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40 The Nurse Practitioner • Vol. 40, No. 6

Fall prevention in older adults Abstract: Falls in older adults are a major public health concern and can often have fatal results. Practitioners need to be aware of assessment and diagnostic techniques to prevent falls in older adults.

B y S c o t t J . S a c c o m a n o , P h D , R N , G N P -B C a n d L u c i l l e R. F e r r a r a , E d D , M B A , R N , F N P -B C

ne ot the major public health concerns of older adults is falls. Falls are defined as an unintentional loss of balance that results in a posi­ tion change and contact with the ground.1Practitioners who work with older adults must know and understand the implications of falls and work to improve the quality of life for the older adult who has fallen.


■ Epidemiology

Approximately one third of individuals over the age of 65 fall each year, rising to 50% by the age of 80A6 Falls in older adults are the leading cause of nonfatal and fatal injuries. In 2012, EDs treated almost 2.5 million older adults who had suffered nonfatal falls resulting in 722,000 hospitalizations.7 The CDC reported that in 2012, the adjusted medical cost of falls was approxi­ mately 30 billion dollars. As the population ages, the num ber of falls is ex­ pected to increase as well as the cost of treating them.8 Over the last 10 years, death rates from falls have risen dramatically with almost 23,000 fall-related deaths in 2011. Men have a higher death rate from falls than women, and older White men are almost three times more likely to die from a fall than older Black men.8 ■ Pathophysiology of falls

The origin of falls is multifactorial. While hazardous behavior may cause falls, walking, stepping, or position changes cause the majority of falls. Lower extrem­ ity weakness, balance disorders, postural hypotension, central nervous system diseases, abnormalities in cognition and sensation, and unsafe environments all contribute to falls.9 ■5 *

K e y w o r d s : f a l l a s s e s s m e n t, f a l l p r e v e n t io n , f a l l r is k , f a l l s , f e a r o f f a l l i n g , g e r i a t r i c s , m o b ility , o l d e r a d u lt s

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Fall prevention in older adults

During the normal aging process, visual impairment and ocular disease increase. Glare intolerance and slow adaptation to changes in light level are normal and related to the aging process. 10 Peripheral and central vestibular function as well as sensory cues help to maintain balance. Age-related changes in the inner ear and changes in transmission signals from the periphery cause disequilibrium and unsteadiness in older adults. 11 Depression and acute changes in mental status also contribute to falls in older adults. Other factors that can lead to falls include medications, especially sedating drugs, BP changes, and imbalances in fluid and electrolytes. 12,13 Changes in the aging cardiovascular system impair nor­ mal homeostatic mechanisms of BP control and perfusion, leading to hypotension and an inability to maintain proper balance. Balance and gait are affected by joint disease and musculoskeletal changes as well as environmental factors,

■ History and physical exam

Is the fall an isolated event? If not, is there a pattern to the falls? If there is a pattern to the falls, how often and when do the falls occur, and are the falls increasing in frequency? Is there a particular triggering factor or event to the fall? Was any alcohol consumed? What caused the fall? What activity was the patient doing at the time of the fall? Patients who are arising from bed or off a toilet may do so quickly, thus, inadvertently causing orthostatic hy­ potension. Did the fall involve exertion, change of position of the head (looking up then down)? Patients who are reaching up or extending their neck can cause vertebro­ basilar insufficiency, thereby decreasing blood flow to the brain, causing dizziness or blackouts. Micturition syncope, which can affect older adult males especially at night, occurs after rapid urination that causes a sudden drop in BP resulting in syncope . 9,31 The level of consciousness should be asked about. Was there any loss of Chronic illness such as hypertension, kidney consciousness? Does the patient re­ disease, diabetes mellitus, and arteriosclerosis member falling? Sudden “blackouts” or increase the patient's risk for falls. falling can be caused by underlying car­ diac or neurologic disorders and require fu rth er investigation. The p atient should be asked if there was a warning or associated symp­ such as scattered rugs, loose electric cords, and clutter. Fear toms before the fall (palpitations, shortness of breath, diz­ of falling after a fall has occurred is common among older ziness, chest pain, vertigo, dizziness) . 32 Did the patient have adults because they have lost their self-confidence and feel a loss of balance? Patients may state they felt weak, dizzy, or that they are losing control over their lives. 14 Fear of falling faint prior to falling; these symptoms require a more inproduces additional cautious behaviors as well as diminished depth evaluation. What was the patient status after the fall? activity and ambulation, which may put the older adult at Continued weakness, disorientation, incontinence, and a risk for future falls. 15 bitten tongue can indicate neurologic dysfunction and re­ quire further evaluation. ■ Conditions for fall predisposition Witnesses are important in the evaluation of a witnessed Disorders that are common in older adults, such as muscu­ fall, as they can report the circumstances before, during, and loskeletal diseases, are often the cause of falls and fall-related after a fall. This is important in describing fall behaviors, injuries. Osteoarthritis, osteoporosis, and low back pain have such as tonic-clonic movements, mental status, and level of a significant association to fall-related injuries . 16 Neuro­ consciousness. logic conditions in older adults that can increase fall risk Patients reporting a history of tripping and falling include gait and balance disorders, sensory impairments, should be further assessed. Are there visual defects present? stroke, Parkinson disease, and cognition impairments. Car­ Has the patient had a recent eye exam? Does the patient diovascular risk factors for falls include orthostatic hypoten­ have blurred vision, or is vision loss present? Patients who sion, which is a common medical condition in older adults. present with visual disturbances, such as presbyopia, cat­ Chronic illness such as hypertension, kidney disease, diabe­ aracts, glaucoma, and age-related m acular degenera­ tes mellitus, and arteriosclerosis also place the patient at risk tion, should be followed for appropriate evaluation and for orthostatic hypotension, which increases the fall risk. 17,18 treatm ent . 14,27 Additional risk factors for falls include medications, espe­ C om ponents of the physical exam should include cially the use of multiple medications known to increase the vital signs— particularly postural vital signs— and cardiorisk of falls, alcohol abuse, visual disturbances, foot prob­ vascular/neurologic evaluations. The cardiovascular ex­ lems, coordination and balance impairment, and urinary am ination should include an assessment of pulses for incontinence . 19' 30 (See Risk factors for falls.)


42 The Nurse Practitioner • Vol. 40, No. 6

Fall prevention in older adults

irregularities in rhythm or an abnormal rate— especially atrial fibrillation or bradycardia. The recording of BP in lying, sitting, and standing positions is critical, especially if there is evidence of postural hypotension in the history. A drop of 20 mm Hg in the systolic pressure with standing is noteworthy, as a 20 mm Hg drop can cause changes in balance, leading to falls. Carotid bruits should be assessed for. Auscultation of the heart can provide evidence of m urm urs, such as aortic stenosis, regurgitation, mitral stenosis, or regurgitation.14,33 The neurologic examination includes assessment of muscle wasting, muscle strength, tone, and a sensory sys­ tem assessment— especially if neuropathies are suspected. Muscle wasting can be seen in diseases of disuse, such as arthritis. Mobility and gait testing are quick and easy and can predict the risk of falls. The ‘timed up and go” test is a timed test that is the modified version of the “get up and go” test; it entails regular footwear and any regular walk­ ing aid where the patient rises from a seated position in a chair with their arms folded across the chest, ambulates 10 feet, then turns around to return to the chair to sit down. The ease of gait, mobility, balance, position, change, and tu rn in g is evaluated. Patients taking longer than 30 seconds to complete the test are considered function­ ally dependent.34 Another performance test for gait and balance and fall risk is The Tinetti Performance Oriented Mobility Assess­ m ent (POMA). The Tinetti POMA measures 16 items (9 items of balance and 7 items of gait) in older adults with three-point ordinal scores ranging from 0 to 2; the higher score indicates independence, a score of less than 19 is an individual at high risk for falls, 19 to 24 medium risk for falls, and 25 to 28 low risk for falls.35,36 ■ Fall prevention in the older adult

Patient history and physical exam are key in the formula­ tion of differential diagnosis specific to fall risk and pre­ vention. A thoro u g h and com prehensive history and physical exam should be performed to provide a baseline assessment of neurologic and cognitive function, visual and hearing acuity, musculoskeletal strength and stability, as well as cardiopulmonary stamina. Questionable or sug­ gestive findings will then guide the provider’s choice for further study. Metabolic studies. Metabolic factors should be consid­ ered, such as infection, polypharmacy, hypoglycemia, and dehydration. Routine lab testing for the older adult is typi­ cally obtained during the annual physical exam or in some cases depending more frequently upon medication regimen and other comorbidities, such as hyperlipidemia, cardiovas­ cular disease, or diabetes. Baseline testing can greatly assist

Risk factors for falls1 2 141730 Aging-Falls increase with age and increasing frailty Gender-Women are more likely to have a nonfatal fall, while men who suffer a fall are approximately 50% more likely to have a fatal fall Medications-Common medications in older adults, such as diuretics, beta-blockers, antidepressants, nitrates, angiotensin-converting enzyme inhibitors, and antihista­ mines, are thought to precipitate orthostatic hypotension and cause falls as a result of syncopal adverse reactions. Benzodiazepines, psychotropics, and sedatives can cause confusion, leading to falls. Polypharmacy-Using four or more medications causing interactions and adverse reactions are likely to cause falls. Even using one medication known to cause falls can increase risk

Alcohol abuse-can cause instability from acute intoxica­ tion. Alcohol abusers can be predisposed to falls second­ ary to polyneuropathy, Wernicke encephalopathy, and Korsakoff syndrome Diabetes-related neuropathy can predispose one to balance impairments, motor weakness, and loss of sen­ sation, leading to lower extremity weakness, which can cause frequent tripping and inability to navigate stairs and rise from a seated position

Visual disturbances-lncreased falls related to visual disturbances is becoming more common. Visual distur­ bances, such as presbyopia, cataracts, glaucoma, and age-related macular degeneration, are associated with increased tripping, slips, and falls

Coordination and balance-impairments related to chang­ es in musculoskeletal impairments, resulting in disorders of gait and lower extremity weakness

Foot problems-Older adults with deformities of toes, bunions, callus nail deformities (even improper foot­ wear) can cause increased pain when ambulating and can lead to balance difficulties and falls

Urinary incontinence-Falls from urinary incontinence are a direct result from trying to do two things at once; urine is to be held before being expelled at the bathroom Depression-Coupled with the use of antidepressive med­ ication, diminished physical functioning, and cognitive deficits, depression is known to increase the risk of falls in older adults

the provider in determining the underlying cause associ­ ated with a fall or detect potential conditions that may in­ crease the patient’s propensity to fall. Medicare or other third-party insurance carriers may not always cover some of these baseline blood tests. The complete blood cell count, baseline metabolic panel, thyroid studies, and hemoglobin A1C offer a solid foundation. Ane­ mia, impaired kidney function, electrolyte imbalances, thyroid disease, and diabetes are easily detected with these The Nurse Practitioner • June 2015 43

Fall prevention in older adults

an easy and relatively safe exam with low radiation expo­ sure that greatly assists in the calculation of bone den­ sity loss. Results can provide a useful guide for nurse practitioners when considering pharmacologic treatment for osteoporosis as well as other interventions, such as strength training exercise, nutritional supplementation, and therapy.38 Cognitive assessment. There is a significant correlation between falls and dementia. Creating a safe environment for all patients—especially those with dementia— is central to their overall care. Assessing the older adult at baseline and m onitoring at least annually (or more frequently if warranted) aids in early detection of dementia. The Mini Mental State Exam (MMSE) is a simple and convenient tool to use when performing a baseline assessment as well as for trending progressive cognitive im pairm ent.34 The MMSE is a standardized test that has sound reliability and validity; it evaluates registration, atten­ tion and calculation, recall, language, simple commands, and orientation. Arthritis accounts for approximately 15% to The maximum score is 30. 20% o f falls in adults over the age of 45 due A score of 26 or above is considered to limitations in mobility. normal. If the older adult scores below 26, further evaluation by a neurologist is recommended to differentiate the degree and type of dementia that may be present. Another capture more complex dysrhythmias that are transient or tool that is used to detect mild cognitive impairment is the paroxysmal. Doppler studies provide a baseline vascular Montreal Cognitive Assessment (MoCA). The MoCA is also evaluation and can also be used to monitor and track the a 30-point tool that assesses attention and concentration, progression of documented vasculopathies, such as carotid executive functions, memory, language, visuoconstrucartery occlusion.34,37 tional skills, conceptual thinking, calculations, and orienta­ Visual and hearing assessment. Many falls occur in tion. A score of 26 or above in the MoCA is also considered the patient’s home during the night when there is less light. normal. Again, older adults scoring below 26 should be A routine eye exam and hearing screening will help to evaluated further.39 complete the comprehensive evaluation for fall prevention. Bowel and bladder assessment. A comprehensive An annual eye exam is recom m ended, especially if the history with regard to the patient’s bowel and bladder patient has diabetes or documented retinopathy, cataracts, habits is essential. Questions should focus on overall bow­ or other visual pathology. Patients should also be cautioned el and bladder habits, bladder continence, the presence of with regard to certain lens types, such as bifocals, as these constipation, the use of laxatives and diuretics, and any types of lenses may alter depth perception and increase the other over-the-counter (OTC) m edications the patient chance of falls.34 may use. Urinary incontinence poses a major risk factor Musculoskeletal assessment. During the m usculo­ for falls. These falls frequently occur due to the patient’s skeletal assessment, arthritic changes in the joints and attem pting to get to the bathroom quickly to avoid an lim itations in mobility are detected. Arthritis accounts incontinent episode. In addition, wet bathroom floors due for approximately 15% to 20% of falls in adults over the to urinary incontinence increase the risk of slipping. Con­ age of 45 due to decreased strength and lim itations in stipation on the other hand also presents fall risk for the mobility.38 In addition to the musculoskeletal physical older adult who may use various laxatives and other aids assessment of the older adult patient, the provider must to alleviate constipation. Some laxatives may increase also consider the direct correlation of osteoporosis to episodes of diarrhea that in turn increases the incidence falls in older adults due to loss of bone density experi­ of dehydration, which may also increase dizziness and enced from the effects of osteoporosis. Dual X-ray ab­ syncope.34 sorptiom etry (also known as the DXA or DEXA scan) is

simple lab studies, and when appropriately corrected, can significantly aid in fall prevention.34 Assessment o f balance. A nother factor associated with falls is imbalance disturbances that can range from benign positional vertigo (BPV) to more complex neu­ rologic disorders, such as Parkinson disease. Simple screening exams, such as the single leg stance test and the “timed up and go test,” establish a baseline for impaired balance and justification for further investigation with other testing.34 Cardiovascular assessment. Impaired balance can be attributed to cardiovascular conditions, including dysrhyth­ mias (such as atrial fibrillation) and vasculopathies (such as carotid artery atherosclerosis). A simple baseline ECG can detect dysrhythmias, but when symptoms such as syn­ cope are present, Holter monitoring—either a 24-hour study or longer event monitoring (30 days)— may be required to

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Fall prevention in older adults

Fall assessment tools. In addition to the above dis­ cussed fall assessment, there are a num ber of tools that have been developed for the assessment of falls in the older adult (see Useful provider websites). The CDC has published a pocket guide for providers, which contains an algorithm for fall assessment as well as a fall checklist for providers and their patients to use for additional fall risk screening ( steadi/pocket_guide_preventing-falls.pdf). The Morse Fall Scale (1989) is another tool that was developed by J.M. Morse for the rapid evaluation of fall risk for patients who are either hospitalized or in long-term care.40'41 The Morse Fall Scale assesses six parameters for falls, history of falls, secondary diagnoses, am bulatory aids, current I.V., gait, transference, and m ental status. O ther assessment and screening tools can also be found on the website created by the Ohio Department of Health (http://www.healthy. ■ Pharmacology

Useful provider websites Fall assessment tools An algorithm for falls risk assessment and interventions algorithm_fall_risk_assessment.pdf A fall risk checklist steadi-2015.04/Check_for_Safety_brochure-a.pdf Common screening and assessment tools screening-assessment-tools NICHE fall assessment:

orthopedist that the patient is taking a sleep aid, the ortho­ pedist prescribes oxycodone and acetaminophen for pain. The com bination of the two drugs has the potential to increase somnolence and gait imbalance due to sedation, which in turn increases fall potential. Reviewing the pa­ tient’s medications regularly can significantly decrease the incidence of polypharmacy. Comprehensive medication reconciliation should include having the patient physi­ cally bring all of their medications with them to the pro­ vider visit.43

The pharmacy intervention for falls focuses on supple­ mentation for bone health and careful review of current medication regimens. Falls often occur after a fracture due to osteoporosis and most commonly affect the hip and spine. Increasing the strength of the bones— specifically the longer bones— will decrease the chance of fracturerelated falls. V itam in D, bisphosphonates, raloxifene, denosumab, or teriparatide may be used for the treatment ■ Nonpharmacologic measures of osteoporosis.34'37 Central to fall prevention are the nonpharmacologic in­ Many older adults experience decreased appetite and terventions that should be considered and discussed with eat less. Vitamin supplementation is recommended, and the the older adult and his or her caregivers. When evaluating use of most OTC multivitamins is sufficient. Iron supple­ the risk factors for falls, safety is of param ount concern. mentation can also be included if the patient is found to Creating a safe environment. Proper lighting, espe­ have iron deficiency. cially during the evening and nighttim e, will increase Cognitive impairment and meta­ bolic changes increase the risk of falls. That being said, medication reconcili­ Age-related changes in the inner ear and ation should be perform ed at every transmission signal changes from the visit to ensure proper medication use, periphery cause unsteadiness in older adults. evaluation for polypharmacy, medica­ tion adherence, and evaluation of ad­ verse events.42-43 It is not uncom m on for older adult patients to have more than one provider, visibility— especially for those older adults with diminished specifically those providers in specialty, such as cardiology, visual acuity and in some cases, impairment. Ensuring that neurology, urology, pulmonology, and orthopedics. Each flooring is secure, such as carpeting and tiles, will decrease of these providers may prescribe disease-specific medica­ the chance of tripping or slipping. Cautioning patients with tion and frequently, duplication or over prescribing of a regard to walking when there is ice, snow, or other wet specific drug class can occur. A good example is as follows: surfaces outside should be part of the safety conversation the patient is seen by the neurologist who prescribes lowand instructions. dose zaleplon for sleep. The patient is also being seen by an Many older adults drive, and this also poses a major orthopedist for a recent wrist fracture. Unbeknownst to the safety risk. The National Highway Safety Commission


The Nurse Practitioner • June 2015


Fall prevention in older adults

( provides informa­ tion with regard to driver safety for the older adult as well as links to driver assessment programs throughout the United States. These programs assess older adult driving ability. This can greatly assist caregivers or children of older adult patients when faced with making the decision to stop the older adult from driving due to limitations, such as sight, reaction time, and hearing. For those patients (depended upon assistive devices for ambulation such as walkers and canes), safety education with regard to proper use and importance of using these devices is key. It is also important to explore the patient’s thoughts and opinions regarding the use of assistive devices— especially in their own home environment. ■ Strength training and improvement of balance

The various musculoskeletal changes that occur in the older adult include decreased muscle tone and strength, which directly affect balance and coordination. Physical therapy (PT) can im prove muscle tone and strength through specific exercises that target certain muscle groups. The physical therapist will work on strengthening leg and arm muscle groups as well as incorporate repetitive exer­ cises, such as sitting and standing (getting up from a chair), ambulating, ambulating safely with assistive devices, and stair climbing . 34 In addition to PT, occupational therapy is also beneficial for fall prevention. The occupational therapist will evaluate the older adult’s environment and make recommendations for increased safety, such as grab bars in the bathroom, modifications with regard to kitchen tools, arranging cabi­ nets for easy access, and other household changes that will promote a safe environment. In addition to the traditional therapies for strength training and improvement of balance, studies looking at yoga, tai chi, and tai ji have demonstrated increased strength and balance through the implementation of these forms of exercise. 44,45 Footwear and care of the feet are also recommended for fall prevention. Older patients should have regular visits to a podiatrist for foot care, espe­ cially if patients have foot deformities or experience pain— both of which limit mobility.34 ■ Nutritional guidance

In addition to vitamin D supplementation and the other pharmacologic interventions that help to decrease bone loss, proper nutrition is crucial. A diet that is well balanced with fruits, vegetables, and protein provides a great source of vitamins and minerals. Having the older adult patient meet with a nutritionist is also recom m ended— especially in cases where comorbidities such as hyperlipidemia and dia­ betes are prevalent.46 © 4 6 The Nurse Practitioner • Vol. 40, No. 6

REFERENCES 1. Centers for Medicare Services. Accountable care organizations 2012 program analysis.Quality Performance StandardsNarrativeMeasureSpecifications.2011. edicare/M edicare-Fee-for-Service-Payment/share dsavingsprogram/Downloads/ ACO_QualityMeasures.pdf. 2. Moore M, Williams B, Ragsdale S, et al. Translating a multifactorial fall pre­ vention intervention into practice: a controlled evaluation of a fall prevention clinic. J Am Geriatr Soc. 2010;58(2):357-363. 3. Caterino JM, Karaman R, Arora V, Martin JL, Hiestand BC. Comparison of balance assessment modalities in emergency department elders: a pilot crosssectional observational study. BMC Emerg Med. 2009;9:1-719. 4. Annweiler C, Montero-Odasso M, Schott AM, Berrut G, Fantino B, Beauchet O. Fall prevention and vitamin D in the elderly: an overview of the key role of the non-bone effects. / Neuroeng Rehabil. 2010;7:50. 5. Frick KD, Kung JY, Parrish JM, Narrett MJ. Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults .J Am Geriatr Soc. 2010;58(1):136-141. 6. Thomas S, Mackintosh S, Halbert J. Does the ‘Otago exercise programme’ reduce mortality and falls in older adults?: a systematic review and meta­ analysis. Age Ageing. 2010;39(6):681-687. 7. Centers for Disease Control and Prevention (CDCa), National Center for In­ jury Prevention and Control. Web-based Injury Statistics Query and Report­ ing System (WISQARS) [online]. 8. Centers for Disease Control and Prevention. Cost of falls among older adults. 9. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35(suppl 2):ii37-ii41. 10. Popescu M, Boisjoly H, Schmaltz H, et al. Age-related eye disease and mobil­ ity limitations in older adults. Investigative Ophthalmology and Visual Science. 2011;52(7):7168-7174. 11. Walther LE, Rogowski M, Schaaf H, Horm ann K, Lohler J. Falls and dizziness in the elderly. Otolaryngol Pol. 2010;64(6):354-357. 12. Iaboni A, Flint AJ. The complex interplay of depression and falls in older adults: a clinical review. Am } Geriatr Psychiatry. 2013;21(5):484-492. 13. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the im­ pact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009; 169(21): 1952-1960. 14. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75(1):51-61. 15. Dias RC, Freire MT, Santos EG, Vieira RA, Dias JM, Perracini MR. Char­ acteristics associated with activity restriction induced by fear of falling in community-dwelling elderly. Rev Bras Fisioter. 2011; 15(5):406-413. 16. Lee WK, Kong KA, Park H. Effect of preexisting musculoskeletal diseases on the 1-year incidence of fall-related injuries. / Prev Med Public Health. 2012;45(5):283-290. 17. Low PA. Prevalence of orthostatic hypotension. Clin Auton Res. 2008;18(suppl 1):8-13. 18. Mager DR. Orthostatic hypotension: pathophysiology, problems, and preven­ tion. Home Healthc Nurse. 2012;30(9):525-530. 19. Shaw BH, Claydon VE. The relationship between orthostatic hypotension and falling in older adults. Clin Auton Res. 2014;24(1):3-13. 20. Ungar A, Rafanelli M, Iacomelli I, et al. Fall prevention in the elderly. Clin Cases Miner Bone Metab. 2013; 10(2):91 -95. 21. World Health Organization (WHO). WHO global report on Falls Preven­ tion in older age. Publications of the World Health Organization, Geneva, Switzerland; 2007. 22. Hammond T, Wilson A. Polypharmacy and falls in the elderly: a literature review. Nurs Midwifery Stud. 2013;2(2):171-175. 23. Zeimer H. Medications and falls in older people. Geriatric Therapeutics. 2008;38(2): 148-151. 24. Ker K, Chinnock P. Interventions in the alcohol server setting for preventing injuries. Cochrane Database Syst Rev. 2008;(3):CD005244. 25. Miller TR, Spicer RS. Hospital-admitted injury attributable to alcohol. Alco­ hol Clin Exp Res. 2012;36( 1):104-112. 26. Morrison S, Colberg SR, Mariano M, Parson HK, Vinik AL Balance train­ ing reduces falls risk in older individuals with type 2 diabetes. Diabetes Care. 2010;33(4):748-750.

Fall prevention in older adults

27. Reed-Jones RJ, Solis GR, Lawson KA} Loya AM, Cude-lslas D, Berger CS. Vi­ sion and falls: a multidisciplinary review of the contributions o f visual im­ pairment to falls among older adults. Maturitas. 2013;75( 1):22-28. 28. Leveille SG, Jones RN, Kiley DK, et al. Chronic musculoskeletal pain and the occurrence o f falls in an older population. JAMA. 2009;302(20):22142221 . 29. Chaiwanichsiri D, Janchai S, Tantisiriwat N. Foot disorders and falls in older persons. Gerontology. 2009;55(3):296-302. 30. Foley AL, Loharuka S, Barrett JA, et al. Association between the geriatric gi­ ants of urinary incontinence and falls in older people using data from the Leicestershire MRC Incontinence Study. Age Ageing. 2012;41(l):35-40. 31. Sherman C. Determining the cause of fainting spells. Clinical Advisor. 2007;10(3):87-92. 32. Brignole M. Distinguishing syncopal from non-syncopal causes o f fall in older people. Age Ageing. 2006;35(suppl 2):ii46-ii50. 33. American Geriatrics Society, British Geriatrics Society 2010. AGS/BGS clini­ cal practice guideline: prevention of falls in older persons. New York, NY: American Geriatrics Society; 2011. 34. Waldron N, Hill AM, Barker A. Falls prevention in older adults— assessment and management. Aust Fam Physician. 2012;41(12):930-935.

39. Smith T, Gildeh N, Holmes C. The Montreal Cognitive Assessment: validity and utility in a memory clinic setting. Can J Psychiatry. 2007;52(5):329-332. 40. Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fallprone patient. Canadian Journal on Aging. 1989;8:366-377. 41. Schwendimann R, De Geest S, Milisen K. Evaluation of the Morse Fall Scale in hospitalised patients. Age Ageing. 2006;35(3):311-313. 42. Agashivala N, Wu WK. Effects of potentially inappropriate psychoactive med­ ications on falls in US nursing home residents: analysis of the 2004 National Nursing Home Survey Database. Drugs Aging. 2009;26(10):853-860. 43. Kojima T, Akishita M, Nakamura T, et al. Association of polypharmacy with fall risk among geriatric outpatients. Geriatr Gerontol Int. 2011;11(4):438-444. 44. Maciaszek J, Osi_ski W. The effects of Tai Chi on Body Balance in Elderly People— a review of studies from the early 21st century. Am J Chin Med. 2010;38(2):219-229. 45. Li F, Harmer P, Stock R, et al. Implementing an evidence-based fall prevention program in an outpatient clinical setting. J Am Geriatr Soc. 2013;61(12):21422149. 46. Johnson CS. The association between nutritional risk and falls among frail elderly. J Nutr Health Aging. 2003;7(4):247-250.

35. Salzman B. Gait and balance disorders in older adults. Am Fam Physician. 2010;82(l):61-68.

Scott J. Saccomano is an assistant professor at Herbert H. Lehman College, De­ partment of Nursing, Bronx, N.Y.

36. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34(2):119-126.

Lucille R. Ferrara is an associate professor, director Family Nurse Practitioner Program at Pace University, College of Health Professions, Pleasantville, N.Y.

37. Campbell AJ, Robertson MC. Fall prevention: single or multiple interventions? Single interventions for fall prevention. / Am Geriatr Soc. 2013;61(2):281-287. 38. Barbour KE, Stevens JA, Helmick CG, et al. Falls and fall injuries among adults with arthritis— United States, 2012. M M W R Morb Mortal Wkly Rep. 2014;63( 17):379-383.

The authors and planners have disclosed no potential conflicts of interest, finan­ cial or otherwise. DOI-10.1097/01

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L ip p in c o t t W illia m s & W ilk in s , p u b lis h e r o f The N urse P ractitio ner

t io n fe e o f $ 2 1 .9 5 t o : L ip p in c o t t W illia m s & W ilk in s ,

jo u r n a l, w i l l a w a r d 2 .0 c o n t a c t h o u r s f o r t h is c o n t in u in g n u r s in g

CE G r o u p , 7 4 B ric k B lv d ., B ld g . 4 , S u ite 2 0 6 , B ric k , N J

e d u c a t io n a c tiv ity .

0 8 7 2 3 . W e w ill m a il y o u r c e r tific a te in 4 t o 6 w e e k s .

L ip p in c o t t W illia m s & W ilk in s is a c c r e d ite d a s a p r o v id e r o f c o n t in u in g

F o r fa s t e r s e r v ic e , in c lu d e a fa x n u m b e r a n d

n u r s in g e d u c a tio n b y t h e A m e r ic a n N u rs e s C r e d e n tia lin g C e n te r's C o m m is ­

w e w ill fa x y o u r c e r tific a te w it h in 2 b u s in e s s d a y s o f

s io n o n A c c r e d it a tio n .

r e c e iv in g y o u r e n r o llm e n t f o r m .

T h is a c t iv it y is a ls o p r o v id e r a p p r o v e d b y t h e C a lif o r n ia B o a r d o f

• Y o u w i l l re c e iv e y o u r CE c e r t if ic a t e o f e a r n e d c o n ­

R e g is te r e d N u r s in g , P r o v id e r N u m b e r C EP 1 1 7 4 9 f o r 2 .0 c o n t a c t h o u r s .

ta c t h o u r s a n d an a n s w e r k e y t o r e v ie w y o u r re s u lts .

L ip p in c o t t W illia m s & W ilk in s is a ls o a n a p p r o v e d p r o v id e r o f c o n t in u in g

T h e r e is n o m in im u m p a s s in g g r a d e .

n u r s in g e d u c a t io n b y t h e D is t r ic t o f C o lu m b ia a n d F lo r id a # 5 0 -1 2 2 3 .

• R e g is tr a tio n d e a d lin e is J u n e 30, 2 0 17.

Y o u r c e r t if ic a t e is v a lid in a ll s ta te s .

The Nurse Practitioner

June 2015


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Fall prevention in older adults.

Falls in older adults are a major public health concern and can often have fatal results. Practitioners need to be aware of assessment and diagnostic ...
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