Sunday General Session Preventing Falls in the
Transcript of Sunday General Session Preventing Falls in the
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Sunday General Session
Preventing Falls in the Elderly
Dale Moquist, MD Former Geriatric Coordinator Memorial Herman Family Medicine Residency, Sugar Land Horseshoe Bay, Texas Educational Objectives By completing this educational activity, the participant should be better able to: 1. Identify risk factors for falls in the elderly. 2. Appropriately screen patients who may be experiencing falls. 3. Effectively evaluate patients who fall. 4. Discuss evidence‐based measures to reduce the risk for falls.
Speaker Disclosure Dr. Moquist has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company.
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TAFP Annual Session & Primary Care SummitDale C. Moquist, MD
November 7, 2021
Preventing Falls in the Elderly
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DISCLOSURE
Dr. Moquist has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company.
Dr. Moquist will not discuss or present information that is related to an off-label or investigational use of any therapy, product, or device.
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Learning Objectives
By completing this educational activity, the participant should be better able to:1. Identify risk factors for falls in the elderly. 2. Appropriately screen patients who may be experiencing falls. 3. Effectively evaluate patients who fall.4. Discuss evidence-based measures to reduce the risk for falls.
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The 5 Ms of Geriatrics Mind Maintaining mental activity Manage Dementia Treat & prevent Delirium
Mobility Maintaining ability to walk and/or maintain balance Preventing falls
Medications Reducing polypharmacy De-Prescribing Prescribing treatments based on an older person’s needs
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….The 5 Ms of Geriatrics
Multi-Complexity Helping older adults manage a variety of health conditions Assessing living conditions when they are impacted by age, health
conditions, and social concerns
Matters Most Coordinating Advance Care Planning Helping manage goals of care Making sure a person’s individual, personally meaningful health
outcomes, goals, and care preferences are reflected in treatment plans5
Audience Question #1According to the CDC, how many adults >65 y/o report falling in the previous year?
1. One in Ten2. One in Four 3. One in Three4. One in Two
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Audience Question #2Among those with a history of a fall in the previous year, the annual incidence of falls is?
1. 25%2. 40%
3. 60%
4. 75%
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Audience Question #3What percentage of falls result in fracture, head trauma, or serious soft-tissue injury?
1. 5-10%
2. 25%
3. 50%
4. 75%
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Audience Question #4What percentage of hip fractures are caused by falls?
1. 10%
2. 20%
3. 40%
4. 75%5. 90%
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OUTLINE
Epidemiology
Causes
Evaluation
Intervention
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Epidemiology
Definition
Epidemiology
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Definition
Coming to rest inadvertently on the ground or at a lower level Very common geriatric syndrome
Most falls are NOT associated with syncope Falls literature usually excludes falls associated with LOC
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Epidemiology of Falls
Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term care facilities, experience falls
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Epidemiology of Falls
Annual incidence of falls is close to 60% among those with history of falls
Complications of falls are the leading cause of death from injury in people
Number increases progressively in both sexes and all racial and ethnic groups
Fall related injuries NOT common cause of death Recovery from falls often delayed in older persons
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…Epidemiology Significant Morbidity Decline in functional status Hospital stays are twice as long Greater likelihood of nursing home placement Increased use of medical services
Marker of Poor Health Sign of acute illness Acute exacerbation of chronic illness
Third of community-dwelling in 1 year 5-10% result in fractures Fractures: 75% of serious injuries 1-2% of falls: Hip FX
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…Epidemiology
90% of hip fracture occur with falls
Falls in the elderly rarely have a single cause
Only ½ of older adults can get UP Concerned about the “Long Lie”
Most falls DO NOT cause injury Fear of falling Self-Restriction of activities Increasing Immobility: > Risk for falls
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Causes
Risk Factors
Age-Related Changes
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Risk Factors: Nonmodifiable Older Age: > 80 yo
Cognitive impairment
Female gender
Past history of a fall
Stroke/TIA
Parkinson’s
History of falls
Arthritis
History of fractures
Recent discharge from hospital (< 1 month)18
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Modifiable Risk Factors
Leg/Gait problems Foot disorders Balance Anemia Hypovitaminosis D Psychotropic meds or polypharmacy Alcohol use Orthostatic Hypotension Environmental hazards Sensory impairment
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Age-Related Changes Visual Reduced visual acuity Reduced depth perception Reduced contrast sensitivity Reduced dark adaption
Proprioceptive loses sensitivity in the legs Vestibular Loss of labyrinthine hair cells Loss of ganglion cells Loss of nerve fibers
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More Age-Related Changes
Increase in measured sway
Gait speed deteriorates Older activate proximal then distal muscles
Decline in baroreflex sensitivity
Reduced total body water
Rigidity of leg muscles
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Evaluation
Screening Algorithm
Positive Screen
Evaluation Tools
History
Multifactorial Causes
Physical
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Screen for Fall Risk Yearly Fall in the past year? How many times? Were you injured?
Feels unsteady when standing or walking?
Worries About falling?
YES to any question: Evaluate gait, strength, and balance
Part of the Medicare Wellness Visit
STEADI uses a 12-question tool: At risk if score > 4
cdc.gov/steadi
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NO to ALL Screening Questions
Individualized fall interventions: Low risk Educate patient Assess Vitamin D intake Assess Calcium intake Refer for to community exercise or fall prevention program
Reassess yearly or any time patient presents with an acute fall
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YES to Any Screening Questions
Evaluate gait, strength, and balance using: Timed up and go test 30-second chair stand 4-stage balance test
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Timed Up and Go Test
Get up out of a standard armchair without using arms
Walk 10 feet
Turn around
Walk back to chair
Sit down without using arms
May or may not be timed
If timed, use 12 seconds as an increased risk of falls
Timing provides a measure of performance over time
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Chair Stand Test
Patients are asked to cross their arms over their chest while seated in a chair
It should be noted if the patient needs to use their arms
Clinician records how many times the patient can fully stand and sit in 30 seconds
In men 75-79, < 11 chair stands is abnormal
In women 75-79, < 10 chair stands is abnormal
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Chair Stand Test
755 Community Dwelling: 64.1% female
Mean Age: 78.1
Short physical performance battery: Gait, chair stand performance and balance
5 Repeated chair stands
16.7 Second cut-point: Independent predictor
Predictor of Falls: Not fall-related fractures
Fall history and slow chair stand: 2-year cumulative incidence rate of injurious fall of 46%
Ward R. Functional Performance as a Predictor of Injurious Falls in Older Adults. JAGS 2015 63:315-320.
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4 Stage Balance Test
Patients asked to stand for at least 10 seconds in following: Feet adjacent Semi-tandem stance Tandem stance On one foot
Unable to perform the semi-tandem test for 10 seconds are at increased risk of falling
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4 Stage Balance Test
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Results of Screening Normal timed Up and Go: Consider low risk If abnormal Up and Go: Consider Hx of falls and injury If NO fall history: Moderate risk Educate patient Refer to PT to improve gait, strength, and Balance Refer to community fall prevention program
If falls and or injury: Conduct multifactorial risk assessment Falls history Physical exam Use of mobility aids Footwear check
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Diagnostics Tests
No set of “standardized” tests Rare to find cause with blood or x-ray
Should consider CBC, UA, BMP Dehydration, anemia, diabetes mellitus
No role for “routine” EKG, Holter, ECHO, or CT scan Order driven by findings of H&P exam
Consider Vitamin D level
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History…
What was the activity at the time of the fall?
Were there any associated symptoms?
Where did the fall occur?
What is the condition of the environment?
Was the fall inside or outside?
Any furniture cause the fall? What was the lighting?
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…History
What footwear was she wearing?
Were stairs involved?
What type of flooring?
What is the lighting?
Was she using any assistive devices?
Is the device in good condition? Has she/he fallen before?
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Functional History
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THINK
CATASTROPHE
Functional Inquiry Caregiver & Housing Alcohol Treatment (Meds) Affect (Depression) Syncope Teetering Recent Illness Ocular Problems Pain With Mobility Hearing Environmental Hazards
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Risk Factor Assessment
Frequently: Related to accumulated effect of multiple disorders superimposed on age-related changes
Likelihood of fall increases with # of risk factors A single fall may have multiple causes Repeated falls may have a different etiology
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Intrinsic Risk Factors
Past History of Fall
LE Weakness
Age
Female Gender
Cognitive Impairment
Balance Problems
Anemia
Psychotropic Drug Use
Alcohol
Arthritis
History of Stroke
Orthostatic Hypotension
Dizziness
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Don’t Forget the MEDS!
Specific classes Benzodiazepines Antidepressants Antipsychotics
Recent med dosage adjustment
Total number of prescriptions > 4
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Drugs Associated with Falls
Sedative Hypnotics Tricyclic Antidepressants
Anticholinergics
Alcohol
Antihypertensives
Nonsteroidals
Hypoglycemic Drugs Cholinesterase Inhibitors
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Extrinsic Risk Factors
Environmental Hazards
Poor Footwear Restraints: Especially in the Nursing Home
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Environmental Hazards
Cracked or uneven pavement
Lack of adequate railings
Poor lighting
Slip rugs
Uneven stairs
Unstable furniture Wet or slippery surfaces
Poor footwear44
Precipitating Causes
Trips and slips
Drop attack
Syncope
Dizziness
Acute medical illness
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Multifactorial Causes of Falls
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Physical Findings
I HATE FALLING
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….Physical FindingsInflammation
HypotensionAuditory & Visual ABN.TremorEquilibrium: Balance
Foot ProblemsArrhythmiaLeg-length DiscrepancyLack of ConditioningIllnessNutritionGait Disturbance48
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Relative Risks for Falls
Muscle Weakness 4.4 History of Falls 3.0
Gait Deficit 2.9
Balance Deficit 2.9
Assistive Device 2.6
Visual Deficit 2.5
Arthritis 2.4 Impaired ADL 2.3
Depression 2.2
Cognitive Impairment 1.8
Age > 80 Years 1.7
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Intervention
Guideline Recommendations
Home Environment
Medications
Postural Hypotension
Foot Problems
Exercise
Vitamin D
Vision
Heart Rate50
USPSTF on Falling 2018
The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risks for falls. Grade B
The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions is small. Grade C
The USPSTF recommends against Vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older. Grade D
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AGS Screening Recommendations
1. All older individuals should be asked whether they have fallen in the past year.
2. An older person who reports a falls should be asked about the frequency and circumstances of the falls.
3. Older individuals should be asked if they experience difficulties with walking or balance.
4. Older persons who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance should have a multifactorial fall risk assessment.
5. Older persons with a Single Fall should be evaluated for gait/balance
2010 American Geriatrics Society Clinical Practice Guideline: Prevention of Falls in Older Persons52
Modify Home Environment
Home assessment with environmental modification reduces the risk of falling among older adults who have fallen or are at high risk of falling because of visual impairment
Fall in Bathroom: Shower seats, grab bars, nonslip floor coverings
Fall on Stairs: Repair stairs, improve lighting, single-level housing
Order OT assessment to evaluate
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Minimize Medications
Gradual taper of psychotropic meds
Complete review of ALL meds including OTC Cessation of meds or dose reduction
Which meds are truly life preserving?
What meds were recently started?
Use Beers Criteria
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Manage Postural Hypotension
Sensation of dizziness is strongly associated with increased risk of falls Better control of systolic BP associated with decrease in postural
changes
Most Common: Dehydration, medications, and autonomic Neuropathy
Take lying and standing BPs
No single intervention decreases falls
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Manage Foot Problems & Footwear
Reduction in falls among older adults wearing a nonslip shoe covering during icy conditions
Higher heels and decreased surface area associated with an increased risk of falls
Use walking shoes with high contact surface area Avoid in those with a shuffling gait
Inspect for bunions, toe deformities, and ulcers
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FEATURES OF SAFE FOOTWEAR
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Prescribe Exercise Should be individually tailored
Tai Chi can be effective
Exercise classes in community using gait training, balance, and strengthening reduces the risk of falls
Home-based and group exercises reduces the risk of injurious falls in the community
Cochrane Review in 2017: 40% reduction in fractures in adults 50 years and older Functional task training: 24% reduction The addition of resistance: 34% reduction
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Vitamin D Supplement 5 years ago, I would inform you to definitely prescribe
Review for USPSTF did not reduce the risk of falls among community-dwelling adults
Vit D reduced the risk of falls in community-dwelling adults with a lowVitamin D at baseline
The effectiveness of Vit D supplementation on fall prevention is mixed.
High-dose Vitamin D supplementation is associated with increased risk of falls, 500,000 IU Q Yr or 60,000 IU Q month
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Vit D & Falls-Related Hospitalizations 1348 Community-dwelling Australian women aged > 70
Followed for 14.5 years
Baseline Vitamin D, grip strength, Timed Up and Go Low < 50 nmol: 384 Medium 50 to < 75 nmol: 491 High > 75 nmol: 473
Women in high significantly lower hazards for a fall-related hospitalization
Higher levels associated with better TUG performance
Sim M. Association Between Vitamin D Status and Long-term Falls-Related Hospitalization Risk in Older Women. JAGS October 2021 DOI:10.1111/jgs.17442
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Vision Impairment
First cataract surgery decreases rate of falls Second cataract surgery showed NO benefit in reducing falls
Routine eye screening with correction of visual defects is NOT effective in reducing falls
When visual RX with exercise the OR of falling was 0.17.
The AGS/BGS recommends cautioning older adults with multifocal lenses to be more attentive to falling when walking
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Manage Heart Rate & Arrhythmia
One trial demonstrated a reduction in the rate of falls among older adults with carotid sinus hypersensitivity treated with a pacemaker
Most Common: Carotid Sinus Hypersensitivity Vasovagal Syndrome Bradyarrhythmia
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Effect on Falls
Intervention % Reduction NNT Prevent 1
Exercise 6.9% 14
Vision 4.4% 23
Home Hazard 3.1% 32
EX + Vision 11.1% 9
EX + Home 9.9% 10
Vision + Home 7.4% 14
EX+Vision+Home 14.0% 7
Day L. Randomized Factorial Trial of Falls Prevention Among Older People Living in Their Own Homes. BMJ 2002;325:13066
Nursing Home Patients
Vitamin D supplementation demonstrated a reduction in the rate of fall
Vitamin D 800 IU daily Multifactorial interventions should be considered
Exercise programs should be considered
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Summary
Screen yearly or more often if patient falls Rarely caused by one factor Interaction of multiple and diverse risk factors High prevalence of comorbid diseases Greater number of risk factors, greater risk of falling Marker of poor health and declining function Remember to ASK!
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Questions?
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An 80-year-old woman comes to the urgent care center because she slipped on wet steps yesterday while watering her plants. She scraped her leg but did not hit her head.
She has fallen 3 other times in the last year. Her last fall was 3 months ago.
• On that occasion, she went to the ED because she struck her head on the bathroom vanity.
• Non-contrast CT of the head showed nonspecific microvascular ischemic changes and no acute bleeding.
History: Hypertension, well-controlled diabetes mellitus, atrial fibrillation Medications: Lisinopril, carvedilol, metformin, warfarin
CASE 1 (1 of 4)
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Examination• Blood pressure 132/86 mmHg (no postural changes), heart rate
80 bpm and irregularly irregular• Neurologic findings are normal• INR: 3.0• The posterior surface of her right leg has a superficial abrasion
with surrounding ecchymoses; there are no other injuries. • She walks slowly, with a shortened stride length on a slightly wide
base and turns in bloc.
CASE 1 (2 of 4)
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Which one of the following is the best next step?
1. Discontinue warfarin2. Refer to a community exercise program3. Begin cholecalciferol 50,000 IU weekly4. Provide educational materials about fall risk
Audience Question #5 – CASE 1 (3 of 4)
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79-year-old man is concerned about falling. He wants to get his eyes examined, because he thinks his vision has deteriorated. He lives alone.
Four days ago, he missed a step and slid down 5 or 6 steps• He had no injury other than bruising over his buttocks. • He purchased a medical alert necklace after the fall, and he is
thinking about moving his bedroom to a spare room downstairs. He last fell 1 year ago, when he got out of bed to go to the bathroom. History: Heart failure with preserved ejection fraction, gout, chronic
insomnia• Neurologic and cardiovascular findings are unremarkable
CASE 2 (1 of 4)
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Medications: Furosemide, carvedilol, lisinopril, aspirin, allopurinol, temazepam
At his last eye exam 2 years ago, findings were normal except for presbyopia and myopia in both eyes.
Examination• He completes the Timed Up and Go test in 20 seconds. • Using the Snellen eye chart, visual acuity is 20/40 in both eyes
when he wears his glasses. • Neurologic and cardiovascular findings are unremarkable
CASE 2 (2 of 4)
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Which one of the following would most likely reduce this patient’s fall risk?
1. Bifocal glasses
2. Cognitive-behavioral therapy for fall-related anxiety
3. Taper of temazepam
4. Lower bed
Audience Question #6 – CASE 2 (3 of 4)
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Resources
2010 American Geriatrics Society and British Geriatric Society Clinical Practice Guideline: Prevention of Falls in Older Persons. www.americangeriatrics.org. Accessed on October 7, 2015.
Geriatrics Review Syllabus 10th Edition. Falls. Updated March 2021
Ganz D. Prevention of Falls in Community-Dwelling Older Adults. NEJMVol. 382:734-743. February 20, 2020.
Liu-Ambrose T. Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Swelling High-Risk Older Adults After a Fall. A Randomized Clinical Trial. JAMA 2019;321(21):2092-2100.
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Resources
Guirguis-Blake J. Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018;319(16):1705-1716
Poulton G. Exercise to Reduce Falls in Older Adults. FPIN’s Clinical Inquiries. American Family Physician Vol 101(1):42-43. January 1, 2020.
www.cdc.gov/steadi. Accessed on Oct. 7, 2021.
Falls Prevention in Community-Dwelling Older Adults: Interventions. April 17, 2018.
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