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F3ALLS Approach to Preventing Falls

Falls occur in 30% of community dwelling older persons (1, 2). Falls are 3 times more frequent in persons living in long term care compared to those in the community (3) In the United States in 2015, the medical cost of falls was approximately $50 billion (4). Falls are more common in persons with dementia due to an increase in leukoariosis in persons with vascular dementia and a dual tasking deficit (5-8). Persons with diabetes mellitus have an increased risk of falls and fractures at an early age (9-11). Falls represent a major cause of fractures in older persons (12).

Persons with frailty and sarcopenia are at particular risk for falling (13-16). Rapid screens for frailty, the FRAIL (17-19) and sarcopenia, the SARC-F (20-22) have been developed and both predict an increased propensity for older persons to fall. The FRAIL-NH is a predictor of falling in nursing homes (23, 24).

In view of the high medical costs associated with falls the Centers for Disease Control and Prevention has developed the Stopping Elderly Accidents, Deaths and Injuries (STEADI) methodology (25-27). While the algorithm has a number of positive features it is complex to use and more time consuming than can be undertaken in an average general practitioner visit. For this reason we have developed the simple F3ALLS approach to fall prevention (Table I).

Both previous falls (28) and fear of falling (29, 30) are associated with an increased fall risk. These patients should be referred to a physical therapist who should do the Toulouse St. Louis University Mini Falls Assessment (31) and then carry out appropriate therapy. Following therapy, they should be enrolled in a long-term exercise program such as the Modified Otago Exercise Program (32-36). There is reasonable evidence supporting resistance exercise and balance training for preventing falls, but it should be continued for life (1, 37-39).

Foot pain should result in an assessment for diabetic neuropathy. If present improved diabetic control within the modern guidelines should be instituted (40, 42). Supervised balance exercises should be instituted (43). Persons with other foot abnormalities should be referred to a podiatrist (44). A cane or other walking aids should be offered to these individuals (45).

Self-reported unsteadiness predicts fear of falling and falls (46). These persons require a medication review and referral for balance related exercises.

The SARC-F or handgrip strength should be used to diagnose sarcopenia in those persons complaining of loss of strength (47-49). They should then be referred for resistance exercise training (50, 51) and leucine enriched essential amino acids (52, 53).

Low systolic blood pressure increases the risk of falls in older persons and those with diabetes mellitus (54, 55). Orthostatic hypotension is strongly associated with falls (56-58). Postprandial hypotension is a common cause of falls in older persons and diabetics with autonomic neuropathy (59). It can be treated with α-1-glucosidase inhibitors (acarbose or miglitol), which increase glucagon like peptide-1 and slow gastric emptying (59-61).

Table 1
figure1

The F3ALLS Approach to Preventing Falls

Approximately 30% of falls in older persons and persons with diabetes mellitus are due to syncope (62, 63). When the person does not have orthostasis or postprandial hypotension the most likely cause is an arrhythmia. Investigation for an arrhythmia requires an event monitor, but because they often occur months apart, an implantable loop recorder is commonly indicated (64, 65).

It would seem that the F3ALLS represents a rapid and easily computerizable, approach to falls prevention.

References

  1. 1.

    Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;12(9):CD007146.

    Google Scholar 

  2. 2.

    Gomez F, Wu YY, Auais M, et al. A simple algorithm to predict falls in primary care patients aged 65 to 74 years: The international mobility in aging study. J Am Med Dir Assoc 2017;18:774–779.

    Article  PubMed  Google Scholar 

  3. 3.

    Rapp K, Becker C, Cameron ID, et al. Epidemiology of falls in residential aged care: Analysis of more than 70,000 falls from residents of Bavarian Nursing Homes. J Am Med Dir Assoc 2012;13:187.e1–e6.

    Article  Google Scholar 

  4. 4.

    Florence CS, Bergen G, Atherly A, et al. Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc 2018 Mar 7. Doi: 10..1111/jgs.15304.

    Google Scholar 

  5. 5.

    Morley JE. White matter lesions (leukoaraiosis): A major cause of falls. J Am Med Dir Assoc 2015;16:442–443.

    Google Scholar 

  6. 6.

    Morley JE. Gait, falls, and dementia. J Am Med Dir Assoc 2016;17:467–470.

    Article  PubMed  Google Scholar 

  7. 7.

    Morley JE. Frailty, falls, and fractures. J Am Med Dir Assoc 2013;14:149–151.

    Article  PubMed  Google Scholar 

  8. 8.

    Montero-Odasso M, Speechley M. Falls in cognitively impaired older adults: Implications for Risk Assessment and prevention. J Am Geriatr Soc 2018;66:367–375.

    Article  PubMed  Google Scholar 

  9. 9.

    Vinik AI, Camacho P, Reddy S, et al. Aging, diabetes, and falls. Endocr Pract 2017;23:1117–1139.

    PubMed  Google Scholar 

  10. 10.

    Chode S, Malmstrom TK, Miller DK, Morley JE. Frailty, diabetes, and mortality in middle-aged African Americans. J Nutr Health Aging 2016;20:854–859.

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Morley JE, Abbatecola AM, Woo J. Management of comorbidities in older persons with type 2 diabetes. J Am Med Dir Assoc 2017;18:639–645.

    Article  PubMed  Google Scholar 

  12. 12.

    Blain H, Masud T, Dargent-Molina P, et al. A comprehensive fracture prevention strategy in older adults: The European Union Geriatric Medicine Society (EUGMS) statement. J Nutr Health Aging 2016;20:647–652.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Liu Z, Wang Q, Zhi T, et al. Frailty index and its relation to falls and overnight hospitalizations in elderly Chinese people: A population-based study. J Nutr Health Aging 2016;2:561–568.

    Article  Google Scholar 

  14. 14.

    Papachristou E, Wannamethee SG, Lennon LT, et al. Ability of self-reported frailty components to predict incident disability, falls, and all-cause mortality: Results from a population-based study of older British men. J Am Med Dir Assoc 2017;18:152–157.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Kojima G. Frailty as a predictor of future falls among community-dwelling older people: A systematic review and meta-analysis. J Am Med Dir Assoc 2015;16:1027–1033.

    Article  PubMed  Google Scholar 

  16. 16.

    Liu Z, Wang Q, Zhi T, et al. Frailty Index and its relation to fall and overnight hospitalizations in elderly Chinese people: A population-based study. J Nutr Health Aging 2016;20:561–568.

    Article  CAS  PubMed  Google Scholar 

  17. 17.

    Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging 2012;16:601–608.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Woo J, Yu R, Wong M, et al. Frailty screening in the community using the FRAIL scale. J Am Med Dir Assoc 2015;16;412–419.

    Article  PubMed  Google Scholar 

  19. 19.

    Dent E, Lien C, Lim WS, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. J Am Med Dir Assoc 2017;18:564–575.

    Article  PubMed  Google Scholar 

  20. 20.

    Cao L, Chen S, Zou C, et al. A pilot study of the SARC-F scale on screening sarcopenia and physical disability in the Chinese older people. J Nutr Health Aging 2014;18:277–283.

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    Woo J, Leung J, Morley JE. Validating the SARC-F: A suitable community screening tool for sarcopenia? J Am Med Dir Assoc 2014;15:630–634.

    Article  PubMed  Google Scholar 

  22. 22.

    Malmstrom TK, Miller DK, Simonsick EM, et al. SARC-F: A symptom score to predict persons with sarcopenia with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle 2016;7:28–36.

    Article  PubMed  Google Scholar 

  23. 23.

    Kaehr EW, Pape LC, Malmstrom TK, Morley JE. FRAIL-NH predicts outcomes in long-term care. J Nutr Health Aging. 2016;20:192–198.

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Luo H, Lum TY, Wong GH, et al. Predicting adverse health outcomes in the nursing homes: A 9-year longitudinal study and development of the FRAIL-minimum data set (MDS) quick screening tool. J Am Med Dir Assoc 2015;16:1042–1047.

    Article  PubMed  Google Scholar 

  25. 25.

    Sri-On J, Tirrell GP, Kamsom A, et al. A high-yield fall risk and adverse events screening questions from the Stopping Elderly Accidents, Death, and Injuries (STEADI). Guideline for older emergency department fall patients. Acad Emerg Med 2018;Mar 25. DOI: 10.111/acem.13413 [Epub ahead of print].

    Google Scholar 

  26. 26.

    Sarmiento K, Lee R. STEADI: CDC’s approach to make older adult fall prevention part of every primary care practice. J Safety Res 2017;63:105–109.

    Article  PubMed  Google Scholar 

  27. 27.

    Mark JA, Loomis J. The STEADI toolkit: Incorporating a fall prevention guideline into the primary care setting. Nurse Pract 2017;42:50–55.

    Article  PubMed  Google Scholar 

  28. 28.

    Naseri C, Haines TP, Etherton-Beer C, et al. Reducing falls in older adults recently discharged from hospital: A systematic review and meta-analysis. Age Ageing 2018;Mar 23. Doi: 10.1093/ageing/afyo43 [Epub ahead of print].

    Google Scholar 

  29. 29.

    Whipple MO, Hamel AV, Talley KMC. Fear of falling among community-dwelling older adults: A scoping review to identify effective evidence-based interventions. Geriatr Nurs 2017; Sep 21 DOI: 10.1016/j.gerinurse.2017.08.005.

    Google Scholar 

  30. 30.

    Sakurai R, Fujiwara Y, Yasunaga M, et al. Older adults with fear of falling show deficits in motor imagery of gait. J Nutr Health Aging 2017;21:721–726.

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Morley JE, Rolland Y, Tolson D, Vellas B. Increasing awareness of the factors producing falls: The mini falls assessment. J Am Med Dir Assoc 2012;13:87–90.

    Article  PubMed  Google Scholar 

  32. 32.

    Liew LK, Tan MP, Tan PJ, et al. The Modified Otago exercises prevent grip strength deterioration among older fallers in the Malaysian falls assessment and intervention trial (MyFAIT). J Geriatr Phys Ther 2018;Jan 29 doi: 10.1519/ JPT.0000000000000155. [Epub ahead of print].

    Google Scholar 

  33. 33.

    Deverall E, Kvizhinadze G, Pega F, et al. Exercise programmes to prevent falls among older adults: Modelling health gain, cost-utility and equity impacts. Inj Prev 2018;Jan 23. Doi: 10.1136/injuryprev-2016-042309. Epub ahead of print].

    Google Scholar 

  34. 34.

    Mat S, Ng CT, Tan PJ, et al. Effect of modified Otago exercises on postural balance, fear of falling, and fall risk in older fallers with knee osteoarthritis and impaired gait and balance: A secondary analysis. PM R. 2018;10:254–262.

    Article  PubMed  Google Scholar 

  35. 35.

    Day L. The Otago strength and balance exercise programme lowers the risk of death and falls in the older people at 12 months. Evid Based Nurs 2011;14:76–78.

    Article  PubMed  Google Scholar 

  36. 36.

    Shubert TE, Smith ML, Goto L, et al. Otago exercise program in the United States: Comparison of 2 implementation models. Phys Ther 2017;97:187–197.

    Article  PubMed  Google Scholar 

  37. 37.

    Hewitt J, Goodall S, Clemson L, et al. Progressive resistance and balance training for falls prevention in long-term residential aged care: A cluster randomized trial of the Sunbeam program. J Am Med Dir Assoc 2018;19:361–369.

    Article  PubMed  Google Scholar 

  38. 38.

    Silva RB, Eslick GD, Duque G. Exercise for falls and fracture prevention in long term care facilities: A systematic review and meta-analysis. J Am Med Dir Assoc 2013;14:685–689.e2.

    Article  PubMed  Google Scholar 

  39. 39.

    Chan WC, Yeung JW, Wong CS, et al. Efficacy of physical exercise in preventing falls in older adults with cognitive impairment: A systematic review and metaanalysis. J Am Med Dir Assoc 2015;16:149–154.

    Article  PubMed  Google Scholar 

  40. 40.

    Strain WD, Hope SV, Green A, et al. Type 2 diabetes mellitus in older people: A brief statement of key principiles of modern day management including the assessment of frailty, a national collaborative stakeholder initiative. Diabet Med 2018;Apr 7, doi: 10.111/dme.13644 [Epub ahead of print].

    Google Scholar 

  41. 41.

    Sinclair AJ, Abdelhafiz A, Dunning T, et al. An international position statement on the management of frailty in diabetes mellitus: Summary of recommendations 2017. J Frailty Aging 2018;7:10–20.

    CAS  PubMed  Google Scholar 

  42. 42.

    Sinclair A, Morley JE, Rodriguez-Manas L, et al. Diabetes mellitus in older people: Position statement of behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J am Med Dir Assoc 2012;13:497–502.

    Article  PubMed  Google Scholar 

  43. 43.

    Morrison S, Simmons R, Colberg SR, et al. Supervised balance training and Wii Fitbased exercises lower falls risk in older adults with type 2 diabetes. J Am Med Dir Assoc 2018;19:185.e7–185.e13.

    Article  Google Scholar 

  44. 44.

    Cockayne S, Adamson J, Corbacho Martin B, et al. The REFORM study protocol: A cohort randomized controlled trial of a multifaceted podiatry intervention for the prevention of falls in older people. BMJ Open 2014;4(12):e006977.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Rodriguez-Sanz D, Tovaruela-Carrion N, Lopez-Lopez D, et al. Foot disorders in the elderly: A mini-review. Dis Mon 2018;64:64–91.

    Article  PubMed  Google Scholar 

  46. 46.

    Donoghue OA, Setti A, O’Leary N, Kenny RA. Self-reported unsteadiness predicts fear of falling, activity. Restriction, falls, and disability. J Am Med Dir Assoc 2017;18:597–602.

    Article  PubMed  Google Scholar 

  47. 47.

    Kim S, Kim M, Won CW. Validation of the Korean version of the SARC-F questionnaire to assess sarcopenia: Korean frailty and aging cohort study. J Am Med Dir Assoc 2018;19:40–45.e1.

    Article  PubMed  Google Scholar 

  48. 48.

    Tanaka S, Kamiya K, Hamazaki N, et al. Utility of SARC-F for assessing physical function in elderly patients with cardiovascular disease. J Am Med Dir Assoc 2017;18;176–181.

    Article  PubMed  Google Scholar 

  49. 49.

    Balogun S, Winzenberg T, Wills K, et al. Prospective associations of low muscle mass and function with 10-year falls risk, incident fracture and mortality in community-dwelling older adults. J Nutr Health Aging 2017;21:843–848.

    Article  CAS  PubMed  Google Scholar 

  50. 50.

    Vlietstra L, Hendrickx W, Waters DL. Exercise interventions in healthy older adults with sarcopenia: A systematic review and meta-analysis. Australas J Ageing 2018;Apr 11. DOI: 10.1111/ajag.12521 [Epub ahead of print].

    Google Scholar 

  51. 51.

    Papa EV, Dong X, Hassan M. Resistance training for activity limitations in older adults with skeletal muscle function deficits: A systematic review. Clin Interv Aging 2017;12:955–961.

    Article  PubMed  PubMed Central  Google Scholar 

  52. 52.

    Bauer JM, Verlaan S, Bautmans I, et al. Effects of a vitamin D and leucine-enriched whey protein nutritional supplement on measures of sarcopenia in older adults, the PROVIDE study: A randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc 2015;16:740–747.

    Article  PubMed  Google Scholar 

  53. 53.

    Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE study group. J Am Med Dir Assoc 2013;14:542–559.

    Article  PubMed  Google Scholar 

  54. 54.

    Moncada LVV, Mire LG. Preventing falls in older persons. Am Fam Physician 2017;96:240–247.

    PubMed  Google Scholar 

  55. 55.

    Quigley P, Bulat T, Kurtzman E, et la. Fall prevention and injury protection for nursing home residents. J Am Med Dir Assoc 2010;11:284–293.

    Article  PubMed  Google Scholar 

  56. 56.

    Arnold AC, Raj SR. Orthostatic hypotension: A practical approach to investigation and management. Can J Cardiol 2017;33:1725–1728.

    Article  PubMed  Google Scholar 

  57. 57.

    Zhang R, Malmstrom TK. Implications of orthostatic hypotension in older persons with and without diabetes. J Am Med Dir Assoc 2017;18:84–85.

    Article  PubMed  Google Scholar 

  58. 58.

    Iwanczyk L, Weintraub NT, Rubenstein LZ. Orthostatic hypotension in the nursing home setting. J Am Med Dir Assoc 2006;7:163–167.

    Article  PubMed  Google Scholar 

  59. 59.

    Trahair LG, Horowitz M, Jones KL. Postprandial hypotension: A systematic review. J Am Med Dir Assoc 2014;15:394–409.

    Article  PubMed  Google Scholar 

  60. 60.

    Pavelic A, Krbot Skoric M, Crnosija L, Habek M. Postprandial hypotension in neurological disorders; Systematic review and meta-analysis. Clin Auton Res 2017;27:263–271.

    Article  PubMed  Google Scholar 

  61. 61.

    Lee A, Patrick P, Wishart J, et al. The effects of miglitol on glucagon-like peptide-1 secretion and appetite sensations in obese type 2 diabetics. Diabetes Obese tab 2002;4:329–335.

    Article  CAS  Google Scholar 

  62. 62.

    Kenny RA. Syncope in the elderly: Diagnosis, evaluation, and treatment. J Cardiovasc Electrophysiol 2003;14(9 Suppl):S74–S77.

    Article  PubMed  Google Scholar 

  63. 63.

    Shaw FE, Kenny RA. The overlap between syncope and falls in the elderly. Postgrad Med J 1997;73:635–639.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Task Force for the Diagnosis and Management of Syncope: European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS), Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631-2671.

  65. 65.

    Shanmugam N, Liew R. The implantable loop recorder -an important addition to the armentarium in the management of unexplained syncope. Ann Acad Med Singapore 2012;41:115–124.

    PubMed  Google Scholar 

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Morley, J.E. F3ALLS Approach to Preventing Falls. J Nutr Health Aging 22, 748–750 (2018). https://doi.org/10.1007/s12603-018-1046-0

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Key words

  • Falls
  • cost of falls
  • frailty