SPECIAL SERIES: CLINICAL PRACTICE

JAGS 49:664–672, 2001

© 2001 by the American Geriatrics Society

0002-8614/01/$15.00

Guideline for the Prevention of Falls in Older Persons

American Geriatrics Society, British Geriatrics Society, and American Academy of

Orthopaedic Surgeons Panel on Falls Prevention

Key words: falls; risk of falling; fall assessment; fall inter-

vention; fall prevention

BACKGROUND AND SIGNIFICANCE

Falls are among the most common and serious problems

facing elderly persons. Falling is associated with consider-

able mortality, morbidity, reduced functioning, and pre-

mature nursing home admissions.

1–5

Falls generally result

from an interaction of multiple and diverse risk factors

and situations, many of which can be corrected. This inter-

action is modified by age, disease, and the presence of haz-

ards in the environment.

6

Frequently, older people are not

aware of their risks of falling, and neither recognize risk

factors nor report these issues to their physicians. Conse-

quently opportunities for prevention of falling are often

overlooked with risks becoming evident only after injury

and disability have already occurred.

7–9

Both the incidence of falls and the severity of fall-

related complications rise steadily after age 60. In the age

65-and-over population as a whole, approximately 35% to

40% of community-dwelling, generally healthy older per-

sons fall annually. After age 75, the rates are higher.

10,11

Incidence rates of falls in nursing homes and hospitals

are almost three times the rates for community-dwelling

persons age

65 (1.5 falls per bed annually). Injury rates

are also considerably higher with 10% to 25% of institu-

tional falls resulting in fracture, laceration, or the need for

hospital care.

12

Fall-related injuries recently accounted for

6% of all medical expenditures for persons age 65 and

older in the United States.

12,13

A key concern is not simply the high incidence of falls

in older persons (young children and athletes have an even

higher incidence of falls) but rather the combination of

high incidence and a high susceptibility to injury. This pro-

pensity for fall-related injury in elderly persons stems from

a high prevalence of comorbid diseases (e.g., osteoporosis)

and age-related physiological decline (e.g., slower reflexes)

that make even a relatively mild fall potentially dangerous.

Approximately 5% of older people who fall require hospi-

talization.

14

Unintentional injuries are the fifth leading cause of

death in older adults (after cardiovascular, neoplastic, cere-

brovascular, and pulmonary causes), and falls are responsi-

ble for two-thirds of the deaths resulting from uninten-

tional injuries. More pointedly, 75% of deaths due to falls

in the United States occur in the 13% of the population age

65 and over.

15

In addition to physical injury, falls can also

have psychological and social consequences. Recurrent falls

are a common reason for admission of previously indepen-

dent elderly persons to long-term care institutions.

16,17

One

study found that falls were a major reason for 40% of

nursing home admissions.

14

Fear of falling and the post-fall

anxiety syndrome are also well recognized as negative con-

sequences of falls. The loss of self-confidence to ambulate

safely can result in self-imposed functional limitations.

1,18

RISK FACTORS FOR FALLING

As detailed in Table 1, a number of studies have identified

risk factors for falling. These can be classified as either in-

trinsic (e.g., lower extremity weakness, poor grip strength,

balance disorders, functional and cognitive impairment, vi-

sual deficits) or extrinsic (e.g., polypharmacy (i.e., four or

more prescription medications) and environmental factors

such as poor lighting, loose carpets, and lack of bathroom

safety equipment). Although investigators have not used

consistent classifications, a recent review of fall risk factor

studies ranked the risk factors and summarized the relative

risk of falls for persons with each risk factor (Table 1).

11

In

addition, a meta-analysis that studied the relationship of

falls and medications, which included studies that examined

both multiple and single risk factors, found a significantly

increased risk from psychotropic medication (odds ratio

(OR)

1.7), Class 1a antiarrhythmic medications (OR

1.6), digoxin (OR

1.2), and diuretics (OR

1.1).

32

Perhaps as important as identifying risk factors is ap-

preciating the interaction and probable synergism between

multiple risk factors. Several studies have shown that the

risk of falling increases dramatically as the number of risk

factors increases. Tinetti et al. surveyed community-dwell-

This guideline was developed and written under the auspices of the Ameri-

can Geriatrics Society (AGS) Panel on Falls in Older Persons and approved

by the AGS Board of Directors on April 5, 2001.

Address correspondence and reprint requests to: Nancy Lundebjerg, Senior

Director, Professional Education and Publications, American Geriatrics

Society, 350 Fifth Avenue, Suite 801, New York, NY 10118.