Falls

James talks to Associate Professor Mark Latt about falls, a common presentation in hospital and the Emergency Department, especially in the geriatric population.

Summary Writer:  Alexandra Bolger

Editor:  Mark Latt

Interviewee:  Mark Latt

About Mark Latt

Mark Latt is a Staff Specialist in Geriatric Medicine and runs a multidisciplinary outpatient Falls Management Service at Royal Prince Alfred Hospital. He is a Principal Investigator in NHMRC funded trials examining the prevention of falls in Parkinson’s disease, dementia and minor neurocognitive disorder.

Falls

With Associate Professor Mark Latt, Geriatrician at Royal Prince of Wales Hospital, Sydney, Australia

Introduction

Falls are a common presentation on the wards and in the Emergency Department especially in the geriatric population. Falls costs the health system more than any other type of injury including road trauma. The cause of falls is often multifactorial including mechanical accidents, gait and balance problems, muscle weakness, sensory impairment, hypotension, polypharmacy and many more.  An interdisciplinary team approach is the most important factor in optimising outcomes for our geriatric falls patients.

Case

You are a junior doctor working an after hours shift and you are called to review an 80-year-old female who has had a fall whilst attempting to go to the bathroom.

  • What are the vital signs?
  • What is the level of consciousness – especially in the elderly patient?
  • Was there any head strike or evidence of head trauma if unwitnessed?
  • Where is the pain?
    • Is there spinal or pelvic tenderness – these may suggest you need to attend to the patient more urgently
  • History
    • Get a good history from the nursing staff or patients family if the fall was witnessed
    • Talk to the patient and ascertain the circumstances behind the fall
    • What was the patient doing when they fell?
    • Where on the ward did they fall? Were they in a slippery bathroom?
    • Was the fall mechanical?
    • Did patient have lightness in the head, vertigo or dizziness?
  • Examination
    • Vital Signs! This is the most important determinant of how urgent/serious the injury is
      • Level of consciousness is very important in elderly
        • Is the patient delirious? – This may present as a fluctuation in level of attention or consciousness
        • Is the patient alert and oriented?
    • Cardiovascular and neurological examination are very important in assessing a fall
      • Also assess for any bony tenderness especially pelvic and spinal
      • Postural blood pressure can be checked at a later date by the nursing staff
      • It is important to make nursing staff aware that if the patient mobilises they may require more supervision than previously
    • RED FLAGS for a fall
      • Haemodynamic instability
        • Drop in blood pressure – may indicate bleeding
        • Bradycardia or tachycardia may suggest a cause of the fall
        • Delirium
        • New neurological signs may suggest complication of fall for example an intracranial bleed or may indicate that a neurological event for example stroke or a seizure has precipitated the fall
  • Investigations need to be tailored to the specific patient and mechanism of the fall
  • If hypotensive, then close monitoring is required specifically of the cardiovascular system
  • If bradycardia, tachycardia or abnormal rhythm an ECG is required
  • If there is evidence of soft tissue or bony injury then imaging of that area is useful
  • If a seizure precipitated the event an EEG may assist in management – this can be performed at the time of the fall or at a later date
  • If a neurological event caused the fall or the patient has new neurological signs then a head CT is reasonable
    • If any evidence of head injury or history head strike then CT should also be performed
    • If the patient is on anticoagulants have a low threshold for performing CT for a head CT. This includes antiplatelet therapy.
  • Blood testing may be required if they have not been performed earlier that day
    • EUC may be useful if the patient is taking diuretics, in acute renal failure or at risk of electrolyte disturbances
    • A haemoglobin may be useful if the patient has evidence of bleeding
    • Troponin testing is only necessary if evidence of cardiac ischaemia, worsening heart failure, change in ECG or hypotension. Troponins need to be retested in 4-6 hours time as well.
  • Nursing staff can also be asked to perform neurological observations hourly after a fall if the doctor is worried about a possible head injury
  • Delirium is the most common cause of a fall in hospital – any disease or drug can cause delirium. Withdrawing and administering new drugs can both cause delirium. Patients that are delirious as well as patients with dementia need closer monitoring and a higher level of nursing care to prevent falls.
  • Psychotropic medications – i.e. any medication that crosses the blood brain barrier is potentially a psychotropic medication. Particularly psychotic medications associated with olanzapine, haloperidol, quetiapine, benzodiazepines and anti-depressants.
  • Commencing a new antihypertensive or increasing the dose of an antihypertensive
  • Limited number of nursing staff to assist mobilisation
  • Environmental causes
    • Differing environment
    • Changing beds and wards frequently on admission is very disorientating
    • Slippery floors
    • Patient not having access to their regular walking frames and shoes
  • Two large randomized controlled trials in Australia called the ‘Coming at All’ study in the Lancet and the ‘6-PACK’ study from Victoria. Neither of those studies found any interventions routinely used in hospital actually prevent falls.
  • Nursing staff attendance and assistance is likely a big help
  • Junior medical staff can help by identifying which patients are likely to fall or have a history of falls
    • Dementia is the biggest risk factors for falls
    • Stroke, Parkinson’s disease, polypharmacy and psychotropic medications are also important risks to identify
  • If patients are at high risk of falling there is a protocol called FRAMP or Falls Risk Assessment Management Plan, which identifies certain therapies or precautions which can be put in place e.g. walking aids, location of bed in relation to toilet and visual aids
  • Nursing staff are at the front line of falls prevention. It is important for them to identify patients with falls risk and give them more supervision and prompt attendance.
  • Physiotherapists are also important in falls prevention as most studies that have shown benefit for falls reduction include exercise training that promotes balance and strength
  • An occupational therapist home visit has been shown to reduce falls in the community in patients that have been discharged from hospital following a fall
  • Don’t fear the dizzy patient, the lightheaded patient or the patient that falls over
  • It is expected that we do our best to prevent the problem but there is no magical solution and solving the issue of falls completely is beyond our immediate resources

Related Podcasts

Tags: #BMJ,#cardiac ischaemia,#delirium,#dizzy patient,#Falls,#falls patients,#Falls Risk Assessment,#FRAMP,#Geriatrics,#head trauma,#heart failure,#hypotension,#muscle weakness,#Parkinson’s disease,#polypharmacy,#seizure,#sensory impairment,#vertigo

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