 2011). 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).

An Israeli study looked at executive function, attention, and other cognitive domains in 256 community-living older adults with an average age of 76 years. Participants were free of dementia and had good mobility upon entrance into the study. Baseline cognitive function was established using computerized cognitive tests. Gait was assessed during single and dual task conditions. Falls data were collected prospectively using monthly calendars. The researchers found that among community-living older adults, the risk for future falls was predicted by executive function and attention tests conducted five years earlier, indicating that screening executive function will likely enhance fall risk assessment and that treatment of executive deficits may reduce fall risk (Mirelman et al., 2012).

Cardiovascular Disorders

Cardiovascular complications are a significant cause of recurrent falls in older adults. Cardiovascular causes can be from neurally mediated 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.

A study in The Netherlands involving 215 older patients (average age, 77 years) looked at echo (Doppler) cardiographic abnormalities to determine if certain findings were indicators of increased risk for falls. Risk of falls was increased if regurgitation of the mitral, tricuspid, or pulmonary valve was present. The level of risk increased according to the severity of the regurgitation. An increased fall risk was also found for high tricuspid-regurgitation velocity and high pulmonary systolic pressure, which was used as a proxy for pulmonary hypertension (van der Velde, 2007).

Current cardiovascular status may be related to risk of falling. In a retrospective case-control study of 13 acute hospital patients who had fallen in the last year, researchers found that the fallers displayed a larger change in blood pressure and heart rate readings over 12 hours than those in the matched control group. In the control, blood pressure and pulse changed an average of 10% over 12 hours, while those who had fallen had a variation in their heart rate and blood pressure of approximately 20% (Freilich and Barker, 2009).

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).

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).

Physical restraints have been used in nursing homes and hospitals both as safety devices and as falls prevention tools. Theoretically, a restrained patient cannot fall or, in the case of bedrails, cannot roll out of bed. Several studies have shown no statistically significant difference in falls compared with historical controls when bedrails are removed. In fact, restrained patients appear to have a modest increase in fall risk or fall injuries (CDC, 2012a).

Restraint use can have significant negative outcomes—they have been shown to increase the length of hospital stays and increase mortality, pressure sores, hospital-acquired infections, falls, and aggression (Strout, 2010). Several studies have reported extensive injuries among nursing staff while applying physical restraints, as well as distress, anxiety, and anger among nursing staff when the need to maintain safety and control conflicts with their professional values (Strout, 2010).

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, and equipment. It also takes a commitment on the part of individual healthcare workers and family members to educate themselves about fall-risk reduction strategies. Despite these difficulties the use of physical restraints can be significantly and safely reduced by making certain environmental and equipment modifications:

• Keep hallways free of equipment and obstacles
• Install rails in hallways
• Install grab bars in bathrooms, bedrooms, and showers
• Install floor-to-ceiling transfer poles next to chairs and beds
• Install half-rails on beds
• Lower beds—place mattress on floor if necessary
• Remove wheels from beds and chairs
• Adapt wheelchairs to improve posture and support
• Provide “pressure-relief” wheelchair cushions to improve comfort
• Lower wheelchairs to allow self-propelling with feet
• Provide comfortable alternative seating
• Install carpeting to reduce injury from falls
• Use undergarments with pads over the hips to reduce injuries from falls

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).