In this section : Care of the Elderly
Stroke Care
Prescribing Advice on Admission – Medication for Parkinson’s Disease
Adults With Incapacity
Principles for Light Touch Patients – B2
Falls
Immobility
Parkinson’s Disease
Delirium
Functional & Social Assessment
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Falls
Last updated 3rd December 2020
Epidemiology of Falls
- 30-40% of patients in community >65 years will fall each year.
- 50% of patients over 65 in long term care will fall each year
- 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
- Minor soft tissue injury such as cuts and bruises are common.
- Major injuries including fractures, subdural haematoma or major lacerations in 5-10%. Patients on warfarin are at higher risk of subdural.
- Fallers develop a fear of falling and restrict their activities.
- Risk of nursing home admission increases progressively with number of falls.
- Death from complication of fall in 2%.
Essential History
- What was the patient doing at the time of the fall?
- Where and when did the fall occur.
- Did fall occur without warning or were there prodromal symptoms?
- Did they lose consciousness and if so was there a witness?
- Have they fallen before?
- What drugs were they taking?
How to Distinguish Between a Simple Fall and Syncope
- Can be difficult because elderly are often amnesic for loss of consciousness (LOC).
- If patient cannot remember hitting floor then transient LOC likely.
- Obtain witness account if at all possible. Phone relative, GP or care home if necessary.
Essential Examination
- Cardiovascular examination must include lying and standing blood pressure.
- Neurological examination must include assessment of vision, sensory input including proprioception, vestibular function, lower limb power and exclusion of Parkinson’s disease.
- Musculoskeletal examination must include assessment of joints and of feet including bunions and calluses.
Investigations
- Routine tests should include haemoglobin, urea and electrolytes, glucose. Infection screen if muddled and off legs.
- 24 hour ECG, echo, carotid doppler and CT scan are of limited value unless indicated by clinical findings.
- Assessment of carotid sinus sensitivity may be indicated in patients with unexplained multiple falls.
Management of a Fall
- Treat the complications of the fall as indicated.
- 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.
- Recognise the psychological impact to an older person and their carer of having fallen.
- Any medication which may have contributed to falls should be reviewed – often best done by GP.
- Patients not admitted – refer back to GP for further management/assessment and to local community rehab teams for physio/OT.
- In-patients – refer to local community rehab team. The ward based OT/physio will do this.
- Patients with more difficult problems especially recurrent and unexplained falls may be referred to Falls Clinic (Dr Holden).
Falls Prevention Programme
- This is a Physiotherapy led service in Dumfries & Galloway
- Any patient with a balance or mobility problem predisposing them to falling or any patients who feel at risk of falling may be referred
- Referral is not necessary after a single explained fall with normal gait and balance.
- 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
- Give the reason for referral and details of any relevant past medical history
- 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.
- Note this programme is separate to Dr. Holden’s falls clinic which is for patients with recurrent unexplained falls.