Falls are very common in the geriatric population. They are the leading cause of injury and death by injury in adults over the age of 65 years (Lee, 2013, p.37). Falls can have devastating results in the geriatric population. Fear of falling is a defined geriatric syndrome that may contribute to further functional decline in an already frail patient. When people experience something unpleasant, their natural response is an aversion to that experience. People may begin to limit their activities after a fall or as they become weaker and less agile with increasing age. This leads to a more sedentary lifestyle and physical atrophy, which further predisposes them to falls (Lee, 2013, p.37).
According to Al-Aama (2011):
A fall is a complex multifactorial phenomenon. In order to understand the mechanism of falls, it is essential to understand the prerequisites of normal gait. Essential substrates for a normal gait include fine neural networks such as the cortical–basal ganglia loop and the basal ganglia–brainstem system, exquisite musculoskeletal structures with appropriately regulated muscle tone, and proper processing of sensory information (p. 772).
A fall in the geriatric population could be the result of various long-term or short-term factors. A short-term factor could include an acute illness or an adverse drug reaction. Normal gait and balance requires freely moving joints; muscles contracting at the right time with the appropriate strength; and accurate visual, vibratory, and proprioceptive input. As patients age, they may experience stiffened joints, decreased muscle strength, and impaired neurologic feedback (Lee, 2013, p.37). These factors, along with other risk factors, increase the chance of a fall. Medications are a well-established risk factor for falls. Medication classes that have been associated with an increased risk of falls include the following: antihypertensive agents, sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (Al-Aama, 2011, p.773).
According to Al-Aama (2011):
Independent risk factors for falling include the following (arranged in order of evidence strength): previous falls, balance impairment, decreased muscle strength, visual impairment, polypharmacy (more than 4 medications) or psychoactive drugs, gait impairment and walking difficulty, depression, dizziness or orthostasis, functional limitations, age older than 80 years, female sex, incontinence, cognitive impairment, arthritis, diabetes, and pain (p.772).
The most important step to take in preventing falls is discussing the history of falls with the patient. In 2010, the American and British geriatrics societies released updated clinical practice guidelines for fall prevention in older adults. The guidelines state that all patients age 65 years or older should be asked yearly about previous falls (Lee, 2013, p.37). These guidelines urge physicians to screen their patients yearly and implement interventions for patients at risk. Some actions should be taken to help patients that are at a high risk for falls. It is important to ask about the patient’s history of falling. It is also important to perform an assessment of the patient’s physical and functional abilities. It is also recommended to also perform an examination of their feet and footwear, their home, cognitive evaluation, and visual acuity exam.
Interventions can be used alone or combined together. There are various options of interventions to help prevent falls in home and in hospitals. Vitamin D supplementation could help at risk patients. Moreover, vitamin D supplementation is the only intervention that has been shown to decrease the rate of falls in long-term care (Al-Aama, 2011, p.773). Exercise and physical therapy that are aimed at improving balance, gait, and strength have helped prevent falls in the geriatric population. Tai Chi is a low-impact exercise that combines strength and balance training. Tai Chi can help prevent falls and also has other health benefits. Medications can also help prevent falls, even though some medications increase the risk of falls. Gradual withdrawal of psychotropic medication reduces the rate of falls, and a prescribing modification program implemented by primary care physicians substantially reduces the risk of falling among elderly patients. However, great caution and patience should be exercised when weaning patients off medications, particularly when they have been used chronically (Al-Aama, 2011, p.773-774).
Assessing visual problems and trying to correct the problem can help prevent falls. Visual impairment is an important risk factor for falls. However, a comprehensive vision assessment and management program that resulted mainly in new eyeglasses prescriptions found an increased rate of falls, particularly in the first few months, perhaps owing to difficulty adjusting to new glasses or to increased activity (Al-Aama, 2011, p.774). Elder individuals that wear multifocal lenses are more likely to fall than those that do not wear multifocal lenses. Providing older people who are active outdoors with single-lens distance glasses reduces falls (Al-Aama, 2011, p.774).
Cardiac pacing is also another intervention that can help prevent falls. One study addressed dual-chamber pacing in patients with cardioinhibitory carotid sinus hypersensitivity (defined as 3 or more seconds of asystole after carotid massage) and unexplained falls. Pacing resulted in a reduction in the total number of falls by more than two-thirds (Al-Aama, 2011, p.774).
Home safety can help prevent falls in geriatric patients. Home safety is a primary prevention for those who are at a higher risk. Home modifications can help patients while they are home. A physician may ask an occupational therapist to go to the patient’s home and provide services. Occupational therapists can help the patient with by giving information on fall prevention and instructing how to do certain things safely. Geriatric patients can make their home safe by getting rid of items that they could potentially trip over. Grab bars are another item that could help the patient in their home. Adding grab bars on the inside and outside of their tub or shower can help prevent falls before and after bathing. Grab bars beside the toilet can help an elder person up after using the bathroom and prevent falling. Rails on both sides of the stairs and more lightening is also recommended.
Physicians and other health care team members should be aware that in hospitals, nurses perform fall prevention assessments for every patient using standardized tools. Tools for assessing risk for falls include: the Morse Fall Scale, the Hendrich II Fall Risk Model, the Briggs Risk Assessment Form, and the Conley Risk Assessment Tool, among others (Lee, 2013, p.38).
Kaiser Permanente uses the Schmid Fall Assessment Tool. It involves evaluation of the patient’s mobility, mentation, toileting, fall history, and use of psychoactive medications (Lee, 2013). Some interventions that are used in the hospitals are: appropriate reorientation strategies, access to patient’s hearing aids or glasses, call bell, access to patient’s personal items, use of patient’s walking aids, frequent comfort rounds, patient and family education about fall risk, early and frequent mobilization, nonslip footwear, elimination of barriers to transfer or ambulation, minimization of use of restraints, and use of bed alarm when necessary (Lee, 2013, p.38).
Given the devastating effects falls have on patients and the increased burden on family members and the health care system, screening and assessment for fall risk are paramount priorities. Screening may be easily performed in the ambulatory and hospital settings, with simple interventions producing meaningful results. Physicians should coordinate with other health care team members to provide effective multifactorial interventions to their patients. With each fall that is prevented, the patient, their family members, the health care team, and the health care system all benefit (Lee, 2013, p.39).

References
Al-Aama, T. (2011). Falls in the elderly: Spectrum and prevention. Canadian Family Physician, 57(7), 771–776. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135440/
Lee, A., Lee, K.-W., & Khang, P. (2013). Preventing Falls in the Geriatric Population. The Permanente Journal, 17(4), 37–39. http://doi.org/10.7812/TPP/12-119