Worried about falls in an older parent or relative? If so, do you know if their doctor has considered the most useful prevention approaches?
Fall risk can be reduced, but it generally takes some thought and effort. That’s in part because most older adults have multiple factors making them vulnerable to falls.
In a related article on this site, I’ve explained that best fall prevention plans involve identifying an older person’s particular risks — especially risks related to health conditions — and trying to counter those.
So for instance, if an older person has diabetes and is having frequent moments of low blood sugar (also known as hypoglycemia), then to reduce falls, addressing the hypoglycemia is as important, if not more, as starting an exercise program.
In other words, I always recommend that aging adults and families learn to tailor their fall prevention plans. You want to focus on what are the most important modifiable risk factors for that individual person.
That said, over the years I’ve noticed that there are four approaches that I find myself using over and over again, in almost all my patients who have had repeated falls.
These four approaches are used often by geriatricians, but much less often by busy primary care doctors. Unless, that is, a proactive family asks about them.
My Four Most-Used Fall Prevention Approaches
They are:
- Medication review, followed by reducing medications that increase fall risk.
- Checking blood pressure (BP) sitting and standing.
- This to make sure that BP isn’t overall on the low side (e.g. sitting systolic BP less than 120), and also that it’s not dropping a lot when the older person stands up.
- Gait, strength, and balance evaluations, often in collaboration with physical therapy.
- An evaluation often confirms that an older adult has poor balance and diminished leg strength. Doing exercises specifically designed to improve balance and strength, such as the Otago program, can counter this.
- Home safety assessment and modification, in collaboration with occupational therapy when possible.
- An occupational therapy evaluation usually needs to be ordered by a health provider, as part of skilled home health services.
- The Occupational Therapy Geriatric Group at the University at Buffalo also offers an excellent free home safety workbook here: Home Safety Self-Assessment Tool (HSSAT)
You can hear me explain these four approaches in the related podcast episode embedded below. (Click the magnifying glass for a searchable transcript.)
What about Vitamin D for fall prevention?
I do still recommend that most older adults take a vitamin D supplement, however, I no longer particularly recommend it for fall prevention.
Vitamin D used to be my fifth general recommendation for fall prevention. Even though it seemed the effect on falls reduction was small, at least it’s an easy thing to implement, and a daily dose of 800-1000 IU/day is extremely unlikely to cause harm.
However, the accumulating research evidence has been suggesting that Vitamin D supplementation has no benefit, when it comes to preventing falls. (At least, not in “community-dwelling” adults over age 65, which means older adults who are not in the hospital or in nursing homes.)
In 2018, the US Preventive Services Task Force recommended against Vitamin D supplementation to prevent falls in community-dwelling older adults.
Caveat: they say “Recommendations apply to community-dwelling adults not known to have osteoporosis or vitamin D deficiency.”
That is actually a fairly large group to exclude, given that both osteoporosis and vitamin D are fairly common.
Since vitamin D is unlikely to cause harm and may help some older adults, I still recommend it, just not specifically for fall prevention.
For more, see Vitamin D: the Healthy Aging Dose(Plus Answers to 7 FAQs).
Review your fall prevention plan if you’ve fallen or been concerned!
Perhaps the most important strategy to apply is to be proactive in getting help with falls.
Research has found that older adults often don’t report falls to their health providers. Worse yet: when they do, health providers often fail to provide adequate evaluation and management in response.
So, although it’s good to tell your doctor if you’ve fallen, it’s even better to do a little homework and be ready to ask about the four fall prevention approaches I’ve listed in this article:
- Medication review, followed by reducing medications that increase fall risk
- Checking blood pressure sitting and standing
- Gait, strength, and balance evaluations, often in collaboration with physical therapy
- Home safety assessment and modification, in collaboration with occupational therapy when possible
Here are some related articles to help you:
- 8 Things to Have the Doctor Check After an Aging Person Falls
- Preventing Falls: 10 Types of Medications to Review if You’re Concerned About Falling
- Why Older People Fall & How to Reduce Fall Risk
If you want to equip yourself to be even more proactive, you can learn more about how your health providers should be addressing falls on the CDC’s STEADI website.
I’ve also recently compiled a Fall Prevention Resource Guide, click the link below to get your free copy of this PDF resource. It’s short and lists my top recommended online fall prevention resources, so that you have a way to find them fast.
With some gentle reminders from you and others, your health providers will do a better job helping you reduce falls.
Questions or comments? Post them below!
This article was revised and updated on 9/25/20.
My grandma has been prone to falls as of late. We want to try to protect her as best we can. We didn’t know that there was so much we could do. We’ll be sure to follow the tips you gave to try and provide her with some fall protection.
I’ve really enjoyed reading your blog over the past year. I stumbled upon it when got more focused on the problems that seniors have with mobility and injuries, and I was immediately hooked by your focus on senior wellness. I really enjoyed your post about fall prevention. When dealing with senior’s like my grandparents and their friends, it was no surprise to see the same challenges facing them every day. One of the biggest problems I notice with my grandparents is their mobility starting to slow down.
Hello Dr Kernisan,
I am student and currently working on an a weareable sock with grips to prevent falls for elderly. Please give some idea about which exact parts of your sole needs grip or strength while walking and which areas on our sole slip?…………. Thankyou
As an internist and geriatrician, I’m not expert on just which part of the foot requires grip or strength. You could try asking someone specialized in physical therapy or podiatry. We do generally recommend non-slip footwear, to help reduce the risk of falls.
May I add, many seniors have difficulty pulling on socks due to knee problems, arthritis and other issues. Plus many are not wearing grippy footwear to bed so they are at risk of slipping when getting up in the night.
Because of all that, many wear a “slide” style of shoe, which can certainly help, but they can be floppy and not hold the foot well. And many of these have inadequate slip resistance.
A very easy to slip on shoe that holds the foot (maybe somewhat grippy on the insole) as well as slip resistant on the sole is something to consider.
Another factor is that many elderly people shuffle their feet, so something too grippy causes problems too.
I’m no expert, these are just observations. Innovations are needed, but there’s a lot to consider. Start hanging out at senior centers–you’ll learn a lot!
It is a common error to believe that the more grip the less falls. It isn’t just a matter of maximizing friction but of getting it about right since walking, whether on stairs or on the level, has gliding components.
Your efforts would be better if applied to anti-slip treatments to use under rugs. Various approaches and each could be improved or delivered better – kitchen drawer liners, spray, purpose-designed mats, floor wax (and wax removal), etc.
Can you enlighten me on your #5 on the list? How does this relate to falls?
I am trying to get a bigger picture on all the aspects of fall risks since my background is in Physical Therapy I would like more insight into the medication/medical aspects on fall risk.
Thanks
Research at one point suggested that vitamin D supplementation might help reduce fall risk in community dwelling adults, so the US Preventive Services Task Force and other experts recommended it for fall prevention, in their 2012 recommendations.
However, the latest reviews of the research are concluding that vitamin D is not actually very effective in reducing falls. The USPSTF is updating its recommendations and the draft recommends against vitamin D for falls.
I think it’s still useful for older adults to take a vitamin D supplement, mainly to prevent deficiency. It’s unclear just what the health effect of vitamin D deficiency is, but as it’s inexpensive and extremely low risk when taken as a supplement of 800-1000 IU, I still recommend it.
For more on medications and falls, see: Preventing Falls: 10 Types of Medications to Review if You’re Concerned About Falling
There are glaring problems with some of these “in community” studies showing no effectiveness for vitamin D supplementation in preventing falls, since most falls aren’t reported unless there’s a hospital visit and compliance with supplementation is by recollection of the senior. Residential elderly are much easier to gain accurate information on and showed enormous reduction in falls, along with an array of other health benefits provided by D.
The dosages used in most of these studies illustrate why they found no benefits, even though the literature supports the use of D for improving skeletal muscle strength and bone density.
“Five trials reported mixed findings. Only 1 trial showed a statistically significant reduction in falls; however, another study using high doses of vitamin D (500,000 IU per year) showed a statistically significant increase in falls). Pooled analyses showed neither a significant reduction in falls nor a significant effect on the number of persons experiencing a fall with vitamin D supplementation Only 2 trials reported on the number of injurious falls; 1 trial using an annual high dose of vitamin D reported an increase in injurious falls (and the other trial reported no statistically significant difference, Only 1 trial reported on fractures and found a nonsignificant increase in fractures with vitamin D supplementation Four trials reported mixed results on the number of persons experiencing a fracture. Vitamin D formulations and dosages varied among trials. Five trials used cholecalciferol at doses of 700 IU per day, 800 IU per day, 150,000 IU every 3 months, or 500,000 IU per year; 1 trial used 1-hydroxycholecalciferol (1 μg per day) and another used calcitriol (0.25 μg twice per day).” These are either way too low, or way too high, when the Goldilocks effect on D supplementation to be helpful is 2000 to 5000 iu daily.
“Studies conducted solely in populations with specific medical diagnoses that could affect fall-related outcomes or for which interventions could be considered disease management (eg, osteoporosis, vitamin D deficiency, visual impairment, and neurocognitive disorders) were excluded. Five studies on vitamin D supplementation reported no difference in the frequency of harms between intervention and control groups. However, as mentioned previously, the study using the highest dose of vitamin D (500,000 IU per year) reported an increase in falls, injurious falls, and the number of persons experiencing falls. Other reported harms were rare and included kidney stones, diabetes, transient hypercalcemia, and hypercalciuria; it was unclear if these rare harms were attributable to vitamin D supplementation. However, in a separate evidence review commissioned by the USPSTF on vitamin D supplementation to prevent fractures, the incidence of kidney stones increased with combined vitamin D and calcium.”
The one study cited that did find fall reduction benefits from D and sex hormone supplementation, was not used in the studies that found no benefits, which is actually almost criminal, considering their astounding findings. “Compared to the lowest quartile, men and women in the highest sex-specific quartile of total testosterone had a 78% and 66% decreased risk of falling if those individuals also took calcium plus vitamin D the anti-fall effect was enhanced to 84% among men and 85% among women Women in the top quartile of dihydroepiandrosterone sulfate (DHEA-S) had a significant 61% lower risk of falling compared to those in the lowest quartile. Other sex hormones and SHBG did not predict falling in men or women.
Conclusion
Higher physiologic total testosterone in both genders and higher DHEA-S levels in women predicted a more than 60% lower risk of falling. The anti-fall benefit of higher physiologic testosterone levels is enhanced to over 80% by additional calcium and vitamin D supplementation.” These researchers gave only 700 iu per day, so most of the benefits appear to be from testosterone and DHEA-S blood levels.
Thanks for your comment. I wasn’t able to review all of the studies that you mention, but my experience in practice is that we don’t use hormone replacement very often because of potential side effects.
The researchers in that study did not use hormone replacement tx either, but the association with falls reduction and hormone levels was so strong, that it should be considered for those most at risk of falls, with measurable low levels. Considering the extreme risk of falling for those over 85 vs heart attacks/ strokes/ cancers is valid, but reportedly these “side effects” are from synthetic hormones not bio-identical hormones. There are diet and exercise methods for improving hormone levels as we age that could bypass that concern.
I would like to do physical therapy for a back situation I had. However – my insurance co-payment is $40 per session!!! Any suggestions as to how I could get my co-payment down without a major increase in price to my monthly insurance premium?
Hi Sandra and I’m sorry that I don’t have any advice about your health insurance.
I practice in Canada where there are many uninsured services despite our socialized system. I sometimes suggest to advise my patients’ families to consider contributing to a “health fund” rather than buy gifts for holidays and birthdays. It can be a good investment in future health.
Excellent article. But, I have different kind of approach that can manage such kind of situation. Likewise,
1. Avoid stress
2. Drink plenty of water,
3. No smoking
4. Regular exercise
5. Eat healthy foods
Those are certainly healthy lifestyle habits, very good for health in general. Only certain types of exercises are well proven to reduce fall risk.
Yes Leslie, Along with regular exercise like walking and running, practicing yoga is also good. I have found an article regarding this entitled’ “21 Yoga Poses for Anti Aging – Yoga Turns the Clock Back” at zovon.
Joshua Miller … all good advice, but am not sure that it can be accomplished in later years; for instance, at ages 70+ and already in a more frail state than younger folks due to poor health and various medications for such.
Begin those good practices while younger – one won’t become fragile so quickly.
Leg strength, walking speed and rising from seated to standing position are great predictors of future disability and likelihood of falls. Balance and strengthening exercises don’t have to be strenuous to gain improvement, just a routing healthy habit. That’s the hard part apparently, changing habits, so better not to have too daunting a goal for now sedentary seniors.
Isn’t that just general advice for healthy living?
I am 84 and I am sure that my falls are caused by my not lifting my big size l0 feet, so I catch a toe of
my shoe on a crack in the pavement. I need to focus on raising my feet when I walk, and also on
watching the ground when I walk.
I have size 10 feet too 🙂
It’s possible that you aren’t lifting your feet enough and this could contribute to falls. But in most older adults, there are multiple factors causing falls. So I would recommend letting your health providers know about your falls. The CDC STEADi website describes how providers should evaluate and manage falls. I also cover this in my fall prevention mini-course. Good luck!
I am 85 years old and have practiced yoga most of my adult life. However, a few months ago I realize I was having difficulty getting up from the floor after a yoga pose.
After some research, I realized I was losing leg strength. I started holding on to a counter for support, and bending my knees toward the floor in a squat position. I gradually gained strength over a few months by doing this daily.
I can now do a full squat and back up with no arm support. A little bit daily can make a bit difference and give confidence in walking.
Hi Thelda and thanks so much for sharing your success story! That’s commendable that you found a way to regain strength through exercise. The routine you describe reminds me of the Otago exercises. Your advice about daily exercise is so spot on. Keep going!
My “over-80” methods: I never go for a walk without my gardening knee pads on (pinned to my pants leg to prevent them working their way down) and a cane-chair in hand (a cane which unfolds into a three legged chair which I can use to get myself back up (pushing up from the chair seat) after a fall AND use to break a fall if I find myself tipping forward.
Hi Dotty and thanks for sharing those tips! I love to hear about ways that older adults have found to stay active and mobile. I hope you never need to use those devices!
When I see someone in my Geriatrics office who is having “near falls”, I do a work up that’s similar to what I would do in an actual fall, as Dr. Kernisan shares in this article.
I am 81 and had a bad fall walking down a wet aluminum ramp. I was being careful and holding the railing. This could have been prevented by my assessing the situation as dangerous and not walking down the ramp. The fall has made me overly careful when walking on wet surfaces. Using common sense is important in avoiding falls!
I’m so sorry to hear about your fall, Amy Jo and you’re right that being careful is a big part of moving safely. Don’t be too hard on yourself though. We have all had careless moments that led to hours of regret!