Assessment of falls Flashcards
Why is it important to assess falls?
Falls are a major threat to older adults’ quality of life, often causing a decline in self-care ability and participation in physical and social activities. Fear of falling can lead to further limiting of activity, independent of injury.
Comorbidity is a serious problem both in terms of contributing to the cause of the fall and to the outcome.
Which age group has the highest risk of falling?
People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year.
What are the risk factors for falls?
Age >80. Female gender (this may be a true gender difference or a result of women being more likely to seek medical care and advice after a fall). Low weight. History of fall in the previous year. Dependency in activities of daily living. Orthostatic hypotension Medication - the leading culprits are psychotropics (especially benzodiazepines, antidepressants, antipsychotics), blood pressure-lowering drugs and anticonvulsants. Polypharmacy Alcohol misuse. Diabetes mellitus. Confusion and cognitive impairment. Disturbed vision. Disturbed balance or coordination. Gait disorders. Urinary incontinence. Inappropriate footwear. Environmental factors including home hazards. Muscle weakness. Depression.
What are the risk factors of injury after a fall?
Weak bones
- Osteoporosis
- Osteomalacia
- Paget’s disease of bone
- Metastases (to bone)
Predisposition to falls
- Dementia is a particular risk factor for falls.
- In those with dementia, impaired visuospatial ability is often associated with increased risk of falling.
Poor self-protection
This is common in the elderly. Examples include:
-Lack of protective subcutaneous fat.
-Neurological problems (preventing reflex breaking or cushioning of the fall).
-Falls associated with loss of consciousness (for example, syncope).
-Motor and sensory problems.
-Multiple contributory factors (for example, slow and stiff joints, drugs and environmental factors are a common combination of factors).
What are drop attacks?
Falls are called drop attacks when the cause is unknown, the event unexpected and there is no loss of consciousness.
What are the common causes of drop attacks?
Cardiovascular disease (as for those causes associated with loss of consciousness but in a less severe form).
Carotid sinus hypersensitivity (tends to cause drop attacks rather than syncope).
TIAs (there may be weakness or confusion for a few seconds or several minutes with no residual neurological signs).
Orthostatic hypotension (a fall of at least 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure on moving from a supine to an upright position)
What are the common causes of orthostatic hypotension?
Dehydration.
Treatment of hypertension.
Autonomic neuropathy.
Reduced adaptability of the ageing circulation.
What should you ask a px presenting with a fall?
Was the fall an isolated event or one of many? If many, is there any pattern?
How often do they occur? Are they becoming more frequent? Does there seem to be any common precipitating factor? Was alcohol involved?
What caused the fall?
What was the patient doing at the time? Was it something involving exertion? Did it involve looking up?
Was there any loss of consciousness?
Was there any warning before the fall? Was there any loss of balance? If terms like ‘giddy’, ‘dizzy’ or ‘faint’ are used, explore what is meant.
How was the patient after the fall?
PMH and current medication.
Is appetite good and weight steady? A negative reply may point to more serious underlying disease. How is mobility? Is locomotion becoming slow and laboured?
What is the normal functional status of the patient? Do they require assistance dressing, washing, cooking, for example?Are mental faculties still sound or is there evidence of cognitive decline?
What are the examinations done to assess the cause of a fall?
Mental state exam
Visual impairment
Cardiovascular examination
Neurological and locomotor examination
What are the pragmatic tests recommended by NICE to assess the risk of falls?
Timed Up and Go Test: request that the patient rise from a chair without the support of their arms, walk three metres, turn round and sit down again. A walking aid can be used if required. Completion of the test without unsteadiness or difficulty suggests a low risk of falling.
Turn 180° Test: request that the patient stand up and step around until they are facing the opposite direction. If more than four steps are required to do this, further assessment is indicated.
How can falls be prevented?
Measures such as the installation of handles and rails can reduce the risk of falls.
Patients should be encouraged to keep active and to exercise as much as possible. This strengthens muscles and maintains joint position sense and balance.
There may be neurological disease causing motor and sensory impairment and increased risk of falls. Where possible, the underlying disease should be treated. For example:
-Even minor strokes can cause significant weakness.
-Parkinson’s disease impairs mobility (abnormal posture, freezing of gait, frontal impairment, poor leaning balance and leg weakness are independent risk factors).
-Neuropathy may occur with, for example, diabetes.
Treatment of alcoholism
What is done to reduce the risk of falls in hospitals?
NICE recommends that the following patients should be considered at risk of falls (prior use of risk assessment tool not necessary):
- All patients over the age of 65.
- All patients aged 50-64 judged by a clinician to be at risk of falls by virtue of their condition.
A multifactorial assessment should be performed which should include:
- Cognitive impairment.
- Continence problems.
- History of falls, including causes and consequences (such as injury and fear of falling).
- Footwear that is unsuitable or missing.
- Health problems that may increase their risk of falling.
- Medication.
- Postural instability, mobility problems and/or balance problems.
- Syncope syndrome.
- Visual impairment.
Multifactorial interventions should be offered which should:
- Promptly address the patient’s identified individual risk factors for falling in hospital.
- Take account of whether the risk factors can be treated, improved or managed during the patient’s expected stay.
What is involved in the secondary prevention of falls?
Strength and balance training.
Home hazard intervention and follow-up.
Medication review.
Cardiac pacing where indicated.
What are the investigations done to assess falls?
Basic blood tests including:
- FBC (macrocytosis may indicate alcohol misuse).
- U&Es.
- LFTs - abnormal LFTs may indicate alcohol misuse, especially gamma GT.
- TFTs.
- Vitamin B12.
- Random blood glucose.
Urinalysis may reveal unsuspected diabetes to account for vascular disease, neuropathy and poor vision.
ECG to confirm or suggest:
- Atrial fibrillation.
- Conduction defects where there is a prolonged PR interval, inferior ischaemia or bundle branch block.
Ambulatory ECG may be required to discover episodes of bradycardia with possible heart block or even tachyarrhythmia.
Echocardiography is indicated in heart failure, atrial fibrillation and valvular disease, to assess ventricular or valvular function or to detect atrial thrombus.
Visual assessment by an optician.
Syncope or TIAs require additional investigations including neuro-imaging.
