14.2 Falls, Gait Assessment & Polypharmacy
Key Takeaways
- Falls and clinical pharmacology and aging are enumerated under other primary geriatric topics.
- All adults 65 and older should be asked annually about falls, and a positive answer triggers a multifactorial assessment.
- Psychotropic medications, including benzodiazepines, antipsychotics, sedative hypnotics and antidepressants, are among the strongest modifiable fall risk factors.
- The AGS Beers Criteria identify potentially inappropriate medications in older adults and are a starting point for judgment rather than a prohibition list.
- Deprescribing should be prioritized by harm potential and aligned with the patient goals of care and estimated time to benefit.
Last updated: August 2026
1. Fall Risk Stratification & Gait Assessment
Falls are the leading cause of fatal and non-fatal injury in adults aged >=65 years. More than 95% of hip fractures result from falls, carrying a 1-year mortality of 20-30%.
CDC STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Algorithm
Every older adult should be screened annually with the 3 STEADI Screening Questions:
- Have you fallen in the past year? (If yes, how many times and were you injured?)
- Do you feel unsteady when standing or walking?
- Do you worry about falling?
If the patient answers YES to any question, they are at elevated fall risk and require objective gait, balance, and strength testing.
Objective Bedside Physical Assessments
| Assessment Test | Procedure & Measurement | Clinical Thresholds & Interpretation |
|---|---|---|
| Timed Up and Go (TUG) Test | Patient rises from a standard arm chair, walks 3 meters (10 feet) at a comfortable pace, turns around, walks back, and sits down. | < 10 seconds: Normal mobility, low fall risk.<br/>> 12 seconds: High fall risk; mandates multifactorial fall evaluation and physical therapy referral. |
| 4-Stage Balance Test | Patient attempts to hold 4 progressively challenging foot positions for 10 seconds each without support:<br/>1. Side-by-side stance<br/>2. Semi-tandem stance (heel of one foot beside big toe of other)<br/>3. Tandem stance (heel directly touching toes of other foot)<br/>4. Single-leg stance | Inability to hold the tandem stance for a full 10 seconds indicates significant balance impairment and high fall risk. |
| 30-Second Chair Stand Test | Patient sits with arms crossed across chest; counts number of full stands achieved in 30 seconds. | Evaluates proximal lower extremity muscle strength.<br/>Scores below age- and sex-adjusted normative values (<10-12 stands) indicate sarcopenia and high fall propensity. |
| Orthostatic Blood Pressure Measurement | Measure BP and HR after lying supine for 5 minutes, then repeat at 1 minute and 3 minutes after standing. | Positive Orthostatic Hypotension: Drop in SBP >= 20 mmHg OR drop in DBP >= 10 mmHg within 3 minutes of standing.<br/>- Neurogenic Orthostasis: HR fails to increase by >10 bpm (autonomic failure, Parkinson disease, diabetic autonomic neuropathy).<br/>- Non-Neurogenic Orthostasis: HR increases by >15-20 bpm (volume depletion, vasodilatory antihypertensives). |
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2. Polypharmacy & The 2023 AGS Beers Criteria
Definitions and Prescribing Cascades
- Polypharmacy: The concurrent use of >=5 medications (Hyper-polypharmacy: >=10 medications).
- Prescribing Cascade: An adverse drug reaction (ADR) is misinterpreted as a new medical condition, prompting the initiation of an additional drug, which causes secondary ADRs. Classic examples:
- Amlodipine (Dihydropyridine CCB) -> causes peripheral ankle edema -> misdiagnosed as heart failure -> Furosemide started -> causes hypokalemia, orthostasis, and urinary frequency -> Oxybutynin started -> causes acute delirium and constipation.
- NSAID -> causes systemic hypertension -> Lisinopril started -> causes bradykinin dry cough -> Dextromethorphan / Codeine started -> causes sedation and falls.
2023 American Geriatrics Society (AGS) Beers Criteria
The Beers Criteria categorize medications that are potentially inappropriate in most older adults due to an unfavorable risk-to-benefit profile.
| Medication Class & Specific Agents | Primary Clinical Risks & Adverse Sequelae | Mechanistic Rationale & Deprescribing Actions |
|---|---|---|
| Anticholinergics (Strong)<br/>Diphenhydramine, Hydroxyzine, Oxybutynin, Chlorpheniramine, Amitriptyline, Paroxetine | Acute delirium, cognitive impairment, memory decline, urinary retention, severe constipation, dry mouth, blurred vision, falls/fractures | Competitively blocks central and peripheral muscarinic ($M_1-M_5$) receptors. Avoid completely. Substitute non-pharmacologic sleep hygiene or second-generation antihistamines (Cetirizine, Fexofenadine). |
| Benzodiazepines & Z-Drugs<br/>Diazepam, Lorazepam, Alprazolam, Clonazepam, Zolpidem, Eszopiclone, Zaleplon | Acute delirium, ataxia, psychomotor slowing, motor vehicle collisions, falls, hip fractures | Positive allosteric modulators of $GABA_A$ receptors. Age-related reduction in hepatic oxidation and increased central sensitivity. Avoid in all older adults. Reserve exclusively for alcohol withdrawal, severe generalized seizure disorders, or severe REM sleep behavior disorder. |
| Antipsychotics (Typical & Atypical)<br/>Haloperidol, Olanzapine, Quetiapine, Risperidone, Aripiprazole | FDA Black Box Warning: Significantly increased mortality (cardiac sudden death, aspiration pneumonia) and ischemic stroke in dementia-related psychosis | Avoid for behavioral and psychological symptoms of dementia (BPSD) unless non-pharmacologic interventions fail AND patient exhibits severe, dangerous physical aggression threatening immediate harm to self/others. If used, titrate to lowest effective dose and taper rapidly. |
| NSAIDs (Non-COX-selective & COX-2 selective)<br/>Ibuprofen, Naproxen, Meloxicam, Ketorolac, Indomethacin, Celecoxib | Gastrointestinal ulceration/bleeding, acute kidney injury (inhibition of afferent arteriolar prostacyclin vasodilation), worsening hypertension, fluid retention, heart failure exacerbations | Avoid chronic scheduled use. If unavoidable for severe osteoarthritis, co-prescribe a Proton Pump Inhibitor (PPI) or misoprostol; prefer topical NSAIDs (Diclofenac gel) or Acetaminophen. Indomethacin and Ketorolac carry the highest CNS and GI toxicity and should be completely avoided. |
| Skeletal Muscle Relaxants<br/>Cyclobenzaprine, Methocarbamol, Carisoprodol, Metaxalone, Baclofen | Sedation, dizziness, confusion, strong anticholinergic toxicity, fracture risk | Poorly tolerated in older adults with minimal evidence of efficacy for chronic musculoskeletal spasms. Avoid entirely. |
| Sulfonylureas (Long-Acting)<br/>Glyburide, Glimepiride | Prolonged, severe, life-threatening hypoglycemia (due to active metabolites cleared renally) | Glyburide is strongly contraindicated due to extreme risk of sustained hypoglycemia. Glimepiride also carries elevated risk. If a sulfonylurea must be used, Glipizide is preferred (shorter duration, inactive metabolites). First-line alternatives: Metformin, SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors. |
| Sliding-Scale Regular Insulin (SSI) | Higher risk of hypoglycemia without improvement in glycemic control; creates erratic glycemic swings | Avoid reactive sliding-scale regular insulin monotherapy without basal insulin. Use scheduled basal insulin (Glargine/Degludec) with fixed prandial insulin if intensive glycemic therapy is clinically indicated. |
| Proton Pump Inhibitors (PPIs)<br/>Omeprazole, Pantoprazole, Esomeprazole, Lansoprazole | Clostridioides difficile colitis, osteoporotic hip/spine fractures, hypomagnesemia, vitamin B12 deficiency, community-acquired pneumonia, acute interstitial nephritis | Avoid scheduled use > 8 weeks unless high-risk compelling indications exist (e.g., severe erosive esophagitis LA Grade C/D, Barrett esophagus, chronic daily oral NSAID/corticosteroid therapy, Zollinger-Ellison syndrome). Taper and discontinue or switch to H2-receptor antagonists (Famotidine). |
STOPP / START Criteria for Systematic Deprescribing
- STOPP (Screening Tool of Older Persons' Prescriptions): Identifies clinically inappropriate medications (e.g., duplicate drug classes, loop diuretics for ankle edema without heart failure, aspirin for primary prevention in adults >70 without clinical ASCVD).
- START (Screening Tool to Alert to Right Treatment): Identifies evidence-based clinical omissions (e.g., statin for secondary prevention of stroke/CAD, ACE inhibitor/ARB in heart failure with reduced ejection fraction or chronic kidney disease with albuminuria, bone protection in osteoporosis).
Test Your Knowledge
A 78-year-old woman presents for an annual Medicare wellness visit. Her medical history includes hypertension, bilateral knee osteoarthritis, osteoporosis, and chronic insomnia. Her current medication list includes Amlodipine 10 mg daily, Lisinopril 20 mg daily, Omeprazole 40 mg daily (taken for 3 years following a resolved episode of non-ulcer dyspepsia), Ibuprofen 600 mg three times daily as needed, Diphenhydramine 50 mg nightly at bedtime for sleep, and Alendronate 70 mg once weekly. She complains of persistent morning grogginess, dry mouth, chronic constipation, and occasional lightheadedness when rising from bed. Physical examination reveals blood pressure of 134/78 mmHg sitting and 118/70 mmHg standing. Her Timed Up and Go (TUG) score is 16 seconds. Which of the following medication management plans is most appropriate according to the 2023 AGS Beers Criteria and deprescribing principles?
A
B
C
D