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Characteristics of outpatients reporting recurrent falls in a fall prevention clinic.


The objective of this study was to identify characteristics which distinguished idiopathic recurrent fallers and individuals reporting one or no falls. A retrospective chart review of patients referred to an outpatient, multidisciplinary fall prevention clinic was conducted in a large urban Department of Veterans Affairs Medical Center. Data collected per standard fall prevention clinic protocol included a self-reported history and performance tests (Tinetti Gait & Balance and Berg Balance tests). Exclusion criteria for the study were Parkinson's disease, multiple sclerosis, or cerebral vascular accident with residual impairment. Of the 163 charts reviewed, 98 were included. Charts were grouped according to self-reported falls in the three-month period prior to attending the clinic: 0-1 fall (n = 50) and [greater than or equal to] 2 falls (n = 48). Individuals in the [greater than or equal to] 2 falls group had significantly higher Geriatric Depression Scores, were more likely to report the sensation of self and/or surroundings spinning, more likely to report a fear of falling, and less likely to report receiving training for use of assistive devices. All other demographic (e.g., age, body mass index, visual impairment, diabetes, medications for sleep or depression) were equally distributed between the two groups. In conclusion, the characteristics which distinguish recurrent fallers from individuals reporting one or no falls may be amenable to Kinesiotherapy interventions.

Key Words: Falls, Recurrent Falls, Geriatric, Elderly, Vestibular, Depression, Fear of falling


Falls are a major cause of morbidity and mortality in the elderly population and are an independent predictor variable leading to nursing home admission (36). Twenty percent of those over age 65 suffer serious falls each year (8). Falls are the leading cause of accidental death in the geriatric population (31). Falls, however, do not have a common etiology. Moreover, psychological and social effects of falls are long-lasting (37). Medical, pharmacological, or functional issues (e.g., visual impairment, vestibular dysfunction, gait abnormalities, medications for sleep or depression, or mental status) may independently or jointly increase the likelihood of falls (23,28).

Much work has been done to identify acute and nursing home patients at risk for falls based on risk factors associated with falls (e.g., Morse Fall Scale (21), STRATIFY (25), Resident Assessment Instrument (RAI) (20), Fall Risk Assessment Tool (FRAT) (16), Hendrich Fall Risk Model (11), High Risk for Falls Assessment Form (6), Royal Melbourne Hospital (RMH) Risk Assessment Tool (19)). Routinely, acute and nursing home patients are assessed for fall risk upon admission to the facility in order to determine level of nursing intervention necessary to prevent falls while in the facility. In the outpatient setting, however, routine fall risk assessment is rarely done and the importance of onetime accidents, such as trips and slips, is often minimized by the patient and/or caregiver (13). Additionally, the need for interventions to prevent functional decline, which impede the ability to respond to environmental obstacles, is often recognized only after the initial fall or recurrent falls.

Much work has been done to identify risk factors for falls. Rawsky (26) reviewed 21 articles published between 1979 and 1996 related to falls in the elderly in a variety of settings (e.g., inpatient hospital, community, psychiatry facility, rehabilitation center, and long-term care facility). They found that cognitive impairment/psychological status, acute/chronic illness and mobility, sensory deficits, fall history, and elimination were cited most often. Rubenstein and Josephson (27) summarized 12 articles and reported accidents, gait/balance or weakness, dizziness/vertigo, drop attacks, confusion, postural hypotension, and visual disorders as the main single precipitating causes of falls in the elderly based on relative risk and odds ratios reported. Additionally, Tinetti et al. (35), in a prospective study of community dwelling elderly, identified the highest adjusted odds ratios for sedative use, cognitive impairment, and lower-extremity disability. Mahoney et al. (17) identified the following factors upon discharge from the hospital as factors for falls after hospitalization: decline in mobility, use of assistive device, cognitive impairment, and self-report of confusion. Generally, these studies have focused on the distinction between those who fall (one or more times in some defined period of time) and those who did not fall. Studies by Lipsitz et al. (14) and Morse et al. (24) focused on factors which distinguished those who reported recurrent falls from those who reported no falls since prior falls are the leading predictor of future falls (21). Additionally, recurrent falls have been shown to increase morbidity (22) and may even be indicative of impending death (9).

Little is known about the heterogeneous group of individuals who fall repeatedly without specific diagnoses (e.g., Parkinson's disease, cerebral vascular accident), especially in the outpatient setting. Morse et al. (24) examined the demographics, gait and supervision of hospitalized patients reporting no falls compared to hospitalized patients reporting multiple falls defined as two falls in one month or three falls in one year). The study found no significant differences between the two groups with respect to weight, temperature, pulse, orthostatic hypotension, mental status, or hearing impairments. The only demonstrated significant characteristics found between the two groups were that those patients reporting no falls reported increased use of wheelchairs, side-rails and ambulatory aids. This study, however, did not distinguish between extrinsic (slips or trips) and intrinsic (dysequilibrium or lower-extremity weakness) factors for the fall. Lipsitz, et al. (14) compared characteristics of ambulatory nursing home residents who fell (two or more falls in six months) and who did not fall (no falls in six months). They found that those residents with multiple falls were more likely to be functionally impaired, report the use of assistive devices, and take on average one more medication than those who did not fall. Neither of these studies, however, evaluated characteristics, which can distinguish those who reported one fall from those who report recurrent falls. The purpose of this study was to identify characteristics distinguishing outpatients referred to a falls prevention screening clinic who reported recurrent falls (two or more falls in a three-month period) from those reporting one or no falls in a three-month period. These data will lead to clinical intervention protocols which may reduce the likelihood of recurrent falls.



A cross-sectional, retrospective chart review was conducted on 163 charts from patients referred to the Physical Medicine & Rehabilitation Fall Prevention Clinic at the VA Greater Los Angeles Healthcare System from 1997 to 2000. Referrals were made from the primary care outpatient clinics of the VA Greater Los Angeles Healthcare System and all patients exhibiting multidisciplinary (both frailty and rehabilitative) indications for falls were seen in the clinic by a geriatrician and a physiatrist. This retrospective chart review was given waiver of consent by the Institutional Review Board at the VA Greater Los Angeles Healthcare System. When reviewing the charts, exclusion criteria for this study were evidence from self-report or medical records of (1) Parkinson's disease, (2) multiple sclerosis or (3) cerebral vascular accident with residual impairment. These diseases have been shown to be independently linked to recurrent falls.


Demographic data were gleaned from the Fall Clinic charts. Standard protocol for all Falls Prevention Clinic patients included an initial self-reported medical history, relevant medical records and performance tests (Tinetti Gait & Balance (33) and Berg Balance (1) tests). Data reported from the self-reported medical history for were mainly in the form of dichotomous questions, such as "Do you experience spinning?" or "Do you notice your surroundings spinning?" Description of most recent fall was categorized as extrinsic (e.g., slip or trip) or as intrinsic (dysequilibrium or lower-extremity weakness).


Associations between fall group and nominal parameters (e.g., presence of orthostatic hypotension, training on assistive device) were made using chi square analysis. Comparison of continuous parameters (e.g., Geriatric Depression Scale score (4,30), Mini-Mental Status Exam (7), Tinetti Gait & Balance Test, Berg Balance Test) across fall group were made using an independent t-test. StatView (v. 5.0, SAS Institute, Cary, NC) was used for all statistical analyses. The level of significance used in this study was p [less than or equal to] 0.05.


Of the 163 charts reviewed, 98 met the inclusion criteria. The 98 charts were divided into two groups based on the self-reported number of falls: 0-1 fall (n = 50), [greater than or equal to] 2 falls (n = 48). Most characteristics were not significantly between the two groups (Table 1). Most fall clinic patients were men (> 90%) and over the age of 65 (> 70% within each group). Overall, across the groups, less than 30% of the falls clinic patients reported a history of diabetes, but over 30% had a history of cardiac disease and about 60% reported symptoms of orthostatic hypotension (lightheadness/dizziness when rising). Almost 70% of the patients referred to the clinic used assistive devices and over 40% reported pain while walking. Visual impairments (including impairments correctable by corrective lenses) were common in almost 50% of the population.

Specific differences across groups, however, were observed (Table 1). Over three-fourths of the group reporting [greater than or equal to] 2 falls reported the sensation of self and/or surroundings spinning (indication of vestibular dysfunction), while less than a third of those reporting 0-1 fall reported this sensation (68% vs. 28%; p < 0.0001). The mean Geriatric Depression Score was significantly higher (higher scores indicate greater likelihood of depression) for the group reporting [greater than or equal to] 2 falls relative to the other group (mean [+ or -] standard deviation: 7 [+ or -] 4 vs. 4 [+ or -] 3; p = 0.0004). Those who had fallen [greater than or equal to] 2 times reported that they had a fear of falling more often (76% vs. 56%; p = 0.0425) and reported that they had received training for use of an assistive device less often (34% vs. 58%; p = 0.003) than the group who had not fallen or fallen only once. There was a strong trend toward decreased Berg Balance scores (decreased values indicated decreased balance abilities and more likelihood of fall) (p = 0.059). When examining the factors associated with the most recent fall, however, no differences between the groups were observed.


Similar to previous studies focusing on demographics of individuals reporting recurrent falls, we found that few medical characteristics distinguish those reporting recurrent falls from those reporting no falls or few falls. We did, however, observe some potentially modifiable factors, which may be used to develop interventions to reduce the rate of recurrent falls.

Much work has been done to identify distinguishing characteristics between patients who fall and those who do not. These characteristics have been utilized to develop a variety of assessment tools (6,11,16,19-21,25) to provide identification of whom is likely to fall based on intrinsic characteristics or risk factors of the patient (e.g., psychological status, mobility dysfunction, fall history, elimination frequency/dependence, acute/chronic illnesses, and sensory deficits). These risk factors appear similar across studies with broad categories of cognitive impairment/psychological status, acute/chronic illness, and decline in mobility most often cited (26). These factors, however, do not appear to be related to number of falls based on our data, as we were unable to find distinguishing medical characteristics between those who reported recurrent falls ([greater than or equal to] two falls in three months) and those who reported none or one fall within the three months. Lipsitz et al. (14) and Morse et al. (24) also did not demonstrate distinguishing medical characteristics between patients who fell two or more times and those who did not fall.

It is possible, however, that, since our data and those of Lipsitz et al. (14) and Morse et al. (24) utilized patient populations, most risk factors would be similar and related to the severity of the patients' conditions.. Thus, even the control groups (those who did not fall) in the Lipsitz et al. (14) and Morse et al. (24) studies were not healthy, community-dwelling individuals. In our study, charts were obtained from patients who had all been referred to a fall prevention screening clinic. They were already identified as at risk for falling by a healthcare provider's referral to the clinic, even if they had not fallen in the previous three-month time period. Lipsitz et al. (14) evaluated ambulatory nursing home residents who by the fact that they are nursing home residents were most likely at risk for falling. Morse et al. (24) observed hospitalized patients suggesting a standardized level of illness. None of these studies used a true control group, which would potentially underestimate actual variations between those with recurrent fall and those who have not fallen in the general population as even those who did not fall were potentially at risk for falling, especially in our study.

The factors which did distinguish between those patients who reported none or one fall and recurrent falls in our study focused primarily on psychological (fear, depression, training) and balance (spinning sensation, Berg Balance score) issues. Lipsitz et al. (14) demonstrated use of assistive device/training appeared to be associated with multiple falls in the nursing home resident population, Morse et al. (24) observed that the use of and training with assistive devices appear to be associated with fewer falls in the hospitalized population. In the nursing home, it may be possible that, due to more vigilant screening, those patients at high risk of falling are given ambulatory aids more readily. However, the fallers may present with more learning difficulty and thus may not use the assistive device correctly, placing the resident at more risk. In an inpatient population, learning difficulty may not be as large an issue and thus, patients likely used the assistive devices correctly with appropriate training, reducing the fall risk by improving gait and balance. In our population, use of assistive device was not statistically significant, but a lack of training on assistive device was reported. Our subjects' source of assistive devices was not known, but often community-dwelling individuals buy canes from the market or are given them from non-healthcare providers and may not receive proper training as a result. These data suggest the importance of appropriate assistive device training done by appropriate healthcare providers.

The recurrent falls group did not appear to fall due to extrinsic factors associated with slips and trips, as would be expected from inappropriate use of assistive devices. While mental status (Mini-Mental Status Exam) was not significantly different across the groups, Geriatric Depression Scores were significantly higher in the recurrent falls group compared with those falling 0-1 time. Depression may lead to inattentiveness, decreased physical activity and slowing of reflexes and thus, a sense of loss of control when faced with activities of daily living (32,38). The subject might be able to avoid tripping or slipping on the obstacle, but might have difficulty making the proper postural, kinetic adjustments in time to avoid collapsing or dysequilibrium when performing activities of daily living. The greater report of a sensation of spinning in subjects within the [greater than or equal to] 2 falls group may further explain the inability of multiple fallers to react. The sensation of spinning, or dizziness, has been strongly associated with fear of falling, restriction of activities, balance deficits, and depression in older adults (2).

Psychological parameters of depression and anxiety, as well as gait and balance parameters, have been associated with fear of falling (2,18,34). Fear of falling combined with the increased depression scores and dizziness appear to be major issues for individuals with multiple falls. Maki (18) observed reduced stride length, speed, and increased double-support time, which represent more stabilizing gait parameters, to be associated with fear of falling, but stride-to-stride variability was associated with falling one or more times without relationship to fear. Increasing variability does not provide stabilization during walking, but rather most likely represents impaired motor control. This prospective study, however, did not separate the results of subjects with single and multiple falls (14 subjects fell more than once). Maki (18) proposed that increased variability represented increased risk of falling during walking as a result of impairment of foot placement and/or center-of-mass displacement.

A limitation to this study was the reliance on self-reports of falls by the subjects. Thus, we cannot confirm actual numbers or circumstances of falls. It is easier to confirm reports of falls in an inpatient or nursing home setting where such events are routinely recorded, although not always witnessed. Although we did not confirm the reported number of falls in the chart with a caregiver or family member, the mean Mini-Mental Status Exam scores were not different between the groups. Thus, it is unlikely that the report of recurrent falls was due to profound cognitive deficits. It was possible, however, that each individual defined falling differently and that some individuals, for a variety of reasons, had a specific agenda in reporting multiple or few falls. Tideiksaar and Kay (32) suggested that intentional falls, or fictitious accounts of falls, might serve as ways to gain attention or end one's life. From anecdotal evidence, Catchen (3) characterized individuals reporting multiple falls as "denying their illness of mental condition and as 'strong willed, determined individuals.'" This may explain their increased tendency to fall despite being fearful of falling. Additionally, future study of gait parameters of these individuals who fell recurrently may assist in the understanding of if they had developed fear-related adaptations which stabilized gait or exhibited impaired motor control parameters such as increased variability (18).

Preventative measures combating fear and depression seem to be most appropriate interventions for individuals who report recurrent falls. Both depression (5) and fear of falling (15,29) have been shown to decrease with supervised exercise programs, especially in institutionalized residents. Exercise programs focusing on lower-limb strengthening and flexibility could easily be implemented by kinesiotherapists in nursing home facilities as a group exercise program emphasizing social interaction and enjoyment to increase participation (5). Consequently, risk factors shown in our study to identify recurrent fallers can be modified through the use of exercise programs. Additionally, vestibular testing to distinguish causes of reports of sensation of spinning is necessary to provide interventions most appropriate to these individuals with recurrent fall reports. Lastly, gait and assistive device evaluation are important interventions to determine if compensatory adaptive strategies are employed but ineffective or not developed. This is an area where kinesiotherapists could have a large impact in the prevention of recurrent falls in the elderly. Maki (18) proposed that those with a fear of falling developed conscious effort to avoid falls and consequently developed gait parameters, which were adaptive to increasing stability. The individuals in our study who fell recurrently may not have developed these adaptive strategies, but rather have impaired motor control, which would increase the risk of falling. Our proposed model (Figure 1) based on the retrospective data can serve as the foundation for a prospective study. This model indicates the cumulative effects of multiple falls on depression and the lack of activity that follows. The model is based on the demographics of patients who reported recurrent falls in this study and in previous studies describing the association between falls and depression (2,32,34). It is suggested that falls reoccur because of muscle wasting (as a result of depression or immobility), vestibular dysfunction, or denial of the need to address a falls risk and obtain assistance on assistive devices. These factors, however, may be amenable to Kinesiotherapy intervention. Consequently, kinesiotherapists working with elderly adults can contribute largely to the reduction of falls in this population by focusing on exercise interventions which will reduce muscle atrophy, depression, and fear of falling, as well as ensuring appropriate assistive device training.



This study was supported by an American Federation for Aging Research Fellowship to Dr. Skolnick and a VA Clinical Initiative to Dr. Perell.


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Adam H. Skolnick, MD (1), Karen L. Perell, PhD, RKT (2, 3, 4), Maria L. Manzano, MA (3), Dorene Opava-Rutter, MD (3), Steven C. Castle, MD (3,4)

(1) Harvard Medical School, Cambridge, MA, (2) California State University, Fullerton, Fullerton, CA, (3) VA Greater Los Angeles Healthcare System--West Los Angeles Healthcare Center, Los Angeles, CA, 4UCLA School of Medicine, Los Angeles, CA

Address all correspondence to:

Karen L. Perell, PhD, RKT

California State University, Fullerton

Division of Kinesiology & Health Science

800 N. State College Blvd.

Fullerton, CA 92834

(714) 278-4384

fax: (714) 278-5317

Table 1. Characteristics of included charts divided by group based
on the number of falls within a 3-month time period. Continuous
variables are presented as group means [+ or -] standard deviation.
Nominal variables are presented as percentage of observations
within the specific group.

 Group 1
 (0-1 falls)

Age (years) 73 [+ or +] 11
Geriatric Depression Scale (GDS)# 4 [+ or +] 3#
 (5/15 = depression) (4)
Body Mass Index (kg/[m.sup.2]) 25.8 [+ or +] 4.9
Tinetti Gait & Balance (1) 23 [+ or +] 4
Berg Balance (<48/56 = fall risk) (10) 43 [+ or +] 9
Mini-Mental Status Exam (MMSE) (24/30 27 [+ or +] 3
 = cognitive deficit) (12)
Gender (% men) 96
History of arthritis 40
History of diabetes 22
History of cardiac disease 32
Assistive devices (e.g., cane, walker, 64
 wheelchair or orthotic shoes)
Visual impairments (2) 44
Medications for depression/sleep 34
Report of peripheral neuropathy 54
 symptoms (3)
Report of orthostatic hypotension 59
 symptoms (4)
Report of pain while walking 49
Report of spinning sensation# (5) 28#
Report of fear of falling# 56#
Report of extrinsic cause (e.g. slip/ 26
 trip) of most recent fall
Report of training for use of 58#
 assistive device#

 Group 2
 ([greater than or
 equal to] 2 falls) P value

Age (years) 60 [+ or +] 14 0.1000
Geriatric Depression Scale (GDS)# 7 [+ or +] 4# 0.0004#
 (5/15 = depression) (4)
Body Mass Index (kg/[m.sup.2]) 27.0 [+ or +] 4.8 0.2500
Tinetti Gait & Balance (1) 21 [+ or +] 4 0.2460
Berg Balance (<48/56 = fall risk) (10) 38 [+ or +] 11 0.0590
Mini-Mental Status Exam (MMSE) (24/30 28 [+ or +] 3 0.2493
 = cognitive deficit) (12)
Gender (% men) 96 >0.9999
History of arthritis 56 0.1075
History of diabetes 25 0.5532
History of cardiac disease 42 0.3210
Assistive devices (e.g., cane, walker, 73 0.3427
 wheelchair or orthotic shoes)
Visual impairments (2) 48 0.6973
Medications for depression/sleep 51 0.0977
Report of peripheral neuropathy 60 0.5797
 symptoms (3)
Report of orthostatic hypotension 57 0.8630
 symptoms (4)
Report of pain while walking 64 0.1336
Report of spinning sensation# (5) 68# <0.0001#
Report of fear of falling# 76# 0.0425#
Report of extrinsic cause (e.g. slip/ 27 0.9491
 trip) of most recent fall
Report of training for use of 36# 0.0030#
 assistive device#

(1) Score of < 19 indicates high risk for fall; 19-24 indicates
moderate risk for fall, > 24 indicates low risk of fall (33)

(2) Self-report of cataracts, glaucoma, diabetic retinopathy or
macular degeneration

(3) Self-report of numbness/tingling in hands/feet

(4) Self-report of lightheadedness or dizziness when rising

(5) Self-report of sensation of self or surroundings spinning
within the past year

Note: Values represent significant (p < 0.05) characteristics
is indicated with #.
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Author:Skolnick, Adam H.; Perell, Karen L.; Manzano, Maria L.; Opava-Rutter, Dorene; Castle, Steven C.
Publication:Clinical Kinesiology: Journal of the American Kinesiotherapy Association
Article Type:Clinical report
Date:Dec 22, 2004
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