After a fall patients may regress and become more housebound and worried about falling outside.
CT head if any concerns of neurology, anticoagulation to exclude SDH
Check blood glucose, Check L/S BP, ECG, Medications
ABCDE, top to toe front and back assessment
Radiological assessment if fracture suspected
Persisting hip/pelvic pain/limited SLR consider MRI pelvis to exclude #
- A fall is defined as an event that causes a person to, unintentionally, rest on the ground or other lower level.
- A long lie is a fall that is defined as an event that causes a person to, unintentionally, rest on the ground or other lower level for at least one hour.
- Usually seen in elderly and causes are multifactorial
The most important history in a patient with falls is whether it was preceded by a loss or impairment of consciousness. If so get a witness account. Check L/S BP, look for murmur of aortic stenosis, check ECG for heart block, review BP control, review hypoglycaemic meds.
- Inpatient falls are a growing problem with over 200,000 falls in hospitals each year
- 40% of those over the age of 80 fall each year
- Falls cause 90% of hip fractures in this age group
- Some 3-5% of falls result in fracture
- Falls are an independent risk factor for nursing home placement.
- Muscle weakness
- History of falls
- Abnormal gait or balance
- Use of walking aid
- Visual impairment
- Impaired ADLs
- Cognitive impairment
- Age over 80
- Psychotropic medication
- Transient loss of consciousness (See article)
- Hypotension, Stroke
- Weakness and Sarcopenia
- Dyspraxia and Cerebrovascular disease
- Cerebellar degeneration
- Low BM usually diabetic
- Drugs - sedation, Alcohol
- Infections - Urine/chest
- Severe aortic stenosis, MI
- Arrhythmias, Seizures, Accidental
- Parkinson's, Vascular dementia
It will also help reduce postural hypotension, defined as a
drop in BP of > 20 mmHg systolic or > 10 mmHg diastolic pressure on standing from supine
|Quick On call Falls check list|
ABCDE and assess if unwell e.g. coma, low BP, low BM get help
Are they on anticoagulants (increased risk of SDH/ICH)
Check patient stable and no severe injury
Do they need senior medical review
Review history of PMH and fall history
Review Examination top to toe
Check basic bloods and review ECG and NEWS
CT head if head injury and anticoagulant or altered neurology
Other radiology: pelvis, ribs, humerus as needed if tender
Examine drug chart for any issues. Consider harm from anticoagulants
Document in notes and day team can take it further
- NEWS and are the cardiovascular/neurology stable
- Preceding symptoms.
- Ask about syncope, dizziness, instability
- Cardiac or neurological causes
- Stroke, Infection, Vertigo, TIA
- Old disability e.g stroke or small vessel disease
- Poor vision, Pets, Clutter
- Has this happened before
- Previous tests and assessments
Contributing factors: Gravity +
- Acute illness of any cause
- Frailty, Dementia, Sarcopenia
- Cardiac disease and drugs and hypotension
- Stroke, Neuropathy, Dyspraxia, Cerebellar disease, PD
- Alcohol, sedation, Anticonvulsants
- Poor lighting, lack of walking aid
- Simple trips , pets, loose rugs, obstructions
- Poor vision, not wearing glasses, distractions, lack of care
- Arthritis and pain, Delirium
- Rushing: phones, doorbell, urge incontinence/diuretic
Quick On call check list
Immediately Pre Fall Assessment
- Look for any pre-syncopal symptoms e.g. feeling dizzy, light-headed, palpitations
- What were they doing? Standing from sitting or lying (postural hypotension?)
- Getting off toilet, or standing urinating (micturition syncope)
- After a large meal ( Vasovagal)
- When already up and walking (arrhythmia?)
- Turning head/looking up their head (carotid sinus hypersensitivity?)
- Take a close history so you can play the event back in your mind
- Get a witness report if any loss of consciousness even to ringing people
- If they fell do they remember falling and hitting floor
- Was it a simple trip
- Did they manage to protect themselves e.g. # wrists from arm outstretched to protect. A black eye and head injury suggests less self protection and may have had LOC before fall
- If LOC then for how long
- Any incontinence or tongue biting
- Any limb jerking or urinary/faecal incontinence to imply seizure
- Could they get back up and if not why not
- Were they able to mobilise independently following the fall?
- Do they have any pain - have they a fracture
- Were they well-oriented following the fall?
Pre morbid health
- Assess frailty if frail
- Walking: do they use aids e.g stick, frame, furniture walk
- Do they have careline and could they use it
- If unwell assess patient using ABCDE approach
- If any new neurology and head injury urgent CT head
- If any bone pain then X-Ray for possible fractures, dislocation
- Identify causes especially if (pre) syncope before hand
- Cardiovascular: Pulse, AF, Low BP or postural drop, Murmurs
- Respiratory: COPD or Bronchiectasis and cough. SOBOE. Frail. Steroids
- Abdominal : constipation, urinary retention, prostatism
- Neurological : seeing gait is most useful. If not power, tone, vision, cerebellar signs, neuropathy, cognition
- Cognition: AMTS or MMSE. Use CAM if suggestion of delirium
- Trauma: Any head injury or fractures. Look for tenderness or deformity
- Treated Diabetes Mellitus: was it a hypo or neuropathy
- Hypertension: Do you need to reduce them, any recent increase
- Epilepsy: any history of seizures?
- Previous falls: aetiology. Always seek the worst and go into details
- Hearty disease: palpitations/ECG/ Need telemetry and echo
- Neurological disease: old stroke, Parkinsonism, dementia, SVD
- Poor vision: Glaucoma, ARMD, Cataract, Hemianopia
- Cognitive impairment : Dementia, Dyspraxic
- Bone Health : steroids, old #, Osteoporosis, Paget's Disease
Drug history relevant to falls
- Postural hypotension: Alpha-receptor blockers in male patients with prostatism g. tamsulosin, ACEI, ARB, CCB, Diuretics
- Analgesia: e.g. codeine
- Sedatives: antihistamines, benzodiazepines
- Diuretics: urge incontinence
- Anticoagulants : increased risk of bleed (SDH/Traumatic ICH) get CT head if worried
- Psychotropic Drugs SSRIs, benzodiazepines, all increase the risk of falls
- FBC, U&E, ESR, CK if long lie
- ECG and 24 hr tape if syncope(presyncope)
- Echo if suspected aortic stenosis or structural heart disease
- Issues are the fall and harm caused. This may require CT head or X-Rays looking for broken bones.
- Pelvic X-rays can occasionally miss a hip fracture and if pain persists then CT or MRI is indicated.
- Chest x-ray: may show infection or rib fractures
- Patients should not go under the elderly team until a fracture that might require surgery has been excluded.
- Next issues are why the fall and how to prevent a recurrence and this demands detective work and critical thinking.
- One major issue is the fall itself causes a huge loss of confidence and patients become very withdrawn and anxious and resist mobilisation.
- It must all be assessed in the context of the living environment. There are many strategies and ways to minimise falls and their effect.
- One major worry is falling downstairs and a chairlift or moving bed downstairs might help. Patients may have cognitive impairment and varying degrees of insight.
- Review medications eg. sedatives, psychoactive drugs (such as benzodiazepines), stop drugs that can cause postural hypotension
- Ask about alcohol.
- History of falls.
- Gait, balance and mobility, and muscle weakness.
- Osteoporosis risk.
- Perceived impaired functional ability and fear relating to falling.
- Visual impairment.
- Cognitive, neurological, and cardiovascular problems.
- Urinary incontinence.
- Home hazards.
- Polypharmacy (the use of multiple drugs)
Rare but useful Interventions
- Pacemaker if symptomatic bradycardia
- Aortic valve replacement if severe AS
- Anticonvulsants if Seizure
- Stopping meds if Drug induced hypotension or unsteadiness
- Avoiding drugs or patches that cause sedation
- Cataract surgery for poor vision
- Exercise for limb strength
- Calcium and vitamin D supplementation: may help
- Home: environment assessment and modification
- Anti-slip and well fitting shoes
Later interventions commonly offered by specialist falls services
- Strength and balance training: helps older community-dwelling people with a history of recurrent falls or balance and gait deficit.
- Home hazard assessment and intervention should be offered to older people who have received treatment in hospital following a fall.
- Vision assessment and referral.
- Medication review and discontinued if possible.
- Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.
- The only way to stop falls risk is to not allow patients to walk but this reduces quality and probably length of life
- Falling is bad but falling downstairs is very high risks and is an issue to address with downstairs living or stairlift
- Once we cannot change the patient we need to change their world around them
- May need additional support at home. A package of care may help with ADLS and check patient is all right
- In extreme cases placement is preferred to ensure safety, either RH or NH based on level of dependence
- Occupational therapy and community home visits can be helpful in frail patients who might have cluttered houses with uneven floors
- Good lighting and using lights when going to toilet overnight. Using a bedside commode to save having to walk to distant bathroom.
- Consider a microenvironment "Studio" with downstairs living in one room with easy access to commode and handrails. If needed a stair lift to go upstairs.
- Some may need a hospital bed and hoist of high level of care and very immobile
- Pendant alarms if patient has cognition to use one and to wear it at all times. A mobile phone can be useful. Some have put internet cameras for family to observe.
- Newer models have in-built impact sensors that are set-off as a fall happens
- Falls clinic and exercise and balance classes can help some