Falls – history, examination, investigations and management
How to investigate and manage patients with falls. Free revision for medical student finals, OSCEs and PACES
History
- As with most of medicine – and geratology particular – history plays an important factor when performing an assessment of a patient who has fallen. The structure below is particularly important in the context of falls:
- Before the fall
- Any pre-syncopal symptoms e.g. feeling dizzy, light-headed, palpitations?
- What were they doing?
- Getting up from lying/sitting (postural hypotension?)
- From the toilet (vasovagal?)
- In the middle of walking (arrhythmia?)
- Turning their head (carotid sinus hypersensitivity?)
- How is their general health? Any infective symptoms (e.g. dysuria, cough, cellulitis?)
- How do they usually mobilise? Do they walk independently or use a stick/sticks/frame/need supervision (implying underlying frailty and poor mobility?)
- During the fall
- Do they remember falling?
- Was it witnessed?
- If so, obtain a detailed collateral history
- If not, assume that there may have been some loss of consciousness (LOC)
- Was there any LOC?
- Are they able to describe the mechanism of the fall?
- If they say they ‘must have tripped’ this is not the same as remembering a definite mechanical reason for the fall!
- Where they able to put out their hands to prevent injury?
- A fractured wrist where they have tried to protect themselves is consistent with no LOC
- A significant head (e.g. black eye) is consistent with no attempt to protect themselves, and as such LOC (likely sudden onset – e.g. arrhythmia) prior to the fall.
- After the fall
- Any limb jerking or urinary/faecal incontinence to imply seizure?
- Some myoclonic jerking following a syncopal episode is not uncommon, so do not read too much into this
- Were they well-oriented following the fall?
- Rapidly recovering orientation is in keeping with no LOC, or syncopal episode
- Persistent confusion/drowsiness implies a post-ictal state and potential seizure as cause
- Were they able to mobilise independently following the fall?
- If not, and secondary to pain, be on the lookout for bony injuries
- Confused patients can often fail to localise pain
- How long were they on the floor for?
- The longer the lie, the higher the risk of rhabdomyolysis: ensure as CK is checked
- Any limb jerking or urinary/faecal incontinence to imply seizure?
Past Medical History
- Diabetes Mellitus
- Are they good at detecting hypoglycaemia?
- Was a blood sugar checked at the time of the fall?
- Any history/evidence of peripheral neuropathy that might be contributing to falls risk?
- Hypertension
- Are they on multiple anti-hypertensives which might be leading to postural hypotension
- Epilepsy
- Do they have a history of seizures?
- If so, how well controlled are the seizures and are they compliant with anti-epileptic medications?
- Previous falls
- Have they had other falls (even “small” ones that didn’t require admission)?
- How does this one compare to the previous ones? Is it a similar story?
- Cardiac History
- History of palpitations/ECG-confirmed arrhythmias
- Do they have a copy of an old ECG?
- If your patient as an abnormal ECG, giving them a copy to take home with them in future is useful, as they can show it to future admitting doctors to allow comparison
- Ischaemic heart disease or other underlying cardiac problems that might mean the patient is on beta-blocker
- Other neurological history
- Any previous stroke/neurological disorder that has left them with a persistent focal deficit, and hence frailty that might be contributing to the falls risk
- History of tremor/shuffling gait/rigidity to imply Parkinsonism
- Continence history
- Issues with incontinence/overactive bladder can lead to falls as patients often try to mobilise late at night to the toilet in the dark
- State of vision
- History of glaucoma or age-related macular degeneration, which might leave them visually impaired?
- Cognitive impairment
- Bone Health
- Evidence of previous fractures
- Evidence of osteoporosis and risk of fragility fractures
- Drug History
- Anti-hypertensives
- May lead to postural hypotension
- Alpha-receptor blockers in male patients with prostatism
- g. tamsulosin
- Can cause a profound postural drop in BP
- Antihyperglycaemics
- Use of insulin or sulphonylureas can cause hypoglycaemic events
- Analgesia
- Side-effects of drowsiness can increase the risk of falls
- Evidence of poor-pain control can imply frailty and poor mobility
- Bone Protection
- Vitamin D replacement
- Calcium replacement
- Bisphosphonates
- Steroid Use
- g. long-term use in COPD with multiple exacerbations or in polymyalgia rheumatic (PMR)
- Associated with increased risk of fragility fracture secondary to effects on bone
- Long-term use associated with proximal myopathy, and subsequent frailty-associated falls risk
- Diuretics
- Use of diuretics is associated with increased urinary frequency, and the associated issues with continence as discussed above
- Check the timings of administration, and try to not prescribe your diuretics in the evening if possible (if BD dosing, give the second dose at lunchtime) – this will help to avoid nocturnal micturition
- Anti-epileptics
- Anti-cholinesterase inhibitors
- Implies the diagnosis of dementia (if not already established from past medical history)
- Associated with increased risk of syncope (and hence syncope-related falls)
- Anti-coagulants
- Risk of bleed (e.g. subdural haematoma) if patient on warfarin or novel oral anticoagulant (NOAC)
- Have a lower threshold for a CT head
- Psychotropic Drugs
- g. SSRIs, benzodiazepines, dopamine antagonists can all increase the risk of falls
- Anti-hypertensives
- Social History
- House/flat/bungalow
- Stairs and associated equipment (e.g. stair rails, stair lift)
- Upstairs/downstairs toilet/commode
- Who else is at home with the patient
- Any pre-existing package of care (POC)
- Level of independence for activities of daily living (ADLs)
- Alcohol history
- Potential associated alcohol neuropathy
- Intoxication-related falls
- If history of dependence, offer support to help quit, and monitor for withdrawal
- Smoking history
- Should always form part of every social history
- Again, offer support to help quit
- Who does cooking/shopping/cleaning of house?
- Do they have a pendant alarm?
- Do they have a key safe?
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- Systems Enquiry
- The multi-factorial nature of most geriatric falls means that a systems enquiry has already been performed during the above history
- Systems Enquiry
Examination
- A full formal clerking should then be performed to assess for both any sign of injury as a result of the fall, but also to gain a better understanding into possible causes.
- On a system-by-system basis, here are a few things to keep in mind and look out for.
- Cardiovascular
- Pulse
- Regular/irregular to imply AF or intermittent heart block?
- Strong or weak (weak may suggest underfilling)?
- Blood pressure
- Always try to obtain 3 postural (lying to standing) blood pressure readings
- Ensure they are taken correctly (do not settle for a “lying to sitting”)
- Murmurs
- ESM to imply aortic stenosis as a cause of syncope?
- PSM to imply MR and CCF/AF from atrial dilatation
- Pulse
- Respiratory
- Evidence of LRTI/pneumonia as an underlying infection?
- Evidence of chronic respiratory problems leading to SOB and increased frailty?
- Equal, pain-free air entry?
- Inspiration can be limited by the pain from fractured ribs from the fall
- Hypoventilation (and associated atelectasis) due to pain is a risk factor for pneumonia
- Abdominal
- Evidence of constipation that might be leading to a delirium?
- Evidence of an enlarged bladder (urinary retention) leading to a delirium?
- Neurological
- Please do not document neurology as “grossly normal”
- “Grossly normal” equates to “couldn’t be bothered to examine”
- Instead, do a formal neurological examination for:
- Evidence of stroke/disability from previous stroke
- Cerebellar signs to imply balance is impaired
- Peripheral neuropathy from alcohol or diabetes that reduces proprioception and balance
- Check their gait and use of walking aids
- Mental state and cognitive assessments (click on links below for details)
- Please do not document neurology as “grossly normal”
Investigations
- ECG
- Look for any evidence that could be predisposing them to syncope e.g. heart block, arrhythmia, over-treatment with beta-blockade
- Blood glucose
- Evidence of diabetes or hypoglycaemia
- Urine dip
- Evidence of UTI as source of infection
- If legs are particularly oedematous (and hence contributing to the risk of falls) look for urinary protein
- Blood tests
- FBC
- Anaemia leading to shortness of breath on exertion
- Raised white count to imply infection
- High MCV to imply B12 deficiency (and potential associated peripheral neuropathy)
- Urea and electrolytes
- Uraemia or other metabolic disturbance leading to confusion
- CRP
- Underlying infection
- Calcium and phosphate
- Evidence of bone pathology e.g. myeloma which is causing pain, and hence increasing falls risk
- Liver function
- Evidence of alcohol abuse
- Clotting
- Especially if on warfarin
- Abnormally high INR may increase your suspicion of causative or resultant intracranial bleeds
- If low, be on the lookout for corresponding complications (e.g. stroke for AF, PE for VTE)
- Other blood tests may be indicated based on your findings so far from history and examination
- g. TFTs if evidence of hyper- or hypothyroidism
- The above list is not exhaustive, and should be tailored towards your suspected diagnosis
- FBC
- Imaging
- Chest x-ray
- Evidence of infection as a cause of the fall
- Can also confirm rib fractures which will require adequate analgesia to allow good, deep respiration and hence reduce the risk of subsequent infection
- CT Head
- Although there are national trauma guidelines over who should receive a CT head in the emergency department, it is reasonable to have lower threshold for a CT head in the elderly population
- Subdural haematoma is a not uncommon cause of confusion in the elderly (even without a clear history of trauma, especially if on anticoagulants)
- This is particularly important if the patient is frail and likely to be an in-patient on thromboembolic prophylaxis for several days
- Evidence of infection as a cause of the fall
- Chest x-ray
Management of patients with falls: in-patient, discharge, and follow-up
- Immediate inpatient management will clearly depend on findings of above history, examination and investigations.
- Management should be multidisciplinary: including doctors, nurses, physiotherapists and occupational therapists.
- General geriatric management strategies include:
- Inpatient
- Identify those who are at high risk of further falls to help reduce the chance of an in-patient fall
- 1-1 nursing may be required for confused/delirious patients
- Low-rise beds and mattresses on the floor to reduce the risk of injury
- Non-slip socks
- Adjustment of medication regimens to reduce falls risk
- Training how to use appropriate walking aids is very important to help reduce falls
- Identify those who are at high risk of further falls to help reduce the chance of an in-patient fall
- Additional support
- POC if going back home
- May require placement to ensure safety, either RH or NH based on level of dependence
- Outpatient
- Home visits can be helpful in frail patients who might have cluttered houses with uneven floors
- Modification of the home environment
- Downstairs living
- Commode
- Hand rails
- Stair lift
- Hospital bed
- Hoist
- Pendant alarms
- Newer models have in-built impact sensors that are set-off as a fall happens
- Follow-up
- Specialist geriatric clinic follow-up
- Falls clinic
- Balance classes
Click here for background to falls (including complications) or click here for pages on loss of consciousness and syncope