13. Falls

Etiology and Risk Factors

Usually the cause of falls is multifactorial in elders. See Geriatrics section for further information on prevention of falls. Key causes of falls:

  • Neurologic: seizures, CVA/TIA (bleed, embolus, ischemia), gait disorder, Parkinson’s, vertigo, dementia, normal pressure hydrocephalus, poor proprioception.
  • Cardiac: arrhythmia, MI, vasovagal, hypovolemia, orthostatic hypotension, valvular disease.
  • Meds: sedative/hypnotics, antidepressants, vasodilators, alcohol, diuretics (requiring frequent trips to bathroom).
  • Musculoskeletal: arthritis, pain, deconditioning, weakness.
  • Other: anemia, poor eyesight, dim lighting, room change, bed rails left down, wet floor.

Evaluation

  • Assess the patient for any injury; always go see the patient and ask for a full set of vital signs +/- fingerstick glucose when called about a fall.
    • Any focal signs on exam must be worked up in the appropriate manner (e.g., head CT, plain films, immobilization, etc.). In particular, look for:
    • Ecchymoses, abrasions, fractures, pain, asymmetry, deformity, decreased range of motion.
    • Look at head, hands, shoulders, hips, knees, and feet.
    • Do a complete neurologic exam including gait, strength, and cerebellar tests.
    • Mental status testing may be necessary if the patient is confused or altered.
  • Try to find out the circumstances of the fall.
    • Witnessed? By whom?
    • Loss of consciousness (does the patient remember hitting the ground?).
    • Was this a syncopal episode, a mechanical fall, or related to altered mental status?
    • Mechanism (getting out of bed, going to the bathroom, standing up, turning around, etc.).
    • Associated symptoms (premonitory aura, incontinence, dizziness, headache, visual symptoms, palpitations, chest pain, dyspnea).
    • Preceding actions (coughing, urinating, straining, standing suddenly).
    • Past medical history (diabetes, heart disease, CVA, sensory deficits, Parkinsonism, arthritis, depression, new medications, prior falls).
    • Check chart for recent platelets, PT/PTT, and any anticoagulants/antiplatelets to determine the risk for bleed.

Management

  • Have a low threshold for head CT if the patient hit their head during the fall, especially if the patient is altered or the fall was unwitnessed.  If the patient has a focal neurologic deficit that is new, you must get a stat head CT.  If the patient lost consciousness or doesn’t remember falling, strongly consider a head CT.
  • Extrapolating from the emergency medicine literature (based on the New Orleans Criteria), any patient with loss of consciousness (or unwitnessed/unclear history) and any ONE of the following characteristics should get a head CT:
    • headache, vomiting
    • age > 60
    • intoxication
    • short-term memory deficits
    • physical evidence of trauma above the clavicles
    • seizure
  • Serial neurologic exams after the fall are a must to rule out progressive neurologic deficits from head injury (i.e., subdural hematoma).
  • Write an event note detailing the circumstances of the fall, your evaluation and plan (including what will need to be followed up on by the primary team).

Key points

  • Although witnesses' (including nurses' and family member) accounts of the fall can be helpful, remember to evaluate the patient as objectively as possible.
  • Always go see a patient promptly when you are called about a fall.
  • Perform serial neurological exams and document stability.
  • Always write an event note detailing circumstances of fall, initial evaluation and pending tests at time of note (e.g., head CT).

Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100-105.

Smits M, Dippel DW, de Haan GG et al. External Validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in Patients with Minor Head Injury, JAMA 2005;294 : 1519-1525.