Falls

Over 280 000 falls occur in acute, community and mental health hospitals across England and Wales each year (1). Falls can increase the length of stay and prevent patients from returning to independent living and at worst result in severe injuries and death (1, 2).

Dr Josh Deb-Barman is a speciality doctor in Elderly Care Medicine and Stroke Medicine at the Countess of Chester Hospital. In this episode we have an in depth discussion about falls in the elderly. It is longer than normal but this represents how complex the topic can be. Listen below:

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As a junior doctor working in hospitals, you will come across falls either as part of the acute intake of patients, whilst on call or if you work on acute medical or elderly care wards. They are common occurrences with consequences that range from minor to serious and potentially life threatening. Knowing what puts people at risk of falls, what aspects of the assessment you can undertake, who else to involve in either investigating or managing a fall and how to rehabilitate the patient is vital to improve outcomes for these patients.

At Risk

Typically, we think of patients at risk of falling as the frail elderly patients. However, including the well and active cohort of patients over the age of 65, their annual risk of falling is about 30% which increases to 50% for those aged over 80 (3, 4).

In particular, the elements that put people more at risk of falling include:

Cognitive impairment
Mobility problems
Previous falls
Balance or gait disturbances
Medication
Poor eyesight or memory, especially when outside the patient’s own environment
Continence
Environmental factors

This list is short, but the research into this often provides lengthy tables with multiple factors that increase the risk of falling (6, 7). It is not a simple thing to say someone if at no risk of falling. Rather, when a person presents who either has fallen or would appear to be at risk, we need to evaluate what risk factors are present and what is modifiable.

We may not think of simply mobilising around the home as being “risky business” but certain behaviours may result in an increased risk of falls. This may be the person who walks around the home using furniture and doors for support which themselves are mobile due to hinges or wheels.

Flooring plays a part as well. The commonly thought of example are the rugs or mats that aren’t secured and the corners have turned up. Even the type of flooring has an impact with a carpeted floor reducing the incidence of both falls and hip fractures from those falls (5). Compare this to most hospitals where the flooring is a slippery laminated floor and the patient’s free slippers are exactly that with little to no support or grip underneath.

Acute Assessment

Your assessment of a fallen patient should follow a two-stage approach. Firstly, are then any life-threatening illnesses or injuries? Secondly, why has the patient fallen?

If you believe the patient to be unwell then perform an ABCDE assessment.

Remember that a fall may be an indication of a deterioration in the underlying medical condition of the patient.

Life-threatening injuries include head injuries and fractures.

Immediate Investigations

What you do immediately will be guided by the picture in front of you. A truly mechanical fall where someone has been witnessed to or gives a good history of a definite slip or trip may require no investigations. Investigations will look for either consequences of the fall or causes for the fall. They could include:

X-rays of injured areas (A non-mobile patient whom was previously mobile or who cannot move a limb has a fracture until proven otherwise. Do not forget the spine, especially the cervical spine in the elderly)
Blood glucose
Urinalysis (caution in using a dipstick test and using the label of UTI based on this as the sole contributor)
ECG
Lying/standing blood pressure (ensure the standing is taken after a delay of 2-3 minutes not just immediately)
Bloods (the exact bloods would be guided by what you think is the underlying cause and not every fall needs bloods.)
CT (consider need for either CT head or cervical spine or both based upon clinical assessment and local/national policies and guidance (8))
Medication review (perhaps not truly an investigation but should be undertaken in case of contributory medication)

Of course, in the middle of the night you will likely focus on acute problems to identify and treat. With good clear documentation, you can leave a note to highlight to the parent team elements that need looking into during working hours such as medication.

CT Head

NICE guidance about performing CT scans are designed for Emergency Departments seeing patients. However, they provide a good guide for who we should perform a CT scan with. The criteria are (8):

For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

GCS less than 13 on initial assessment in the emergency department.

GCS less than 15 at 2 hours after the injury on assessment in the emergency department.

Suspected open or depressed skull fracture.

Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).

Post-traumatic seizure.

Focal neurological deficit.

More than 1 episode of vomiting.

1.4.8 For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:

Age 65 years or older.

Any history of bleeding or clotting disorders.

Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).

More than 30 minutes’ retrograde amnesia of events immediately before the head injury.

Patients having warfarin treatment

1.4.12 For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having warfarin treatment, perform a CT head scan within 8 hours of the injury.

The challenge you may have in hospital is the unwitnessed falls where staff attend having heard a bang, or the patient who attends the ED having been found on the floor. Especially if the patient is taking warfarin, any suspicion of a head injury these days warrants a CT. This may seem excessive, but the research supports a low threshold for CT scans in this patient cohort due to the substantially increased risk (9). In a patient with GCS 15 and no neurological symptoms, the adverse event rate may be as low as 2.7%, but that is still 1 in 40 patients.

Once satisfied that you do or do not need to undertake investigation for a head injury, it is worth considering whether a fracture may be present. Fractures of the neck of femur carry a high mortality rate (10).

A patient who was previous mobile but is now unable to mobilise should prompt assessment for an occult fracture following a comprehensive musculoskeletal assessment. Similarly, a patient use is unable to move part of their body should prompt assessment in that area. Remember that 3-5% of falls result in fractures (11, 12)

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Further assessment

The first important point to make is to beware of labelling someone as having had a “mechanical fall”. Elderly patients may look to rationalise the events according to what they think might have happened.

In the acute setting, you may not have the time to go through everything related to the fall. However, you can start the process by simply highlighting likely risk factors or someone who may be at increased risk of falls.

NICE recommend (21):

Multifactorial assessment may include the following:

identification of falls history
assessment of gait, balance and mobility, and muscle weakness
assessment of osteoporosis risk
assessment of the older person’s perceived functional ability and fear relating to falling
assessment of visual impairment
assessment of cognitive impairment and neurological examination
assessment of urinary incontinence
assessment of home hazards
cardiovascular examination and medication review

Syncope

Your questioning into the exact events may elicit more than just “I think I tripped”. There may be some intrinsically medical factors involved. The person falling may not be able to tell you what they tripped on. If they can’t remember, especially if they don’t remember the event of falling or landing on the ground then it suggests that their consciousness has been impaired.

There may be associated pre-syncopal symptoms such a feeling of light-headedness or dizziness. Dizziness itself may relate to vertiginous symptoms and can be difficult to differentiate between the two. It would be more likely to happen after mobilising for a short period and there may be a history of postural symptoms on standing.

The collapse may be associated with certain activities such as defecation or urination.

A lack of these preceding symptoms and a sudden, unexpected collapse should make you consider a cardiac cause, in particular an arrhythmia as the cause. These are more likely in those with existing structural heart disease or previous MIs.

Some medications may contribute to syncopal episodes and certainly in hospital, you may find a low-normal blood pressure and concomitant anti-hypertensive therapy.

Medication

Certain medication are classically associated with the risks of falling including anti-hypertensive agents and hypnotic agents such as benzodiazepines (13). Polypharmacy, regardless of the combination, increases the risk of falls (14). A not exhaustive grouped list with some examples includes:

Benzodiazapines (diazepam, lorazepam, temazepam, nitrazepam)
Anti-depressants (amitriptyline, fluoxetine, citalopram, sertraline)
Anti-psychotics (olanzapine, haloperidol)
Anti-epileptics (phenytoin, carbamazepine)
Anti-cholinergics (oxybutynin)
Sedative agents (zopiclone)
Cardiovascular medications (any anti-hypertensives, beta-blockers, nitrates, diuretics, digoxin)

As Josh mentions, some of these medications may have been commenced in good faith when the patient was at a better level of health. However, now the patient is older and at a reduced functional level may not have the same need for the stricter therapeutic targets. If you are in doubt as to what is appropriate then it is worth discussing the therapeutic aims of treatments with your seniors.

Continence

Nocturia has been found to have an odds ratio of 1.95 for falls, increasing the risk potentially two-fold (6) and urinary symptoms may be implicated in a significant number of falls (15).

Patients will do whatever they can to avoid becoming incontinent. This may lead patients to engaging is riskier behaviour when mobilising to the toilet. This has issues both at home and in hospital.

At home, bathrooms are conveniently designed to include lots of solid objects close to one another at a height likely to be collided with when falling. In hospital, a patient who gets up to visit the toilet may already be catheterised and trip over the catheter tubing or be tethered to the bed by it. The patient will be in an unfamiliar environment with extra obstacles that can cause fall. Remember in the setting of postural hypotension, it is often when patients reach the bathroom that they suffer the full effect and collapse, not always immediately after standing.

Mobility

Poor mobility and the use of walking aids is associated with increased risk of falls (2-4, 6). It may seem counter-intuitive that a walking aid which is being use to help with mobility may increase the risk of falls but they may be used or sized incorrectly for the patient. Patients may have started using a stick that was sized for their spouse that is too short or long. I have certainly witnessed patients using walking frames by lifting them up to carry and putting down when they finish.

Physiotherapists and occupational therapists are essential in assessing how a patient mobilises and their safety in doing so. A decrease in mobility may be the first sign of a deterioration in a patients condition so it is worth being vigilant to concerns raised.

Consequences Of Falls

We have already discussed fractures and head injuries. However, one overlooked consequence is the impact on the confidence of the patient.

Following a fall, the patient may lose confidence in their ability to mobilise and reduce their activity levels as a result. Sometimes a patient becomes fearful of falling and this has been associated with a further increased risk of falling and decreased mobility.

Once a patient starts upon the path of reduced mobility it can create a downward general trend.

Imagine a patient who attends following a fall. They spend two or three days in bed not wanting to mobilise in part out of fear but also because we in hospital are very good at providing our patients needs at the bedside and reducing their need to mobilise. Over those days their muscle strength diminishes and mobilising becomes more difficult. The physios perform an assessment and decide they need a frame now which requires instruction and training to use. The patient then only mobilises when the physios come once a day. An assessment is made and it’s decided the patient needs extra rehab in a community hospital. They now spend two weeks in hospital and have become deconditioned to independent living at home and have a greatly reduced confidence in doing so.

They fall again 6 months later

This time it’s decided that the patient needs residential care as their confidence and muscular strength has declined. Within 6 months a person has gone from independently living to dependent living. It’s not an uncommon story, though perhaps accelerated. This tale is supposed to highlight the importance of ensuring mobile patients stay mobile once they are under our care in hospital.

In the literature, the Post-fall syndrome is described (16). This is typified by a fear of falling resulting in a tendency to grasp at things for support and overcompensation. The overcompensation may be someone who had a tendency to fall forwards leaning back to prevent this and falling and as a result falling backwards. Simply having a fear of falling which can occur even without falling increases the odds of reduced mobility, acute hospital admissions and GP attendences (17).
Falls Clinic

Most if not all trusts will have a falls clinic you can refer to. You may not have the ability to fully investigate a fall and these clinics are ideal. Commonly, they will have all the health care professionals they need in one clinic. This would include not just doctors but physios, occupational therapists and nurses who can perform all the assessment they need to determine the interventions necessary.

Vitamin D

Josh talks about vitamin D in the podcast at the end. There have been studies investigating theneffect of vitamin D on the rates of falls and fractures resulting from falls. The suggestion from the literature is that rather than applying this to every fall, there are certain populations where it might be of benefit which is predominantly those in care facilities (18-20). However, searching of the literature reveals contradictory sources. Rather than applying generally, it would be better to read the literature for yourself if interested and discuss with your local Elderly Care Physicians for their take on it.

Summary

Falls are not easy sometimes and it will take some effort to figure out exactly why someone has fallen. There will never be any two that allow you to apply exactly the same method to each one. Take each in turn, decide whether there is an acute problem first, then decide on the likely underlying cause and what investigations are needed, finally decide upon who else needs to be involved with the patient to both rehabilitate and prevent further falls. If in doubt, ask!

Speak soon,

Gareth

@garEMlyn

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References

3 replies on “Falls”

[…] dealing with a patient who has fallen or is at risk of falls, check out our previous discussion here. We use a case example to aid […]

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