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Communication skills
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Falls – Assessment, Investigation & Management

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Background

Those over the age of 65 have the highest risk of falling with 30% of those over 65 and 50% of those over 80 falling at least once a year.¹ Falls can have a profoundly negative impact on the quality of life of the elderly and their carers. Physical distress, pain and injury are also associated with loss of confidence and independence. This negatively affects morbidity and mortality with associated financial implications for the NHS.

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History of presenting complaint

A detailed history is essential in determining the cause of falls. The table below highlights key information that should be gathered when taking a history.

WHO Who has seen you fall? Ensure adequate collateral history including addressing the when, where, what and why.
WHEN When did you fall?

What time of day?

What were they doing at the time?

  • Looking upwards (vertebrobasilar insufficiency)
  • Getting up from bed (postural hypotension)
WHERE Where did you fall? In the house, or outside?
WHAT What happened before/during and after the fall?

Before

  • Was there any warning?
  • Was there any dizziness/chest pain or palpitations?

 

During

  • Was there any incontinence or tongue biting? (indicating seizure activity)
  • Was there any loss of consciousness?
  • Was the patient pale/flushed? (may indicate vasovagal attack)
  • Did the patient injure themselves?
  • What part of the body had the first contact with the floor?

After

  • What happened after the fall?
  • Was the patient able to get themselves up off the floor?
  • How long did it take them?
  • Was the patient able to resume normal activities afterwards?
  • Was there any confusion after the event? (head injury)
  • Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)
WHY Why do you think you fell? May have tripped over a rug or started a new medication
HOW How many times have you fallen over the last 6 months? Allows you to gauge the severity of the problem

Be cautious in cases where the patient is unable to recall events clearly, as this may indicate new confusion associated with a head injury.

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Systems enquiry

A systems enquiry may identify other relevant information that may relate to falls.

General
  • Fatigue
  • Weight loss
Cardiovascular
  • Chest pain
  • Palpitations
Respiratory
  • Shortness of breath
  • Cough
Neurological
  • Loss of consciousness
  • Seizures
  • Motor or sensory disturbance
Genitourinary
  • Incontinence
  • Urgency
  • Dysuria
Gastrointestinal
  • Abdominal pain
  • Diarrhoea
  • Constipation
Musculoskeletal
  • Joint pain
  • Muscle weakness

Past medical history

General
  • Visual/hearing impairment
  • Diabetes
  • Anaemia
Cardiovascular
  • Cardiovascular disease
  • Arrhythmias
Respiratory
  • COPD
Neurological
  • Parkinson’s disease
  • Peripheral neuropathy
  • Stroke
  • Dementia
Genitourinary
  • Recurrent urinary tract infection
  • Incontinence
Gastrointestinal
  • Diverticulitis
  • Chronic diarrhoea
  • Alcoholic liver disease
Musculoskeletal
  • Arthritis
  • Chronic pain
  • Fractures

Social history

  • Alcohol intake
  • Support at home – friends/family and carers
  • Mobility – use of mobility aids and when (e.g. zimmer frame downstairs only)

Medication review

Most medications have side effects which can increase the likelihood of falls. Polypharmacy itself is a risk factor for falls. It is good practice to review medications and de-prescribe those which are no-longer indicated.

Examples of medications that increase the risk of falls:

  • Beta-blockers (bradycardia)
  • Diabetic medications (hypoglycaemia)
  • Antihypertensives (hypotension)
  • Benzodiazepines (sedation)
  • Antibiotics (intercurrent infection)

Clinical examination

General
  • Is the patient alert and orientated?
  • Are they able to perform the timed “up and go” test?: Ask the patient to get up from the chair/bed and walk three metres then turn around and sit down again. The patient should be permitted to use their walking aid.
Cardiovascular
  • Pulse: may have irregularities such as AF or bradycardia
  • Blood pressure – hypotension
  • Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
  • Murmurs: aortic stenosis/regurgitation, mitral stenosis
Respiratory
  • Inspection: increased work of breathing
  • Auscultation: coarse crackles (e.g. pneumonia)
  • Percussion: dullness (e.g. pleural effusion)
Neurological
  • Cranial nerve examination: stroke or visual impairment
  • Power: weakness (e.g. stroke, disuse atrophy)
  • Tone: increased in stroke
  • Reflexes: absent (e.g. diabetic neuropathy), hyperreflexia (e.g. upper motor neuron pathology)
  • Sensation: may be reduced secondary to upper or lower motor neuron pathology
  • Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration)
Gastrointestinal
  • Abdominal tenderness
  • Organomegaly
Musculoskeletal
  • Check for injuries associated with falls and examine carefully the point of contact with the floor
ENT
  • Is there any evidence of ear wax?
  • Are the tympanic membranes intact?

Investigations

Investigations are based on your history and examination but could include some of those mentioned below.

CATEGORY TEST POSSIBLE CAUSE OF FALL
Bedside Vital signs (BP/HR/RR/SpO2/Temperature)
  • Sepsis
  • Bradycardia
Lying and standing blood pressure
  • Orthostatic hypotension
Urine dipstick
  • Infection
  • Rhabdomyolysis (+++ blood)
ECG
  • Bradycardia
  • Arrhythmias
Cognitive screening (e.g. AMT)
  • Cognitive impairment
Blood glucose
  • Hypoglycaemia secondary to poor oral intake
Bloods Full blood count
  • Anaemia
  • Infection (raised white cells)
Urea and electrolytes
  • Dehydration
  • Electrolyte abnormalities
  • Rhabdomyolysis
Liver function tests
  • Chronic alcohol use
Bone profile
  • Calcium abnormalities in malignancy
  • Over-supplementation of calcium
Imaging Chest X-ray
  • Pneumonia
CT head
  • Chronic or acute subdural
  • Stroke
Echo
  • Valvular heart disease (e.g aortic stenosis)
Specialist Tilt table test  
Dix-Hallpike test
  • Benign paroxysmal positional vertigo
Cardiac monitoring (e.g. 48hr tape)
  • If no symptoms during monitoring episode in hospital

Differential diagnosis

The differential diagnosis of falls is very broad. It is important to determine whether the patient has suffered a transient loss of consciousness or a simple mechanical fall.

Some possible causes of falls are shown in the table below.

General
  • Mechanical (e.g. poor footwear/visual impairment)
  • Polypharmacy
Cardiovascular
  • Arrhythmias
  • Orthostatic hypotension
  • Bradycardia
  • Valvular heart disease
Neurological
  • Stroke
  • Peripheral neuropathy
Genitourinary
  • Incontinence
  • Urinary tract infection
Endocrine
  • Hypoglycaemia
Musculoskeletal
  • Arthritis
  • Disuse atrophy
ENT
  • Benign paroxysmal positional vertigo
  • Ear wax

Management

Once transient loss of consciousness has been ruled out, it is important to complete a full falls risk assessment. This is indicated in order to identify any causative features especially as older people are likely to have multiple co-existing risk factors. Although priority should be to treat any underlying medical cause (e.g. pacemaker if complete heart block), all causes should be addressed where possible. Due to the complex aetiology, it is important to continue to search for possible risk factors and causes of falls even when one has been found.

The table below includes some of the key components of a full falls risk assessment.

  ASSESSMENT POSSIBLE INTERVENTION
1 Gait
  • Physiotherapy
2 Visual problems
  • Eye test and ensure wears glasses
3 Hearing difficulties
  • Remove earwax
  • Hearing assessment
4 Medications review
  • Reduce unnecessary medication
5 Alcohol intake
  • Alcohol cessation advice
  • Alcohol service referral
6 Cognitive impairment
  • Referral to a psychiatric team
7 Postural hypotension
  • Review medication
  • Improve hydration
8 Continence
  • Treat or rule out infections
  • Continence assessment
9 Footwear
  • Ensure good fitting footwear
10 Environmental hazards
  • Turn on lights
  • Take up rugs

References

  1. Falls in older people: assessing risk and prevention. Clinical guideline [CG161]. Published date:June 2013. Available from: [LINK]

 

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