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Health/Medical Factors

Many health factors can contribute to the risk of falls. The history obtained from the person should include:

  • Medications

  • Use of alcohol including nightcaps                                                          (an alcoholic beverage consumed right before going to bed)

  • Acute and/or chronic medical problems

  • Functional abilities                                                                   (assessment of basic and instrumental activities of daily living)

  • Mobility (including use of ambulatory assistive devices or mobility aids)

  • Lower urinary tract symptoms (especially urinary urgency, frequency, nocturia and urge incontinence)

The physical exam should include:

 1. A targeted neurological examination including:

  • Mental status: Examples of assessments tools include: the Mini-Mental State Examination (MMSE), Standardized Mini-Mental Status Exam (SMMSE), Montreal Cognitive Assessment (MoCA)

  • Vestibular function

  • Lower extremity strength                                                                 (e.g., Can the patient stand from sitting without using their arms?)

  • Lower extremity sensation & reflexes

  • Extrapyramidal signs                                                                       (e.g., tremor, rigidity, akinesia, and postural instability)

  • Coordination


 2. A targeted musculoskeletal examination focusing on:

  • Lower extremities (joints, range of motion, pain, deformities)

  • Feet/footwear: foot problems, especially multiple ones and painful ones such as plantar fasciitis, are associated with an increased risk of falling. In-home falls have been associated with being barefoot or wearing socks without shoes and slippers.


 3. A cardiovascular examination including:

  • Heart rate and rhythm

  • Postural pulse and blood pressure


 4. Assessment for orthostatic (postural) hypotension:

  • Lying and standing pulse and blood pressure: ideally the assessment for orthostatic (postural) hypotension should be done in the following manner:

    • Check blood pressures (BPs) 30+ minutes after any medications or a meal.

    • Have the client lying down for between 5 to 10 minutes, and then measure lying pulse and BP. Measuring after sitting (not lying) will miss some cases.

    • Then have the client stand and check pulse and BP after standing. While there is some controversy regarding how long to wait after standing before measuring BP, generally the standing BP is measured at 1 minute (for screening purposes a single 1 minute reading is usually sufficient) and 3 minutes after standing.

    • Orthostatic hypotension is present if there is a drop of at least 20 mm Hg in systolic blood pressure or of at least 10 mm Hg in diastolic blood pressure within 3 minutes of standing.


 5. Impaired vision:

  • Annual vision assessments should be encouraged.

  • Assessments should ideally include:

    • Acuity

    • Contrast sensitivity

    • Depth perception

    • Visual field loss

    • Glasses – check if using multifocal/ bifocal and/or transition (photochromic) lenses

  • Some aspects of a thorough visual assessment (e.g., contrast sensitivity, depth perception, visual field losses) especially if the deficits are subtle, would require the involvement of an optometrist or ophthalmologist.


 6. Assessment for osteoporosis:

  • Ask about osteoporotic fractures and any prior bone mineral density determinations.

  • Look for a humped back (also known as a Dowager’s hump and thoracic kyphosis). Its presence suggests the possibility of osteoporotic fractures of the thoracic spine.

  • Ask about historical heights and measure current height. See what the difference might be. A historical height loss of > 6 cm suggests the presence of vertebral fractures.

  • Measure the occiput-to-wall distance. An occiput-to-wall distance of > 5 cm indicates the presence of kyphosis possibly from vertebral fractures.

  • Check rib to pelvis distance. A rib-pelvis distance of less than two finger’s breadth suggests the presence of vertebral fractures.

  • See 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada Quick Reference Guide


 7. Lower Urinary Tract Symptoms (LUTS):

  • Certain LUTS (i.e., urge incontinence, mixed incontinence, overactive bladder symptoms like frequency and urgency, nocturia 2 - 3+ per night) are associated with a moderate (i.e., 1.3 - 2.0 fold) increase in the risk of falls among older individuals.

  • The association with overactive bladder symptoms and falls could be explained by rushing to the toilet and/or the distress/anxiety related to the aftermath of not being able to get to the toilet in time.

  • The cognitive demands of performing multiple tasks simultaneously such as walking quickly, concentrating on controlling the flow of urine and negotiating household obstacles in order to get to the toilet are not trivial and may have detrimental effects on balance in older individuals.

  • Sleep patterns can be altered by nocturia. Disruptive sleep might lead to day-time symptoms such as dizziness and drowsiness. Poorly lit night-time journeys to the toilet in a drowsy state after rapidly going from lying to standing could be associated with falls. Slipping on urine could be a rare cause of falls.

  • There are stronger individual risk factors for falls than LUTS such as a history of falls and balance/gait abnormalities. The prevalence of LUTS and falls both increase with age - their occurrence together could be from chance. Any association between falls and incontinence could be due to common risk factors (e.g., limited mobility, cerebrovascular disease).

  • The effect of treating LUTS on subsequent falls risk is currently unknown. First-line potential interventions would include behavioural strategies and lifestyle measures.

  • Medications (e.g., anticholinergics, alpha blockers) would be an option but might increase falls risk themselves because of potential adverse effects (e.g., dizziness, orthostatic hypotension, cognitive dysfunction and/or impaired psychomotor performance from central anticholinergic effects).

  • Older adults being evaluated for falls should be asked about LUTS. A questionnaire such as the Bladder Control Self-Assessment Questionnaire (B-SAQ) could be used. If relevant symptoms are detected, interventions to further assess and/or treat them should be considered as part of the treatment plan.