06. Falls

Geriatric patients who suffer ground level falls suffer four times greater mortality than non-elderly patients.

Risk Factors

1. Age

  • All patients aged 65 years or older
  • Patients aged 50-64 years who are judged by clinician to be at higher risk due to underlying conditions.

2. Environment: lighting, footwear, flooring, furniture, and fittings such as hand holds

3. Cognitive impairment

4. Continence problems

5. History of falls

6. Health problems that may predispose to falls

7. Medications: new dose or new medication (especially antihypertensives, alpha-blockers, sedatives), antidepressants, benzodiazepines, antipsychotics, opioids

8. Postural instability, mobility, and/or balance problems

9. Syncope syndrome

10. Visual impairment

Fall risk assessments

  • Timed Up and Go test (TUG): rise from hard-backed chair, walk 10 feet, turn, return to chair, and sit. Greater than 12 seconds is abnormal
  • One foot balance: <30 seconds is abnormal

Evaluation

Differentiate mechanical fall vs. transient loss of consciousness. Pursue syncope/seizure workup if unclear history.

For mechanical falls (no transient loss of consciousness prior to the fall):

1. History

a. Prior falls, baseline mobility, activity during the fall, prodrome, home context, environmental factors, footwear, risk factors for violence/assault, medications (new and old), identification of chronic diseases (dementia, stroke, mobility impairment, arthritis, diabetes).

b. Do not neglect alcohol use and illicit drug history in older patients.

c. Obtain collateral from family or caregivers.

2. Exam

a. Check orthostatic vitals, head trauma, cranial nerves, nystagmus, palpation along entire spine/shoulder/abdomen/hip, cardiac auscultation and peripheral pulses, orientation, neurologic exam (focal findings are strongest predictor for need of neurosurgical intervention), proprioception, cerebellar testing, foot exam, gait examination.

3. Imaging

a. CT head: obtain in adults > 65 who have fallen with headstrike (particularly if loss of consciousness after the fall), any focal neurologic deficits, abnormal GCS, or evidence of head injury.

b. X-ray for joints with tenderness or swelling.

4. Labs

a. CBC, platelets, PT/PTT if concern for bleed.

b. BMP (Na, BUN, Cr) particularly if dizziness.

c. 25-OH Vit D for future risk factor reduction.

d. Consider nutritional deficiencies (e.g., B12/subacute combined generation, thiamine/Wernicke’s in the right clinical picture).

If a patient falls while in the hospital, always assess at bedside. Speak to patient, nurse, and any other witnesses. Document the fall (i.e. an Event Note) and follow any institutional algorithm.

Multifactorial Interventions

The goal is to reduce risk factors for falls.

1. Address inpatient environment factors

  • Fall precautions
  • Minimize restraints and tethers (both formal and informal such as IVs, nasal cannula, SCDs, pulse ox, telemetry)
  • Lower beds and keep wheels locked
  • Bed rails should not be used as a restraint, consider lowering at least one rail
  • Keep items and mobility aids within reach and monitor patient frequently – bed alarms, family, staff including bedside sitter – and remind patient of fall risk

2. Delirium precautions

3. Continence issues: consider ordering scheduled toileting or having bedpan/urinal within reach

4. Footwear: no-slip socks and/or shoes with good grip

5. Review risk / benefit of all medications

6. Order PT/OT assessment for postural instability, mobility, and/or balance problems

  • Strength and balance training
  • Exercise for patients in extended care setting

7. Syncope syndrome: cardiac pacing for those with carotid sinus hypersensitivity / heart block

8. Vision assessment and referral

9. Engage the whole healthcare delivery team and the family; review the case with nursing and PT, and institute a post-fall plan

Transitions of Care

  • PT and OT to evaluate for assistive devices, home therapy needs, and home safety evaluation
  • Update the primary care provider to follow up:
    • Home safety evaluation
    • Outpatient or home PT/OT
    • Strength and balance training
    • Vitamin D replacement
    • Medication changes
  • Engage the patient and caregivers to create a multifactorial approach to prevent falls

Spaniolas K, Cheng JD, Gestring ML, Sangosanva A, Stassen NA, Bankey PE. Ground level falls are associated with significant mortality in elderly patients. J Trauma. 2010; 69(4): 821-5.

University of Chicago – Care of the Hospitalized Aging Medical Patient  (CHAMP)

http://champ.bsd.uchicago.edu/falls/index.html

American Geriatrics Society/ British Geriatrics Society Clinical Practice Guideline 2010: prevention of falls in older persons.

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010

Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012, Issue 12.

National Institute for Health and Care Excellence (NICE). Guidelines on Fall: assessment and prevention of falls in older people. June 2013.

Bischoff HA, Stähelin HB, Monsch AU et al. Identifying a cut‐off point for normal mobility: a comparison of the timed ‘up and go’ test in community‐dwelling and institutionalised elderly women. Age Ageing 2003 32 (3): 315-320.

Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol 1991; 46:M164.

Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003; 348:42.