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Prevenção Quedas
Prevenção Quedas
Clinical Practice
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence
supporting various strategies is then presented, followed by a review of formal guidelines, when they exist.
The article ends with the authors’ clinical recommendations.
From the Geriatric Research, Education, A 79-year-old woman presents for her annual wellness visit. She reports having
and Clinical Center and the Center for the
fallen 9 months ago and again a few weeks ago. She does not remember the details
Study of Healthcare Innovation, Imple-
mentation, and Policy, Veterans Affairs of the first fall, but for the second fall, she notes having tripped over uneven pave-
Greater Los Angeles Healthcare System, ment while walking outside of her home. Despite some difficulty, she was able to get
and the Division of Geriatrics, Department
up unassisted and did not seek medical attention; she recalls having taken an over-
of Medicine, David Geffen School of
Medicine at University of California, Los the-counter “sleep aid” the night before. She said she has no fear of falling, dizziness,
Angeles — all in Los Angeles (D.A.G.); or loss of consciousness. Office staff perform a Timed Up and Go test, and it takes
and the Research Program in Men’s
her 15 seconds to complete the test (≥12 seconds indicates an increased risk of falls).
Health: Aging and Metabolism, Boston
Claude D. Pepper Older Americans Inde- How would you evaluate this patient and manage the risk of future falls?
pendence Center for Function Promoting
Therapies, Brigham and Women’s Hospi-
tal, Boston (N.K.L.). Address reprint re- The Cl inic a l Probl em
F
quests to Dr. Ganz at the Veterans Affairs
Greater Los Angeles Healthcare System, alls, defined as “an unexpected event in which the participants
11301 Wilshire Blvd., 11G, Los Angeles,
come to rest on the ground, floor, or lower level,”1 occur at least once annu-
CA 90073, or at dganz@mednet.ucla.edu.
ally in 29% of community-dwelling adults 65 years or older — a rate of 0.67
N Engl J Med 2020;382:734-43.
falls per person per year.2 Population-based studies suggest that 10% of older
DOI: 10.1056/NEJMcp1903252
Copyright © 2020 Massachusetts Medical Society. adults fall at least twice annually3; patients regularly visiting clinician offices are
presumed to be more likely to belong to this high-risk group, given the prevalence
of diseases and impairments that increase the risk of falling. After falling, a quar-
ter of older adults restrict their activity for at least a day or seek medical attention.2
More serious injuries, such as fractures, joint dislocations, sprains or strains, and
concussions, occur in approximately 10% of falls.4 Rhabdomyolysis due to muscle
ischemia can develop in persons who are unable to get up after a fall and are
An audio version
of this article
“found down” after a long period. After a fall, a fear of falling develops in 21 to
is available at 39% of those who previously had no such fear; persons who fear falling may re-
NEJM.org strict their activity and have a reduced quality of life.5 In aggregate, fall injuries
lead to 2.8 million emergency department visits and 800,000 hospital stays in the
United States annually,2 with total health care costs of $49.5 billion.6
Most falls result from a combination of intrinsic risks (e.g., balance impair-
ment) and extrinsic risks (e.g., trip or slip). Given the many contributors to the risk
of falls,7 focusing on the factors that are the final common pathways to falls and
are those most commonly evaluated in randomized trials leads to a core set of risk
factors (Table 1).3,29 Deficits in gait and balance are the most prominent predispos-
ing risk factors at the population level. Medications (including over-the-counter
drugs), alcohol, visual deficits, impairments in cognition and mood, and environ-
mental hazards can also contribute. Because some they sought medical attention. Patients with sus-
syncopal events manifest as unexplained falls, pected syncope or cardiac symptoms preceding
cardiovascular disease can also play a role.30 a fall should be referred for cardiac evaluation.
The propensity for fall-related harm depends Simple office-based tests of gait, balance, and
on the risks of both falls and injury on impact. strength are routinely indicated in patients who
Osteoporosis is an important contributing cause have a positive screening result for a history of
of fall-related fractures, and the incidence of falls or a fear of falling that limits daily activi-
osteoporotic fractures increases progressively ties. A history of two falls or more in the past
with age.31 Patients receiving anticoagulation year, a visit to an emergency department for a
therapy are also at increased risk owing to a fall in the past year, or a fall in the past year
modest absolute increased risk of fall-related combined with an overt balance or walking
bleeding.32 problem (e.g., positive Timed Up and Go test)
are markers of high risk warranting multifacto-
rial intervention (Fig. 1).
S t r ategie s a nd E v idence
Evaluation Management
The guidelines of the American Geriatrics Soci- Exercise
ety and the British Geriatrics Society recommend All patients should be encouraged to exercise,
annual screening for the risk of falls among if they can. A meta-analysis of 59 randomized
patients 65 years of age or older,27 because pa- trials, which included both healthy participants
tients often do not volunteer information about and those with chronic conditions who were
a previous fall.33 Screening questions about the recruited from generalist and specialist outpa-
number of falls in the past year and about tient clinics, supports the benefits of fall-preven-
whether a fear of falling limits daily activities tion exercise in those at average or high risk for
can be asked as part of a previsit questionnaire falls.35 The rate of falls was 23% (95% confi-
or during the intake interview.34 Trained office dence interval [CI], 17 to 29) lower among the
staff can also perform the Timed Up and Go test participants in the exercise groups than among
to assess mobility (see the Supplementary Ap- those in the control groups (who received inter-
pendix, available with the full text of this article ventions not thought to reduce falls and who
at NEJM.org); times of 12 seconds or longer are had, on average, 0.85 falls per person per year);
considered to indicate an increased risk of the participants in the exercise groups had 0.20
falls.34 Patients who report a history of falls fewer falls per person per year.35 More limited
should be asked for further information about evidence suggests that exercise may reduce the
predisposing factors (e.g., medication and alco- number of falls resulting in fractures (10 trials
hol use), precipitating factors (e.g., preceding showed a 27% [95% CI, 5 to 44] lower rate with
symptoms), circumstances of the fall, associated exercise than with control interventions) and falls
loss of consciousness or injuries, and whether resulting in medical attention (5 trials showed a
Table 1. Risk Factors for Falls That Are Commonly Evaluated in Randomized Trials of Multifactorial Interventions.*
* Data on risk factors were obtained from meta-analyses of observational studies.8-16 The limitations of these data include considerable het-
erogeneity across studies in their definitions of risk factors for falls and evidence of publication bias in some cases. Also, the odds ratio is
known to overestimate the relative risk when the outcome of interest is common (as in the case of falls). These data are shown to provide
a general context for the increased risk of falls associated with each risk factor among older adults. ADL denotes activity of daily living (in-
cludes bathing, dressing, eating, transferring, walking, and toileting), and IADL instrumental activity of daily living (includes preparing
meals, shopping, managing money, and using the telephone).
† Prevalence reflects point estimates or a range of point estimates from population-based studies involving older adults or the 95% confi-
dence intervals of the prevalence from meta-analyses. Data are shown for cohorts of adults 60 years of age or older,17,18 65 years of age or
older,19-23 72 years of age or older,24 and 75 years of age or older.25
‡ The prevalence estimate of 35% was derived from Table 1 of the study by Studenski et al.19 (results of the Third National Health and
Nutrition Examination Survey).
§ Functional visual impairment was defined as difficulty in seeing the words or letters in ordinary newspaper print.20
¶ Orthostatic hypotension was defined as a “sustained reduction in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure
of at least 10 mm Hg within 3 minutes of standing.”26
‖ Examples of hazards include trip hazards (e.g., throw rugs and loose electrical cords), slippery areas, and poor lighting.
Ask about:
No. of falls in the past year
Presence of fear of falling that limits
daily activities
No Yes
No Yes
Prescribe exercise for general Assess gait, balance, and Did the patient have ≥2 falls Evaluate for syncope
health (may include fall- strength and prescribe fall- within the past year?
prevention exercise) prevention exercise or No to all Did the patient go to the
physical therapy, assistive emergency department
device, or both, as appropriate for a fall within the past
year?
Does the patient have overt
balance or walking
problems?
Yes to any
Multifactorial assessment
and management
39% [95% CI, 21 to 53] lower rate).35 Most exer- designed to reduce the risk of falls and include
cise programs lasted at least 12 weeks, and almost exercises that improve leg strength and chal-
one third had a duration of at least 1 year.35 lenge balance with progressively more difficult
Both home-based exercise programs (e.g., the activities.36 There is also some evidence of a
Otago Exercise Program [see the Supplementary lower rate of falls with tai chi, with programs
Appendix]) and group-based exercise programs offering classes one to three times per week for
have been shown to reduce the rate of falls. The 13 to 48 weeks (7 trials showed a 19% [95% CI,
most effective programs have been specifically 1 to 33] lower rate with tai chi than with control
Assessment Domain29 Assessment Strategy Potential Interventions Evidence from RCTs for Fall Outcomes
Balance, gait, strength Watch the patient rise from a Group exercise in the communi- Systematic reviews of large numbers of RCTs
chair, walk, and stand with ty; home-based exercise pro- strongly favor exercise (high certainty of
feet in side-by-side, semi- gram; outpatient physical evidence).36
this information can be used to match a patient Functional Status and Home Safety
with an exercise program, including physical This assessment starts with identifying patients’
therapy if needed. The assessment, which gener- limitations in basic and instrumental activities
ally takes 5 minutes,45 includes watching the pa- of daily living; patients with limitations can be
tient walk to assess gait speed and any obvious queried about whether they have the necessary
gait abnormalities; testing balance by asking the adaptive equipment (e.g., a shower chair for bath-
patient to stand with feet in side-by-side, semi- ing) or someone to assist them. For patients
tandem, and full-tandem positions; and watch- with difficulties in basic activities of daily living,
ing the patient rise from a chair of normal a home-safety evaluation ordered through a home-
height without using the hands to push off. On health agency is appropriate among those who
the basis of clinical experience, a visibly slow are eligible. Although Medicare does not cur-
gait speed (e.g., <0.6 m per second)46 or any rently cover the cost of home modifications
discernible gait abnormalities, difficulties hold- identified through a home-safety evaluation, for
ing side-by-side or semi-tandem stances for 10 patients with limited means, community agen-
seconds, preexisting use of an assistive device, cies and some municipalities may provide assis-
or inability to rise from a chair may indicate the tance with home modifications at little or no
need for either home-based physical therapy or cost.47 Medicare covers a part of the costs for
outpatient physical therapy. Prescriptions for phys- some adaptive equipment (i.e., durable medical
ical therapy should specify any gait, balance, or equipment prescribed by a physician). Most devel-
strength deficits noted during this part of the oped countries provide some support for home
examination. Patients may also benefit from modifications and adaptive equipment for older
physical therapy if they have substantial musculo- people with limited means through a variety of
skeletal pain, neurologic or vestibular symp- funding approaches, including health care sys-
toms, or cognitive impairment that would limit tems, charitable organizations, and tax refunds.
participation in standard exercise programs. Pa- Vision
tients without appreciable deficits are potentially Eye examinations are recommended every 1 to
appropriate for a community-based or home- 2 years for adults 65 years of age or older. Re-
based exercise program focused on fall preven- garding patients who have not had a recent eye
tion. Patients with balance deficits who do not examination or who report new visual problems,
have an assistive device should be encouraged to distance vision can be tested in the office, and
use a cane, wheeled walker, or both, which can be prompt referral can be made in the case of
kept in the clinic for demonstration purposes. newly identified deficits in visual acuity. Patients
Medication Review with balance deficits who wear multifocal lenses
All prescribed and over-the-counter drugs should and regularly go outdoors may also benefit from
be reviewed, with a focus on tapering or discon- a referral for single-lens distance glasses to use
tinuing medications without a compelling indi- when outdoors.38 For patients with a corrected
cation or for which the potential harm is greater visual acuity worse than 20/80 in the better eye,
than the benefit.28 Particular attention should be a home assessment by an occupational therapist
paid to medications that may cause sedation, is recommended on the basis of a lower rate of
confusion, or orthostatic hypotension (e.g., anti- falls observed among such patients who received
depressants, antipsychotics, benzodiazepine- a home-safety program than among those who
receptor agonists, antiepileptic drugs, opioids, did not; a lower rate of falls was not observed
and antihypertensive agents)11,13,28 and medica- among those who received an exercise program.48
tions that may interact with alcohol use. Re- Cognition and Mood
sources are available to support clinicians in Brief instruments, such as the Mini-Cog49 and
stopping or reducing the dose of medications the Patient Health Questionnaire-9,50 are helpful
that increase the risk of falls and to help pa- screening tools to assess cognitive impairment
tients in the tapering of such drugs. For patients and depressive symptoms, respectively. Both of
who are tapering their use of insomnia medica- these conditions are associated with an increased
tions, nonpharmacologic strategies (e.g., cognitive risk of falls, independent of the medications
behavioral therapy and guidance on sleep hy- prescribed for them (Table 1). Patients who meet
giene) are available. the criteria for dementia or depression can be
evaluated for reversible causes (e.g., hypothyroid- one trial showing a decrease in the risk of falls,
ism). Because antidepressants are associated with and one trial showing an increase in the risk of
an increased risk of falls11 and cholinesterase falls.29 Thus, prescribing vitamin D expressly to
inhibitors with an increased risk of syncope,41 prevent falls is not recommended.51
nonpharmacologic treatments should be offered
first; pharmacologic treatment should be pre- Injury Prevention
scribed only after weighing the benefit of treat- Injury prevention should focus on assessing and
ment against the potential side effects, including managing a patient’s risk of fractures. Patients
fall risk. with previous vertebral or hip fracture after
Orthostatic Hypotension minimal trauma should be offered pharmaco-
Orthostatic hypotension is defined as a sus- logic treatment for osteoporosis, and women 65
tained fall in systolic blood pressure of at least years of age or older (or with other major risk fac-
20 mm Hg or diastolic blood pressure of at least tors for osteoporosis) without a previous verte-
10 mm Hg within 3 minutes of standing.26 Pa- bral or hip fracture should undergo testing of bone
tients who have a drop in blood pressure imme- mineral density.52 Hip protectors are not recom-
diately on standing that normalizes by 3 minutes mended for community-dwelling older adults,
can be educated about rising slowly and not since a meta-analysis showed no difference in
ambulating immediately after standing. In pa- the risk of hip fractures in this population.53
tients with confirmed orthostatic hypotension,
potentially causative medications (e.g., those with A r e a s of Uncer ta in t y
anticholinergic side effects) that are not neces-
sary should be discontinued, and adequate hy- The effectiveness of multifactorial evaluation
dration should be encouraged. Patients with re- and management for reducing the risk of seri-
fractory symptoms or profound drops in blood ous fall injuries has not been established; two
pressure on standing (i.e., from supine hyper- large multicenter, pragmatic trials addressing
tension to standing hypotension) should be this are under way (ClinicalTrials.gov number,
evaluated (or referred for evaluation) for neuro- NCT02475850, and Current Controlled Trials
genic causes and for potential pharmacologic number, ISRCTN71002650).54,55 Most trials of fall-
treatment. reduction strategies have excluded cognitively
Other Strategies impaired persons35,44; a meta-analysis of three
Features of multifactorial assessment in some trials involving patients with cognitive impair-
randomized trials have included assessment for ment supports the benefit of exercise,36 but more
cardiovascular causes (e.g., carotid sinus hyper- data are needed in this population.
sensitivity or arrhythmia), footwear or foot prob-
lems, hearing, musculoskeletal pain, neurologic Guidel ine s
findings (e.g., parkinsonism or peripheral neu-
ropathy), urinary incontinence, and vestibular Guidelines for the evaluation and management
disorders.29 These areas should be pursued as of the risk of falls have been published by the
dictated by the circumstances of the patient’s U.S. Preventive Services Task Force51 and by the
falls that were identified during the initial evalu- American Geriatrics Society and British Geriat-
ation. rics Society.27 The current recommendations are
largely concordant with these guidelines.
Vitamin D
Although previous studies showed that the risk C onclusions a nd
of falls was lower with vitamin D supplementa- R ec om mendat ions
tion than with control interventions, a recent
systematic review of randomized trials of vita- The 79-year-old woman described in the vignette
min D (or analogues) to reduce the risk of falls is at high risk for future falls, given that she had
among community-dwelling older adults who two falls in the past year and had a positive
had no other indications for vitamin D supple- Timed Up and Go test. She should be observed
mentation did not support a benefit, with five getting up from a chair without using her hands
trials showing no difference in the risk of falls, and then walking, and her balance should be
evaluated by asking her to stand with her feet in signs, cognition, and mood are also warranted,
side-by-side, semi-tandem, and full-tandem posi- either at the current visit or the next. The patient
tions. If there are no major deficits, she can be should understand that falls are not an inevita-
referred to a community-based exercise program ble part of aging and that the risk of falls can be
and prescribed a cane for outdoor walking. markedly reduced if she addresses identified risk
Medications for insomnia should be discouraged factors.
in favor of nonpharmacologic strategies. We The views expressed in this article are those of the authors
would review other medications, confirm that and do not necessarily reflect the position or policy of the De-
she is independent in her basic and instrumental partment of Veterans Affairs or the U.S. government.
No potential conflict of interest relevant to this article was
activities of daily living, refer her for an eye reported.
examination if she has not had one in the past Disclosure forms provided by the authors are available with
1 to 2 years, and review test results of bone the full text of this article at NEJM.org.
We thank Shalender Bhasin, Carolyn J. Crandall, Thomas M.
mineral density (or refer her for testing if none Gill, David B. Reuben, and Paul G. Shekelle for comments on a
were available). Reviews of orthostatic vital previous version of the manuscript.
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