An approach to FALLS

Falls. Frequent in the elderly population, multifactorial, and sometimes fatal.

What is a fall? According to the World Health Organization, a fall is defined as an event, which results in a person coming to rest inadvertently on the ground or floor or other lower level.

We often hear the expression of mechanical fall. Nobody should use that line because we might think that the fall is not medically related when in fact it is, the opposite is also true. Let’s just use the word “fall”, period.

Here is an approach to fall that I learned in the last few weeks.

There are 3 things we should consider with falls. In emergency medicine, we are good with 2 of them (not bad!). There is a third one that needs a comprehensive geriatric assessment, and is the reason why a fall clinic is so relevant for “frequent fallers”.

Predisposing factors <–> Precipitating factors

They both lead to a FALL –> Complications of falls

Complications of falls are easy to address: Is there a fracture? Laceration? Sprain? Head injury? Home return problems?

Precipitating factors are easy to addressed in the ED by taking vitals sign, orthostatic vitals, review of the medical reason that may have cause the fall (infection, ACS, stroke, etc) and a careful brown bag biopsy.

What are the medications that may lead to falls? Here is a list that needs our special attention.

  • Anti-hypertensive
  • Diuretics
  • Beta blockers
  • Anti-arythmic
  • Benzos
  • Any antidepressant
  • Neuroleptic
  • Anti-cholinergic (incontinence rx, anti histaminic, the sleeping pill over the counter, TCA, olanzapine, paroxetine)
  • Opioids

For more information about poly-medication, there is a previous post on the subject.

Then, predisposing factors. An approach to it is a head-to-toe evaluation. You might now think that it might be getting far too complicated for an emergency visit? Let’s take a closer look.

HEAD

  • Think brain (stroke, tumor, chronic subdural hematoma, Parkingson disease, etc.)
  • Think cognition (dementia)
  • Slower reaction normal with aging
  • Vision
  • Hearing
  • Mouth (medication)

CARDIO-RESPIRATORY SYSTEM

  • Orthostatism
  • CHF
  • Angina
  • COPD / Shortness of breath

GASTRO-INTESTINAL

  • Lost of appetite, lost of weight, etc.

SPINE

  • Myelopathy
  • Spinal stenosis
  • Back pain
  • Osteoporotic fracture

SOFT TISSUE

  • Sarcopenia
  • Osteoarthritis
  • Neuropathy (Diabetes, Vit B12 deficit)

FOOT

  • Deformity
  • Footwear (It is amazing how much information you can get by looking at their shoes, do the exercice, you will see!)

ENVIRONMENT

  • Where the person lives, how many stairs, crowded apartment? Multiple pets and carpets?
  • Home safety evaluation (Occupational therapist home evaluation, safety bracelet)

It is comprehensive but a lot of these predisposing factors could be briefly evaluated in the ED just by doing a thorough neurological exam, head to toe exam, look at their shoes and watch them walk. Then you ask the GEM nurse to review the physical/social environment. There you go, you have very good evaluation done in the ED.

Remember, falls are almost always multifactorial in elderly. If the first fall did not lead to any complication, the second might, and we can prevent it by having a focussed geriatric approach and an interdisciplinary team in the ED. Not that complicated after all!

 

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