Gerontology, Palliative Care & Prevention · Topic 3 of 13

Falls & Immobility

Geriatrics · falls and deconditioning

Falls & Immobility

A prior fall predicts the next: after any fall, look for injury and the cause, review the medications, and keep the patient moving.

Key numbers

High-risk fall: full multifactorial assessment≥ 2 falls in 12 months

Check orthostatic BP supine, then standingSBP drop ≥ 20 mmHg

Slow gait or slow Timed Up and Gogait < 0.8 m/s

01 · RiskA prior fall predicts the next

A previous fall is the most consistent predictor of falling; falls are usually multifactorial — intrinsic (age-related decline, disease, medications), extrinsic (environmental hazards) and situational (rushing to the bathroom at night).

02 · Defined byHigh-risk fall: full multifactorial assessment

A fall plus injury, 2 or more falls in 12 months, frailty, a long lie of 1 hour or more, or suspected loss of consciousness = high risk: offer a multifactorial falls risk assessment.

03 · DoHead strike, over 60 or anticoagulated: CT

Image the head liberally after a fall with head injury when the patient is over 60 or takes an anticoagulant or antiplatelet drug, even if alert; reverse anticoagulation for life-threatening bleeding.

Do right now

In this order

First moves

After an inpatient fall: injury, mechanism, precipitant

→

Head strike, over 60 or anticoagulated: CT

→

Long lie: dehydration, rhabdomyolysis, hypothermia, pressure injury

→

Review and deprescribe fall-risk drugs

Why each step

After an inpatient fall: injury, mechanism, precipitantAfter a fall in the hospital, assess for injuries, establish the mechanism, look for a precipitating cause such as new illness, complications or delirium, then reassess fall risk factors and adjust the prevention plan.

Head strike, over 60 or anticoagulated: CTImage the head liberally after a fall with head injury when the patient is over 60 or takes an anticoagulant or antiplatelet drug, even if alert; reverse anticoagulation for life-threatening bleeding.

Long lie: dehydration, rhabdomyolysis, hypothermia, pressure injuryLying on the floor for over an hour causes dehydration, electrolyte disturbance, renal failure, hypothermia, pneumonia, pressure injury and pain; prolonged immobilization can cause rhabdomyolysis — check electrolytes, renal function and CK.

Review and deprescribe fall-risk drugsDo a structured medication review after a fall: psychoactive drugs (benzodiazepines, Z-drugs, antipsychotics, antidepressants, antiepileptics, opioids) and antihypertensives or diuretics raise fall risk — deprescribe, and avoid 3 or more CNS-active drugs (Beers).

Management

Orders

Check orthostatic BP supine, then standingMeasure BP supine (after 5 minutes) and at 1 and 3 minutes of standing; orthostatic hypotension = SBP drop ≥ 20 mmHg or DBP drop ≥ 10 mmHg within 3 minutes.

Slow gait or slow Timed Up and GoGait speed < 0.8 m/s is the World Falls Guidelines' preferred falls-risk test; the Timed Up and Go (rise, walk 3 m, turn, return, sit) over 15 seconds is the alternative.

Individualized prevention for every inpatient over 65Give every inpatient 65 or older falls education and prevention tailored to their risks — delirium prevention, toileting help, a clear path to the bathroom, beds at the lowest level; restraints increase agitation.

Targeted tests, not a fixed fall panelNo standard lab panel explains a fall: check CBC, glucose and electrolytes as the history guides; get ECG, monitoring or echo only for a suspected cardiac cause, and neuroimaging for new neurologic findings.

Unexplained or syncopal fall: syncope work-upA fall with suspected transient loss of consciousness, or one with no explanation after assessment, should trigger a syncope evaluation (see Syncope).

Mobilize early; bed rest is seldom warrantedOrder early, regular mobilization for hospitalized older adults: prolonged bed rest is seldom warranted, and low mobility in the hospital is linked to loss of muscle mass and functional decline.

Prescribe balance and strength exerciseExercise is the core prevention (USPSTF grade B, community-dwelling adults 65+ at risk): balance and functional training at least 3 times weekly for 12 weeks or more, plus Tai Chi or resistance work; refer to PT.

Vitamin D only if deficient or at riskReserve vitamin D for patients at risk of deficiency rather than routine falls prevention; reduce injury by screening for and treating osteoporosis.

Red flags & don'ts

Avoid harm

Bed rest deconditions within days complicationComplete bed rest cuts muscle strength significantly within the first several days and causes contractures, lower aerobic capacity, bone loss and DVT; a few days can cost a frail older adult independent function.

The rules

Know these

Skip scored fall-risk tools in hospitalGive every hospitalized adult over 65 a multifactorial falls risk assessment; the World Falls Guidelines recommend against scored falls risk screening tools in hospitals because scoring does not reduce falls.

More detail

Reference

Show 5 reference facts

Falls are the leading cause of injury-related death in adults 65 and older; about 37% of older adults who fall sustain an injury needing treatment or restricting activity.

One in 8 older adults who fall lie on the floor for more than an hour, and up to 80% of those over 90 cannot rise from the floor unaided.

Standing on one leg for 10 seconds with eyes open and an accurate 3-meter tandem walk make a significant intrinsic balance deficit unlikely.

Assess fear of falling with the Short FES-I in hospital; exercise, cognitive behavioral therapy and occupational therapy reduce it.

USPSTF (2024) advises individualizing multifactorial interventions for community-dwelling older adults at increased risk because their net benefit is small (grade C).

Pearl

An old person can lose independent mobility in a day — every fall and every day in bed counts.

Sources · Merck Manual Professional — Falls in Older Adults (Aug 2025) · Montero-Odasso M et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 2022;51:afac205 · Merck Manual Professional — Approach to the Trauma Patient (head imaging in older or anticoagulated patients) · 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria. J Am Geriatr Soc 2023;71:2052–2081 · Merck Manual Professional — Orthostatic Hypotension · Merck Manual Professional — Hospital Care and Older Adults (bed rest effects, falls, restraints) · Merck Manual Professional — Rhabdomyolysis · Merck Manual Professional — Overview of Evaluation of the Older Adult (immobility during hospitalization) · USPSTF. Interventions to Prevent Falls in Community-Dwelling Older Adults: Recommendation Statement (2024) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).