Falls Assessment in Older Adults: STEADI, Gait Tests, Medications and the Home

A falls assessment follows the CDC STEADI sequence: screen every older adult yearly and after any fall, assess gait, strength, balance and the modifiable risk factors in anyone who screens positive, then intervene on each finding and follow up in 30 to 90 days. The screen is three questions: has the patient fallen in the past year, do they feel unsteady, do they worry about falling. A Timed Up and Go of 12 seconds or more, an inability to hold a tandem stance for 10 seconds, or a below-average 30-second chair stand confirms risk, and the plan always includes progressive strength and balance exercise, a medication review and attention to orthostatic blood pressure, vision, feet and the home.

Screening: who needs an assessment

STEADI applies to community-dwelling adults 65 and older. Screen yearly, and any time the patient presents with an acute fall, with either tool:

• The three key questions. A yes to any one is a positive screen. If the patient has fallen, ask how many times and whether there was an injury.
• The Stay Independent brochure, a 12-question patient checklist. A score of 4 or more is at risk; with a score below 4, ask whether the patient fell in the past year, and a yes still counts as at risk.

The 2022 World Falls Guidelines add severity to the screen. A fall with any of the following makes the patient high risk and leads straight to a multifactorial assessment: an injury, two or more falls in the previous 12 months, frailty, being unable to get up without help for at least an hour, or suspected transient loss of consciousness (which also needs a syncope evaluation). A single non-severe fall with gait or balance problems is intermediate risk; no falls, or one non-severe fall with normal gait and balance, is low risk.

Patients who screen negative still receive prevention: education, an assessment of vitamin D intake with a daily supplement if intake is deficient, referral to a community exercise or fall-prevention program, and rescreening yearly.

Gait, strength and balance tests

While timing the TUG, watch the walk: a slow tentative pace, short strides, shuffling, little arm swing, en bloc turning, steadying on walls or misuse of the device. These findings suggest neurologic disease such as parkinsonism, normal pressure hydrocephalus or myelopathy and need further evaluation in their own right.

STEADI below-average 30-Second Chair Stand scores:

The multifactorial assessment

The STEADI algorithm lists the risk factors to assess once the screen is positive.

Fall history

Ask what happened: the activity, the time of day, the location, warning symptoms, loss of consciousness, injury and how long the patient was on the floor. Falls on the way to the bathroom at night point to nocturia, sedatives and orthostasis. A fall with no recollection of falling is syncope until proven otherwise.

Medications

Identify fall-risk-increasing drugs using the Beers Criteria or STOPPFall, a European Delphi-based tool built specifically for fall-risk drugs. The 2023 Beers Criteria list these to avoid in patients with a history of falls or fractures unless safer alternatives are unavailable: antiepileptics, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics (zolpidem, eszopiclone, zaleplon), antidepressants (tricyclics, SSRIs, SNRIs), opioids and, new in 2023, anticholinergics. Add the drugs that cause orthostatic hypotension (alpha-1 blockers, diuretics, nitrates, other antihypertensives) and hypoglycemia (insulin, sulfonylureas). The action, in STEADI terms, is to stop, switch or reduce the dose.

Orthostatic blood pressure

Measure after the patient has been lying down for 5 minutes, then after standing for 1 minute and 3 minutes. Orthostatic hypotension is a sustained fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing; record symptoms too, because lightheadedness on standing matters even below the threshold.

Vision, feet, vitamin D and comorbidities

Check visual acuity with a Snellen chart and ask about multifocal lenses. Examine the feet and footwear for deformity, neuropathy, poor fit and heel height. Assess vitamin D intake. Identify comorbidities that raise risk or worsen the consequences of a fall, especially depression, osteoporosis, Parkinson disease, stroke, diabetes with neuropathy, urinary incontinence and cognitive impairment. The World Falls Guidelines recommend routine cognitive assessment in a falls evaluation, with a tool such as the MoCA.

Home hazards and fear of falling

Ask about throw rugs, clutter, poor lighting, stairs without rails and a slippery tub. Fear of falling that limits activity leads to deconditioning and more falls, so it belongs in the plan.

Interventions matched to findings

Exercise: the core intervention

The USPSTF (2024) gives exercise interventions a grade B for community-dwelling adults 65 and older at increased risk of falls, and multifactorial interventions a grade C, meaning the provider offers them selectively based on prior falls, comorbidity and patient values. The trials most often used group or individual programs of gait, balance and functional training plus strength training, typically 2 to 3 sessions a week for 12 months. The World Falls Guidelines recommend balance-challenging and functional exercise three or more times a week, individualized and progressed for at least 12 weeks and continued longer, with Tai Chi or progressive resistance training added where feasible. Benefits fade when exercise stops, so the plan is long term.

Vitamin D

The USPSTF (2024) statement does not address vitamin D for fall prevention. The World Falls Guidelines reserve it for people at risk of deficiency, and STEADI recommends it when deficiency is observed or likely. Routine high-dose supplementation in replete adults is not a fall-prevention measure.

Follow-up, referral and urgent evaluation

STEADI schedules follow-up in 30 to 90 days to review the plan, check adherence and address barriers; patients who screened negative are rescreened yearly or after any fall. Refer to a falls clinic or geriatrics for recurrent falls despite intervention, and to cardiology when syncope, a new murmur or an arrhythmia is suspected.

Send the patient for same-day or emergency evaluation after a fall with head injury while on an anticoagulant or antiplatelet, a new focal neurologic deficit, inability to bear weight or suspected hip fracture, a long lie with concern for rhabdomyolysis or pressure injury, or syncope with exertion, chest pain or palpitations. A fragility fracture also calls for osteoporosis evaluation and treatment.

Patient and caregiver education

Explain the patient's own risk factors and which are modifiable. Agree on the strategies the patient is willing to do, frame fall prevention as protecting independence, and put the plan in writing. Teach slow position changes and foot pumps for orthostasis, night lights on the route to the bathroom, removal of rugs, grab bars and rails, well-fitting shoes with low heels, and how to get up from the floor or call for help. Caregivers should know which medications were changed and which symptoms to report.

How the exam tests this

• The screening question. Options offer an annual DEXA, a home visit or the three key questions; the screen is the questions, yearly and after any fall.
• The cut-off. A TUG of 13 seconds is at risk under STEADI; an inability to hold tandem stance for 10 seconds is at risk.
• The single best intervention. When the stem asks what reduces falls in a community-dwelling older adult at increased risk, the answer is exercise (grade B), not vitamin D, hip protectors or a walker alone.
• The vitamin D trap. Vitamin D is for deficiency or risk of deficiency, not universal prevention.
• The medication item. A patient who fell is on zolpidem, a benzodiazepine, an anticholinergic or a newly started alpha blocker; the answer reduces or removes the drug, tapering where needed.
• Orthostatic numbers. A drop of 20 systolic or 10 diastolic within 3 minutes of standing is orthostatic hypotension; the answer addresses the causative drug before adding fludrocortisone or midodrine.
• The syncope signal. A fall without recall, or with palpitations, is a syncope work-up, not a balance referral.

Practice question

An 81-year-old woman reports two falls in the past 6 months, both while walking to the bathroom at night; she was not injured and got up on her own. She has hypertension, osteoarthritis of the knees and insomnia. Medications: hydrochlorothiazide 25 mg daily, lisinopril 20 mg daily, zolpidem 10 mg at bedtime for 3 years and acetaminophen as needed. Blood pressure is 132/78 mm Hg after 5 minutes lying and 124/74 mm Hg after 3 minutes standing, without symptoms. Timed Up and Go is 16 seconds with short, cautious strides. Visual acuity is 20/30 with her glasses. Serum 25-hydroxyvitamin D is 34 ng/mL. Which of the following is the most appropriate plan?

• A. Start vitamin D 50,000 IU weekly and recheck the level in 3 months.
• B. Taper and stop zolpidem with sleep-focused behavioral therapy, refer to physical therapy for progressive strength and balance training, and arrange a home safety evaluation.
• C. Discontinue hydrochlorothiazide and lisinopril because of orthostatic hypotension.
• D. Prescribe a four-wheeled walker and hip protectors and recheck in 1 year.

Answer: B. She has two falls in 12 months and a TUG well above 12 seconds, so she is high risk and needs a multifactorial plan built on the findings: a long-term hypnotic that the Beers Criteria list to avoid in patients with falls, impaired gait and balance, and nighttime falls that make the home route worth evaluating. Option A treats a vitamin D level that is not deficient; supplementation is for deficiency or risk of deficiency, not universal fall prevention. Option C misreads the vital signs: a drop of 8 mm Hg systolic without symptoms does not meet the orthostatic threshold of 20 systolic or 10 diastolic. Option D offers devices without exercise or medication change and abandons follow-up for a year, when STEADI calls for review in 30 to 90 days.

Key points

Related NPPace guides

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• How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
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