#503: Falls with Dr. Alyson Michener and Suzanne Zukoski, MSPT

November 3, 2025 | By Matthew Watto, MD

Audio

Video

Transcript available via YouTube

More than just mechanical!

Keep older adult patients on their feet, literally! Learn to map the Age-Friendly 5Ms Framework onto multifactorial risk factor assessment and management and incorporate other evidence-based fall prevention interventions with the expertise of an interdisciplinary team. We are joined by geriatrician Alyson Michener (@AlysonMichener University of Pennsylvania) and physical therapist Suzanne Zukoski (Good Shepherd Penn Partners).

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Show Segments

• Intro
• Rapid fire questions
• Case
• Terminology
• Applying the Geriatric 5Ms Framework
• Physical Therapist Assessment
• Targeted Diagnostic Testing
• Multifactorial Risk Factor Assessment and Management
• Anticoagulation and Falls
• Discharge Disposition
• Exercise Programs
• Home Modifications
• Outro

Disclosures

Alyson Michener and Suzanne Zukoski report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

The production of this episode was supported by the Penn Geriatrics AGE-SMART Geriatric Workforce Enhancement Grant. This podcast content is solely the responsibility of the authors and does not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.

Falls Pearls

1. Fall definition:“coming to rest unintentionally on a lower surface”. Avoid premature closure by labeling a fall as “mechanical,” and perform an appropriate workup in high risk individuals (older adults!)  regardless of whether syncope occurred.
2. Falls are geriatric syndromes! Definition: multifactorial conditions resulting from age-related physiologic changes, chronic diseases, and social and environmental factors.
3. The Geriatric 5Ms framework facilitates history taking and the development of a systematic, individualized management plan for geriatric syndromes (like falls!).
4. Physical therapy assessments are CRUCIAL and complement the fall evaluation by identifying additional risk factors and informing safe discharge planning.
5. Post-fall diagnostic testing should be targeted based on the history and exam. Potential studies include orthostatic vitals, echocardiography/telemetry, transthoracic echo, joint examination, cognitive evaluation, selected laboratory studies, and medication review.
6. Evidence-based fall prevention comes in three categories: 1) multifactorial risk factor assessment and management, 2) exercise, and 3) home modifications.
7. Exercise programs emphasizing balance and strength have the strongest evidence for fall prevention. Guide patients to programs appropriate to their mobility and function.
8. Home modifications, guided by insights from a multidisciplinary home-based team, can reduce falls and promote independence.

Falls with Drs. Alyson Michener and Suzanne Zukoski

Terminology

Fall

A fall is defined as “coming to rest unintentionally on a lower surface, the ground or floor” (Ganz 2020). Dr. Michener recommends avoiding the term “mechanical fall,” which is non-specific and can result in premature closure about the underlying cause. Syncope could be one etiology of a fall and carries its own differential diagnosis. Words like “slips” and “trips” add some information about the mechanism, but at the end of the day a fall is a fall and deserves an appropriate workup.

Geriatric Syndromes

A fall exemplifies a geriatric syndrome (definition: common clinical condition that older adults experience that is multifactorial and results from age-related physiologic changes, chronic diseases, and social and environmental factors (Inouye 2007).

Applying the Geriatric 5Ms to Falls

The Geriatric 5Ms framework–Mobility, Multimorbidity, Mind, Medications, and Matters Most–can guide history-taking and care planning. Compared with traditional disease- or organ-based approaches, the framework offers an effective structure for evaluating geriatric syndromes like falls. Following a comprehensive geriatric assessment, the clinician can create a management plan for identified risk factors (Tinetti 2017, Colón-Emeric 2024).

Multimorbidity

– Chronic medical conditions

– Acute illnesses

– Prior falls

– Other geriatric syndromes

– Sensory Impairments

Medications

– Psychoactive and anticholinergic (e.g. antidepressants, anxiolytics, sedative-hypnotics, antipsychotic)

– Analgesics (i.e. opioids, anti-epiletics)

– Cardiovascular agents (i.e. antihypertensives, beta-blockers, loop diuretics)

– Antihyperglycemics

– Over-the-counter or non-prescribed substances

– Any medication in excess!

Mind

– Dementia (impaired safety awareness, poor executive function, visuospatial changes)

– Depression

– Delirium

Mobility

– Baseline mobility and functional status (ADLs, IADLs)

– Recent changes in mobility

– Assistive device use

Matters Most

– Home environment

– Family and social supports

Physical Therapist Approach to Falls

Like most geriatric syndromes, falls are best evaluated and treated by interdisciplinary teams (which includes expert physical therapists!). 

History

Suzanne suggests beginning with a thorough chart review, then interviewing the patient and/or care partner to further clarify the details of the fall. She focuses on the home environment which includes common places to fall (i.e. stairs, bathrooms), available equipment (i.e. assistive devices, stair glides, railings), and home hazards (i.e. area rugs). 

Physical Exam

In the hospital setting, Suzanne uses a standard approach adapted to each patient’s abilities. She observes the patient’s performance through progressive tasks:

– Supine blood pressure

– Rising to sit at the edge of the bed

– Sitting unsupported

– Holding up a leg against gravity

– Seated blood pressure

– Standing with two-wheeled walker

– Standing blood pressure

– Ambulation (to the chair, in the room, in the hallway)

During each step, she notes balance, range of motion, pain, strength, endurance, cognition, safety awareness, orthostasis, and need for assistance or prompting.

Specific Mobility Testing

Validated mobility tests are most commonly used in the outpatient setting for fall risk stratification but can inform hospital-based assessments as well. 

Key examples:

– Berg Balance Scale (Berg 1992) – balance and fall risk

– 5 Times Sit to Stand (Buatois 2008) – fall risk

– 30 Second Sit to Stand (Jones 1999) – lower body strength

– Timed Up and Go (Podsiadlo 1991) – functional mobility

Other Diagnostic Testing

Most patients presenting after a fall should be evaluated with orthostatic vitals, a medication review, and PT/OT evaluations (Ganz 2020, Colón-Emeric 2024). 

Dr. Michener emphasizes targeting additional testing based on the clinical picture. For example, checking a hemoglobin A1C is only helpful if hypoglycemia from tight glycemic control is suspected. Other context-dependent studies might include electrocardiography, telemetry, echocardiography, detailed joint exams, cognitive or vision assessment, or further labs.

Evidence-Based Fall Prevention Interventions

Evidence supports three main arms of fall prevention interventions: 

1. Multifactorial Risk Factor Assessment and Management

This approach systematically addresses each identified risk factor, often organized using the 5Ms. Though study protocols vary, meta-analyses show roughly a 23% relative risk reduction in falls with multifactorial interventions (Ganz 2020). Another analysis estimated a number needed to treat (NNT) ≈ 8.8 (Giurguis-Blake 2024). Such an approach is most effective for those at highest risk of falling–those with recurrent falls, major injury, or unsteadiness on their feet.

Example: a multifactorial risk factor assessment may identify a patient’s bradycardia as a contributor to falls. The clinician should then perform a medication review, which can identify metoprolol and donepezil as potential culprits. These medications can then be dose-reduced or deprescribed, depending on their indication and clinical appropriateness, which will reduce future fall risk.

2. Exercise Programs

Strong evidence supports exercise for fall prevention in older adults—both in those with and without a history of falls. Meta-analyses show a 23% relative risk reduction, with NNT ≈ 9.3 (Ganz 2020; Giurguis-Blake 2024).

Exercise counseling should be tailored to the specific patient based on their level of independence and degree of fall risk. Considerations include: home or public setting, individual or group, and supervised or unsupervised activity (Ganz 2020, see Supplementary Appendix B for exercise selection algorithm). Patients may progress from individual home-based PT-supervised therapy to group exercise classes as mobility improves. Similarly, a person may require an assistive device initially, but could progress to a less restrictive device or full independence over time.

One well-studied program is Tai Chi for Arthritis and Fall Prevention (Chen 2023), for which Suzanne is a certified instructor (scroll down to “Tai Chi for Fall Prevention” for videos)!

1. Home Modifications

Meta-analyses show about a 23% relative risk reduction with tailored home modifications (Ganz 2020).

Since most internists do not do house calls, it can be helpful to collaborate with physical and occupational therapists who can perform home safety evaluations. They can suggest equipment– like a grab bar, shower chair, or stair glide– as well as strategies to improve accessibility– like putting commonly used kitchen items in reachable cabinets.

The CDC’s STEADI (Stopping Elderly Accidents, Deaths & Injuries (STEADI) program includes a practical checklist patients can use to evaluate their own home and make modifications.

Additional Pearls

Communicating with Patients about Falls

Roughly one in four older adults falls each year, but only about half report it to clinicians—often due to fear of losing independence or belief that falls are “normal aging” (Ganz 2020).

Clinicians should ask patients directly about falls, then provide reassurance and education that fall risk can be mitigated. Dr. Michener emphasizes reviewing results of the multifactorial risk assessment and discussing the care plan with patients and care partners.

Management of Anticoagulation

Whether to hold anticoagulation in high fall-risk patients is nuanced and depends on risk factors, goals, and overall trajectory. Dr. Michener typically continues anticoagulation acutely (if no bleeding) and encourages shared decision-making with the patient’s primary care provider or cardiologist.

Discharge Disposition

Therapists document assistance levels needed for basic mobility and ADLs (more info on assist levels and PT/OT jargon here). Patients needing physical assistance for basic mobility or ADLs are generally unsafe to live alone and may require skilled nursing (SNF) or sub-acute rehab (SAR) for additional support and therapy (< 3 hours/day).

If patients or families opt to discharge home, Dr. Michener stresses clear communication of reasoning and a focus on what matters most to the patient, while putting safety supports in place.

Vitamin D and Falls

Evidence for vitamin D supplementation is inconsistent. It may help specific subgroups—those with vitamin D deficiency or nursing-home residents (Panel on Prevention of Falls 2011)—but most recent data suggest no overall reduction in fall risk among community-dwelling older adults (Ganz 2020).

Goal

Listeners will develop a framework to approach the prevention, evaluation, and management of falls.

Learning objectives

After listening to this episode listeners will…  

1. Define and contextualize falls as a geriatric syndrome, including appropriate terminology and epidemiology.
2. Apply the Geriatric 5Ms framework to evaluate an older adult after a fall as part of a multifactorial risk factor assessment and management strategy.
3. Collaborate with interdisciplinary team members to implement evidence-based fall prevention interventions, including exercise and home modifications.

Citation

Schmucker AM, Miller RK, Michener AR, Zukoski S, Williams PN, Watto MF. “Falls with Dr. Alyson Michener and Suzanne Zukoski”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date November 3 2025.