Falls

Epidemiology

• Falls occur in >30% of age over 65 years in community
• Serious injury occurs in >20% of falls in older adults
• Most falls occur in and around the patient’s home
• complications – 5-10% falls result in major injuries (e.g. #, head trauma, lacerations); rates of fall-related major injury for nursing home residents higher (10-30%); only 50% of elderly individuals who fall are able to rise without help

Causes

• D – drugs and alcohol
• A – age-related (e.g. vision, balance, gait, cognitive)
• M – medical problems
  • acute – e.g. infection, dehydration, arrhythmia
  • chronic – e.g. Parkinson’s, past stroke, osteoarthritis, diabetes, peripheral neuropathy, cognitive impairment
• E – extrinsic 

Differentials for Falls

1. Mechanical Falls (Extrinsic Factors):

• Environmental Hazards:
  • Uneven surfaces, slippery floors, loose rugs, poor lighting, and clutter.
  • Improper use or lack of assistive devices (e.g., cane, walker).
• Footwear Issues:
  • Ill-fitting shoes or inappropriate footwear, such as high heels or slippers.
• Gait Instability:
  • Decreased balance or improper foot placement during walking.
• Muscle Weakness:
  • Particularly in the lower extremities, reducing stability during movement.
• Reduced Range of Motion (ROM):
  • Joint stiffness, often related to conditions like arthritis.

2. Non-Mechanical Falls (Intrinsic or Medical Causes):

Neurological Causes:

• Stroke/Transient Ischemic Attack (TIA): Sudden onset of weakness, confusion, or visual disturbances.
• Seizures: Unexpected falls associated with loss of consciousness or convulsions.
• Parkinson’s Disease: Gait disturbances, shuffling, and postural instability.
• Peripheral Neuropathy: Sensory deficits leading to instability.
• Dementia: Cognitive impairment affecting judgment, gait, and balance.

Cardiovascular Causes:

• Syncope: Brief loss of consciousness due to decreased cerebral perfusion (e.g., vasovagal syncope, arrhythmias).
• Postural (Orthostatic) Hypotension: A sudden drop in blood pressure upon standing, causing dizziness and falls.
• Arrhythmias: Irregular heartbeats leading to transient loss of consciousness.
• Aortic Stenosis: Reduced blood flow leading to syncope, dizziness, or falls.

Metabolic Causes:

• Hypoglycemia: Low blood sugar causing dizziness, confusion, or fainting.
• Dehydration: Volume depletion contributing to dizziness or postural hypotension.
• Electrolyte Imbalances: Disturbances such as hyponatremia, which can impair balance and cause falls.

Vestibular Causes:

• Benign Paroxysmal Positional Vertigo (BPPV): Positional vertigo causing loss of balance.
• Meniere’s Disease: Recurrent episodes of vertigo, tinnitus, and hearing loss.

Musculoskeletal Causes:

• Arthritis: Joint pain and stiffness reducing mobility.
• Fractures/Osteoporosis: Pre-existing fractures or high risk of fractures from falls.

Medications:

• Polypharmacy: Taking more than four medications significantly increases fall risk.
• High-Risk Medications:
  • Antihypertensives (e.g., postural hypotension)
  • Psychotropic drugs (e.g., benzodiazepines, antipsychotics)
  • Diuretics (e.g., dehydration, electrolyte imbalances)

Psychiatric Causes:

• Depression: May lead to psychomotor slowing, decreased motivation, and poor coordination.
• Anxiety Disorders: Fear of falling or dizziness related to panic attacks.

Risk Factors for Falls:

1. Environmental Hazards: The most common cause, such as loose rugs, poor lighting, and uneven floors.
2. Altered Gait or Balance: Impaired mobility or difficulty in maintaining balance increases fall risk.
3. Lower Extremity Muscle Weakness: Weakness in the legs can reduce stability and lead to falls.
4. Dizziness or Vertigo: These symptoms can cause instability and unsteadiness, contributing to falls.
5. Syncope: Sudden loss of consciousness or fainting episodes.
6. Postural Hypotension: A drop in blood pressure when standing, leading to light-headedness or fainting.
7. Decreased Visual Acuity: Poor vision can lead to misjudgment of surroundings and hazards.
8. Arthritis: Joint pain and stiffness reduce mobility and increase the likelihood of falls.
9. Dementia or Altered Level of Consciousness: Cognitive impairment may lead to disorientation and falls.
10. Major Depression: Depression can lead to decreased activity levels, slower reflexes, and poor coordination.
11. Medication Use: Taking more than four medications significantly increases fall risk, particularly:
    • Class IA Antiarrhythmics
    • Digoxin
    • Diuretics
    • Anticonvulsants
    • Psychotropic Medications, including:
      • Benzodiazepines
      • Antipsychotics

Screening and Evaluation for Fall Risk: Get Up and Go Test

Test Procedure:

1. Starting Position: The patient sits in a straight-back chair.
2. Rising: The patient stands up (preferably without using armrests).
3. Walking: The patient walks 3 meters (using any assistive device they normally use).
4. Turning: The patient turns around.
5. Return Walk: The patient walks back to the chair.
6. Sitting: The patient sits down again.

• Trial Run: The patient is allowed one trial run before being timed.

Timing Interpretation:

• <10 seconds: No risk of falling.
• 10–19 seconds: Minimal risk of falling.
• 20–29 seconds: Moderate fall risk. Referral to physical therapy is advised for scores of 20 seconds or more.
• >30 seconds: Definite risk for falling.

Factors to Observe:

• Sitting Balance: Assess the patient’s stability while seated.
• Transfers: Evaluate the ability to move from sitting to standing smoothly.
• Walking Pace and Stability: Observe gait speed and steadiness.
• Turning: Ensure the patient can turn without staggering or losing balance.

This test helps identify patients at higher risk for falls, especially when combined with clinical judgment regarding their mobility and balance.

Functional Reach Test:

1. Positioning: The patient stands with one shoulder close to the wall.
2. Movement: They extend their fist forward, parallel to the wall, and lean forward without stepping or losing balance.
3. Measurement: The patient extends their fist as far forward as possible while maintaining stability.
   • Normal Result: The patient should be able to move their fist forward by at least 15 cm.
   • <15 cm: Indicates a significant risk of falls.

Additional Assessments:

1. Vital Signs:
   • Blood Pressure (BP):
     • Measure BP while lying down and then after standing for 1 minute and 3 minutes.
     • Postural Hypotension: Defined as a drop of >20 mmHg in systolic BP or >10 mmHg in diastolic BP, or the presence of symptoms.
   • Pulse: Monitor for at least 1 minute.
2. Cardiovascular Examination:
   • Assess for:
     • Postural Hypotension
     • Arrhythmias
     • Carotid Bruits
3. Neurologic Examination:
   • Cognitive Testing: Briefly assess orientation, ability to follow complex commands, 3-item recall, and clock drawing.
   • Vestibular Function: Have the patient march in place with eyes closed.
   • Lower Extremity Assessment:
     • Check muscle tone, reflexes, coordination, and sensation, including proprioception.
4. Coordination and Balance:
   • Assess proprioception and vibration sense.
   • Test range of motion (ROM), as restrictions may impair reflexes and precision.
   • Gait Assessment: Evaluate for abnormalities.
5. Miscellaneous Examination:
   • Vision: Test visual acuity and fields; assess for cataracts and macular degeneration.
   • Hearing: Perform a bedside whisper test.
   • Joint Examination:
     • Inspect the feet for deformities such as bunions, calluses, or arthritis.

Diagnostics in Cases of Fall History:

1. Less Useful Investigations (unless clinically indicated):
   • Full Blood Count (FBC): To check for anemia, but typically not a primary concern unless symptoms suggestive of blood loss or chronic disease.
   • Electrolytes, Urea, and Creatinine (EUC): To assess for dehydration or electrolyte imbalances; useful if the patient has signs of dehydration or metabolic disturbances.
   • Blood Glucose Levels (BGL): To screen for diabetes or hypoglycemia, especially if there’s concern about blood sugar fluctuations contributing to falls.
   • Chest X-ray (CXR) and Electrocardiogram (ECG): Generally performed to exclude underlying cardiac pathology but may not be routinely necessary unless signs of cardiac issues are present.
2. Further Investigations Based on Clinical Presentation:
   • X-ray: If there is a suspicion of a fracture (e.g., after a traumatic fall or presenting with pain, swelling, or deformity).
   • CT Head: Indicated if there are signs of neurological involvement, head trauma, or unexplained cognitive or motor deficits post-fall.
   • Holter Monitor: Useful if there is suspicion of arrhythmias, especially in patients with an unclear cause of falls or transient loss of consciousness.
   • Echocardiography: Indicated if a heart murmur or other signs of structural heart disease are noted during the physical examination or if there’s suspicion of a cardiac etiology for the fall.

Management of Falls

A comprehensive approach is necessary to manage and prevent falls, combining environmental modification, medication review, physical training, and psychological support.

1. General Measures:

• Home Assessment:
  • Remove Hazards: Eliminate loose rugs, cords, clutter, uneven floors, and difficult locks.
  • Redesign: Install handrails, ramps, non-slip mats, and improve lighting.
  • Assistive Devices: Provide walking aids like canes, wheeled walkers, wheelchairs, or a commode if needed.
  • Counseling: Educate on appropriate footwear, adequate lighting, and avoiding high-risk activities.
• Avoid Bedrails and Physical Restraints: These increase fall risk in long-term care and should be avoided.
• Medication Review:
  • Adjust Medications: Withdraw, substitute, or reduce medications associated with increased fall risk, such as:
    • Benzodiazepines
    • Neuroleptics
    • Antihypertensives
    • Nitrates

2. Nutritional Support:

• Vitamin D Supplementation:
  • Low vitamin D levels are associated with muscle weakness and increased fall risk.
  • Recommended: 800 IU of Vitamin D + 1200 mg of elemental calcium daily to support muscle strength and bone health.

3. Specific Interventions Based on Risk Factors:

• Resistance Training: Use ankle weights or other methods to strengthen lower limb muscles to counteract weakness.
• Balance Training: Activities such as supervised backward walking help improve postural stability.
• Vision: Refer patients with poor vision to an ophthalmologist for further evaluation and correction.
• Postural Hypotension Management:
  • Behavioral Changes: Instruct patients to rise slowly, cross their legs, perform ankle pumps or hand clenching, and stay hydrated.
  • Physical Interventions: Elevate the head of the bed, use compression stockings, increase salt intake.
  • Medication Adjustments: Avoid medications like sympathetic blockers and antidepressants that may worsen postural hypotension.
• Pain and Chronic Disease Management:
  • Pain: Optimize pain management for conditions like osteoarthritis.
  • Chronic Diseases: Ensure effective management of diseases like Parkinson’s disease to reduce fall risk.

4. Fall Complication Prevention:

• Hip Protectors:
  • Wearing hip protectors significantly reduces the incidence of hip fractures:
    • With pads: 0.39 hip fractures per 100 falls.
    • Without pads: 2.43 hip fractures per 100 falls.
  • May also reduce pelvic fracture risk.
• Osteoporosis Management: Ensure appropriate medications to improve bone density.
• Pendant Alarm: Equip patients with a pendant alarm to call for help after a fall.
• Techniques for Rising After a Fall: Teach patients safe methods to get up after a fall.

5. Psychological Considerations:

• Post-Fall Anxiety Syndrome:
  • Fear of falling can lead to reduced mobility, loss of confidence, and depression.
  • Efforts should be made to address and support mental health in patients with recurrent falls.
• Anticoagulation in the Elderly:
  • Recurrent falls are not a contraindication for anticoagulant use in elderly patients with atrial fibrillation (AF).
  • The risk of subdural hematoma is so low that, on average, a person would need to fall 300 times per year for the risk to outweigh the benefits of anticoagulation therapy.