Notes

Assessment of Falls in the Elderly
Falls in older adults can result in severe injuries. A simple screen can identify individuals who need a more comprehensive multifactorial assessment of their fall risk factors.

Patients often do not report falling due to fear of losing their independence and stigma associated with the condition. However, unexplained bruises, a history of syncope or other signs indicate a need for further evaluation.
Physical Examination

When assessing patients for fall risk it is important to use a physical exam. This should include evaluation of balance, joint range of motion and muscle strength. Using validated assessment tools such as the Timed Get-Up and Go test or Berg Balance Scale allows physicians to compare results between patients.

A targeted history and physical examination that includes asking about past falls is also essential. This should elicit information about the severity of the fall and any injuries that resulted. This will help identify patients who are at high risk of future falls.

The physical exam should include a 30-second chair stand test, four stage balance tests and a gait analysis. These tests will determine if there is any difficulty with standing from a chair, walking and carrying objects. The physician should also be aware of any medications that could increase the risk of falling (eg. diuretics) and assess for orthostatic hypotension. The patient should be encouraged to participate in a program of exercise that has been shown to reduce falls.
Medical History

Patients with a history of fall should be evaluated by clinicians and underlying risk factors addressed. Falls result in significant morbidity and mortality, especially among older adults. Patients who have fallen are at increased risk of future falls and serious injury, including hip fractures.

A detailed patient history should be obtained, focusing on the when, where and why of the last fall. The physician should also inquire about the frequency of falling and mobility problems. An objective assessment of mobility can be made with a simple timed up and go (TUG) test, which involves measuring the amount of time it takes for the patient to rise from a chair, walk 10 feet, turn, sit down, and return to the original position.

The physical examination should include a review of medications, measurement of blood pressure on both supine and standing, auscultation of the heart to detect signs of valvular disease, and an evaluation for a visual and balance abnormality. Generally, the patient should be referred to a geriatrician and/or a cardiologist for further evaluation. Frequently falling older adults can be managed with multifactorial assessment and interventions such as medication management, environmental modifications, geriatric counseling, physical therapy or occupational therapy, education and dietary/nutritional modification.
Behavioral Assessment

A person with a history of falling can be at risk for many complications. Serious injuries, such as hip fracture, can be fatal in up to 25% of cases and cause permanent loss of mobility and independence. Long-term consequences can include a decline in function, inability to return home, and nursing-home placement.

A targeted history and physical examination addressing potential home hazards, medications (including over-the-counter and prescription medications), cognitive and visual impairment, functional limitations, orthostatic hypotension, and gait and balance abnormalities can help identify fall risk factors. Numerous interventions (single and multicomponent) have been shown to decrease falls.

A behavioral assessment can provide useful information on the patient's ability to change their behaviors to reduce fall risk. It can include a motivational interview with a pharmacist who preforms a review of all a patient's medications and asks open-ended questions about their use and attitudes toward the medication and a physical therapist performing a timed up and go test as well as a standardized balance/gait assessment. Research shows that implementing these interventions decreases falls-related and all-cause ED re-visits, hospital admissions, and acuity of care.
Medications

Falling is a major cause of injury in older adults. Complications from falls can be serious and can include hip fractures. It is important to identify the underlying cause(s) of falls. A thorough physical examination should be performed and all relevant medications reviewed. In addition, temperature should be checked to determine whether a recent fever may have been a contributing factor. Heart rate and rhythm should be assessed to detect obvious bradycardia or resting tachycardia and auscultation should be done to rule out valvular heart disease. Vision should be evaluated and a referral to an eye care provider made if necessary.

adt medical alarms A standardized assessment tool has been developed to help health professionals isolate specific risk factors that are amenable to intervention. Older patients who report a history of falling and have a gait or balance problem on the Get-Up-and-Go Test should be considered high risk and should be offered general information about how to reduce their risks of future falls. These patients can be offered an exercise program such as tai chi or the Otago Exercise Programme that has been shown to be effective in reducing falls in people who are at low or moderate risk.
Environmental Assessment

In some circumstances the environment where a person lives or is being treated may be the cause of their falls. This could include a hazard such as a loose step or poor lighting or it could be their living arrangements such as crowded housing and lack of personal space. Fall risk factors can also be caused by activities and decisions such as walking while distracted or rushing to the toilet.

Falling can have a profound effect on a patient’s quality of life. Aside from the physical injuries that can occur falling also reduces confidence, causes activity restriction and limits social interaction. It can also lead to dependence on carers which puts strain on family and friends.

A comprehensive fall risk assessment will identify the patients who have a high falls risk and further evaluation is required – eg the Morse Fall Scale or Humpty Dumpty Falls Assessment Tool (HDFA). These assessments should be conducted by trained health care professionals. They should also include a review of medications and the possibility that they may be contributing to falls by increasing the likelihood of dizziness or drowsiness.
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