Summary of factors contributing to falls in older adults and nursing implications

Geriatric Nursing xx (2015) 1e10

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Geriatric Nursing
journal homepage: www.gnjournal.com

NGNA Section

Summary of factors contributing to falls in older adults and nursing
implications
Carol Enderlin, PhD, RN, FNGNA a, *, Janet Rooker, MNSc, RNP a, h,
Susan Ball, PhD, RN, GNP-BC, CLNC b, i, Dawn Hippensteel, MS, BSN, RN, CCRN, GCNS c, j,
Joanne Alderman, MS-N, APRN-CNS, RN-BC, FNGNA d,
Sarah Jean Fisher, BA, RN-BC, MSN, FNGNA e, k,
Nanci McLeskey, MCG, MDiv, RN-BC, CHPN, FNGNA f, l,
Kerry Jordan, MSN, APN, ACNS-BC, CNL g, m
a

University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
University of Arkansas Community College at Batesville, USA
c
Pinnacle Health System in Harrisburg, PA, USA
d
National Gerontological Nursing Association, APRN Collaborative Community Practice, USA
e
St. Monica Manor, Philadelphia, PA, USA
f
University of Utah College of Nursing, Salt Lake City, UT, USA
g
University of Central Arkansas, Conway, AR, USA

b

a b s t r a c t
Keywords:
Falls
Fall risk
Fall risk screening

Falls are a common cause of serious injury and injury-related death in the older adult population, and
may be associated with multiple risks such as age, history of falls, impaired mobility, balance and gait
problems, and medications. Sensory and environmental factors as well as the fear of falling may also
increase the risk of falls. The purpose of this article is to review current best practice on screening fall
risks and fear of falling, fall prevention strategies, and fall prevention resources to assist gerontological
nurses in reducing falls by their older adult clients.
Ó 2015 Elsevier Inc. All rights reserved.

Introduction
Falls, defined as unplanned descents to the floor or lower level
with or without injury,1 are a frequent and devastating occurrence
in older adults. The incidence of falls and injuries increases with

* Corresponding author. University of Arkansas for Medical Sciences, 4301 W.
Markham, Slot 529, Little Rock, AR 72205, USA. Tel.: þ1 501 526 7845.
E-mail address: (C. Enderlin).
h
Tel.: þ1 501 526 7035.
i
Tel.: þ1 501 412 4318.
j
Tel.: þ1 716 657 7576.

k
Tel.: þ1 267 312 8555.
l
Tel.: þ1 801 585 9583.
m
Tel.: þ1 501 450 5517.
0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved.
/>
age. Between 30 and 40 percent of community-dwelling people
over the age of 65 years sustain at least one fall per year,2 increasing
to about 50 percent for those 80 years and older.3 Twenty to thirty
percent of older adults who fall suffer moderate to severe injuries.4
Frequently, significant sustained negative outcomes occur in this
population as a result of a fall, including a decline in function, an
increased likelihood of nursing home placement, and an increased
utilization of medical services and costs.5e7
The fear of falling, commonly understood as the level of concern
a person has about falling, or the degree of confidence a person has
in performing common activities without falling, is also a concern.
Fear of falling affects approximately 50e60% of communitydwelling older adults,8 and is particularly prevalent among those
who have previously fallen, occurring in as many as 70% after a fall.9
Gait, mobility and vision issues are related to fear of falling, which is


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C. Enderlin et al. / Geriatric Nursing xx (2015) 1e10

a marker of gait variability.10 Greater fear of falling has also been
associated with age-related macular degeneration and vision loss,11

and with fear-related restriction of activity mitigated by visual
acuity and contrast sensitivity.12 Fear of falling is a psychological
barrier to performing physical activities,13 and often results in
decreased activities of daily living, which may lead to decreased
muscle strength and tone, loss of mobility and decreased quality of
life.14e16 Consequently, fear of falling may also play a role in future
falls.17
The issue of falls in older adults often goes unnoticed by health
care professionals for a variety of reasons which may include: 1) the
older adult does not discuss falling because of fearing loss of independence; 2) at the time of the fall, little or no injury was
incurred therefore the fall goes undocumented; 3) health care
professionals fail to bring up the issue (or history of falls); 4) those
involved (patient, family, health care professionals) think ‘falling’ is
part of the aging process. Nurses have the opportunity to play an
essential role in preventing falls in older adults through application
of best practices.

When, Where & Why) framework as part of the post-fall assessment may provide important insights into the previous fall and
identify risks for future falls. Asking the client how he/she was
feeling at the time of the fall and about the physical and emotional
impact of the fall are also important data to gather in the post-fall
assessment.47
Fall risk factors

One-third of adults over 65 years of age fall every year.18 In the
older adult population, falls are the most common cause of traumatic brain injury,4 and of injury-related death,19 costing billions of
dollars yearly in preventable health care expenditures.20 Age, a
history of falls, impaired mobility, balance and gait problems,
specific medications and polypharmacy have all been identified as
risk factors for falls.21

Currently, both single and multidisciplinary approaches are
used to assess the risk of falls, employing a wide variety of instruments.22,23 There are also a variety of evidence-based fall prevention interventions including exercise or physical therapy,
psychotropic medication withdrawal, and falls education. Collaborative care by an occupational therapist, ophthalmologist, podiatrist, or cardiologist for problems related to home safety, cataracts,
foot pain, or cardiac arrhythmias is also recommended.24 Consequently, the purpose of this article is to review the current best
practice evidence on screening fall risks and fear of falling, fall
prevention strategies, and fall prevention resources to assist
gerontological nurses in reducing falls by their older adult clients.

Risk factors which increase the likelihood of a fall in older adults
can be divided into extrinsic and intrinsic categories.48 Extrinsic
factors are those that are external to the individual, such as uneven
and slippery surfaces, poor lighting, loose rugs and clutter on the
floor, and unsafe footwear. Intrinsic factors are those age-related
changes and health related internal factors which affect the systems involved in effective balance performance and mobility. These
can include things such as sensory loss (sight or hearing), chronic
health conditions such as heart disease, diabetes, stroke, Parkinson’s disease, arthritis, cardiac and antihypertensive medications,
or polypharmacy.49 Specific vision risk factors include binocular
vision (strabismus, amblyopia, diplopia and nystagmus)50 and selfreported poor vision (fair or poor distance vision) regardless of
actual visual acuity.51,52 Other major intrinsic health-related risks
for falls in active older adults have been identified as vertigo, which
may accompany vestibular failure, peripheral neuropathy, and poor
postural stability with associated movement intolerance.53 Among
community-dwelling older adults, orthostatic hypotension and
carotid sinus hypersensitivity were reported as commonly associated with falls.54 Medication-related mechanisms which increase
fall risk include orthostatic hypotension, sedation, sleep disturbance, confusion, dizziness and other central nervous system side
effects.55
Research focused on falls and mental health problems other
than dementia is very limited, although a positive association has
been identified.56 Older adults with cancer who are receiving
neurotoxic agents, especially those who receive multiple agents,

are also at an increased risk of falls and fall-related injuries.57 Often
these fall risk factors do not exist in isolation, but are additive, such
as a sensory deficit worsening an already unsafe environment or
multiple central nervous system-active medications impairing
postural balance.

Fall risk screening tools

Fall risk reduction strategies

Determining the risk for falls is complex and involves many
factors. It is difficult for the nurse to screen multiple risks
adequately without using a systematic method. At a minimum,
simple yearly screening for a history of falls and medications
(particularly those with central nervous system side effects) is
recommended.25 Assessment of cognition should also be considered, since research findings suggest that cognitive decline is
associated with unsafe performance of mobility activities, thereby
increasing the risk of falls.26 Specific fall-related concerns in
community-dwelling older adults can be addressed through the
use of a variety of screening tools related to vision, balance, gait, leg
strength, fear of falling, and home environmental safety. The
following summarized tools require limited training, equipment,
cost and time for administration (Table 1).
Incorporating the use of a general fall risk assessment tool such
as The Hendrich II Fall Risk ModelÔ45 is recommended as a best
practice approach in caring for older adults admitted to acute care
for primary fall prevention screening and in post-fall assessment
and secondary fall prevention.46 This tool, along with documented
evidence and directions for its use are readily available through the
Hartford Institute for Geriatric Nursing.46 Using the “4 W’s” (What,

The Centers for Disease Control18 and the National Institute on
Aging58 have published general fall reduction strategies with
commonalities focusing on exercise, home/environmental modification, medical screening and management of sensory deficits
and medication evaluation. The American Geriatric Society25
made more specific recommendations including exercise (balance, strength, gait-training), management of foot problems and
footwear, the withdrawal or minimization of psychoactive medications, management of postural hypotension, and vitamin D
supplementation of 800 IU/day for those with deficiency or risk of
falls. A recent systematic review further emphasized sarcopenia,
frailty, polypharmacy, multi-morbidity, vitamin D status and
home hazards as risks, noting that risk reduction strategies should
be individualized and applied in combination to be optimally
effective.59

Background and significance

Exercise
Based on a Cochrane Review,24 Tai Chi was the single type of
exercise which was found to significantly reduce the risk of falls,
but this reduction applied to those at low risk of falling only. Tai Chi


C. Enderlin et al. / Geriatric Nursing xx (2015) 1e10

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Table 1
Selected fall risks screening tools used in older adults in the community setting.
Screening tool & risk factor

Administration
time

Older adult population & psychometrics

Sensory function
Snellen eye test
(visual acuity)27

<10 min

Community-dwelling adults 65 years and older
 Visual acuity of better eye <6/12 (odds ratio [OR], 2.47; 95% CI, 1.18e5.18; p < 0.001) were significantly associated
with falls28
 High reliability (r ¼ 0.99)29
 Reliability dependent upon correct distance and lighting with testing30

Physical function
Berg balance scale
(functional balance)31

<20 min

Community-dwelling independent-living adults 65 years and older with & without history of falls
 A score of 40 or < is associated with a fall risk approaching 100%
 A score of 56 or > associated with a 10% probability of falls32
 Inconsistent falls prediction with cut score of 45 in community-dwelling older adults33
Community-dwelling independent-living adults 65 years and older with & without history of falls
 Sensitivity 91% & specificity 82% with best model including 2 factors: balance þ self-report measure of imbalance
history

 Score of 19 or below predictive of falls32
Community-dwelling males 70e104 years
 Reach < or ¼6 inches predictive of falls (OR ¼ 4.02, 1.84e8.77)35
 High test-retest reliability (ICC ¼ 0.81)34
Community-dwelling independent-living adults
Norms available by gender and age group (60e94 years)
 Predictive of falls (OR ¼ 4.03)38
 Discriminates between persons with recurrent, single and no falls (OR ¼ 2.0)
 >15 s to complete task associated with 74% increase in risk of recurrent falls39
Community-dwelling adults mean age 79.5 years
 Predictive of ability to go outside alone safely
 Correlates well with log-transformed Berg Balance Scale (r ¼ À0.81), gait speed (r ¼ À0.61), & Barthel Index of
activities of daily living (r ¼ À0.78)
 Inter- and intra-rater reliabilities (ICC ¼ 0.99 both)
 Scores 30 s or > indicate assistance for many mobility tasks & slow gait speed
 Scores < than 20 s indicate independent mobility or with a cane, reasonable balance, & functional gait speed41

Dynamic gait index
(balance and gait function)32

20e30 min

Functional reach test34

<5 min

Timed sit to stand
(leg strength)36,37

<10 min

Timed up and go
(functional mobility)40,41

<5 min

Psychological function
(fear of falling)
Falls Efficacy Scale:
international version
(fear of falling)42
6-item Activity-specific
Balance Confidence Scale
(ABC-6) (balance confidence
and fear of falling in
performance of ADLs)43
Home
Home Falls and Accident
Screening Tool (Home FAST)44

<10 min

<10 min

20 min

Community-dwelling adults 60e95 years
 Discriminates older adults with history of falls from those without history of falls
 Excellent internal validity (Cronbach’s alpha ¼ 0.96)
 High test-retest reliability (ICC ¼ 0.96)42

Older adults 66e83 years (3 groups: higher level gait disorders [HLGDs], Parkinson’s disease [PD], healthy controls)
 Internal consistency high in 3 groups ranging from 0.81 to 0.90
 Sensitivity 91% for higher level gait disorders and 53% for Parkinson’s disease
 Test-retest reliability between original ABC-16 and ABC-6 ICC ¼ 0.88 (HLGDs), 0.83 (PDs), 0.78 (controls)43

Community-dwelling older adults, two sites with mean ages of 79.7 and 78.1 years
 Sensitivity ¼ 69% for proportion of people with hazards
 Specificity ¼ 90% for proportion of people who do not have hazards identified by expert & second raters
 Cronbach’s alpha ¼ 0.62 for overall checklist44

Adapted from Fabre JM, Ellis R, Kosma M, Wood RH. Falls risk factors and a compendium of falls risk screening instruments. J Geriatr Phys Ther 2010;33:184e197.

has been associated with decreased falls for older adults with
Parkinson’s disease.60 Group exercise and home-based exercise
with multiple components significantly reduced the rate and risk of
falls in those at both a low and high risk of falling.24 Exercise classes
plus home exercise, rather than home exercise alone, demonstrated
a significant reduction in falls rates for community-dwelling older
adults.61 A combination intervention of physical activity with risk
and home safety components was also associated with a reduction
in falls in community-dwelling older adults.62 Physical exercise in
general was associated with a significant effect on fall prevention in
cognitively impaired older adults.63 However, a systematic review
of exercise in residential care settings noted that, while exercise
improved some physical functions which are risk factors for falls,
the actual impact upon falls is less clear.64 Among sporting activities participated in by older men, swimming has been associated
with significantly lower risk of falling.65 The United States
Department of Health and Human Services recommends a minimum of 150 min per week of moderate-intensity or 75 min per
week of vigorous-intensity aerobic physical activity plus muscle
strengthening activities twice per week, in addition to balance

training three or more days per week for older adults at risk for
falling.66
Home and environmental modification
Overall, home safety assessment and modification interventions, including the use of assistive devices, were found to
reduce the rate of falling.24 An occupational therapist plus nurse or
physical therapist home visit intervention, including home
assessment for environmental hazards, information regarding
changes, facilitation of modifications, and training for technical and
mobility aids was effective in reducing the rate of falls in
community-dwelling older adults at high-risk for falling.67 Falls
were also reduced in older adults with a history of falling following
environmental assessment and modification by an occupational
therapist (OT), although the same results were not found with using a trained assessor.68 A single home visit from a research nurse
with offers of a home hazard assessment, information on hazard
reduction and installation of safety devices was ineffective in
reducing falls in older adults, and this failure was attributed to its


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limited effect upon the hazards which remained within the
home.69 Including home hazard education and modification in
multifactorial health promotion home programs also resulted in
reduced overall falls and indoor falls for older adults, which was
significant in those 75 years and older.70 Interventions involving
specific home modifications including handrails for outside steps
and internal stairs, grab rails for bathrooms, outside lighting, edging for outside steps, and slip-resistant surfacing for outside areas

such as decks and porches, were associated with reducing fallrelated injuries by over 33%.71 Single environmental modifications such as placement of high-contrast edge highlighters on stairs
improved foot clearance and foot placement significantly, reducing
the risk of stairway falls.72 Thus, there is some evidence to support
home programs which include hazard awareness and modifications, specific single modifications to high fall risk areas such as
stairs, and OT-led interventions in reducing falls. Working collaboratively with OTs to achieve home modifications may then be the
optimal way for nurses to help achieve fall reduction in older
adults.
Screening and management of sensory deficits
Replacement of multifocal lens with a single lens in glasses used
for indoor/outdoor activities significantly reduced all falls for an
active subgroup of older adults,73 which may be very meaningful
for older adults who choose to walk outdoors for exercise and thus
are more vulnerable to external environmental risk factors. Older
adults with bilaterial cataracts were found to be at high risk for
falls, based on self-report, especially women who lived alone.74
Vision correction itself was associated inconsistently with a
reduction in risk of falls.75 Earlier studies found that cataract surgery on the first eye was significantly associated with a reduction
in the rate of falls, but not in the risk of falling,76 while cataract
surgery on the second eye had no effect upon the rate or the risk of
falling.77 However, a large recent study reported a doubled risk of
falls between the time of the first and second-eye cataract surgery,
and a 34% increase in falls requiring hospitalization during the 2
years following the second-eye cataract surgery when compared
with two years prior to surgery.78 Neither visual acuity assessment
nor referral were associated with a reduction in the rate of falls,79
while vision assessment, eye exam, and referral for mobility
training and canes was actually associated with an increased rate of
falls.80 In older men with poor vision, status of large muscle
function was suggested to mediate fall risks, although this was not
so of older women.81 Thus vision and related vision correction,

mobility and the use of mobility devices, and large muscle functioning should all be considered when evaluating fall risks in older
adults.
Peripheral sensation was also suggested as part of every standard fall risk assessment.82 Multifaceted podiatry including footwear review, customized orthoses, foot and ankle exercises, and fall
prevention education in addition to standard podiatry care were
found to significantly reduce the rate of falls in persons with
disabling foot pain.83 A non-slip device worn on outdoor shoes in
hazardous winter conditions also resulted in a significantly reduced
rate of outdoor falls.84 This could be important to the large numbers
of older adults who suffer with diabetes and arthritis-related foot
problems.
Vitamin D supplementation
Vitamin D was found to benefit muscle strength and balance,85
although vitamin D supplementation reduced the risk and rate of
falls in those with low vitamin D only.24 Combining 800 IU of
vitamin D (cholecalciferol) per day plus calcium 1000 mg was

shown to be superior to calcium alone in reducing the number of
falls in community-dwelling older adults.86 A slightly higher dose
of 1000 IU of vitamin D (ergocalciferol) plus 1000 mg of calcium per
day was associated with a fall reduction of 19% in communitydwelling older women with vitamin D insufficiency and a history
of falling, primarily in the winter months.87 In an effort to improve
medication adherence, research of high-dose, intermittent dosing
of oral vitamin D (cholecalciferol) of 150,000 IU every three months
found neither a beneficial nor an adverse effect on falls in older
women.88 Overall, vitamin D supplementation appears to be the
most beneficial for fall reduction in older adults with insufficient
levels of vitamin D.

Medication modification
Research investigating medication review and modification

combined with an educational component for family practitioners
significantly reduced the risk of falling.89 However, medication
review and modification alone as a single strategy was ineffective.90
Nurses could have an impact on the risk for falling by either
reviewing or facilitating medication reconciliation. This is of
particular concern regarding medications with central nervous
system side effects, such as psychotropics or those which influence
blood pressure. When reviewing medications, nurses can compare
the client’s medications against the Beers Criteria91 to identify
potentially inappropriate medications which are associated with a
high risk of adverse side effects such as orthostatic hypotension
and/or falls. Particular categories of drugs with these high risks
include tertiary tricyclic antidepressants, benzodiazepines, nonbenzodiazepine hypnotics, alpha blockers, and alpha agonists.91
This article reviews the noted high risk medication categories as
well as other commonly used medications related to risk for falls.

Psychotropic medications and falls risks
Psychotropic medications are defined as those which cross the
blood brain barrier and act directly on the central nervous system
(CNS).49 These drugs are also called CNS active or psychoactive
drugs. The use of some classes of psychotropic medications in older
adults has been shown to pose significant risk for falls. Research
indicates that over 20% of community dwelling older adults are
prescribed psychotropic medications92 and over 80% of older adults
living in residential care settings take at least one psychotropic
medication.93,94 Moreover, these same adults often have other
comorbidities or medications that, when added to their psychotropic medication regimen, significantly increase their risks. Community dwelling older adults taking one psychotropic medication
have a 1.5 fold increased risk of falls, and those taking two or more
have a 2.5 fold increased risk of falls compared to non-users.95 The
highest risk is associated with antipsychotic medications followed

by antidepressants and then benzodiazepines.96
Psychotropic drug subcategories that have been linked to
increased fall risk include antidepressants drugs (OR 1.36; 95% CI,
1.13e1.76), drugs used to treat bipolar disorder, anxiolytics or
hypnotics, drugs used in dementia therapy, and antipsychotics (OR
95% CI, 0.94e2.00). When data from 6 of 22 studies included in a
meta-analysis on falls and medications were analyzed, it was noted
that sedative hypnotics, antipsychotics and anxiolytics significantly
increased the likelihood of falling. While most of these studies
examined data from community-dwelling older adults, similar results were noted in residential care settings.96


C. Enderlin et al. / Geriatric Nursing xx (2015) 1e10

5

Antidepressants

Antipsychotics

Roughly 16% of community dwelling older adults use antidepressant medications, and in nursing homes this number rises to
between 18 and 27%.94,97 Antidepressants as a class have been
found to be among the most prescribed fall risk-increasing drugs.98
Antidepressants have also been identified as among the most
common medications associated with falls by older adults treated
in the emergency department.99 Tricyclic antidepressants (TCAs)
have been related to orthostatic hypotension and a widening QT
interval, particularly due to the anti-cholinergic side effects. The
most commonly used are doxepin and amitriptyline.100,101 TCAs are
associated with a 51% increase in fall risk (OR 1.51, 95% CI, 1.14e

2.00). Selective serotonin reuptake inhibitors (SSRIs) also increase
the risk of falls due to anti-cholinergic effects (OR 1.72, 95% CI, 1.40e
2.11).96,102 These medications also have the potential to cause
extrapyramidal effects and sedation. SSRIs are associated with
reduced bone mineral density and higher risk for fractures. These
drugs are widely advertised but they are not benign
medications.101,103

Antipsychotic medications have been categorized as either
typical (older) antipsychotics such as haloperidol and chlorpromazine, or atypical (newer) antipsychotics such as olanzapine
and risperidone. Typical low potency antipsychotics such as
chlorpromazine, still used to bring about rapid behavioral control
in violent patients, have a higher occurrence of anti-cholinergic
symptoms such as urinary retention, constipation, blurred
vision and orthostatic hypotension. Medications such as haloperidol and thioridizine, higher potency typical antipsychotics,
have higher rates of drug-induced Parkinsonism and extrapyramidal side effect (EPS) symptoms which can increase gait abnormalities and balance as well as coordination difficulties.109
After a 1-month follow-up study,110 an increased fall risk with
olanzepine (hazard ratio [HR] 1.74 95% CI, 1.04e2.90) and risperidone (HR 5.05, 95% CI, 1.4e17.75) was reported, after
adjusting for the effects of Parkinson’s disease. Atypical antipsychotic drugs have fewer side effects but still produce side
effects which can increase all fall risk include sedation and
orthostatic hypotension.49,96 Additionally, several studies found
that both typical and atypical antipsychotics increased the risk of
fall-related fractures in dementia patients especially during the
first week of treatment,111 although the risk remained higher for
a longer period with the use of typical antipsychotics. Drugs such
as diphenhydramine and benzotropine given to combat EPS often
contribute to the fall risk by increasing confusion. Any antipsychotic drug has been reported to increase the overall fall risk by
approximately 59% (OR 95%, CI, 1.37e1.83).96 Antipsychotics have
also been identified as among the most common medications
associated with falls resulting in emergency department visits.99

Although the atypical antipsychotics may produce fewer overall
adverse side effects, they do not appear to be any safer than
typical antipsychotics in terms of mitigating fall risks.
In conclusion, the use of psychotropic medications across all
settings poses a significant threat to the safety and health of older
adults because of the increase in fall risk. A thorough physical,
behavioral, and environmental evaluation is a must before any of
these medications are prescribed. Astute observation by nursing
staff and other caregivers will help to mitigate injury related to use
of these medications. However, it seems advisable to avoid the use
of psychotropic medications whenever possible. To reduce the fall
risk for patients requiring psychotropic medications, it is advisable
to consider several of the following issues:

Medications for bipolar disorder
The most commonly used medication in the treatment of bipolar disorder is lithium. Although, lithium is not associated with
falls directly, increased fall risk is associated with the side effects
which include blurred vision, fatigue, tremor and vertigo. Therapeutic ranges for older adults are somewhat lower than they are for
younger adults because of the reduced kidney function found in
older adults, and toxic levels are reached much quicker. Other
medications that are used to treat bipolar disorder include mood
stabilizers. These are also known as anti-seizure medications and
include carbamazepine, valproic acid and lamotrigine. While not
directly associated with increased fall risk, they may increase risk
due to dose-related ataxia. Neurontin, often given to treat peripheral neuropathy in diabetics and sometimes used as a mood stabilizer in violent patients, can increase the risk for falls due to
dizziness and confusion, especially in the morning.104
Anxiolytics
Medications used in the treatment of anxiety, including such
medications as hydroxyzine, benzodiazepines, and antihistamines,
increase the overall fall risk due to the increase in confusion

experienced with age. Anxiolytics produce side effects that are
more prominent in older adults, and increases in fall risk up to 44%
have been reported in nursing home residents.105 In addition to
antidepressants, anxiolytics are one of the two most prescribed fall
risk-increasing medication categories,98 and the longer acting
benzodiazepines have the greatest risks. Side effects such as slower
thought processes and reaction time as well as increased confusion/
delirium have been reported.49,106

1. What is the patient’s initial fall risk?
2. What other risk factors does this patient have that need to be
considered?
3. What alternatives are there to the use of antipsychotic
medications?
4. Are psychotropic medications essential in this situation?
5. When were the indicators for beginning a particular psychotropic medication last evaluated?

Medications for Alzheimer’s disease
There are limited data available on the effects of medications
specifically used to treat Alzheimer’s Disease and other dementias.
Aricept (donepezil), the most commonly used medication for dementia, has side effects which include dizziness, drowsiness, fatigue, ataxia, and syncope, all of which could increase the risk of
falls.107 However, improvements in cognition early in the treatment
can reduce fall risk for those suffering early dementia.108 It is
necessary, therefore, to balance the treatment effects versus risk
factors involved when treating dementia with these drugs.

Reducing the dosage, length of therapy or withdrawing the
high-risk medications altogether has been associated with a
reduced risk of falls and other adverse events in the older population. Non-pharmacologic measures should always be tried first. If
medications are used, they should be reviewed frequently so that

when opportunities arise dosages can be reduced or medications
discontinued over time. Fall risk assessments should be completed
as needed to identify other risk factors in order to reduce the risk of
subsequent falls and related injuries in patients who must take
psychotropic medications.


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Pharmacological and non-pharmacological sleep therapies
and falls
Sleep problems are associated with falls in older adults aged 64e
99 years.112 Forty-four percent of older adults experience one or
more insomnia symptoms a few nights per week or more, and older
adults take more prescription and over-the-counter sleep medications than any other age group.101,113 International research has
focused on the problem of falls in older adults and sleep medications, particularly drugs classified as sedative-hypnotics including
benzodiazepines, “Z” compounds, and antihistamines. As a class,
sedative-hypnotics are thought to increase the risk of falls through
their CNS side effects, particularly those related to balance, sedation
and anti-cholinergic properties, which would include orthostatic
hypotension (low blood pressure on arising).114 Across a variety of
older adult settings (community, residential, acute care, rehabilitation) sedative-hypnotics increase the odds of falling by almost
one-half (pooled Bayesian OR 1.47 [95% CI, 1.35e1.62]).70,96,102
Sedative-hypnotics

with a shorter duration of action were once thought to be a safe
alternative for older adults; however, short-acting benzodiazepines
have been found to strongly increase the frequency of falls in older

adults and should thus be avoided, especially by older adults with
other fall risk factors.126
Non-benzodiazepines
What about the “Z” drugs, and are they a safer alternative for
older adults with sleep problems? These medications significantly
impair body balance in a dose-dependent manner as well. Based on
a review of randomized controlled trials of hypnotics and Z-drug
effects on body balance and standing steadiness, zolpidem and
zopiclone have demonstrated similar impairments as benzodiazepines, and zaleplon significantly impairs balance up to 2 h after
administration.127 One small randomized controlled trial of zolpidem, which investigated the impact of sleep inertia (grogginess on
awakening) on walking and cognition after awakening from sleep,
reported that there were clinically significant balance and cognitive
impairments, with one tandem walk failure per 1.7 older adults
treated.128 Although a small study, this suggested that for every two
older adults treated, one would have difficulty with walking after
taking zolpidem (while still under its effects).

Sedative-hypnotics have been specifically categorized as “fall
risk increasing drugs” and are positively correlated with an
increased incidence of injuries including falls in a study of frail
German elderly 65 years and older.115 Although sedative-hypnotics
increase the odds of falling for all age groups, there is a “doseresponse” relationship only among the elderly, conferring a unique
vulnerability to this age group based on a Swedish national
study.116 This vulnerability is most pronounced in nursing home
residents whose risk of falling increased with even low doses of
sedative-hypnotic drugs, as reported in a study of nursing home
residents in the Netherlands.117 Further, exposure to sedative and
anti-cholinergic medications (measured as the Drug Burden Index)
was significantly and independently associated with falls in
Australian aged care facility residents,118 suggesting that regardless

of other fall risks these medications alone increased the risk of
falling.

While narcotics are not sleep medications, they are taken by
many older adults to assist with chronic pain relief at bedtime.
Taken alone, this class of medications is not suggested to increase
the risk of falls.129 However, narcotics may potentiate gait and
balance changes when they are taken together with other CNSactive medications.114 Exposure to narcotics as well as benzodiazepines was associated with falls during hospitalization,125 which
emphasizes the potential for falls during a time when older adults
are likely to be exposed to the cumulative CNS side effects of
multiple medications while in pain and in an unfamiliar
environment.

Benzodiazepines

Antihistamines

Benzodiazepines, a type of sedative-hypnotic, has been one of
the most common drugs traditionally used for the medical management of sleep problems and has fallen out of favor in the care of
older adults due to CNS side effects. Increased postural sway and
loss of balance,119 is thought to increase the risk of falls, and is
worsened by a loss of position-sense in the toes,101,120 a condition
common to those with peripheral neuropathy or similar sensory
disorders. As a type of sedative-hypnotic, benzodiazepines increase
the odds of falling by slightly over one-half (Bayesian OR 1.57 [95%
CI, 1.42e1.72]).96 Although there has been a shift towards a
reduction in benzodiazepine prescribing practices, the decreased
use has not resulted in a decrease in hip fractures from falls,121,122
suggesting that falls are multifactorial in nature. Dose of benzodiazepine has also been suggested as more important than halflife,123 suggesting that shorter-acting formulations may not be as
effective as lower doses in preventing falls. Although one might

expect the finding that fall risk is higher during the first two weeks
of a new prescription,124 the fact that the fall risk remains elevated
after 30 days105 is alarming, suggesting that older adults do not
“acclimate” to CNS side effects. Last, although families and health
care providers often think of the hospital as a safer place than the
home, exposure to benzodiazepines (controlling for cancer, zolpidem, antihistamines and narcotics) more than doubled the odds of
falling in this setting (OR 2.26, 95% CI, 1.21e4.23) in a casecontrolled study of older adult inpatients.125 Benzodiazepines

Antihistamines, most commonly found in over-the-counter
sleep aids, have also been associated with falls in the hospital
setting.125 These medications are frequently administered to control adverse side effects of other medications such as itching, or to
control symptoms such as nausea and, although often considered
by older adults to be “innocuous”, have CNS side effects on cognition which can be more pronounced in older adults.130 The use of
antihistamines such as diphenhydramine and doxylamine succinate are not recommended for older adults in general,91 but when
they are used, their potential influence and additive influence on
fall risks should be taken into consideration.

Narcotics

Herbals
Melatonin, a melatonin receptor agonist often used for sleep,
does not differ in safety for older compared to younger adults and
does not have the CNS side effects found with benzodiazepines and
“Z” drugs,131 although dizziness is listed as a possible side effect.132
Over-the-counter melatonin formulations are short-acting, but
longer-acting forms are available by prescription, and are designed
to mimic the pattern of naturally-produced melatonin. European
studies of prolonged-release melatonin reported no adverse effects
on cognition or postural stability and found a 31% discontinuation
rate of benzodiazepines or “Z” drugs by older adults with insomnia

prescribed the herbal alternative.133 Although studies of campaigns


C. Enderlin et al. / Geriatric Nursing xx (2015) 1e10

7

Table 2
Falls prevention resources.
Resource and author

Website

Prevention of falls in community-dwelling older adults:
U.S. Preventive Services Task Force recommendation statement2
AGS/BGS clinical practice guideline prevention of falls in older persons25

/>
STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool kit
for health care providers147
NIH senior health: falls and older people148
Falls toolkit149

/>recommendations/2010/
/> /> />
to reduce benzodiazepine and “Z” drug use and to promote prolonged release-melatonin use found they were not largely successful in nine European countries, this was attributed to factors
related to market availability and uptake.134
Cognitive behavioral therapy
Due to the CNS side effects of so many sleep medications, nonpharmacologic sleep interventions may be safer alternatives for
many older adults. Cognitive behavioral therapy is actually

considered the first-line of therapy for insomnia, to be equal in
effectiveness and to have more sustained effectiveness over time
than medications.135 Non-pharmacologic interventions, such as
stimulus control therapy which focuses on the re-association of the
bed and bedroom with sleep,136,137 and relaxation therapy which
focuses on reducing cognitive arousal and somatic (muscle) tension,138 may promote sleep without increasing fall risk. Although
not recommended as a single intervention, sleep hygiene education, which aims to increase client knowledge of the sleep process
and sleep-promoting behaviors, such as the importance of a regular
sleep-wake schedule, may help improve sleep and thus decrease
fall risk.139,140 Sleep hygiene education is consistent with the
teaching role of nursing and engages the client to be an informed
and active participant in his/her own care. Sleep hygiene is also
considered most effective when individually tailored, which is also
consistent with nurses’ views of clients as having unique personal
and cultural preferences and needs.
In summary, sleep medications have been suggested to increase
the risk of falls in older adults through impaired balance, sedation
and other side effects such as orthostatic hypotension in a dosedependent manner. Older adults with dementia, hospitalized
older adults and those taking multiple CNS-active medications
appear to be at particular risk for falls when taking sleep medications. Melatonin and non-pharmacologic sleep interventions may
be safer, effective alternatives to benzodiazepines, “Z” drugs and
antihistamines for older adults who need sleep medications.
Nurses should not only be aware of prescription and over-thecounter sleep medications their clients take, but should assess
the following in older adults: balance, gait, toe sensation, and blood
pressure on rising. Sleep hygiene should be routinely included in
client education, and individualized to the client. Nonpharmacologic interventions should be considered “first choice”,
but if medication is necessary, the lowest dose possible for the
needed effect should be given. Melatonin may also be considered as
an alternative medication. The concurrent use of multiple CNSactive medications should be avoided if at all possible and, where
unavoidable, additional fall precautions should be implemented to

increase safety.
Syncope and falls
Falls and syncope have been addressed as two common and
interrelated geriatric syndromes that cause considerable mortality

and morbidity among older adults.141 Syncope is described as “a
temporary and sudden loss of consciousness, typically due to
transient cerebral hypoperfusion or a decline in blood flow to the
brain.”142 Because brain cells require adequate blood flow to provide a constant supply of energy, an interruption of cerebral
perfusion for only 3e5 s can result in syncope. It can be caused by a
decrease in cardiac output, high blood pressure, a sudden drop in
blood pressure or other neurologic factors. Syncope can also occur
without reduced cerebral blood flow in response to changes in
blood sugar or oxygen levels.143 Conditions such as orthostatic
hypotension, cardiac arrhythmias, cardiopulmonary or cerebrovascular disease may be factors underlying syncope.143 Other cardiac conditions associated with syncope and/or falls include heart
murmurs, angina, heart failure and myocardial infarction.144 Medications such as blood pressure-reducing agents, or drugs affecting
electrolytes or the central nervous system may also contribute to
syncope.142
Syncope is characteristically rapid in onset, short in duration
and spontaneous in recovery. Consequently, older adults may not
even realize they are losing consciousness until they regain
awareness to find themselves on the ground.145 In retrospect, some
older adults may recall warning symptoms of a syncopal episode
such as: dizziness, light-headedness, visual disturbances, cold/
clammy skin, nausea, or sweating. Weakness, loss of postural tone,
a “drop” to the floor, or losing consciousness may also be remembered. It is important to note how quickly the older adult lost and
regained consciousness, along with the presence of confusion and if
he or she fell. Cardiac or stroke-like symptoms should also be
explored further. The nurse should ask what the older adult was
doing immediately before the event (e.g. resting, exertion, coughing, voiding or standing).143 Finally, a complete medication list

should be reviewed.146 Positive responses on the post-syncopal
assessment are “red flags” and should be shared with the older
adult’s primary care provider (PCP) to assist in determining the
likely cause/s of the syncope.
Educating older adults and their families about syncope cannot
be over-emphasized. An at-risk older adult should know how to
recognize it and to discuss suspected syncope with a PCP. Keeping
the PCP apprised of all medications taken should also be stressed to
prevent polypharmacy and allow consideration of possible adverse
effects which could contribute to syncope and falls.
Conclusion
Preventing older adults from falling will become an increasing
challenge with the growth of an older population. Yet, the number
of falls and the severity of injuries can be decreased by identifying,
removing and/or modifying various risk factors and implementing
risk reduction interventions. Nurses caring for this population
across all settings are in an important position to screen, educate
and intervene for better outcomes. With implementation of
evidenced-based practices and continued research related to fall
prevention, we can anticipate new approaches to decrease falls and


8

C. Enderlin et al. / Geriatric Nursing xx (2015) 1e10

injuries sustained by an aging population. The responsibility to not
only provide optimal care for older adults, but also to utilize
existing information and resources (Table 2) as we collaborate with
all other health care professionals to optimize safety in an aging

population is paramount.
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