Mobility and Falls: Risk Assessment, Home Safety, Balance Exercises, and Hip Protectors

Introduction

Falls are the leading cause of fatal and non-fatal injuries in older adults. One in four adults 65+ falls each year, and 20-30% of falls cause moderate to severe injuries (fractures, head trauma). Fall risk is multifactorial and can be reduced through targeted assessment and intervention.

Fall Risk Assessment

Screening Questions (STEADI Algorithm)

Question	Follow-up if “Yes”
Have you fallen in the past year?	Assess for frequency, circumstances, injuries
Do you feel unsteady when standing or walking?	Determine duration, functional impact
Do you worry about falling?	Assess fear of falling (may restrict activity)

Timed Up and Go (TUG) Test

Time	Risk	Interpretation
<10 seconds	Normal/low risk	Independent mobility
10-13 seconds	Intermediate risk	Subtle impairment
14-20 seconds	Moderate risk	Further assessment needed
>20 seconds	High fall risk	Significant mobility impairment
Variant: cognitive TUG	TUG with counting backwards	Detects dual-task impairment

Berg Balance Scale (BBS)

Item	Description (0-4 scale)
Sitting to standing	Need for arm assistance
Standing unsupported	Ability to stand 2 minutes
Sitting unsupported	Sitting with feet on floor
Standing to sitting	Controlled descent
Transfers	Move between chair and bed
Standing with eyes closed	Postural stability without vision
Standing with feet together	Narrowed base of support
Reaching forward	With outstretched arm
Picking up object from floor	From standing
Turning to look behind	While standing
Turning 360 degrees	Continuous, coordinated turn
Placing alternate foot on stool	Stepping onto 4-inch stool
Standing with one foot in front	Semi-tandem stance
Standing on one foot	Unsided

Total Score	Fall Risk
56	Maximum (no impairment)
45-55	Low fall risk
40-44	Moderate fall risk
<40	High fall risk
<20	Very high fall risk (wheelchair/assistance)

4-Stage Balance Test

Stage	Position	Time Required	Criteria
1	Feet together (side by side)	10 seconds	Stand without support
2	Semi-tandem (heel of one foot beside big toe of other)	10 seconds	Stand without support
3	Tandem (heel of one foot directly in front of toes of other)	10 seconds	Stand without support
4	Single leg stance (on non-dominant foot)	10 seconds	Stand without support

Unable to hold tandem stance for 10 seconds = increased fall risk

Multifactorial Risk Assessment

Intrinsic Risk Factors

System	Risk Factor	Assessment
Musculoskeletal	Lower extremity weakness	Chair stand test, manual muscle testing
Musculoskeletal	Gait and balance impairment	TUG, Berg, gait speed (<0.8 m/s = risk)
Neurologic	Parkinson disease, stroke, peripheral neuropathy	Neurologic exam, vibration sense
Cardiovascular	Orthostatic hypotension	Orthostatic vitals (supine, standing 1 and 3 min)
Cardiovascular	Arrhythmia, syncope	ECG, Holter if indicated
Sensory	Visual impairment (cataracts, glaucoma, AMD, need for bifocals)	Snellen, visual field
Sensory	Hearing loss	Whisper test, audiometry
Vestibular	Dizziness, vertigo	Dix-Hallpike test
Cognitive	Dementia, MCI, delirium	MoCA, Mini-Cog
Medications	Sedatives, hypnotics, antidepressants, antihypertensives, hypoglycemics	Medication review (BEERS criteria)
Incontinence	Urinary urgency, nocturia	Bladder diary, assess toileting access
Feet	Foot pain, deformities, inappropriate footwear	Podiatry assessment

Extrinsic (Environmental) Risk Factors

Location	Risk Factor
Flooring	Loose rugs, throw rugs, slippery surfaces, uneven surfaces
Lighting	Dim lighting, lack of night lights, glare, switches not accessible
Stairs	No handrails, uneven steps, poor lighting, clutter
Bathroom	No grab bars, low toilet, slippery tub/shower, no shower chair
Kitchen	Frequently used items in hard-to-reach cabinets
Bedroom	Bed too high/low, no bedside light, path to bathroom obstructed
Furniture	Unstable furniture, sharp corners, low chairs (difficult to rise from)
Outdoors	Uneven sidewalks, curbs, cracks, ice/rain, no handrails

Home Safety Modifications

Room-by-Room Assessment

Room	Modification	Priority
All	Remove loose rugs or secure with non-slip backing	High
All	Ensure adequate lighting, night lights in pathways	High
All	Clear pathways of clutter, cords, furniture	High
All	Maintain clear, wide paths (minimum 36 inches for walker)	Moderate
Bathroom	Install grab bars at toilet and shower	HIGH
Bathroom	Use non-slip mats/strips in shower/tub	High
Bathroom	Install raised toilet seat or commode	Moderate
Bathroom	Use shower chair and handheld shower head	Moderate
Stairs	Install handrails on both sides	High
Stairs	Improve stair lighting (top and bottom switches)	High
Stairs	Contrast tape on edges of steps	Moderate
Kitchen	Place frequently used items within easy reach	High
Kitchen	Use step stool with handrail (never chair)	Moderate
Bedroom	Bed height allows feet to touch floor when sitting	High
Bedroom	Bedside lamp within reach	High
Bedroom	Clear path from bed to bathroom	High
Flooring	Replace thick carpet with low-pile or smooth flooring	Moderate
Outdoors	Repair cracks in walkways, ensure even surfaces	High
Outdoors	Install handrails at entrance steps	High
General	Consider medical alert system	Moderate

Assistive Technology for Fall Prevention

Device	Purpose
Canes	Single-point (walking stick), quad cane (more stability)
Walkers	Standard, front-wheel, four-wheel (rollator with seat)
Grab bars	In bathroom, by toilet, at bed
Raised toilet seats	Reduces hip flexion required to sit/stand
Bed rails	Not recommended for most (entrapment risk; transfer aids preferred)
Bed transfer pole/loop	Attached to bed frame for assisted sitting
Shower chair/bench	Allows seated showering
Handheld shower head	Reduces need to turn/reach
Reacher/grabber	Picks up objects from floor without bending
Long-handled shoehorn/sponge	Dressing/hygiene without bending
Sock aid	Put on socks without bending
Elastic shoelaces	No tying required
Medication dispenser	Reduces risk of improper dosing

Hip Protectors

Types

Type	Description	Advantages	Disadvantages
Hard shell	Rigid polypropylene cup over greater trochanter	Highest energy absorption	Bulky, uncomfortable for sleep, visible under clothing
Soft pad	Foam or gel padding over hip	More comfortable, less visible	Less energy absorption, may shift out of place
Underwear style	Pads sewn into specially designed underwear	No separate belt needed; discreet	Need to remove for toileting; laundry

Evidence

Outcome	Evidence	NNT
Hip fracture reduction in nursing homes	20-30% reduction with high adherence	NNT = 36 (high adherence)
Hip fracture reduction in community-dwelling elderly	No significant benefit (poor adherence)	Not beneficial
Adherence	20-60% at 6 months	Key limiting factor
Falls (any)	No reduction	Expectation: they do not prevent falls, only fracture
Comfort/discomfort	20-40% report discomfort	Most common reason for non-use

When to Recommend

Setting	Consideration
Nursing home residents (high risk)	Strongly consider (evidence of benefit)
Community-dwelling (high risk, high adherence)	Consider (benefits not proven but may help)
Community-dwelling (low adherence)	Not recommended
Osteoporotic patient with prior hip fracture	Discuss as option
Active, independent, low risk	Not indicated

Balance Exercise Programs

Otago Exercise Program

Component	Exercises	Frequency
Strength (ankle)	Ankle plantarflexion/dorsiflexion (with ankle weights)	3x/week
Strength (knee)	Knee extension/flexion	3x/week
Strength (hip)	Hip abduction (side-lying)	3x/week
Balance 1	Knee bends (squats with support)	Daily
Balance 2	Backwards walking	Daily
Balance 3	Walking and turning around	Daily
Balance 4	Sideways walking	Daily
Balance 5	Heel-to-toe walking (tandem walk)	Daily
Balance 6	Standing on one foot	Daily
Balance 7	Heel raises	Daily
Balance 8	Toe raises	Daily
Walking	Outdoor walking (with or without aid)	2x/week (30+ min)

Tai Chi for Fall Prevention

Aspect	Detail
Evidence	30-50% reduction in falls (multiple meta-analyses)
Best form	Yang style (slow, large movements)
Frequency	2-3x/week minimum
Format	Group or individual
Key elements	Weight shifting, controlled movement, trunk rotation, postural control, body awareness
Adapted/prop	Chair-based for lower mobility; Tai Chi for Arthritis (Dr. Paul Lam)
Example sessions	10-60 minutes; warm-up, 8-10 forms, cool-down
Adherence	Usually good (enjoyable, social)

Other Balance Programs

Program	Description	Evidence for Fall Reduction
Stepping On	Multifaceted community program (7 weekly sessions)	30% reduction
Matter of Balance	Group program addressing fear of falling	Reduced fear, increased activity
Fit and Strong!	Chronic disease self-management + exercise	Improved mobility
EnhanceFitness	Community-based group exercise for seniors	Improved strength, balance
SilverSneakers	Nationwide fitness program for Medicare beneficiaries	Improved function
Standing Strong	Otago-based program for community delivery	Similar to Otago
Steady Steps	CDC STEADI implementation program	Varies

Gait Training

Assistive Device	Indication	Fitting Guidelines
Single-point cane	Mild unilateral deficit, mild balance impairment	Handle at wrist crease; hold on opposite side of weak leg
Quad cane	Moderate balance impairment, hemiparesis	Same height as single cane; offers more base support
Standard walker (no wheels)	Significant weakness, poor balance, needs full weight support	Elbow at 15-20 degrees flexion; lift and place
Front-wheel walker	Moderate balance impairment; needs continuous contact	Same as standard; rolling front for smoother gait
Four-wheel walker (rollator)	Moderate balance; needs ability to reduce weight-bearing; saves energy	Same height; hand brakes; may have seat
Hemi-walker	Severely impaired gait; one-handed use needed	Platform for hemiparetic arm or standard grip
Crutches (axillary)	Non-weight-bearing through one leg	2-3 finger widths below axilla; hand grips at wrist level

Vitamin D and Falls

Aspect	Recommendation
Daily dose	800-1000 IU/day
Target level	Serum 25(OH)D >30 ng/mL
Evidence	20% reduction in falls with supplementation (in those with low vitamin D)
Mechanism	Improved muscle strength, function, and balance
With calcium	1000-1200 mg/day calcium (diet + supplement)

Management After a Fall

Immediate	Subacute
Assess for injury (fracture, head trauma, laceration)	Fall risk assessment (multifactorial)
Emergency care if indicated (anticoagulation + head trauma = CT head)	Address modifiable risk factors
Safe mobilization or assist with getting up	Referral to PT (home safety, gait, balance)
Treat injuries	Review medications for deprescribing
	Vision assessment and correction
	Vitamin D supplementation
	Consider assistive device
	Address fear of falling
	Medical alert system discussion