Falls and Immobility- Clinical Skills

History

• Wash hands, Introduce, Check name of date of birth, opening question
• If a single fall (or regarding the worst fall):
  • Has there been loss of consciousness, injury etc and if so, how long were they fallen?  Who found/finds them?
  • Is there anything that precipitates a fall (any dizziness, any movement, any breathlessness, any funny feelings)?  Do they occur when taking your medication? Do they occur in dark places? Is it on the stairs? (Think of DAME)
    • Drugs (& toxins e.g. alcohol/medications); Age-related factors (sarcopenia, immobility); Medical conditions; Environment
  • After a fall do you feel ok?  How long?
• Re: more than one
  • How many? How often?
  • Have they been getting worse with time (more/less frequent)?
• Medical and drug history are very important?
  • Heart conditions- BP drugs? Anti-arrhythmics? Anti-coagulants?
  • Epilepsy and drugs?
  • Anti-depressants?
  • Visual disturbance?
  • Diabetes?
• Social History is also very important
  • Living situation: on their own- self-care / home-help / family; living with someone else; house environment- stairs/rails; clutter etc
  • Do they get out of the house?  Can they do daily tasks e.g. shopping; cooking; cleaning?  How do they get about? (stick/zimmer/chair/rail etc)
• NB Family Hx not so important

Conditions for admission

• cannot walk; acute illness or if they are falling so frequently that home would be unmanageable/too great a risk.

Examination

• Stance
  • Examine standing still, checking balance.  Do Romberg’s test: ask the patient to close their eyes and see if sway worsens (in cerebellar disease, patients can sway to the ipsilateral side).  Also do Trendelenburg’s test– ask the patient (with eyes open and with your support) to stand on one leg for 30s (In weakness/structural/pain problems of the hip adductors, the contralateral hemipelvis will drop)
• Gait
  • Watch the patient walk a few metres, turn and come back again.  Look from all angles.
  • Trendelenburg gait (trunchal lurch to the affected side); spastic gait (hyperextented leg); Parkinsonian gait (shuffling; slow to start; no arm swing); cerebellar ataxia (broad-based gait)
  • Do they need support?
• Examination of limbs
  • On the bed, inspect the limbs for lengthening/external rotation (hip fracture).  Also look for any other signs.
  • Feel the hip and knee joints for deformity/tenderness.
  • (On the bed, carry out Thomas’s Test: Flex both hips and knees and place your hand under the lumbar spine.  Ask the patient to extend the testing hip (A fixed flexion deformity will make this difficult).)
    • NB In practice, many (particularly elderly) patients, will have difficulty doing this.  Furthermore, as it rarely will change the management of a patient, it is no longer routinely performed, although it may still be taught and required in an OSCE
  • Test range of movement (passive and active) of the hip and knee and foot

Differential Diagnosis

Underlying causes and complications of falls are numerous, but the following associations warrant more immediate evaluation:

• Any history of or current change in alertness or level of consciousness: possible causes include cerebrovascular (transient ischemic attack, stroke, seizure), cardiovascular (hypotension, bradycardia or tachycardia), or infectious causes. [31]
• Head trauma: anticoagulation or antiplatelet therapy raise concern for a subdural hematoma. [32]
• Pain suggesting a potential fracture: persistent pain, inability to bear weight, or any obvious anatomical abnormality should prompt a quick evaluation for fracture, along with appropriate orthopedic consultation. Consideration should be given to treating osteoporosis in patients with fractures relating to low-impact falls. [33]

Neuropsychiatric

• Visual impairment: may manifest as blurred vision or diplopia.
• Peripheral neuropathy: may be accompanied by a history of diabetes or neurodegenerative disease.
• Vestibular dysfunction, particularly benign paroxysmal positional vertigo: may manifest itself as dizziness, vertigo, or imbalance.
• Gait and balance disturbance: possible history of disc disease, peripheral neuropathy, arthritis or prior injury; specific abnormality may suggest underlying disorder such as Parkinson disease.
• Fear of falling itself can be a factor in increasing the risk of falls.
• Cognitive or mood impairment: includes dementia, depression, or delirium; behavioral disturbances, functional impairments, and the use of neuroleptics may all contribute to falls.
• Seizure disorder: may have vascular, infectious or malignant causes.
• Subdural hematoma: suggested by head trauma in the presence of anticoagulation.
• Cerebrovascular accident or transient ischemic attack: focal neurologic symptoms of nontransient or transient duration, respectively.

Cardiovascular

• Syncope: for example, cardiac syncope caused by tachyarrhythmias or bradycardia, or vasovagal syncope caused by an abnormal or exaggerated autonomic response to stimuli such as standing or emotion.
• Orthostatic hypotension: suggested by positional symptoms.
• Carotid sinus syndrome: may be elicited by activities such as facial shaving.
• Postprandial hypotension: event documented based on history of observed fall coincident with meal times.

Musculoskeletal

• Joint buckling/instability: may be due to prior injury.
• Mechanical mobility/gait abnormality: patient may have prior fracture or arthritis.
• Deconditioning: insufficient exercise is common with aging.

Toxic/environmental

• Medications: especially benzodiazepines, antidepressants, and antipsychotics; others associated with an increased risk of orthostatic hypotension include alpha-blockers, antipsychotics, antihypertensives, diuretics, beta-blockers, bromocryptine, levodopa, nonsteroidal anti-inflammatory drugs, marijuana, narcotics and sedatives, hypnotics, sildenafil, tricyclic antidepressants, and vasodilators; there is some suggestion that high-dose cholecalciferol supplementation (500,000 IU once yearly) is associated with an increased risk of fall and fracture.
• Polypharmacy; use of 5 or more medications increases the risk of falls by 30% in community-dwelling people, and by at least a factor of 4 in nursing-home patients.
• Substance abuse: including alcohol (chronic misuse or acute intoxication) or OTC medications.
• Environmental hazards such as loose rugs or tiles, poor lighting, recent use of a cane or walker, or living alone: these factors are of increased importance with age.