Name 6 risk factors/causes for falls
- fear of falling
- previous fall in the last 12 months
- balance problems - vertigo and BPPV
- postural hypotension
- gait and mobility problems - parkinson’s, arthritis, fractures, joint fixation
- pain
- drugs - antihypertensives, diuretics, GTN, alpha blockers, benzodiazepines (as sedative), antidepressants
- alcohol
- syncope - MI, arrythmias, situational, vasovagal
- stroke
- cognitive impairment - lack of familiarity with surroundings, imapired judgement
- urinary incontinence
- diabetes - hypoglycaemia, peripheral neuropathy, polyuria
- sensory impairment - visual, hearing
How might someone with a fall present?
- fracture
- found on floor
- head injury
- back pain
- collapse
What questions would you ask about in the HPC for history taking in a fall?
BEFORE
- what were they doing before they fell?
o situational (eating, micturition)
o standing for a long time
o stress
o physical exertion
o exposure to flickering lights
o working with arms above head (subclavian steal syndrome)
- what time of day was it?
- had they eaten recently and fluid intake?
- how did they feel before they fell
o chest pain, palpitations, SOB
o light headed, sweaty, anxious
o visual loss, leg arm weakness, slurred speech, headache, vertigo
o de ja vu, funny taste or smell
- what do they think caused the fall?
DURING
- did they lose consciousness/do they remember everything about the event?
- did anyone else see the event? How would they describe them - pale, blue, jerking
- How long were they out of consciousness
- how did they land on the floor? Any pain or injuries?
- any:
o incontinence
o tongue biting
- anything that made it better?
o lying down with legs raised
AFTER
- Did they manage to get up themselves?
- How long after they fell were they found and by whom?
- How did they feel afterwards - tired
- how long did it take them to fully recover?
Any other symptoms
o UTI - burning when passing urine, urgency, frequency
o chest infection - SOB, cough, sputum
o mobility and walking aids
o trip hazards
o eye sight and hearing problems
o pain
What questions would you ask about in the PMH for history taking in a fall?
- previous falls in the last 12 months and fear of falling
- eye sight and hearing problems
- mobility and walking aids
- dementia
- diabetes
- epilepsy
- heart problems - MI, arrythmias, high cholesterol, high BP, anaemia, peripheral vascular disease
- stroke
- incontinence and recurrent UTIs
- muscle weakness, OA, RA, pain
- parkinson’s disease, peripheral neuropathy
- previous surgery, hospital admissions
What drugs would you ask about in the DH for history taking in a fall?
- drugs - antihypertensives, diuretics, GTN, alpha blockers, benzodiazepines (as sedative), antidepressants
- alcohol
anything that could lower BP, cause sedation, is indicative of an underlying condition (eg parkinson’s meds, dementia meds, antiepileptic, bisphosphonates, vitamin D, antibiotics), anything that could reduce blood sugar levels (diabetes meds), anything that could increase fracture risk (steroids) or could cause bleeding (NSAIDs), or clots (OCP)
What would you ask about in the FH for history taking in a fall?
- stroke
- heart problems - MI, high cholesterol
- diabetes
- parent fractured hip and osteoporosis
- epilepsy
What would you ask about in the SH for history taking in a fall?
- house and trip hazards, home modifications needed
- who they live
- any carers or additional support
- nursing eg district nurses
- mobility and aids
- smoking, alcohol
- driving
What would you do in terms of clinical examination for a pt presenting with a fall?
- cardiovascular - BP, arrhythmia, auscultation for murmurs (aortic stenosis)
- neuro - full exam with GCS, stroke
- resp - chest auscultation
- GI - tenderness eg suprapubic
- examine areas of contact with the floor for injuries including head, bones, hip and pelvis
- timed up and go - observe gait
What investigations would you do for someone who has fallen?
- obs - O2 sats, HR, RR, BP, temperature
- lying and standing BP
- urinalysis (urine dip for blood if suspecting rhabdomyolysis)
- bloods
o FBC - infection, anaemia
o U+Es - dehydration, electrolytes
o LFTs
o Lactate
o Glucose
o Bone profile - calcium, vitamin D - ECG, consider cardiac monitoring and echo
- CXR
- CT head - intracranial bleed, stroke
- blood culture
- XR if suspicion of fracture
What are the factors that would make you more likely to admit a pt with a fall?
- loss of consciousness
- injury suspected
- acute and serious condition - stroke, MI, acute glaucoma, low oxygen and need supplemental oxygen
What are the factors that would make you less likely to admit a pt with a fall?
- infection that can be treated with home treatment service/rapid response team (even if the pt is delirious)
- pt has adequate support at home, family, carers and can look after the pt when nurses are not around
- frailty - consider bedded frailty unit esp if pt has night nursing needs
- pt wants to stay at home and it is feasible and safe to and pt has capacity
- due to a chronic problem (eg OA, dementia, poor footwear) that can be managed with physios, OT etc
How would you manage a geriatric pt that has fallen?
- Immediate management
o analegsia
o dress/suture wounds
o treat underlying cause
- Medication review
- physio - mobility, muscle strengthening, balance
- OT - home modification
- footwear and advice
- Toileting plans and incontinence managementWhat is fear of falling and how can it lead to more falls?
High levels of anxiety in relation to walking
Leads to less activity, muscle degeneration, reduced balance and strength, social isolation, less confidence, cautious gait and more likely to fall
What factors may precipitate or predispose to fear of falling?
- previous fall
- premorbid anxiety
How does the gait of an older person change when they fear falling?
shorter stride
flat-footed gait
less head movement - less likely to see what is going on around you
What questionnaire can you use to ask about fear of falling?
Falls Efficacy Scale-International
asks the pt to rate how confident they are in different scenarios eg:
- getting dressed
- having a shower
- getting out of a chair
- going to the shop
- walking on an uneven surface
How do you manage fear of falling?
- CBT and graded exposure
- activity diary - so that they can log how much they are doing and what they have achieved to look back on
- physio - increase muscle strength and balance
- regular physical activity
- treat other aspects of the CGA:
o Foot health
o Home environment
o Footwear
o Vision
What are the red flags for head injury?
LOC
Amnesia
Vomiting
new focal neurology
Who needs an urgent CT head - within 1 hr?
- GCS <13 initially or <15 after 2 hrs
- suspect skull fracture
- sign of basal skull fracture
- focal neurological deficit
- more than one episode of vomiting
Who needs a rapid CT head (within 8 hours)?
- amnesia for events more than 30 mins before impact
- loss of consciousness or any amneisa and >65 or bleeding disorder
- taking anticoagulants
