Make the Diagnosis: Will This Patient Fall?
The clinical examination can be used to identify patients who are most likely to experience a fall. Falls are common, affecting 27% (95% confidence interval [CI] 19%-36%) of community-dwelling adults age 65 and over each year.1 Multiple falls (2 or more) are less common (frequency 10%, 95% CI 7%-15%).1
Population in Whom the Risk of a Fall Should Be Assessed
All patients, beginning at about age 65, should be assessed for their future fall risk. Patients who use an assistive device to facilitate mobility, who take many (or certain high-risk) medications, or who are affected by orthostatic hypotension, visual impairment, impairment of gait or balance, limitations in activities of daily living, and cognitive impairment should be asked about falls. However, it should be noted that these seemingly obvious risk factors for falls are not necessarily causal so that correcting the problem may not decrease the overall risk of a future fall. While all adult inpatients should be assessed for the risk of falling, this chapter focuses on predicting falls in older outpatients.
Assessing the Likelihood of a Future Fall
Patients with dementia or a clinically evident prior stroke are much more likely to experience a future fall (likelihood ratio [LR] range 15-17) than those without dementia (Table 66-1), however normal cognition does not lower the risk of an older patient falling. Patients with previous falls have an increased likelihood of continuing to fall (Table 66-1). A patient who perceives he or she has a mobility problem or who has a mobility problem detected by his or her clinician is also more likely to fall; the mobility problem can be detected by observing how the patient rises from a chair, having the patient perform a tandem stance, tandem walk, or by detecting a slow walking pace. Vibratory testing can be assessed while the patient is sitting (absent vibratory sense in the feet has an LR of 2.1 for predicting 2 or more falls in the subsequent year). Vibratory sensation is detected with a vibrating tuning fork. Vibration and position sense (proprioception) are associated, as both are mediated through the dorsal columns
Table 66-1Useful Findings for Predicting Falls ||Download (.pdf) Table 66-1 Useful Findings for Predicting Falls
|Finding ||LR+ (95% CI) or Range ||LR- (95% CI) or Range |
| ||LRs for at least 1 fall over the ensuing year |
|Dementia or clinically evident prior stroke ||15-17 ||0.91-0.99 |
|Unable to rise from a chair of knee height without using chair arms ||4.3 (2.3-7.9) ||0.77 (0.66-0.90) |
|History of a fall in the past month ||3.8 (2.2-6.4) ||0.84 (0.77-0.92) |
|Self-perceived mobility problem or abnormal tandem stand ||1.7-2.0 ||0.69-0.74 |
| ||LRs for frequent falls (>1) over the ensuing year |
|Dementia ||13 (2.3-79) ||0.97 ...|