Fall risk assessment for older adults: tests and prevention

Why falls matter, and why a check helps

More than 1 in 4 adults aged 65 and older fall each year, according to the CDC, and fewer than half of them tell their doctor. Falls are the leading cause of injury in older adults, from broken hips and wrists to head injuries. And falling once doubles your chance of falling again.

The good news is that many falls have causes that can be found and fixed: weak legs, a medicine that makes you dizzy, the wrong shoes, a loose rug. A fall risk assessment looks for those causes so you can deal with them before a fall happens, or before the next one.

Fear of falling matters too. People who worry about falling often move less, which weakens their muscles and makes a fall more likely. A clear plan helps break that cycle.

Who should have a fall risk assessment?

The CDC and the American Geriatrics Society recommend that everyone 65 and older is asked about falls at least once a year. The CDC’s screening starts with three questions:

1. Have you fallen in the past year?
2. Do you feel unsteady when standing or walking?
3. Do you worry about falling?

If the answer to any of them is yes, a fuller assessment is worth doing. It’s also worth asking for one if you:

• have numbness, tingling or burning in your feet (neuropathy), or diabetes
• have Parkinson’s disease, have had a stroke, or have arthritis that limits how you move
• get dizzy or light-headed when you stand up, or when you turn your head
• take 4 or more medicines, or have started a new one that makes you drowsy
• haven’t had an eye exam in the past year
• often have to hurry to the bathroom, especially at night
• use a cane or walker, or think you might need one

For families: people often keep falls to themselves. Bruises nobody explains, holding on to furniture to get around the house, walking more slowly or giving up favorite activities can all be signs that someone is unsteady. Asking kindly, and offering to come along to an appointment, can make it easier to talk about.

What happens during a fall risk assessment

A fall risk check can be done by your primary care doctor, often at a yearly checkup, or by a physical therapist. A quick screen takes a few minutes. A full assessment can take up to an hour.

Questions about your health and medicines

You’ll be asked about any falls or near-misses: when and where they happened, what you were doing, and whether you felt dizzy or blacked out first. You’ll also be asked about your health conditions, eyesight, bladder, mood and memory, and every medicine you take, including over-the-counter sleep aids and supplements.

Bring with you:

• your medicines, or a complete list
• your glasses and any hearing aids
• the shoes you wear most, and your cane or walker if you use one
• a family member, if you’d like help remembering details

Balance, strength and walking tests

These are the tests used most often, including in the CDC’s fall prevention program. Someone stays beside you during each one in case you lose your balance.

The tester also watches how you move: whether you push up with your arms, sway, shuffle, take short steps or reach for support.

Other checks

• Blood pressure lying down and standing up, to look for a drop that makes you light-headed when you stand.
• Eyesight, if it hasn’t been checked recently.
• Your feet: feeling in your soles, foot pain, bunions and other toe problems, toenails, and your shoes.
• Heart rhythm, if you’ve fainted or blacked out.
• Your home, through questions or a visit from an occupational therapist.

What the results mean

If your risk is low, the advice is to stay active, keep your legs strong and be checked again next year. If your risk is higher, you’ll get a plan that targets your own risk factors. That might include an exercise program with a physical therapist, changes to your medicines, an eye exam, foot care, a walking aid and changes at home.

Common fall risk factors, and what helps

Exercise: the best-proven way to prevent falls

A major review of more than 100 trials found that exercise programs cut the number of falls in older adults living at home by about a quarter. The programs that worked best combined balance exercises with leg strengthening, done at least 3 times a week. Tai chi also lowered falls. The benefit fades if you stop, so choose something you can keep doing.

Walking is good for your heart, mood and bones, but on its own it doesn’t seem to prevent falls. Add balance and strength work to it.

Exercises a physical therapist often starts with, done next to a kitchen counter or sturdy chair:

• Sit to stand: stand up from a chair without using your hands, then sit down slowly. Repeat 5 to 10 times.
• Heel raises: holding the counter, rise onto your toes and lower slowly, 10 to 15 times.
• Side leg raises: holding the counter, lift one leg out to the side and lower it, 10 times each side.
• Heel-to-toe walking: walk along the counter placing one heel directly in front of the other toes, for 10 steps.
• Standing on one leg: hold the counter and stand on one leg for up to 10 seconds, then switch. Hold on more lightly as you improve.

Stop and sit down if you feel dizzy, short of breath or have chest pain, and tell your doctor.

If you’ve already fallen, use a walker, or have neuropathy, Parkinson’s disease or a past stroke, start with a physical therapist rather than on your own. A therapist tests your balance, builds a program at a safe level and makes it harder as you improve. Learn about gait and balance training at Evolve Health, offered at select Florida offices. Once you’re steadier, a community tai chi or balance class is a good way to keep going.

Medicines that raise your risk

Some medicines make you drowsy, slow your reactions or lower your blood pressure when you stand. Taking several at once adds to the effect. Medicines to ask about include:

• sleeping pills, sedatives and anti-anxiety medicines
• some antidepressants and antipsychotics
• opioid pain relievers and some muscle relaxants
• some nerve pain and seizure medicines, such as gabapentin and pregabalin
• over-the-counter sleep aids and allergy pills that contain diphenhydramine (such as Benadryl or “PM” pain relievers)
• blood pressure pills and water pills (diuretics)
• diabetes medicines that can cause low blood sugar, such as insulin

Don’t stop or change a medicine on your own. Ask your doctor or pharmacist to review everything you take at least once a year, and whenever a new medicine is started. Sometimes a lower dose, a different time of day or a different medicine makes a real difference. Alcohol adds to the effect of many of these medicines.

Dizziness, blood pressure and eyesight

• Light-headed when you stand? Sit on the edge of the bed for a minute before getting up, and stand up slowly. Tell your doctor, because your blood pressure medicines may need adjusting.
• Spinning when you roll over or look up? A common inner-ear problem called BPPV can cause brief spinning spells, and it can often be treated with simple head movements done by a clinician. Ongoing dizziness and unsteadiness can improve with vestibular rehabilitation, a type of physical therapy for balance.
• Fainted or blacked out? See your doctor promptly. It can be a sign of a heart rhythm problem.
• Eyesight: have your eyes checked every year. Bifocal and progressive lenses can blur the ground and steps, so take extra care on stairs and curbs, and ask your eye doctor whether single-vision glasses would be safer for walking outdoors.

Your feet and shoes

Your feet are your base of support, and small problems there add up. Foot pain, bunions, hammertoes, long or thick toenails and weak ankle muscles all make it harder to balance. Numbness from peripheral neuropathy, nerve damage that is common with diabetes, is a major risk because your feet can’t feel the ground well. See our guide to nerve pain and numbness in the feet.

The evidence for foot care on its own is promising but mixed. In an Australian trial of older people with foot pain, a podiatry program of better shoes, insoles, and foot and ankle exercises reduced falls. A larger UK trial found a smaller effect that may have been down to chance. Foot care works best as part of a wider plan with exercise.

Look for shoes that:

• fasten with laces, straps or hook-and-loop closures
• have a firm back that holds your heel
• have a low, wide heel
• have a thin, firm sole with good grip, rather than a thick, very soft one
• fit well, with room for your toes

Avoid backless slippers, flip-flops, high heels, worn-out shoes and walking around in socks or bare feet, especially on smooth floors.

Look after your feet:

• Check your feet every day if you have diabetes or numbness.
• Keep toenails trimmed straight across. If you can’t reach or see them well, a podiatrist can help. See nail care at Evolve Health.
• Have painful corns, calluses and bunions treated rather than living with them.
• Do simple foot and ankle exercises, such as heel raises and ankle circles.

If you have diabetes, special shoes and inserts can protect your feet, and Medicare may help pay for them. See our guide to diabetic foot care.

Make your home safer

• Floors: remove throw rugs or fix them down with double-sided tape, and clear away clutter and cords.
• Lighting: use night lights between the bedroom and bathroom, and have light switches at the top and bottom of the stairs.
• Bathroom: fit grab bars by the toilet and in the tub or shower (towel rails aren’t strong enough to hold you), and use a non-slip mat. A shower chair can help.
• Stairs: have sturdy handrails on both sides, and keep the steps clear.
• Kitchen: keep things you use often within easy reach, so you don’t need a step stool.
• Pets: know where they are, especially at night.
• Help within reach: keep a phone nearby or wear a medical alert device, especially if you live alone.

A home safety visit from an occupational therapist helps most for people at higher risk, such as those who have already fallen.

What to do after a fall

If you fall

1. Stay still for a moment. Take a few breaths and check whether you’re hurt.
2. If you’re hurt or can’t get up, call for help: dial 911, press your alert button or call out. Keep warm with anything nearby, and move your arms and legs gently while you wait.
3. If you feel able to get up, roll onto your side, then onto your hands and knees. Crawl to a sturdy chair, put your hands on the seat, bring your stronger leg forward, push up slowly and turn to sit. Rest before you stand.

Call 911 or go to the emergency room if:

• you can’t get up, or can’t put weight on your leg, especially with hip or groin pain
• you hit your head and take a blood thinner, even if you feel fine
• you have a headache, confusion, vomiting or unusual sleepiness after hitting your head
• you blacked out, or had chest pain or a racing heart before the fall
• you notice face drooping, arm weakness or trouble speaking
• you have neck or back pain with numbness or weakness

See your doctor within a day or two if:

• a bruise, swelling or pain isn’t getting better
• you felt dizzy, light-headed or weak before you fell
• the fall came soon after starting or changing a medicine

Book a fall risk assessment if:

• you’ve fallen in the past year, even without an injury
• you’ve had near-misses, or feel unsteady
• you’re avoiding things you used to do because you’re afraid of falling

Where to start

Ask your primary care doctor for a fall risk check at your next visit, and bring your medicine list. Medicare’s yearly wellness visit is a good time to ask.

If balance or walking is the main worry, a physical therapist can test you and build an exercise program: you can find a physical therapist at Evolve Health. If foot pain, numbness, toenails or shoes are part of the problem, see a podiatrist. Evolve Health accepts many major plans, including Medicare: see which insurance plans we accept and what Medicare covers in podiatry.