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Each year, about 16,000 deaths result from unintentional falls in the United States, about 75% of which occur in people over the age of 64. In addition, non-fatal falls account for about a half million hospitalizations among seniors and nearly 2 million emergency department visits. Unfortunately, many physicians may not always recognize risks of falling among their patients or prescribe measures to prevent falls. There are often grave consequences of falls—among the most serious of which are traumatic brain injuries as well as hip and other fractures—which in turn can lead to hospitalization, loss of independence, and even death.

In the February 2008 issue of Neurology, the American Academy of Neurology (AAN) released guidelines to help neurologists identify patients at increased risk of fall-related injuries. The guidelines call for regular screening of at-risk patients with neurologic problems, specifically those with stroke, dementia, and disorders of gait and balance. Although recent evidence-based guidelines have been published for reducing fall risks for older people, they do not fully address the increased risks among patients with chronic neurologic conditions and don’t fully evaluate screening methods for this patient group.

Who Should Be Screened?

Patients with dementia, stroke, gait and balance disorders, Parkinson’s disease, peripheral neuropathy, lower extremity weakness, sensory loss, and substantial vision loss are at the highest risk for falls. Other general risk factors include advanced age, age-associated frailty, arthritis, impaired activities of daily living, depression, and the use of psychoactive medications (eg, sedatives, antidepressants, and neuroleptics). In general, the AAN guidelines recommend that these patients be screened regularly for their risk of falls.

Several screening tools are available to help physicians identify patients’ risk of falls. The AAN guidelines recommend that doctors routinely ask at-risk patients about recent falls. Recent falls and other risk factors indicate a need for further assessment of neurological function, especially: (1) balance and gait; (2) lower extremity strength, sensation, and coordination; (3) cognition; and (4) vision. Brief standardized screening measures such as the Get-Up-and-Go Test or the Timed-Get-Up-and-Go Test are helpful tools, especially when time is limited as with follow-up office visits. These assessments are quick to administer and can determine the likelihood of falls and the need for prevention help.

Preventing Future Falls

To the greatest extent possible, any underlying neurologic conditions should be treated first. All drugs that patients are taking—both prescription and over-the-counter—need to be carefully reviewed, and the use of psychoactive drugs should be minimized where possible. Depending on the underlying neurologic disorder, exercise programs and balance training may be of benefit, with a focus on strength and flexibility in the lower extremities. Other helpful interventions may include having patients meet with physical therapists and, as needed, train with assistance devices such as a cane or walker. Home assessments may help reduce environmental hazards. Partnering with geriatricians, orthopedists, and physical therapists can be of great benefit.

Open the Dialogue

Perhaps the most important action physicians can take is to routinely ask patients at risk for falls about their fall history and if they have any fears of falling. At each visit, physicians should ask if patients have fallen in the last year, how many falls have occurred, and about the circumstances of the falls. This may help guide physicians to the type of prevention measure needed. Even fears of falling are important: patients often have a sense of their physical instability and may convey that they don’t feel secure with their mobility. While seemingly simple, this open dialogue with patients is important; it may lead to reducing the burden of fall-related injuries and deaths and enhancing quality of life.

David J. Thurman, MD, MPH has indicated to Physician’s Weekly that he has no financial interests to report.