Falls, Gait Disorders, and Immobility
Falls are multifactorial
Falls result from interacting intrinsic and extrinsic factors: prior fall, gait and balance impairment, lower-extremity weakness, cognitive impairment, vision loss, neuropathy, orthostatic hypotension, arrhythmia, and medications (sedative-hypnotics, antipsychotics, antidepressants, antihypertensives, anticholinergics, hypoglycemics). Environmental hazards, footwear, and fear of falling contribute.
Screen annually: ask about falls, near-falls, and fear; observe transfer and gait; use Timed Up and Go (≥12 seconds suggests increased risk) and a chair-stand test. Evaluate for syncope, orthostasis, vision, feet, and medication burden.
Interventions: multifactorial assessment with targeted modification, exercise (Otago, tai chi, balance and strength training), medication review and deprescribing, vision correction, home safety, footwear, and assistive devices. Do not use bed alarms or physical restraints as fall prevention.
Traps: calling a fall 'mechanical' and stopping the workup; missing syncope or arrhythmia; ignoring post-fall injury (hip fracture, subdural hematoma); and prescribing vitamin D indiscriminately-use it for deficiency, not universal fall prevention.
Gait patterns help: magnetic, apraxic gait suggests normal pressure hydrocephalus; shuffling with festination suggests parkinsonism; spasticity suggests myelopathy or stroke.
Worked example: an 85-year-old with recurrent falls, urinary urgency, and progressive cognitive decline has the triad of gait disturbance, incontinence, and dementia-consider normal pressure hydrocephalus and obtain brain imaging and referral.
Rule of thumb: any fall in an older adult deserves a gait, medication, and orthostatic review; never attribute it to aging alone.