Author: V. Dimov, M.D.
Reviewer: R. Christie, M.D.
An 80-year-old Caucasian female, a nursing home (NH) resident had a fall 2 days ago. Nurses observed the fall - the patient rose from a sitting position, tried to walk with legs crossed and toppled over sideways. No injury was noted, vital signs (VS) were recorded: heart rate (HR) 60 bpm, blood pressure (BP) 155/83 mm Hg.
The patient did not remember falling at all. She also fell 2 months ago and had a laceration of her right eyebrow which is healed by now.
Problem list from chart:
Dementia (MMSE 18/30), bipolar disorder, hypertension (HTN), left hip fracture S/P ORIF 4 yrs ago, lower back pain (LBP), Osteoporosis.
Abilify, Actonel, Aricept, buspirone, lisinopril, multivitamin (MVT), Neurontin (gabapentin).
What would you suggest in such situation?
First, examine the patient.
You have to check for orthostatic vital signs (which were normal in this case).
She is a little but vigorously active lady who performs the "get-up-and-go" test with ease. There are no visible signs of trauma and the physical exam is normal.
The reason for the fall most likely was lack of coordination due to her dementia. Cardiovascular or neurological causes are less likely. Her fall risk score is 12 (>10 means increased risk)
PT evaluation and treatment was ordered. Nursing staff will continue to follow.
A 91-year-old African American female (AAF), a nursing home (NH) resident fell yesterday. The patient is not able to provide the history since she does not recall falling at all.
What is your best bet to gather the requires information?
Nurses - check the notes and ask them. Nurses reported that when patient was transferring from her wheelchair, she just slid down on the floor w/o hitting herself or LOC.
Alzheimer's (MMSE 3/30), severe DJD, CAD, Anemia, PACs, chronic kidney disease (CKD).
Actonel, Aricept, FeSO4, MVT, Prilosec, Oyster shell, Tylenol q 6 hr, Tramadol.
What would you suggest in terms of clinical evaluation?
First, examine the patient. She is a happy-looking elderly lady w/o visible injury - you have to document in your progress note that no injury was found.
The cardiovascular examination showed an irregular rhythm and the EKG reveals just what you expected - her well-known PACs.
The musculoskeletal exam showed severe osteoarthritis (OA) with decreased mobility in knee and wrist joints. No signs of acute inflammation.
Neurological examination was normal, other than the abnormal mental status previously present, and due to her dementia.
What is the most likely reason for the fall?
Deconditioning and decreased mobility due to osteoarthritis (OA). Dementia.
What would you suggest at this stage?
PT evaluation and treatment. Try NSAIDs plus PPI for pain management in addition to Tylenol around the clock. Also, you can add Capsacain cream.
Restraints were suggested as a method to prevent falls in this patient but this idea was dismissed because the patient really enjoys the limited mobility she has, and although this is exposing her to risk of falls, the restraints would put her in more danger.
What did we learn from these cases?
Falls are common in the elderly patients, especially in NH residents.
Often the cause is deconditioning or incoordination. Dementia which leads to poor judgement about one's physical ability is also a leading caus of falls in the elderly.
PT can help to prevent future falls.
Very often, there is no need for extensive investigations (Holter, 2D Echo, CT of the head, etc.), if the cause is obvious, like in the patients with OA above.
Thirty percent of community-dwelling elderly people and 60 percent of NH residents fall each year. A fall can be detrimental to a person's health, for example, more than 90 percent of hip fractures occur as a result of falls.
Causes of Falls According to Frequency:
Gait or balance problems, weakness, pain due to DJD
Medications, especially more than 4, e.g. long-acting BDZ, TCA, BP meds
Acute illness, e.g. UTI
Confusion and cognitive changes, e.g. delirium or dementia
Visual problems, CNS or CVS cause, e.g. syncope, epilepsy
Assess the risk of falls by performing "up & go"test or the simpler "get up & go" test. Ask yourself "How safe does this movement appear for the patient?"
How to reduce the fall risk:
PT and balance training
Median survival for incident dementia of 4.5 years.
Falls in the Elderly - AFP 04/00, including a mnemonic for fall causes - I HATE FALLING.
Falls - Merck Manual of Geriatrics
Copyright vs. Open Access at the Bedside: MMSE form disappearing from textbooks, replaced by the Sweet 16 test - NEJM, 2011.
FDA Approves "Alzheimer's CT scan" by Eli Lilly - radioactive agent florbetapir tags clumps of sticky amyloid in brain. WSJ, 2012.