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Home | Articles | Care of the Elderly | Falls

Falls

Last updated 3rd December 2020

Epidemiology of Falls

  1. 30-40% of patients in community >65 years will fall each year.
  2. 50% of patients over 65 in long term care will fall each year
  3. Around 60% of patients with a history of fall in the previous year will have a subsequent fall.

Causes of Fall – ‘DAME’

There is another mnemonic for falls – “I HATE FALLING” – which sounds promising but doesn’t really help a great deal. It includes L = leg length discrepancy and L = lack of conditioning!

Consequences of a Fall

  1. Minor soft tissue injury such as cuts and bruises are common.
  2. Major injuries including fractures, subdural haematoma or major lacerations in 5-10%. Patients on warfarin are at higher risk of subdural.
  3. Fallers develop a fear of falling and restrict their activities.
  4. Risk of nursing home admission increases progressively with number of falls.
  5. Death from complication of fall in 2%.

Essential History

  1. What was the patient doing at the time of the fall?
  2. Where and when did the fall occur.
  3. Did fall occur without warning or were there prodromal symptoms?
  4. Did they lose consciousness and if so was there a witness?
  5. Have they fallen before?
  6. What drugs were they taking?

How to Distinguish Between a Simple Fall and Syncope

  1. Can be difficult because elderly are often amnesic for loss of consciousness (LOC).
  2. If patient cannot remember hitting floor then transient LOC likely.
  3. Obtain witness account if at all possible. Phone relative, GP or care home if necessary.

Essential Examination

  1. Cardiovascular examination must include lying and standing blood pressure.
  2. Neurological examination must include assessment of vision, sensory input including proprioception, vestibular function, lower limb power and exclusion of Parkinson’s disease.
  3. Musculoskeletal examination must include assessment of joints and of feet including bunions and calluses.

Investigations

  1. Routine tests should include haemoglobin, urea and electrolytes, glucose. Infection screen if muddled and off legs.
  2. 24 hour ECG, echo, carotid doppler and CT scan are of limited value unless indicated by clinical findings.
  3. Assessment of carotid sinus sensitivity may be indicated in patients with unexplained multiple falls.

Management of a Fall

  1. Treat the complications of the fall as indicated.
  2. Ensure adequate pain relief for injuries and fractures. Analgesia should be the minimum required. Opiates and tramadol usually worsen confusion/balance/falls and NSAIDs often have contraindications in the elderly, especially renal function. Paracetamol given regularly is usually best/safest escalating to co-codamol if required.
  3. Recognise the psychological impact to an older person and their carer of having fallen.
  4. Any medication which may have contributed to falls should be reviewed – often best done by GP.
  5. Patients not admitted – refer back to GP for further management/assessment and to local community rehab teams for physio/OT.
  6. In-patients – refer to local community rehab team. The ward based OT/physio will do this.
  7. Patients with more difficult problems especially recurrent and unexplained falls may be referred to Falls Clinic (Dr Holden).

Falls Prevention Programme

  1. This is a Physiotherapy led service in Dumfries & Galloway
  2. Any patient with a balance or mobility problem predisposing them to falling or any patients who feel at risk of falling may be referred
  3. Referral is not necessary after a single explained fall with normal gait and balance.
  4. Refer by standard physiotherapy card, letter or fax to Maggie Morrison, Falls Coordinator (West), Castle Douglas Hospital 01556 504686 or to Sarah Kirk, Falls Coordinator (East), Nithbank Hospital 01387 244464
  5. Give the reason for referral and details of any relevant past medical history
  6. The falls team will assess the patient and decide whether they fit into the falls prevention class, the home exercise programme , gait training, walking aid or just advice.
  7. Note this programme is separate to Dr. Holden’s falls clinic which is for patients with recurrent unexplained falls.

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