Falls
last authored: Aug 2010, David LaPierre
last reviewed:
Dave Morris, used with permission
Introduction
A fall is defined as an event where a person comes to rest at a lower level, not related to a major medical event or an extrinsic force (ie collision between a car and a pedestrian).
Falls are very common. They can happen due to syncope, stroke, seizure, or violence, but this article discusses falls with none of these etilologies, occurring primarily in older patients.
Over 35-45% of people over 65 fall every year; in half of these, falls are recurrent (American Geriatrics Society, 2001). The costs are estimated to reach $32 billion in the US in 2020 (Chang et al, 2004).
Falls have a significant impact on patients, especially the elderly. Consequences include fractures, soft tissue injury, psychological stress, reduced mobility, and the need for increased care. A cycle of fear, inactivity, decreased strength, and balance can lead to further falls.
However, falls are also important indicators of frailty and mortality, representing a unique diagnosis.
The Case of Mrs Tyler
Mrs Tyler is an 80 year-old woman who comes to see you, her family doctor, because she has fallen four times over the past three months, once serious enough to send her to the emergency department.
What are some causes of falls?
What would you ask her?
What physical exams would you perform?
Causes and Risk Factors
Falls are typically multi-factorial; less than 10% of falls have a single cause. However, the majority occur when extrinsic factors or hazards overwhelm a patient's balance capacity.
A video-based study in a Canadian long-term care facility found that incorrect weight shifting was responsible for 40% of falls, tripping for 20% (Robinovitch et al, 2013). This study also provides video examples of these types of falls.
intrinsic risk factors (in about half of falls)
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extrinsic factors (in about 90% of falls)
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Pathophysiology
As people age, physiologic changes and cumulative disease impairments combine to seriously challenge the maintenance of stability.
Visual acuity, contrast sensitivity, and depth perception are important in stability. Bifocals can challenge balance as people cannot see their feet through the reading portion.
Hearing affects stability by providing spatial orientation. Many seniors have hearing loss.
The vestibular system maintains visual fixation, while proprioreception assists during changes of position or on uneven ground. Seniors also have increased reaction time.
Decreased strength and muscle mass.
SLower gait and decreased stride, increased lateral sway and forward flexion
Signs and Symptoms
Many patients will not mention falls, as they falsely believe it is a natural consequence of aging. Health care providers should accordingly screen for falls.
- history
- physical exam
- screening for falls
History
Inquire into the specific history of falls:
- number of falls
- circumstances: time, locations, frequency activities, postural changes, slip/trip
- symptoms associated with fall: prodromal, presyncope, post-pre seizure, loss of consciousness, postural hypotension
- injuries
- fears of falling
past medical history
- recent health
- Parkinson's disease
- strokes
- dementia
- cardiac
- neuropathy
review of systems
cognitive function: MMSE, clock-drawing test
fatigue/sleepiness
assistive devices used
vision
medications
A thorough medication review is important. Inquire into recent medication changes, and also ask for:
- diuretics: orthostatic hypotension, nighttime urination, electrolytes
- antidepressants: anticholinergic sx
- OTCs
- ethanol
- vasodilators
social history
- activities of daily living
- home situation: stairs, rugs, etc
- mobility
Physical Exam
vitals: lying and standing to determine orthostatic hypotension (15-20 mmHg systolic)
cardiovascular, respiratory exams
neurologic: sensation, proprioreception, tremor
muskuloskeletal: gait, balance, appropriate use of aid
specific quick tests
- hierarchical assessment of balance and gait (HABAM)
- timed-up-and-go: get up from armless chair, walk 3m, turn around and go sit down; should be accomplished in 30 sec or less
- pick an object off the floor
- functional reach
The Berg Balance Scale can be used for an in-depth study.
Screening for Falls
Four questions for screening include:
- recurrent falls
- difficulty walking or balancing
- fear of falling
- presentation with acute fall
Any positive answer should result in comprehensive testing
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Bloodwork to explore etiology of unexplained falls include:
- CBC
- electrolytes
- BUN, creatinine
- TSH
- glucose
- folate, B12
Diagnostic Imaging
Imaging should be carried out according to specific concerns. These can include:
- cardiac abnormalities: ECG
- cognition, neurological symptoms or findings: CT head
- seizures: EEG
- injury: plain films
Treatments
Management
Future prevention is a critical factor.
Exercise for strength and balance is of significant benefit, particularly in targeted interventions. Helpful exercises include Tai Chi.
Environmental modification should follow assessment, often by an occupational therapist. Important areas of consideration include:
- assistive device training
- telephones on each floor (to avoid rushing up or down stairs)
- lighting
- stairs, rails
- rugs
- appropriately heighted furniture
- bath rails
The best interventions are multifocal and can result in a reduction of up to 45% falls in community-dwelling seniors who do not have dementia (Gillepsie et al, 2003). These can be tailored according to an individual's needs, but should include the following:
- Assess medications and adjust medications, dosage, and scheduling as appropriate. Discontinue unnecessary medications.
- Optimally treat illness
- Visual impairments, such as visual acuity or cataracts, should be identified and treated.
- Identify and suggest discontinuation of high-risk activities (carrying laundry up/down stairs).
- Ensure proper footwear.
- Encourage proper sleep hygiene.
- If low BMD, consider hip protectors, calcium and vitamin D supplementation, and bisphosphonates
- Diagnose and treat postural hypotension with medication adjustment, adequate water and salt intake, and the use of compression stockings. Cardiac pacing should be used if carotid sinus hypersensitivity is identified.
- Referral to PT/OT if evidence for balance or gait problems.
Cognitively impaired seniors are more difficult to treat.
In hospitals, a Fall Prevention Tool Kit (FPTK) can reduce falls in patients over 65 using personalized fall prevention interventions, including bed posters, patient education handouts, and patient-specific plans of care (Dykes et al, 2010).
Consequences and Course
As described, falls have major impact on seniors in a number of ways
- soft tissue injury
- fractures, especially hip fractures
- head injury
nursing home admissions
Additional Resources
American Geriatrics Society. 2001. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 49(5):664-72.
Dykes PC et al. 2010. Fall prevention in acute care hospitals: a randomized trial. JAMA. 304(17):1912-8.
Robinovitch SN, Feldman F, Yang Y, Schonnop R, Leung PM, Sarraf T, Sims-Gould J, Loughin M. 2013. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet. 381(9860):47-54.
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