CLINICAL PRACTICE

Preventing Falls in Elderly Persons

Mary E. Tinetti, M.D.

N Engl J Med 2003; 348:42-49January 2, 2003

http: !!!.ne"#.$rg d$i %ull &0.&0'( NEJM)p020*&9 Thi+ Journal %eature ,egin+ !ith a )a+e -ignette highlighting a )$##$n )lini)al pr$,le#. E-iden)e +upp$rting -ari$u+ +trategie+ i+ then pre+ented, %$ll$!ed ,y a re-ie! $% %$r#al guideline+, !hen they e.i+t. The arti)le end+ !ith the auth$r/+ )lini)al re)$##endati$n+. A 79-year-old woman with a history of congestive heart failure, arthritis, depression, and difficulty sleeping presents for a follow-up visit. She takes several prescription medications, including an antidepressant, a diuretic, an angiotensinconvertingenzyme inhi itor, and a eta- locker, as well as over-the-counter sleep and allergy medications. !er chronic conditions appear to e sta le. !er daughter reports that the patient has fallen twice during the past si" months. #hat can e done to prevent future falls$

%!& '()*)'A( +,-.(&/

M$re than $ne third $% per+$n+ (' year+ $% age $r $lder %all ea)h year, and in hal% $% +u)h )a+e+ the %all+ are re)urrent.&,2 0ppr$.i#ately & in &0 %all+ re+ult+ in a +eri$u+ in"ury, +u)h a+ hip %ra)ture, $ther %ra)ture, +u,dural he#at$#a, $ther +eri$u+ +$%t-ti++ue in"ury, $r head in"ury.3-' 1all+ a))$unt %$r appr$.i#ately &0 per)ent $% -i+it+ t$ the e#ergen)y depart#ent and ( per)ent $% urgent h$+pitali2ati$n+ a#$ng elderly per+$n+.4,( 3ndependently $% $ther health )$nditi$n+, %all+ are a++$)iated !ith re+tri)ted #$,ility; a de)line in the a,ility t$ )arry $ut a)ti-itie+ +u)h a+ dre++ing, ,athing, +h$pping, $r h$u+e4eeping; and an in)rea+ed ri+4 $% pla)e#ent in a nur+ing h$#e. *-9 0lth$ugh a %e! %all+ ha-e a +ingle )au+e, the #a"$rity re+ult %r$# intera)ti$n+ ,et!een l$ng-ter# $r +h$rt-ter# predi+p$+ing %a)t$r+ and +h$rt-ter# pre)ipitating %a)t$r+ in a per+$n/+ en-ir$n#ent.&-'Ea)h $% the %$ll$!ing )$nditi$n+ ha+ ,een +h$!n t$ in)rea+e the +u,+e5uent ri+4 $% %alling in t!$ $r #$re $,+er-ati$nal +tudie+: arthriti+; depre++i-e +y#pt$#+; $rth$+ta+i+; i#pair#ent in )$gniti$n, -i+i$n, ,alan)e, gait, $r #u+)le +trength; and the u+e $% %$ur $r #$re pre+)ripti$n #edi)ati$n+. 1urther#$re, the ri+4 $% %alling )$n+i+tently in)rea+e+ a+ the nu#,er $% the+e ri+4 %a)t$r+ in)rea+e+. &,2 The ri+4 $% %alling in)rea+ed in a )$h$rt $% elderly per+$n+ li-ing in the )$##unity, %$r e.a#ple, %r$# 8 per)ent a#$ng th$+e !ith n$ ri+4 %a)t$r+ t$ *8 per)ent a#$ng th$+e !ith %$ur $r #$re ri+4 %a)t$r+.& 0lth$ugh there i+ a )lear relati$n ,et!een %alling and the u+e $% a higher nu#,er $% #edi)ati$n+, the ri+4+ a++$)iated !ith indi-idual )la++e+ $% drug+ ha-e ,een #$re

-aria,le.&0,&& T$ date, +er$t$nin-reupta4e inhi,it$r+, tri)y)li) antidepre++ant+, neur$lepti) agent+, ,en2$dia2apine+, anti)$n-ul+ant+, and )la++ 30 antiarrhyth#i) #edi)ati$n+ ha-e ,een +h$!n t$ ha-e the +tr$nge+t lin4 t$ an in)rea+ed ri+4 $% %alling. &0-&2 During the #$nth a%ter h$+pital di+)harge, the ri+4 $% %alling i+ high, parti)ularly a#$ng elderly per+$n+ %rail en$ugh t$ re5uire h$#e health )are.&3 6ther peri$d+ $% high ri+4 in)lude th$+e in !hi)h there are epi+$de+ $% a)ute illne++ $r e.a)er,ati$n+ $% )hr$ni) illne++. 0+ di+)u++ed in the ne.t +e)ti$n $% thi+ arti)le, +e-eral +ingle and #ulti%a)t$rial, health )are7,a+ed +trategie+ ha-e pr$-ed e%%e)ti-e in redu)ing the rate $% %alling in )lini)al trial+.&4-2& 8$!e-er, i#ple#entati$n $% the+e appr$a)he+ %$r the pre-enti$n $% %alling #ay ,e )$#pli)ated, %$r at lea+t t!$ rea+$n+. 1ir+t, )lini)ian+ are #$re e.perien)ed at #anaging di+)rete di+ea+e+ than at #anaging #ulti%a)t$rial )$nditi$n+, +u)h a+ %alling. 9e)$nd, alth$ugh #any )$#p$nent+ $% an e%%e)ti-e %all-pre-enti$n +trategy are relati-ely +traight%$r!ard, $ther+ re5uire trade$%%+ and the !eighing $% ri+4+ and ,ene%it+. :erhap+ the #$+t )$#pli)ated )$#p$nent $% a +trategy t$ pre-ent %all+ in-$l-e+ redu)ti$n in the u+e $% #edi)ati$n+. Medi)ati$n+ #ay ,e appr$priately re)$##ended %$r the treat#ent $% a di+ea+e, ,ut they al+$ ha-e ad-er+e e%%e)t+; %alling i+ $ne $% the #$+t )$##$n ad-er+e e-ent+ related t$ drug+.22-24 Many elderly patient+ ha-e +e-eral )hr$ni) )$nditi$n+ %$r !hi)h #ultiple #edi)ati$n+ are pre+)ri,ed, %urther in)rea+ing the a++$)iated ri+4+, in)luding %alling.

S%,A%&0)&S A*1 &2)1&*'&

Assessment and )ntervention ;e)au+e %all+ re+ult %r$# -ari$u+ )$#,inati$n+ $% %a)t$r+, an e%%e)ti-e and e%%i)ient )lini)al +trategy %$r ri+4 a++e++#ent and #anage#ent #u+t addre++ #any predi+p$+ing and pre)ipitating %a)t$r+. 8$!e-er, a )lini)ally +en+i,le +trategy )an ,e e.trap$lated %r$# the a-aila,le )lini)al-trial data, aug#ented ,y $,+er-ati$nal data %r$# !ell-de+igned +tudie+.&-',&0-2& 0 rati$nal appr$a)h t$ the pre-enti$n $% %all+ i+ pre+ented in 1igure &3)04,& 5
0lg$rith# 9u##ari2ing the <lini)al 0ppr$a)h t$ the :re-enti$n $% 1all+ a#$ng Elderly :er+$n+ =i-ing in the <$##unity.. ;e)au+e elderly per+$n+ #ay n$t -$lunteer the in%$r#ati$n, phy+i)ian+

+h$uld, $n at lea+t a yearly ,a+i+, a+4 their elderly patient+ a,$ut any %all+ and a+4 a,$ut and l$$4 %$r any di%%i)ultie+ !ith ,alan)e $r gait. ;rie% +)reen+ +u)h a+ the >?et-@p and ?$A te+t, !hi)h in-$l-e+ l$$4ing %$r un+teadine++ a+ the patient get+ up %r$# a )hair !ith$ut u+ing hi+ $r her ar#+, !al4+ a %e! #eter+, and return+, i+ ea+ily in)$rp$rated int$ +h$rt )lini)al en)$unter+.2',2( 6ther a++e++#ent+ pr$-ide #$re +pe)i%i) in%$r#ati$n a,$ut ,alan)e and gait a,n$r#alitie+.2* 0lth$ugh there i+ n$ )$n+en+u+ a,$ut the $pti#al ti#e t$ initiate +)reening, the rate $% %alling and the pre-alen)e $% ri+4 %a)t$r+ %$r %alling in)rea+e +teeply a%ter the age $% *0 year+. &-4 9ingle-inter-enti$n +trategie+ that ha-e pr$-ed e%%e)ti-e a#$ng elderly per+$n+ dee#ed at ri+4 %$r %alling, either ,e)au+e $% the pre+en)e $% a 4n$!n ri+4 %a)t$r $r ,e)au+e $% a

hi+t$ry $% %all+, in)lude pr$%e++i$nally +uper-i+ed ,alan)e and gait training and #u+)le+trengthening e.er)i+e; gradual di+)$ntinuati$n $% p+y)h$tr$pi) #edi)ati$n+; and #$di%i)ati$n $% ha2ard+ in the h$#e a%ter h$+pital di+)harge in $ne +tudy, tapering and di+)$ntinuati$n $% p+y)h$tr$pi) #edi)ati$n+, in)luding ,en2$dia2epine+, $ther +leep #edi)ati$n+, neur$lepti) agent+, and antidepre++ant+, $-er a &4-!ee4 peri$d !ere a++$)iated !ith a 39 per)ent redu)ti$n in the rate $% %alling. &* 0lth$ugh n$n+pe)i%i) ad-i)e a,$ut #$di%i)ati$n $% h$#e ha2ard+ dire)ted at untargeted gr$up+ $% elderly per+$n+ ha+ n$t pr$-ed e%%e)ti-e, +tandardi2ed a++e++#ent $% h$#e ha2ard+ ,y an $))upati$nal therapi+t, al$ng !ith +pe)i%i) re)$##endati$n+ and %$ll$!-up a%ter h$+pital di+)harge, !a+ a++$)iated !ith a 20 per)ent redu)ti$n in the ri+4 $% %alling. &4,&8 The #$+t )$##$nly re)$##ended #$di%i)ati$n+ in that +tudy !ere the re#$-al $% rug+, a )hange t$ +a%er %$$t!ear, the u+e $% n$n+lip ,ath#at+, the u+e $% lighting at night, and the additi$n $% +tair rail+. 0dheren)e t$ the re)$##ended inter-enti$n+ ranged %r$# &9 per)ent %$r the in+tallati$n $% +tair rail+ t$ *' per)ent %$r the u+e $% ,ath#at+. &8 Bherea+ #ulti%a)t$rial a++e++#ent+ n$t lin4ed t$ targeted inter-enti$n+ ha-e ,een ine%%e)ti-e in pre-enting %all+,&4,28-30 the #$+t )$n+i+tently +u))e++%ul appr$a)h t$ pre-enti$n ha+ ,een #ulti%a)t$rial a++e++#ent, %$ll$!ed ,y inter-enti$n+ targeting the identi%ied ri+4 %a)t$r+.&9-2& 9u)h targeted a++e++#ent and #anage#ent +trategie+ ha-e ,een +h$!n t$ redu)e the $))urren)e $% %alling ,y 2' t$ 39 per)ent CTa,le &D. 9u))e++%ul )$#p$nent+ $% the+e inter-enti$n+ in)lude re-ie! and p$++i,le redu)ti$n $% #edi)ati$n+; ,alan)e and gait training, #u+)le-+trengthening e.er)i+e; e-aluati$n $% p$+tural ,l$$d pre++ure, %$ll$!ed ,y +trategie+ t$ redu)e any de)rea+e+ in p$+tural ,l$$d pre++ure; h$#e-ha2ard #$di%i)ati$n+; and targeted #edi)al and )ardi$-a+)ular a++e++#ent+ and treat#ent+. 0+)ertain#ent $% the )ir)u#+tan)e+ +urr$unding pre-i$u+ %all+ #ay re-eal pre)ipitating %a)t$r+, +u)h a+ en-ir$n#ental ha2ard+, ri+4+ a++$)iated !ith the a)ti-ity at the ti#e $% the %all, and a)ute h$+t %a)t$r+, +u)h a+ a)ute illne++ $r i##ediate e%%e)t+ $% #edi)ati$n, that #ay ,e a#ena,le t$ inter-enti$n. 9pe)i%i) re)$##endati$n+ %$r a++e++#ent and inter-enti$n are +u##ari2ed in The a++e++#ent+ )an ,e per%$r#ed either ,y the patient/+ u+ual phy+i)ian $r ,y a geriatri) +pe)iali+t. 0ll #edi)ati$n+, in)luding $-er-the-)$unter #edi)ati$n+, +h$uld ,e th$r$ughly re-ie!ed and )$n+idered %$r p$++i,le eli#inati$n $r d$+e redu)ti$n; the g$al +h$uld ,e t$ #a.i#i2e the $-erall health and %un)ti$nal ,ene%it+ $% the #edi)ati$n+ !hile #ini#i2ing their ad-er+e e%%e)t+, +u)h a+ %all+. :+y)h$tr$pi) #edi)ati$n+ !arrant parti)ular attenti$n, +in)e there i+ -ery +tr$ng e-iden)e that u+e $% the+e #edi)ati$n+ i+ lin4ed t$ the $))urren)e $% %all+.&0,&&,&* Eedu)ing the t$tal nu#,er $% #edi)ati$n+ t$ %$ur $r %e!er, i% %ea+i,le, ha+ al+$ ,een de#$n+trated t$ redu)e the ri+4 $% %alling. 4* Bhen a++e++ed appr$priately, )lini)ally +igni%i)ant p$+tural hyp$ten+i$n i+ dete)ted in up t$ 30 per)ent $% elderly per+$n+.4(,48 M$re$-er, +$#e elderly per+$n+ !ith p$+tural hyp$ten+i$n d$ n$t rep$rt +y#pt$#+, +u)h a+ di22ine++ $r lightheadedne++. 4( E-iden)e %r$# trial+ $% +ingle and #ulti%a)t$rial inter-enti$n+ +ugge+t+ that all elderly per+$n+ !h$ ha-e any a,n$r#alitie+ $n ,alan)e and gait te+ting +h$uld ,e re%erred t$ phy+i)al therapy

%$r a )$#prehen+i-e e-aluati$n a+ !ell a+ reha,ilitati$n. &',&(,&9-2& 3n additi$n t$ dire)t $,+er-ati$n $% the elderly per+$n !hile he $r +he +tand+ %r$# a +itting p$+iti$n and !al4+, a targeted neur$l$gi) e.a#inati$n #ay re-eal p$tentially treata,le )au+e+ $% ,alan)e $r gait i#pair#ent. :r$pri$)epti-e i#pair#ent due t$ a neur$pathy, %$r e.a#ple, i+ a )$##$n )au+e $% ,alan)e i#pair#ent in elderly per+$n+. 0 de)rea+ed +en+ati$n $% -i,rati$n, a %re5uent ,ut a,n$r#al %inding in thi+ p$pulati$n, i+ a #$re +en+iti-e #ar4er $% neur$pathy than a de)rea+e in the +en+ati$n $% p$+iti$n. 0 gait that !$r+en+ !hen the eye+ are )l$+ed and i#pr$-e+ !hen #in$r +upp$rt i+ gi-en ,y the e.a#iner i+ a %urther )lue t$ pr$pri$)epti-e pr$,le#+. :er+$n+ !h$ ha-e %allen +h$uld ,e a+4ed a,$ut l$++ $% )$n+)i$u+ne++. ?i-en re)ent e-iden)e that +$#e elderly per+$n+ are una!are $% epi+$de+ $% l$++ $% )$n+)i$u+ne++, +yn)$pe +h$uld al+$ ,e )$n+idered in th$+e !h$ rep$rt >"u+t g$ing d$!n.A 49 (a oratory %ests and )maging The r$le $% la,$rat$ry and an)illary te+ting in the pre-enti$n $% %all+ ha+ n$t ,een !ell +tudied. =a,$rat$ry te+t+ that #ight rea+$na,ly ,e per%$r#ed in all per+$n+ at ri+4 %$r %alling in)lude a )$#plete ,l$$d )$unt; #ea+ure#ent $% +eru# ele)tr$lyte+, ,l$$d urea nitr$gen, )reatinine, glu)$+e, and -ita#in ;&2; and a++e++#ent $% thyr$id %un)ti$n. The+e te+t+ are relati-ely ine.pen+i-e, and a,n$r#al re+ult+, !hi)h are li4ely t$ ,e pre-alent, +ugge+t the pre+en)e $% a treata,le entity. 6ther te+t+ +h$uld ,e re+er-ed %$r per+$n+ in !h$# the pre+en)e $% an a,n$r#ality i+ +ugge+ted ,y the hi+t$ry and re+ult+ $% phy+i)al e.a#inati$n. Neur$i#aging i+ indi)ated $nly i% there i+ a head in"ury $r ne!, %$)al neur$l$gi) %inding+ $n the phy+i)al e.a#inati$n $r i% a )entral ner-$u+ +y+te# pr$)e++ i+ +u+pe)ted $n the ,a+i+ $% the hi+t$ry $r e.a#inati$n re+ult+. Ele)tr$en)ephal$graphy i+ rarely help%ul and i+ indi)ated $nly i% there i+ a high degree $% )lini)al +u+pi)i$n $% +ei2ure. 9i#ilarly, a#,ulat$ry )ardia) #$nit$ring i+ help%ul $nly rarely; in elderly per+$n+, thi+ te)hni5ue i+ a++$)iated !ith %re5uent %al+e p$+iti-e+ and %al+e negati-e+. '0 0n e-aluati$n %$r arrhyth#ia i+ !arranted $nly i% there i+ )lini)al e-iden)e $% thi+ diagn$+i+, +u)h a+ a 4n$!n hi+t$ry $% )ardia) e-ent+ $r an a,n$r#al ele)tr$)ardi$gra#. &ducation and -ther /easures Th$ugh repeatedly +h$!n t$ ,e ine%%e)ti-e a+ a +$le inter-enti$n, 38-43 edu)ati$n i+ an i#p$rtant )$#p$nent $% +trategie+ t$ #anage the ri+4 $% %alling. The per+$n at ri+4 and hi+ $r her %a#ily #e#,er+ +h$uld ,e edu)ated a,$ut the #ulti%a)t$rial nature $% #$+t %all+, a,$ut the +pe)i%i) ri+4 %a)t$r+ %$r %alling that are pre+ent, and a,$ut re)$##ended inter-enti$n+. :er+$n+ at ri+4 %$r %alling !h$ li-e al$ne $r !h$ +pend large a#$unt+ $% ti#e al$ne +h$uld ,e taught !hat t$ d$ i% they %all and )ann$t get up, and they +h$uld ha-e a per+$nal e#ergen)y-re+p$n+e +y+te# $r a teleph$ne that i+ a))e++i,le %r$# the %l$$r. 1$r healthy elderly per+$n+ !h$ ha-e n$t %allen and !h$ d$ n$t rep$rt $r +h$! ,alan)e $r gait di%%i)ultie+, the a-aila,le e-iden)e +ugge+t+ that )$##unity-,a+ed e.er)i+e pr$gra#+ n$t +uper-i+ed ,y health )are pr$%e++i$nal+ that in)lude pr$gre++i-e ,alan)e-

training and +trengthening )$#p$nent+ #ay redu)e the li4elih$$d $% a %all CTa,le &D.&4,44,4' N$n+pe)i%i), general e.er)i+e pr$gra#+,3&-3* +el%-#anage#ent and )$gniti-e7 ,eha-i$ral appr$a)he+,38-43 and h$#e-ha2ard #$di%i)ati$n+ %$r $lder per+$n+ !ith$ut a hi+t$ry $% %alling $r re)ent h$+pitali2ati$n ha-e n$t pr$-ed e%%e)ti-e. &4,38,'& =$! ,$ne den+ity in)rea+e+ the ri+4 $% hip and $ther %ra)ture+ and +h$uld ,e identi%ied and treated. The guideline+ $% the Nati$nal 6+te$p$r$+i+ 1$undati$n re)$##end that all !$#en (' year+ $% age $r $lder and !$#en le++ than (' year+ $% age !h$ are p$+t#en$pau+al and !h$ ha-e additi$nal ri+4 %a)t$r+ %$r $+te$p$r$ti) %ra)ture+ C+u)h a+ a lean ha,itu+, a hi+t$ry $% %ra)ture+, $r a hi+t$ry $% )igarette +#$4ingD +h$uld underg$ ,$ne #ineral den+ity #ea+ure#ent t$ a++e++ the ri+4 $% %ra)ture+ and t$ a+)ertain !hether phar#a)$l$gi) $r n$nphar#a)$l$gi) treat#ent !$uld ,e appr$priate. '2 0 di+)u++i$n $% the pre-enti$n and treat#ent $% $+te$p$r$+i+ i+ ,ey$nd the +)$pe $% thi+ arti)le, ,ut in%$r#ati$n i+ a-aila,le %r$# the Nati$nal 6+te$p$r$+i+ 1$undati$n Chttp: !!!.n$%.$rg phy+guideD.'2 3n additi$n t$ $ther therapie+, hip pr$te)t$r+ appear t$ redu)e the ri+4 $% hip %ra)ture a#$ng per+$n+ at high ri+4.'3

A,&AS -3 4*'&,%A)*%6
3t re#ain+ t$ ,e deter#ined !hether the +trategie+ that ha-e pr$-ed e%%e)ti-e in redu)ing the $))urren)e $% %all+ are e5ually e%%e)ti-e in redu)ing the #$+t +eri$u+ in"urie+ that $))ur a+ a re+ult $% %alling, +u)h a+ %ra)ture+ and head in"urie+. 6,+er-ati$nal data +ugge+t that the ri+4 %a)t$r+ %$r %all+ and %$r +eri$u+ in"urie+ due t$ %all+ are +i#ilar 3-'; trial+ $% %all-pre-enti$n +trategie+ t$ date, h$!e-er, ha-e n$t had +u%%i)ient p$!er t$ dete)t !hether they ha-e an e%%e)t $n the in)iden)e $% +eri$u+ in"ury. &4 The e.er)i+e pr$gra#+ %$und t$ ,e e%%e)ti-e ha-e ,een +h$rt ter#, u+ually la+ting $ne year $r le++. 9in)e #$+t $% the ,ene%it+ $% e.er)i+e are #aintained $nly a+ l$ng a+ the e.er)i+e regi#en i+ #aintained, #eth$d+ %$r enhan)ing l$ng-ter# adheren)e are needed. The $pti#al inten+ity, %re5uen)y, and type $% e.er)i+e needed t$ #ini#i2e the ri+4 $% %alling and $% in)urring in"ury !hile #a.i#i2ing #$,ility re#ain t$ ,e deter#ined. 9tudie+ +ugge+t that the nu#,er $% #edi)ati$n+ pre+)ri,ed )an ,e redu)ed +a%ely and e%%e)ti-ely.&4,4*,'4 8$!e-er, pra)ti)al #eth$d+ are needed t$ ,alan)e the ,ene%it+ $% #edi)ati$n+ %$r the treat#ent $% +pe)i%i) di+ea+e+ !ith the ri+4 $% ad-er+e e-ent+, in)luding %all+, in elderly per+$n+. There #ay ,e an $-erlap ,et!een %alling and the pre+en)e $% +yn)$pe: preli#inary data +ugge+t that patient+ !h$ ha-e had re)urrent, une.plained %all+ and !h$ ha-e ,rady)ardia in re+p$n+e t$ )ar$tid-+inu+ +ti#ulati$n ha-e %e!er %all+ !ith )ardia) pa)ing.49 @ntil the+e %inding+ are )$n%ir#ed in )lini)al trial+, h$!e-er, pa)e#a4er therapy %$r the pre-enti$n $% une.plained %all+ )ann$t ,e re)$##ended.

04)1&()*&S
The @.9. :re-enti-e 9er-i)e+ Ta+4 1$r)e re)$##end+ that all per+$n+ *' year+ $% age $r $lder, a+ !ell a+ th$+e *0 t$ *4 year+ $% age !h$ ha-e a 4n$!n ri+4 %a)t$r, ,e )$un+eled a,$ut +pe)i%i) #ea+ure+ t$ pre-ent %all+. '' 3t al+$ re)$##end+ that elderly per+$n+ at high ri+4 %$r %alling re)ei-e indi-iduali2ed, #ulti%a)t$rial inter-enti$n+ in

+etting+ !here ade5uate re+$ur)e+ t$ deli-er +u)h +er-i)e+ are a-aila,le. The 0#eri)an ?eriatri)+ 9$)iety, the ;riti+h ?eriatri)+ 9$)iety, and the 0#eri)an 0)ade#y $% 6rth$paedi) 9urge$n+ ha-e relea+ed "$int, e-iden)e-,a+ed guideline+ %$r the pre-enti$n $% %all+.'(They re)$##end that all elderly patient+ ,e a+4ed a,$ut any %all+ that ha-e $))urred during the pre-i$u+ year and that they underg$ a 5ui)4 te+t $% gait and ,alan)e. The age at !hi)h +)reening +h$uld ,egin i+ n$t +tipulated in the guideline+. 0 #$re )$#prehen+i-e a++e++#ent, %$ll$!ed ,y a #ulti%a)t$rial inter-enti$n +trategy, i+ re)$##ended %$r patient+ !h$ rep$rt re)urrent %all+, !h$ pre+ent a%ter a %all, $r !h$ ha-e di%%i)ultie+ !ith ,alan)e $r gait.

'-*'(4S)-*S A*1 ,&'-//&*1A%)-*S

0ll patient+ *' year+ $% age $r $lder C$r *0 year+ $% age $r $lder, i% they are 4n$!n t$ ,e at in)rea+ed ri+4 %$r %allingD +h$uld ,e a+4ed !hether they ha-e a hi+t$ry $% %all+ and, i% they d$, +h$uld ,e )are%ully 5ue+ti$ned a,$ut the )ir)u#+tan)e+ $% the %all+ and e.a#ined %$r p$tential ri+4 %a)t$r+. 9trategie+ in-$l-ing #ulti%a)t$rial a++e++#ent and inter-enti$n e%%e)ti-ely redu)e the rate $% %alling. 3n the )a+e $% the patient de+)ri,ed in the -ignette, a re-ie! $% the )ir)u#+tan)e+ $% her pre-i$u+ %all+ #ay identi%y high-ri+4 a)ti-itie+ that +h$uld ,e di+)$ntinued, +u)h a+ )arrying laundry up and d$!n +tair+. 8er depre++i-e +y#pt$#+ +h$uld ,e re-ie!ed t$ a++e++ the trade$%% ,et!een the a#eli$rati$n $% depre++i$n and the ri+4 $% %alling a++$)iated !ith her u+e $% antidepre++ant #edi)ati$n. E%%$rt+ +h$uld ,e #ade t$ en)$urage the patient t$ eli#inate $-er-the-)$unter +leep and allergy #edi)ati$n+, ,$th $% !hi)h ha-e anti)h$linergi) e%%e)t+ and thu+ pr$,a,ly )$ntri,ute t$ her ri+4 $% %alling. ;e)au+e her )$nge+ti-e heart %ailure i+ +ta,le, it #ay ,e p$++i,le t$ redu)e the d$+e $% her diureti) $r her )ardia) #edi)ati$n+. 0ny e-iden)e $% p$+tural hyp$ten+i$n !$uld %urther +upp$rt an atte#pt t$ redu)e the d$+e $% her )ardia) #edi)ati$n+. 0de5uate hydrati$n +h$uld ,e en+ured, !hile a-$iding %luid $-erl$ad $r +eri$u+ hyp$natre#ia. '* 3%, a+ i+ li4ely, +he ha+ any ,alan)e $r gait pr$,le#+, +he +h$uld ,e re%erred t$ a phy+i)al therapi+t !h$ !ill train her in the u+e $% an appr$priate a++i+ti-e de-i)e, +u)h a+ a )ane $r !al4er, and !h$ !ill pre+)ri,e a pr$gre++i-e pr$gra# $% ,alan)e and gait training and #u+)le +trengthening. 3% her ,$ne #ineral den+ity i+ l$!, 3 !$uld ad-i+e her t$ !ear hip pr$te)t$r+ and t$ ta4e )al)iu# and -ita#in D +upple#ent+, al$ng !ith a ,i+ph$+ph$nate. The+e inter-enti$n+ !ill redu)e ,y $ne third her ri+4 $% %alling and $% +u+taining a hip %ra)ture. 0dditi$nal in%$r#ati$n $n the pre-enti$n $% %all+, in)luding edu)ati$nal #aterial %$r patient+, )an ,e $,tained %r$# the Nati$nal 3n+titute $n 0ging Chttp: !!!.nia.nih.g$-D, the <enter+ %$r Di+ea+e <$ntr$l and :re-enti$n Chttp: !!!.)d).g$-D, and the 0#eri)an ?eriatri)+ 9$)iety Chttp: !!!.a#eri)angeriatri)+.$rg edu)ati$n %$ru#D.

SOURCE INFORMATION
1r$# the Depart#ent+ $% 3nternal Medi)ine and $% Epide#i$l$gy and :u,li) 8ealth, Fale @ni-er+ity 9)h$$l $% Medi)ine, 333 <edar 9t., :.6. ;$. 20802', Ne! 8a-en, <T 0('20-

802', !here reprint re5ue+t+ )an ,e addre++ed t$ Dr. Tinetti