CPC Geriatric Care and Fall Prevention 1 — Questions and Answers

Question 1: The 'STEADI' (Stopping Elderly Accidents, Deaths, and Injuries) initiative defines older adults as being at HIGH risk for falls if they:

Are aged 65 and have taken a single over-the-counter pain medication
Report 2 or more falls in the past year, 1 fall with injury, or have difficulty walking or balance problems (Correct answer)
Have a BMI over 30 and live alone
Take more than 3 prescription medications for any condition

Correct answer: Report 2 or more falls in the past year, 1 fall with injury, or have difficulty walking or balance problems

CDC STEADI high fall risk criteria: 2+ falls in the past 12 months, any fall with injury, OR self-reported walking/balance difficulty — any one of these places the patient in the high-risk category requiring comprehensive fall prevention intervention.

The CDC STEADI (Stopping Elderly Accidents, Deaths, and Injuries) tool kit provides a structured fall risk screening and intervention framework: 3-question screening: 'Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling?' Positive responses on ≥1 item indicate fall risk and trigger further assessment. High-risk criteria: ≥2 falls in past year, 1 fall requiring medical care/causing injury, or positive walking/balance assessment (TUG >12 seconds, 30-second chair stand test impaired). Community paramedics implement STEADI during home visits, including medication review, orthostatic BP assessment, vision and footwear check, and home hazard assessment.

Question 2: Polypharmacy in geriatric patients is a significant fall risk factor. Which class of medications is MOST commonly associated with an increased fall risk in elderly patients?

Antibiotics
Psychotropic medications (benzodiazepines, antidepressants, antipsychotics) and antihypertensives (Correct answer)
Proton pump inhibitors
Vitamins and supplements

Correct answer: Psychotropic medications (benzodiazepines, antidepressants, antipsychotics) and antihypertensives

Psychotropic medications (sedation, altered cognition, muscle relaxation) and antihypertensives (orthostatic hypotension) are the two most fall-implicated drug classes in the elderly, with benzodiazepines and antidepressants carrying particularly high risk.

Beers Criteria (American Geriatrics Society) identifies high-fall-risk medications in older adults: Benzodiazepines (short and long-acting): sedation, impaired balance, muscle relaxation; Antidepressants (TCAs, SSRIs): sedation, orthostatic hypotension, extrapyramidal effects; Antipsychotics: sedation, extrapyramidal rigidity, orthostatic hypotension; Antihypertensives: orthostatic hypotension (ACEi, diuretics, alpha-blockers, beta-blockers); Opioids: sedation, altered balance; Antihistamines (diphenhydramine): CNS sedation, confusion in elderly. Community paramedics perform medication reviews using the Beers Criteria during home visits, flag high-risk medications, and communicate deprescribing recommendations to the patient's primary care provider.

Question 3: When assessing a 78-year-old patient for cognitive impairment during a home visit, which brief cognitive screening tool is most commonly used?

PHQ-9
Mini-Cog (3-word recall + clock draw) (Correct answer)
CAGE questionnaire
Barthel Index

Correct answer: Mini-Cog (3-word recall + clock draw)

The Mini-Cog (3-item recall + clock-drawing test) is a validated, brief (3-minute) cognitive screening tool designed for primary care and community settings. It has excellent sensitivity and specificity for detecting dementia in diverse populations.

The Mini-Cog consists of: (1) 3-word registration and recall; (2) Clock Drawing Test (draw clock face, set hands to 11:10). Scoring: 0–2 recall + abnormal clock = positive screen for dementia; 3 recall = negative screen regardless of clock. Sensitivity ~76–99%, specificity ~93% for dementia. Advantages over MMSE in community settings: takes <3 minutes, less education-biased, validated across ethnicities, requires no special equipment. The MMSE is more comprehensive but takes 10 minutes. PHQ-9 screens for depression; CAGE for alcohol; Barthel Index measures ADL independence. Community paramedics use Mini-Cog as a routine cognitive screen in patients aged ≥65 and document baseline results for trend monitoring.

Question 4: The 'FRAT' (Fall Risk Assessment Tool) categorizes fall risk. A 79-year-old patient who has had 2 falls in the past year, takes a benzodiazepine, and lives alone would MOST likely be classified as:

Low risk — single fall is common in the elderly
High risk — multiple FRAT risk factors present (Correct answer)
Moderate risk — only one modifiable factor identified
No risk — falls are normal in this age group

Correct answer: High risk — multiple FRAT risk factors present

Multiple concurrent FRAT risk factors (prior falls, psychotropic medication, social isolation) classify this patient as HIGH risk, warranting comprehensive multifactorial fall prevention intervention.

The Fall Risk Assessment Tool (FRAT) and similar instruments (STRATIFY, Morse Fall Scale) assess cumulative fall risk through multiple domains: prior fall history (strongest predictor), medications (psychotropics, antihypertensives), cognitive impairment, functional impairment, sensory deficits (vision, hearing), continence urgency, and environmental hazards. Having 2+ falls + benzodiazepine use + social isolation (lack of assistance, delayed discovery if fallen) creates compounding risk that warrants: medication review (benzodiazepine deprescribing), home hazard assessment, physical therapy referral, balance exercise program (Otago, Tai Chi), and emergency response device (personal emergency response system/PERS) consideration.

Question 5: Which environmental modification is MOST evidence-based for reducing fall risk in elderly patients living at home?

Removing all furniture from the home to prevent obstacles
Installing grab bars in bathrooms and improving lighting, especially on stairs (Correct answer)
Purchasing thick carpeting to cushion falls
Advising the patient to avoid using the bathroom at night

Correct answer: Installing grab bars in bathrooms and improving lighting, especially on stairs

Installing grab bars in bathrooms (near toilet, in shower/tub) and improving lighting — particularly night lighting and stair lighting — are the most evidence-based, low-cost environmental modifications for reducing home fall risk.

Cochrane systematic reviews confirm that home hazard assessment combined with targeted modification reduces falls by ~20–26% in high-risk older adults. High-priority modifications: Bathroom: grab bars adjacent to toilet and in shower/tub (60% of falls occur in bathroom), non-slip bath mat, raised toilet seat; Stairs: handrails on both sides, contrasting color tread edges, adequate lighting (triple illumination); General: nightlights in hallways and bathroom, remove or secure loose rugs, reduce clutter on walkways, ensure telephone or emergency device is within reach. Thick carpeting increases trip risk for users of walkers. Community paramedics perform structured home hazard assessments (using tools like HOME FAST or SAFER-HOME) and coordinate with occupational therapists for complex modifications.

Question 6: The Otago Exercise Programme is an evidence-based fall prevention exercise program that specifically includes:

High-intensity cardiovascular training for older adults
Strengthening exercises and balance retraining in the home, tailored to the individual's ability (Correct answer)
Group aerobic classes at community centers
Aquatic therapy for patients with osteoporosis

Correct answer: Strengthening exercises and balance retraining in the home, tailored to the individual's ability

The Otago Exercise Programme consists of individualized, home-based lower limb strengthening and balance exercises delivered by a trained instructor (nurse or physiotherapist) and is one of the most evidence-based programs for fall reduction in community-dwelling elderly adults.

The Otago Exercise Programme (developed in New Zealand, Campbell et al.) is a falls prevention exercise program for community-dwelling adults aged ≥65 with fall risk. Components: lower limb muscle strengthening exercises (ankle, knee, hip), progressive balance exercises (gradually increasing difficulty), walking plan. Delivery: 4 home visits by trained instructor + 3 phone calls over 12 months. Evidence: RCTs show 35–40% reduction in fall rate and 30–46% reduction in fall-related injuries. Community paramedics trained in Otago delivery can administer the program directly during home visits. Otago is particularly effective in patients aged ≥80 and those who have already fallen. It is recommended in the CDC STEADI toolkit as a Tier 1 evidence-based fall prevention program.

CPC Geriatric Care and Fall Prevention 1

The 'STEADI' (Stopping Elderly Accidents, Deaths, and Injuries) initiative defines older adults as being at HIGH risk for falls if they: