Falls in Elderly Care

Background

  • Falls in the elderly are common (one third of >65 year olds and one half of >80 year olds in the community fall per year.  Half of these are multiple falls)
  • Falls are a symptom- not a diagnosis.  It is also important to recognise that falls can have sequelae (most common cause of mortality in >75)
  • Falls can be caused by a number of factors.  Whilst they are not an inevitable part of aging, physical changes associated with aging increases the risk.

Risk Factors

  • DAME- Drugs; Age related changes; Medical conditions; Environmental factors
  • Factors that could be associated with normal aging
    • Muscle weakness (may be normal i.e. sarcopenia; or abnormal e.g. motor neuron disease)
    • Balance impairment (again could be normal i.e. loss of vestibular cells; or abnormal e.g. cerebellar lesion, orthostatic hypotension etc)
    • Gait change/impaired mobility/increased body sway (also could be normal i.e. loss of strength/balance or abnormal e.g. parkinsons, osteoarthritis etc)
    • Visual impairment (normal- presbyopia or abnormal)
    • Slowed reaction times
    • Low weight
  • Medical factors
    • Impaired sensory input (vision, hearing, balance, sensation)
      • Peripheral neuropathy (particularly in T2DM)
      • Visual loss
      • Balance (ask specifically about symptoms of vertigo and tinnitus)
    • Conditions affecting gait
      • Parkinson’s
  • Drugs
    • Sedatives e.g. benzodiazepines, opiates, classical antipsychotics
    • Antihypertensives e.g. beta-blockers, diuretics
    • Antidepressants, in particular TCAs (cardiac arrhythmias)
    • Antipsychotics/antiparkinsonian drugs
    • Polypharmacy
    • Alcohol

Clinical Approach

Because a fall is potentially a symptom of an underlying condition, as a doctor you should investigate the patient appropriately.

History

  • NB Often a collateral history from an observer will be more useful
  • Ask about the fall itself
    • Location- an outside fall generally has a better prognosis than one in the home (this is not always the case, as it assumes a degree of frailty)
    • Activity- what was going on?
      • getting up from sitting/lying (orthostatic hypotension)
      • after a meal/micturition (consider post-prandial syncope/ micturition syncope)
      • getting to the toilet (any incontinence)
      • turning head (carotid sinus hypersensitivity or vestibular dysfunction)
    • Timing e.g. after medications, in the morning etc
  • Enquire about symptoms relating directly to the particular fall; about symptoms related to other falls and about symptoms in general:
    • dizziness, light-headedness (see also dizziness)
    • vertigo (vestibular dysfunction)
    • palpitations (arrhythmia)
    • chest pain
    • blacking-out (including duration, prodrome and post-drome.  May be suggestive of syncope)
    • incontinence/tongue-biting (epilepsy)
    • numbness in extremities (peripheral neuropathy)
    • visual problems
    • problems walking/turning/initiating movement (parkinsonism)
    • Also ask about drugs and alcohol
  • Previous falls increase the risk of further falls.  An single, once-only fall is more likely to be due to an acute event (e.g. MI, stroke, GI bleed) whereas recurrent falls are more likely to be due to chronic diseases, frailty and dementias.
  • Ask also about home situation and potential hazards at home.  Also about whether the patient feels they are managing at home and whether they are afraid of falling.
  • Ask about incontinence, SOB, visual impairment and any risks for osteoporosis

Examination

  • General examination
    • Does the patient look unwell?  (Do they look shocked, or pale etc)
    • A full cardiovascular exam is recommended
      • Pulse (rate, rhythm, volume)
      • Listen for potential murmers
      • Lying and standing BP (difference of >10mmHg DBP or >20mmHg SBP after 3 mins standing is significant)
    • A neurological and ophthalmological exam may be useful
      • Visual acuity
      • Limb power/tone
      • Check sensation in the legs for peripheral neuropathy
    • Examination of the other systems may reveal an underlying cause so should not be forgotten
    • Get up and go test (Gait assessment)
    • Check also mental state using MMSE (if this is abnormal then a more extensive test may be better e.g. Addenbrooke’s test)

Referring

  • The patient should be referred if they
    • Have had a previous low impact fracture
    • Have two or more intrinsic risk factors for falls
    • Have frequent unexplained falls
    • Have had a loss of consciousness associated with a fall
    • Have attended A&E relating to a fall
    • Have an abnormal gait which requires diagnosis
    • Have had unexplained dizziness related to a fall
    • Have multiple conditions/medications which could be optimised to prevent falls

Further Investigation

  • FBC, U&E, LFTs to check for any results that could point to an underlying cause (also TSH, B12)
  • ECG is important in many patients to rule out arrhythmia, heart problems etc
    • If this shows any abnormality suggestive of a valve problem, echocardiography may be used
    • Holter monitor may be used if falls are frequent and unexplained
  • Tilt-table test may be indicated in cases of syncope (in the absence of cardiac causes); recurrent unexplained falls and/or pre-syncope/dizziness; in differentiating between epilepsy and syncope with jerking.
  • CT scan if multi-infarct disease or seizures are suspected or if the patient has received a head injury following a fall
  • EEG may or may not be useful if seizures are suspected (a normal EEG does not rule out epilepsy)

Management

This is largely dependent on the cause.  If there is a particular underlying cause for a fall, this should be managed appropriately e.g. if there is an acute infection; if the only problem is because they have trouble getting in and out of the bath/shower etc.  On top of this, where appropriate:

  • Strength and balance training should be offered (physiotherapy)
  • Home hazard assessment and intervention (including input from occupational therapy)
  • Optimum management of visual needs
  • Medication review with modification and/or withdrawal of drugs

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