Falls

Thomas Cain, M.D.

Falls are a common and often devastating problem in the elderly. Many result in E.D. visits or hospital admissions. Morbidity associated with falling encompasses not only physical injury but also psychological trauma, with up to 1/3 of elderly fallers limiting their involvement in physical and social activities due to the fear of falling.

Epidemiology

• 1/3 of community dwelling elderly 75 y/o or older fall per year.
• 10% of falls result in major injuries (fractures, dislocations, or lacerations with sutures).
• 5% of falls result in fractures.
• Hip fractures decrease life expectancy 10-15%.

Etiology

Falls are most often multifactorial, due to the cumulative effects of impaired postural stability, chronic medical conditions, and environmental factors, not cardiac arrhythmias or seizures which account for < 2%.
Postural stability is the result of sensory input, the accurate processing of the information, and the correct response of the effector systems.

• Sensory = visual, auditory, vestibular, proprioception
• Processing = CNS, cognitive function, Parkinson's
• Effector = musculoskeletal, joints, foot disorders, peripheral nervous system

Evaluation

A complete history and physical exam is the basic "work-up." The judicious use of tests may assist confirmation of the mechanisms of the fall. Identification of causes which are modifiable is the primary goal.

History

Focus on:

• Events surrounding the fall

  a. Activity of faller, where, when

  b. Prodromal sx (lightheadedness, imbalance, dizziness)

  c. Previous falls/circumstances

• Loss of consciousness (orthostatic, cardiac, neurological)
• Contributing environmental factors
• Medications are contributory in > 40% of cases, especially:

  a. Vasodilators, diuretics, sedative-hypnotics

  b. Polypharmacy, drug-drug interactions

  c. Over-the-counter (OTC)

• ETOH use, substance abuse

Physical Exam

Should be thorough, and incorporate examination of all organ systems. The history will direct further investigation of certain areas. In addition all fallers should be carefully checked for the following.

• Vital signs especially orthostatic changes in BP/pulse
• Signs of trauma
• Visual acuity: examine glasses
• Hearing: whisper test or bedside audiometry-VIII nerve deficit may be associated with vestibular dysfunction
• ROM of neck: R/O vertigo, nystagmus, vestibular sx
• Complete neurological exam:

  a. Sensory/proprioception esp. in lower extremities

  b. Strength esp. in lower extremities

  c. Cerebellar function

  d. Cognitive function = mini-mental status exam

• Gait evaluation: Tinetti "Get up and go test" (Arise from chair, without use of arms, walk 20 feet, turn, and return)
• Foot exam: deformities-bunions, calluses, amputations
• Footwear exam: damaged shoes, unsafe soles, improper fit
• Assistive device evaluation: proper indications, fit, and use

Laboratory Examination

There are no standard tests for assessment of the falling patient. The history and physical dictates the extent of testing. Traumatic injuries should be followed up with radiographic examination. Clinical logic directs evaluation of dehydration, possible infectious processes, or blood loss. The use of routine holter monitors rarely adds information, as falls secondary to arrhythmias are very infrequent. Brain imaging studies and EEG's are reserved for patients with high suspicion of intracranial lesion or seizure disorder.

Treatment

The accurate assessment of the elderly faller will in most cases generate a working hypothesis of the etiologic factor precipitating the falls. Treatment will focus on eliminating or reducing the impact of those factors. Commonly these elements will be:

• Environmental--Risky behavior or unsafe environment
  Rx: Education/counseling regarding risks
  Home safety evaluation
• Medical illness--Acute and/or chronic
  Rx: Treat acute illness
  Maximize medical/supportive therapies
  Evaluate and stop medications/polypharmacy
• Postural instability--Sensory CNS and/or M/S deficits
  Rx: Physical therapy and education
  Improve muscle strength, balance, gait training
  Assistive devices for ambulation
  Ophthalmologic exam, corrective lenses
  Treat Parkinsonism
  Proper footwear

Indications for consultation to Geriatrics or Rehabilitation

Assessment of etiologies of falls
Strengthening and gait training