Falls are the leading cause of injury-related visits to the hospital. Falls can cause injuries including fractures and bleeding, but sometimes may also rarely lead to death of frail patients. Common risk factors for falls in the elderly include increasing age, medication use, issues related to memory and issues related to their senses.
Most falls do not end in death or result in significant physical injury. However, the psychological impact of a fall or near falls often result in a fear of falling and increasing self-restriction of activities. (A near fall is an event in which a person feels a fall is imminent but avoids it by compensatory action, such as grabbing a nearby object or controlling the fall). This self-restriction maybe initiated by the patient themselves, or a close family member. The fear of future falls and subsequent institutionalization (patient being admitted to a care home setting) often leads to dependence and increasing immobility, followed by functional problems and a greater risk of falling.
Older people who survive a fall may tend to have significant after effects. Hospital stays can be up to twice as long in elderly patients who are hospitalized (when compared to elderly patients who are admitted for another reason). Compared with older people who do not fall, those who fall experience greater functional decline in activities of daily living (ADLs) and in physical and social activities.
Falls and concomitant instability can be markers of poor health and declining function. In older patients, a fall may be a non-specific presenting sign of many acute illnesses, such as pneumonia, urinary tract infection or myocardial infarction (heart attack). It may even be a sign of an acute exacerbation of a chronic disease.
A single fall is not always a sign of a major problem and an increased risk for subsequent falls. The fall may simply be an isolated event. However, recurrent falls, defined as more than two falls in a six-month period, should be evaluated for treatable causes. An immediate evaluation is required for falls that produce injuries or are associated with a new acute illness, loss of consciousness, fever or abnormal blood pressure.
History of the fall
A thorough history is essential to determine the following: (1). mechanism of falling; (2). specific risk factors for falls, impairments that contribute to falls; and (3). the appropriate diagnostic work-up.
Many patients attribute a fall to ‘just tripping’, but the doctor would have to determine if the fall occurred because of an environmental obstacle or another precipitating factor.
To determine this, the doctor may ask questions such as what the patient was doing at the time, any preceding symptoms and how help arrived after the fall.
Common risk factors for falls and how to address them
* Older age (specially above 75 years) – this is a non-modifiable risk factor.
* Housebound status – when possible it is important to encourage older patients to walk even short distances. Sometimes physiotherapy would help in this case.
* Living alone – it is important to make sure they have adequate support, if living alone.
* Previous falls – having previous falls is a predictor for subsequent falls. If you have previous falls it is advisable to get them correctly assessed, to prevent subsequent falls.
* Being on multiple medications – patients on four or more medications have been observed to have a higher risk of having falls. The medications need to be rationalized, but if they are indicated then all medications should continue after the assessment.
* Acute illness – it is important to treat any acute illness promptly.
* Chronic medical conditions which affect mobility – diseases such as rheumatoid arthritis, chronic asthma, heart failure and liver disease can limit and affect mobility. It is important to keep these diseases and symptoms under control
* Issues with memory – in this case, the memory needs to be assessed and treatment given if appropriate.
* Problems with vision – vision should be corrected if possible. Sometime a simple solution such as glasses will help.
* Physical defects – if any there are any physical defects, appropriate aids should be given after assessment. These could include walkers or sticks.
* Hearing defects – these may be addressed by hearing aids.
* Environmental hazards – the home environment should be assessed and appropriate measures should be taken to make things safe at home. These may include having rails, removing tripping hazards and changing slippery floors at home.
* Impairment in leg or arm muscle strength – physiotherapy may help in some cases to build up the strength gradually.
* Issues such as postural hypotension – postural hypotension is a condition where the patient’s blood pressure drops significantly following standing up, from a seated or lying down position. Medication review as well as certain behavioural recommendations may help.
* A comprehensive assessment by your doctor after a fall at home would be important. This helps to get to the root cause of falls, returning the patient to baseline function and also to prevent future falls. After the doctor’s assessment, they may refer to other associated specialties for further assessment of a specific issue. Furthermore, they may refer to therapy teams such as physiotherapy to help with issues related to posture, movement and muscle strength. Occupational therapists could assess the home environment to reduce the environmental risks.
By doing the above, the resultant gains in quality of life for patients and their caregivers can be very significant.
(The writer is a Consultant in General Medicine and Geriatric Medicine, MBBS (Colombo), MRCP (UK), MRCP (Geriatric Medicine), FRCP (London).)
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