Falls

Introduction

A fall is to inadvertently come to rest on
the ground or lower level with or without loss of consciousness or injury.
The diagnosis excludes falls associated
with intrinsic events e.g. seizures, stroke
or syncope, or falls from overwhelming environmental hazards.

  • It may be an atypical presentation of acute illness in an older adult.
  • It is also a marker of frailty and impaired mobility in older adults
  • Older adults are more likely to fall with increasing age
  • Risk of falling increases with previous falls
  • Falls account for significant morbidity and mortality in older adults
  • Incidence of falls is approximately equal in older men and women but women are more likely to be injured

Aetiology

Its etiology is Multifactorial
Risk factors

  • Falls’ risk factors are under modifiable, difficult to modify, non modifiable

Intrinsic

  • Age
  • Alcohol use
  • Fear of falling
  • Hearing impairment
  • Medical conditions e.g. arthritis,
    dementia, stroke, Parkinson’s disease, etc.
  • Muscle weakness.
  • Orthostatic hypotension
  • Pain
  • Poor balance
  • Urinary incontinence
  • Vertigo
  • Visual impairment

Extrinsic

  • Medications
  • Anticonvulsants
  • Antidepressants
  • Antihypertensives
  • Antipsychotics
  • Benzodiazepines
  • Diuretics
  • Improper or improper use of assistive devices
  • Inappropriate footwear

Environmental/ Situational

  • Clutter
  • Haste
  • Inadequate lighting
  • Lack of non-skid surfaces in bath tubs
  • Loose mats/rugs
  • Poor housing design/disrepair e.g. uneven steps
  • Slippery floors

Clinical features

  • Patient is found on the ground or at a lower level than s/he was
  • Complications arising from fall

Evaluation

Get Up and Go test
Patient sitting on an arm chair is timed when asked to:

  • Rise from the chair without using the arms.
  • Walk a distance of 3 m across the room
  • Turn, walk back to the chair and sit down

Increased risk of falling if the above activities take more than 13.5 seconds

Complications

Economic
Costs of:

  • Disability
  • Dependence
  • Hospitalization and interventions to
    treat complications

Physical:

  • Dehydration
  • Dependencyl
  • Disability
  • Fractures
  • Haemorrhage e.g. subdural haematoma
  • Hypothermia
  • Immobility
  • Increased likelihood of falling again.
  • Self-imposed reduction in physical activity
  • Severe injuries requiring hospitalization
  • Skin lacerations.
  • Mortality
  • Pneumonia
  • Pressure ulcers

Psychological:

  • Anxiety
  • Depression
  • Fear of falling; falls phobia syndrome

Loss of confidence

  • Social withdrawal

Investigations

  • This should be tailored towards identifying underlying causes e.g. anaemia, arrhythmias, electrolyte imbalance, infections, etc.
  • Additional investigations to confirm or rule out complications as indicated by clinical presentation

Treatment objectives

  • Eliminate or reduce modifiable predisposingfactors, for example:
  • Reduce total number of medications and/or dose of individual medicines if feasible, e.g. in patients with postural hypotension

Non-drug treatment

Please see below (Prevention)

Drug treatment

Specific treatments for underlying
conditions and complications arising from falling

Prevention

  • Vitamin D 800 IU daily plus Calcium 1,200 mg for all older adults at risk of falling
  • Environmental modification
  • Adequate lighting, preferably with switches located at entrances to rooms or hallways
  • Arrange furniture to avoid obstruction.
  • Clean up spills without delay
  • Light source (e.g. flashlight) to be kept handy in the event of power failure
  • Non-skid mats in bath tubs
  • Provide elevated toilet seats
  • Provide handrails on both sides of bathroom
  • Address predisposing factors
  • Educate patients on:
    • Proper use of assistive devices
    • Arising and changing position slowly
    • Signs and symptoms of hypoglycaemia
  • Examine eyes regularly
  • Maintain adequate hydration
  • Provide frequent, small meals
  • Encourage rest after meals

Rehabilitation
Important to address risk of falling again

  • Physical
  • Psychological
  • Social