Clinical Notes : Orthopedics and Trauma

88. Falls in the elderly

Falls are common in older people with 30% of those older than 65 and 50% of those older than 80 falling at least once a year.

Assessment

 

A multifactorial assessment should be performed when falls present in the OOH setting and should include the following elements :

 

1)  Obtain details of falls

  • How did you fall?  What exactly happened?

  • How many falls have you had in the past year?

This helps to differentiate between a one off fall and recurrent falls.

The first ever fall, or an increase in fall frequency, may indicate an acute illness.

 

  • Have you ever blacked out or “just gone down” without warning?

Beware the patient who says “I must have tripped.” Do they actually remember tripping? Older people with or without cognitive impairment may try and be helpful by saying this but you should assess their risk factors.

Consider the possibility of syncope or near syncope causing falls that are unexplained.

 

  • Do you get dizzy if you stand up quickly?  Do you get light-headed?  Do you ever feel the room spinning round?  Do you feel unsteady or unbalanced?

Consider the possibility of syncope or near syncope causing falls that are unexplained.

Conditions such as orthostatic hypotension or those causing vertigo may contribute to falls.

 

  • Do you have to rush to get to the toilet?

Older people with overactive bladder or urinary incontinence will rush to go to the toilet, placing them at increased risk of falls.

 

2) Consider the impact of co-morbidities and review medications

Older people may have multiple co-morbidities for which they may be receiving treatment which may increase the risk of falling, e.g. antihypertensives, anticoagulants, psychotropics.

A pragmatic approach should be adopted in these circumstances, taking into account the benefit of current or intended treatment, the potential harm from continuing or discontinuing the medication, and the patient's own preferences and goals.

Immediate reduction and withdrawal of medication thought to have contributed to the fall should be considered.

 

A more thorough medication review can be performed later by the patients regular attending GP, utilising the STOPP/START Toolkit criteria.

There is often concern about an increased risk of subdural haemorrhage with the use of anticoagulants in patients who fall, although this may be over-estimated. A mathematical model estimated that, in a patient who takes warfarin because of atrial fibrillation and an annual risk of stroke of 5%, a patient would have to fall nearly 300 times a year for the increased risk of subdural haemorrhage with anticoagulation to outweigh its benefits.

An individualised decision should be made for the patient taking into account patient preferences, and the potential benefits and harms of treatment.

 

3) Perform a physical examination focusing on:

  • Vision

  • Heart rhythm and rate

  • Muscle strength

  • Neurological impairment

  • Knee exam

  • Peripheral sensation

  • Feet/footwear

 

A routine ECG should be performed. If falls are unexplained or may be consistent with syncope e.g. "I just go down doctor" then consider the possibility of cardio-inhibitory carotid sinus hypersensitivity or  arrhythmia that may require further assessment. Arrhythmia should particularly be suspected if the resting ECG shows the following abnormalities :

  • Bifascicular block

  • Trifascicular block

  • Prolonged QRS

  • Second degree heart block

  • Sinus bradycardia <50pbm or sinus pause >3 seconds

  • Long or short QT interval

  • Non sustained VT

  • Ventricular ectopics

  • Q waves suggesting myocardial ischaemia

 

Older people living in the community with a history of recurrent falls and/or a balance and gait deficit are mostly likely to benefit from referral for professional strength and balance training.

 

4) Measure both lying and standing blood pressure

Orthostatic hypotension can be tested by asking the patient to lie down for 5 minutes; blood pressure can then be checked supine, immediately on standing, and again at 1 minute and 3 minutes.

Orthostatic hypotension is usually defined by a fall in systolic blood pressure of at least 20mm Hg or in diastolic blood pressure of at least 10 mm Hg.

Patients who become bedbound for long periods of time may become deconditioned, and may develop orthostatic intolerance such that they feel tired or dizzy when sitting out.

Postprandial hypotension can occur due to splanchnic vasodilatation after eating.

5) Perform a "Get up and Go Test" GUG

This very brief observation of of any balance or gait problems, without timing, can easily be performed in the OOH setting and provides extra evidence for the need for more thorough investigation and management.

The "Timed Get up and Go Test" documents more compelling evidence for freailty and the need for referral and follow-up, but is more time consuming, and may thus be less viable in the OOH setting.

6) Assessment of home hazards

This may identify common hazards such as loose carpets, seats that are too low or dim lighting, or identify required safety devices such as handrails or grab-rails.

A cursory look around the home may indicate obvious fall hazards where the OOH response to the fall takes the form of a home visit.

Where such hazards are detected, the patient's regular GP should be alerted so that a professional home hazard assessment may be organised with the local district nurse or OT department.

Management

In light of findings in the above multifactorial assessment in the OOH setting, an immediate decision may be taken between referral to A+E or management at home/residential facility.

In all cases appropriate reporting to the patient's regular GP should follow, for individualised follow-up investigations and management both short-term and long-term.

 
 
 

GUG : Get up and Go Test

Purpose : Observation of of any balance or gait problems, without timing.

Admin time :  5 min

User Friendly :  High

Administered by : GP or nurse 

Content : Instructions for the assessment and recording of balance and gait problems.

Author : Mathias S, 1986

view/access

 

TUG : Timed Get up and Go Test

Purpose : Evaluation tool for frailty, gait and balance.

Admin time :  10 min
User Friendly :  High
Administered by : GP or nurse

Content : Instructions for the assessment and recording of balance and gait problems. Regognised as a valid screening tool for frailty.

Author :  Podsiadlo D, 1991

view/access

 
 
 

STOPP-START

Screening Tool Of Older People's Prescriptions (STOPP)

Screening Tool to Alert to Right Treatment (START)

Purpose : Decision aid for supporting medication review. It consists of a series of rules/suggestions related to high-yield problems in prescribing for older people, both in terms of reducing medication burden (STOPP) and adding in potentially benefical therapy (START)

Admin time :  Highly operator dependent - 5 mins for an expert, up to 20-30 mins

User Friendly :  Moderate

Administered by : GP, Physician, Community Pharmacist

Content : It consists of a series of rules/suggestions related to high-yield problems in prescribing for older people, both in terms of reducing medication burden (STOPP) and adding in potentially benefical therapy (START)

Author : O’Mahony D, 2015

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CDC.png

Mortality, disability, and falls in older persons: the role of underlying disease and disability.

Dunn JE, Rudberg MA, Furner SE, Cassel CK.

 Am J Public Health. 1992;82:395–400.

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A multifactorial approach to reducing injurious falls. 

King MB, Tinetti ME.

Clin Geriatr Med. 1996;12:745–59.

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NICE Quality Standard : QS86

Falls  in Older People

Published : March 2015

Updated : January 2017

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NICE guidelines : CG161

Falls in older people: assessing risk and prevention

Published : June 2013 

view/access 

Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes

Tinetti ME, Inouye SK, Gill TM, Doucette JT. . 

JAMA. 1995;273:1348–53.

view/access


Home & recreational safety: older adult falls

Centers for Disease Control and Prevention

Published : 2015 

view/access 

Professional resources: fall prevention guidelines, training and tools

British Columbia Injury Research and Prevention Unit

Published : 2015 

view/access

Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis.

Deandrea S.

Epidemiology. 2010 Sep;21(5):658-68

view/access


Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force.

Guirguis-Blake JM, Michael YL, Perdue LA, et al.

JAMA. 2018 Apr 24;319(16):1705-16

view/access

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