What defines a fall, in general?
Definition: coming to rest inadvertently on the ground or at a lower level
- Most falls are not associated with syncope (falls lit. usu. excludes falls assoc. w/ LOC)
- Common in geriatric patients, where it is often a marker of poor health/declining function
What are the three levels of age in geriatric patients?
- "Young old": 65-74yo
- "Middle old": 75-84yo
- "Old old": 85+yo
What are risk factors for falls?
- Age (esp. 75+yo)
- Low mobility (use of cane/walker)
- Low body weight
- Impaired gait and balance
- Limited activities of daily living
- Acute illness
- Chronic illness
What are some sequelae of falls?
- Decline in functional status
- Nursing home placement
- Increased use of medical services
- Fear of falling
Half of those who fall are unable to get up without help → “long lie” → predicts lasting decline in functional status
What are some age-related changes?
- Broad-based gait, poor gait initiation
- Flexion of cervical spine, hips, and knees
- Decreased arm swing
- Smaller steps
- Stiff turns
- Dec. baroreceptor sensitivity
- Postural hypotension
- Vision changes
- Decreased total body water
- Decreased proprioception
What are some intrinsic factors for falls?
- Slower reflexes
- Decreased reaction time
- Increased postural sway
- Decreased vision
- Cognitive impairment
- Alcohol use
What are some extrinsic factors for falls?
- 4+ meds
- Poor lighting
- Unsafe stairways
- Irregular walking surface
- No grab bars or handrails
- Improper footwear
What are some medications highly associated with falls?
- Sleeping meds
- Cardiac meds
What are some things to examine in geriatric home safety checks?
- Secure carpets, remove throw rugs
- Reduce clutter
- Remove wires, cords, low chairs/furniture
- Check lighting, access to phone
- Handrails/grab bars
- Rubber mats in bathtub
- Raised toilet seat
- No floor wax
- Secure stairs
- Shelves, step stools
What should be done for geriatric patients who have had single or recurrent falls?
- Ask all older adults about falls in past year
Single fall: check for balance/gait disturbance
Recurrent falls or gait/balance disturbance: obtain relevant medical history, physical exam, cognitive and functional assessment; determine multifactorial falls risk
What is involved in the physical exam for geriatric patients who have fallen?
- Blood pressure and pulse, both supine and standing
- Vision screening
- Cardiovascular exam
- Musculoskeletal exam
- Neurologic exam
What laboratory/diagnostic testing is advised or advised against for geriatric patients who have fallen?
- Tests and procedures should be guided by the history and physical exam: echocardiography, brain imaging, radiographic studies of spine
- Hemoglobin, serum urea nitrogen, creatinine, glucose: can exclude anemia, dehydration, or hyperglycemia
- Holter monitoring: NO PROVEN VALUE for routine evaluation
- Carotid sinus massage with continuous heart rate and BP monitoring: can uncover carotid sinus hypersensitivity
What is the Get up and Go Test?
- Time person as they rise from a standard chair
- Walk 10 ft, turn, walk back to the chair and sit down again
- OK to use walker or cane
- Do one practice trial and then three actual trials. Average the times from the three actual trials to get the score
- < 10 seconds: freely mobile
- <20 seconds: mostly independent
- 20-29 seconds: variable mobility
- >30 seconds: impaired mobility
What are multifactorial interventions for older adults and those who have falls?