9.5 Fall Prevention, Gait & Balance
Key Takeaways
Ask about previous falls, unsteadiness and injury. Investigate unexplained loss of consciousness or acute symptoms separately.
On the CDC Timed Up and Go, 12 seconds or longer signals fall risk in older adults. Observe the movement as well as timing it.
Use the findings to target gait and balance training, medication review, vision and footwear, or home safety.
Screen for falls and mobility difficulty
Ask about falls in the past year, near-falls, unsteadiness and fear of falling. Record the number of events, the setting, symptoms before the fall, any injury and whether the person could get up independently. A fall on a loose rug and an unexplained collapse can require different assessments. A patient with unexplained loss of consciousness, acute neurologic symptoms or suspected significant injury needs prompt evaluation appropriate to that finding.
The 2024 U.S. Preventive Services Task Force recommends exercise interventions to prevent falls in community-dwelling adults aged 65 and older at increased risk. It supports selectively offering multifactorial interventions after considering the person's circumstances and preferences. CDC STEADI provides a structured way to identify risk, evaluate modifiable contributors and plan next steps. Fall risk and skeletal fragility are related clinical decisions. A person can need fall prevention even if their DXA BMD is in the normal range.
Observe mobility safely
In the CDC Timed Up and Go (TUG), the patient begins seated in a standard armchair. Mark a line 3 meters (10 feet) away. Ask the patient to rise, walk at their normal pace to the line, turn, return and sit. The patient can use their usual walking aid. Start timing on “Go” and stop when seated again. Stay close for safety. If the person cannot do the task safely, document the limitation and arrange an appropriate functional assessment.
Under STEADI, a time of 12 seconds or longer indicates fall risk in an older adult. Also observe how the person rises, walks and turns. Staggering, a short stride, or reaching for support can help guide further assessment. The result does not identify the cause of the gait problem or diagnose osteoporosis. Other STEADI tools assess standing balance and chair-rise performance, when appropriate. Avoid relying on a single timed result to dismiss a history of recurrent falls.
Match interventions to findings
| Finding | Possible next step |
|---|---|
| Unsteady turns, lower-limb weakness or difficulty rising | Arrange evaluation for gait, balance and functional strengthening. A physical therapist can help with progression and selection and fitting of a walking aid. |
| Dizziness on standing | Review medications, hydration and clinical history. Check orthostatic vital signs using an appropriate protocol and address the cause. |
| Sedation, multiple medicines or recent dose changes | Review fall-risk-increasing medicines with the prescribing team. Discuss changes and tapering when appropriate. |
| Poor lighting, loose rugs or difficulty entering a shower | Review actual home tasks and barriers. Consider lighting, secure floor surfaces, rails or grab bars, and occupational therapy assessment where useful. |
| Vision changes, foot pain or unsuitable footwear | Address the specific impairment. Review vision, foot health and footwear as part of the overall plan. |
For an older adult who has fallen twice and needs several steps to turn, a reasonable plan can include gait assessment, functional strengthening and balance training, a medication review and home safety changes. Use the history to select priorities. For example, a fall at night on the way to the bathroom calls for checking lighting and the path, while lightheadedness after standing calls for evaluating a different contributor. Work with the patient to identify a change they can make and a clinician or therapist who can review progress.
Interpret the exercise evidence
Training can combine strength and balance tasks such as sit-to-stand, stepping and progressively more challenging balance exercises, adapted to the person's ability. In a randomized trial of older community-dwelling adults at high risk of falling, a specific therapeutic Tai Ji Quan program reduced the fall rate compared with stretching and with the study's multimodal exercise program. That result describes the tested intervention and population. Select a program the individual can access and perform safely, with help when needed.
At follow-up, ask what changed, whether there were further falls and whether new barriers appeared. Recheck function when it can guide therapy. A patient can show improved confidence or safer transfers even if the osteoporosis treatment plan and DXA schedule stay separate. Document the agreed action and arrange reassessment when the risks or the patient's abilities change.
CDC STEADI Timed Up and Go · CDC fall prevention · USPSTF fall prevention recommendation · World Falls Guidelines · Tai Ji Quan randomized trial
An older adult completes the CDC Timed Up and Go in exactly 12 seconds with their usual cane. What is the appropriate interpretation?
Fall risk begins only above 12 seconds, so the result rules it out.
A cane invalidates every Timed Up and Go measurement.
The time meets the CDC fall-risk criterion. Consider gait observations, history and other findings.
The time identifies orthostatic hypotension as the cause of the mobility difficulty.
An older adult reports nighttime falls when walking to the bathroom and dizziness on standing. Which plan addresses both contributors?
Review lighting and the path to the bathroom, and evaluate orthostatic symptoms and medicines with the care team.
Focus only on the DXA T-score because it identifies the fall mechanism.
Stop all antihypertensive medicines immediately without a prescribing review.
Order hip imaging alone to assess every modifiable fall risk.
An older adult with impaired turning and weak chair rise wants a fall-prevention program. Which choice is supported by the evidence?
Unsupervised jumping because high impact is required to reduce falls.
Avoid strength or balance training until the DXA category improves.
Prescribe a particular Tai Ji Quan program and promise the same benefit as in every trial.
Arrange individualized functional strength and balance training, with professional help if needed for safe progression.
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