Introduction

Around a third of elderly patients living in the community fall annually with 5-15% of falls resulting in significant injuries such as fractures and head trauma.  In the UK there is 1 fall associated death every 5 hours.  So, falls in the elderly pose a significant health problem.

Aetiology

The cause of a fall may not always be straight forward and may be multifactorial.  Risk factors include increasing age, living in residential care and chronic disease.

Intrinsic Causes

Neurological

 

Cardiovascular

Metabolic

Gastrointestinal

Musculoskeletal

Genitourinary

Psychological

Pharmacological

 

Environmental Causes

 

 

Stroke, cerebellar disorders, visual impairment, Parkinsonism, seizures

MI, arrhythmia, orthostatic hypotension

Hypoglycaemia, hypothyroidism, dehydration

Diarrhoea, bleeding

Arthritis, muscular weakness

Incontinence, nocturia

Delirium, dementia, depression

Polypharmacy, antihypertensives, diuretics, alcohol

 

Poor lighting, steps, ice, shoes, rugs, walking aids

History

The Fall

Depending on the circumstances, it may be necessary to obtain a collateral history.

  • Environmental cause e.g. fall down stairs
  • What can they remember before and after: retrograde and anterograde amnesia are worrying symptoms of head injury
  • What were they doing at the time: a fall after standing from sitting or lying is suggestive of postural hypotension
  • Symptoms before fall e.g. dizziness
  • Loss of consciousness: suggestive of head injury or epilepsy
  • Symptoms after fall
  • Associated injuries

 

Past Medical History

A detailed past medical history may indicate the cause. Specifically ask about:

  • Previous falls
  • Recent infection
  • Recent vomiting and diarrhoea

 

Drug History

  •  Beta blockers and diuretics can cause postural hypotension

 

Social History

  • Alcohol history
  • Mobility
  • Use of adaptions e.g. walking aids, handrails
  • Housing
  • Care

Examination

Neurological

  • Conscious level
  • Orientation: consider MMSE
  • Muscle bulk, tone, power, coordination and sensation
  • Visual acuity and visual fields

       

      Cardiovascular

      • Pulse: arrhythmias
      • Postural BP

       

        Musculoskeletal

        • Signs of arthritis e.g. deformities, crepitus
        • Range of movement

         

        The mnemonic I HATE FALLING can be used to remind you of the common treatable causes of falls which may be apparent on physical examination.

        Inflammation of joints

        Hypotension

        Auditory and visual abnormalities

        Tremor (e.g. Parkinson's)

        Equilibrium problems

        Foot problems

        Arrhythmia, heart block or valvular disease

        Leg-length discrepancy

        Lack of conditioning (generalised weakness)

        Illness

        Nutrition (e.g. poor, weight loss)

        Gait disturbance

        Investigations

        • FBC: macrocytosis may point to alcoholism, anaemia may suggest blood loss
        • U&Es
        • LFTs
        • TFTs
        • Random blood glucose
        • Urinalysis
        • ECG

          Indications for Immediate CT Scan

          • GCS <13 on presentation
          • GCS <15 2 hours after injury
          • Suspected open or depressed skull fracture
          • Any sign of basal skull fracture e.g. 'panda' eyes, CSF coming from ear or nose
          • Post-traumatic seizure
          • Focal neurological deficit
          • >1 episode of vomiting
          • >30 minutes of retrograde amnesia
          • Some loss of consciousness/amnesia and either >65, coagulopathy or dangerous mechanism of injury e.g. RTA

          Gait and Balance Assessment

          An assessment of balance and gait could include:

          •  Observation of sitting to standing
          •  Observation of transfers
          •  Romberg test
          •  Tandem walking
          •  Timed walk

          Management

          Falls should be managed by firstly treating the underlying cause.  The involvement of a multidisciplinary team including physiotherapists and occupational therapists is useful.

           

          Modification of risk factors

          •  Weight bearing exercise
          •  Balance training
          •  Hip protectors
          •  Home visits e.g. to assess need for handrails, improved lighting

          Algorithm for the Investigation and Management of Falls

          Complications

          The complications of falls can vary and include:

          •  Fractures
          •  Soft tissue damage
          •  Subdural haemorrhage
          •  Loss of confidence and independence
          •  Decreased quality of life
          •  Death

          Bibliography and Further Reading

          Akyol AD.  Falls in the elderly: what can be done? International Nursing Review 2007;54:191–196.

          Clark M, Kumar P.  Kumar & Clark’s Clinical Medicine.  7th ed. pp 1096-7.  London: Saunders Elsevier, 2009.

          Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR.  Oxford Handbook of Clinical Medicine.  8th ed. p 26.  New York: Oxford University Press, 2010.

          National collaborating centre for acute care. Head injury: Triage, assessment, investigation and early management of head injury in infants, children and adults. NICE, September 2007.

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