Fall Risk: Comprehensive Geriatric Assessment

Clinical meaning

Fall risk assessment in geriatric patients requires a multidimensional approach that goes beyond a single screening tool. The NP performs a COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) that evaluates multiple interacting domains contributing to fall risk. GAIT AND BALANCE: age-related changes (sarcopenia, decreased proprioception, vestibular decline, slowed righting reflexes) combined with pathological conditions (Parkinson's disease, peripheral neuropathy, stroke, osteoarthritis, spinal stenosis) create compound gait impairment. Validated assessment tools include: Timed Up and Go (TUG) -- ≥12 seconds indicates impaired mobility; 30-Second Chair Stand Test -- evaluates lower extremity strength; 4-Stage Balance Test (feet together, semi-tandem, tandem, single-leg) -- inability to hold tandem for 10 seconds indicates balance impairment; gait speed -- <0.8 m/s predicts falls, hospitalization, and mortality. COGNITION: executive function impairment (planning, attention, dual-tasking) is a STRONGER predictor of falls than memory impairment; cognitive-motor dual-task testing (walking while performing a cognitive task) reveals fall risk that single-task assessments miss; delirium is an acute, reversible cause of both cognitive impairment and falls. VISION: corrected visual acuity, depth perception, contrast sensitivity, and peripheral vision all affect fall risk; multifocal lenses (bifocals, progressive lenses) impair depth perception on stairs and uneven surfaces; cataracts, macular degeneration, glaucoma, and diabetic retinopathy each affect different visual domains relevant to falls. CARDIOVASCULAR: orthostatic hypotension (prevalence 30-50% in elderly), postprandial hypotension, carotid sinus hypersensitivity, and cardiac arrhythmias (particularly bradyarrhythmias and intermittent heart block) cause syncope and near-syncope contributing to falls. MUSCULOSKELETAL: sarcopenia (age-related muscle mass and strength loss), osteoarthritis limiting range of motion, foot deformities (bunions, hammer toes) impairing balance, and inappropriate footwear. CONTINENCE: urinary urgency and nocturia drive patients to rush to the bathroom; anticholinergic bladder medications worsen cognition; urinary tract infections cause confusion and delirium in elderly.

Diagnosis & workup

Diagnostics & workup: - Multifactorial fall risk screening: the CDC STEADI (Stopping Elderly Accidents, Deaths, and Injuries) algorithm provides a structured approach: (1) screen -- ask 3 key questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? (2) assess -- if any screen is positive, perform gait/balance/strength testing and comprehensive assessment, (3) intervene -- implement evidence-based interventions targeted to identified risk factors - Timed Up and Go (TUG) test: time from sitting in a standard chair, rising, walking 3 meters at usual pace, turning, walking back, and sitting; normal <12 seconds; 12-20 seconds indicates impaired mobility; >20 seconds indicates significant mobility impairment requiring assistive device; can be combined with cognitive dual-task (counting backward while walking) to assess cognitive-motor interference - Orthostatic vital signs: measure BP and HR supine (after 5 minutes), then at 1 minute and 3 minutes of standing; document both the magnitude of change and symptoms; orthostatic hypotension may be present only in the morning (postural changes worse after overnight recumbency) -- test at different times if initial testing is negative but clinical suspicion remains - Comprehensive medication review using Beers Criteria, STOPP/START criteria, and ACB scale: identify all FRIDs, calculate total anticholinergic burden, assess for drug-drug interactions that compound fall risk, and develop a prioritized deprescribing plan - Vision assessment: Snellen chart for visual acuity (corrected and uncorrected), assess contrast sensitivity, evaluate for untreated cataracts and other pathology; ask about use of multifocal lenses (bifocals/progressives) -- these impair depth perception on stairs and may need to be replaced with single-vision distance glasses for outdoor walking - Home safety assessment: ideally performed by an occupational therapist during a home visit; assess lighting (especially stairs and bathroom), flooring (loose rugs, uneven surfaces), bathroom safety (grab bars, non-slip mat, shower chair), stair safety (handrails, visibility of edges), and general clutter; provide specific recommendations and assist with modifications - Vitamin D level: vitamin D deficiency (25-OH vitamin D <30 ng/mL) is associated with muscle weakness, impaired balance, and increased fall risk; prevalence is very high in elderly populations (50-80%); supplementation (800-1000 IU daily) reduces falls by approximately 20% in vitamin D-deficient individuals

Risk factors: - History of falls in the past 12 months: the SINGLE strongest predictor of future falls; a single fall doubles the risk of falling again; two or more falls in the past year defines a 'recurrent faller' requiring comprehensive multifactorial assessment - Gait and balance impairment: assessed using TUG (≥12 seconds = impaired), gait speed (<0.8 m/s = impaired), 30-Second Chair Stand Test, and 4-Stage Balance Test; any abnormality indicates the need for physical therapy referral and targeted strength/balance training - Polypharmacy and fall-risk-increasing drugs (FRIDs): each additional medication increases fall risk ~14%; specific high-risk classes include benzodiazepines, opioids, antihypertensives (causing orthostatic hypotension), diuretics, anticholinergics, antipsychotics, and sedating antidepressants - Visual impairment: cataracts (reduced contrast sensitivity), macular degeneration (central vision loss), glaucoma (peripheral vision loss), and uncorrected refractive errors; bifocal/progressive lenses impair depth perception on stairs; annual comprehensive eye examination is recommended - Cognitive impairment: dementia, mild cognitive impairment, and delirium impair safety judgment, spatial navigation, and the ability to process dual-task demands (walking while talking, carrying objects); executive function impairment is a stronger fall predictor than memory loss - Orthostatic hypotension: systolic BP drop ≥20 mmHg on standing; prevalence 30-50% in community-dwelling elderly; caused by baroreceptor dysfunction, dehydration, autonomic neuropathy (diabetes, Parkinson's), and antihypertensive medications; may be asymptomatic ('silent orthostatic hypotension') - Environmental hazards at home: loose rugs, poor lighting, cluttered walkways, bathroom without grab bars, stairs without handrails, pets underfoot, electrical cords across paths; home safety assessment is an essential component of fall risk evaluation

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