Falls

Falls are bad. Most people recognise this fact. However they’re particularly bad in the elderly for a number of reasons, making them the leading cause of mortality in those over 75. Preventing them is a damn sight better than trying to deal with the consequences.

Reasons why falls are bad:

  • They hurt
      • fear of falling and loss of quality of life
      • loss of independence
      • residential home admittance
  • They cause damage
      • osteoporosis and co-morbidities make fractures more likely
      • Fractures lead to immobility, pain, and risky operations
      • They also cost a lot (¬£5 million a week)
  • They can cause much more damage
    • If on the ground for a long time
      • This can lead to muscle breakdown and kidney damage (rhabdomyolysis)
      • They may not be able to take their medication while on the floor (comorbidities)
      • They may be bleeding, and if they’re on Warfarin, this is going to be worse

Risk factors for a fall are important, and need to be ruled out, or at least acknowledged before letting someone go home, especially if they live alone:

If anyone is going to fall, it’s Marjorie. She’s 80, and a very thin little lady who’s had a lot of health problems in the past. She fell down the stairs last year and has since become dependent on her daughter to help look after her at home. She gets terribly confused about her medications because there are so many, and she worries about falling over because she has to keep rushing to the toilet every so often. Her son bought her some crocs for her birthday, which made her very sad, but the whiskey made it a little better…

  • Over 80
  • Female
  • Low BMI
  • Previous fall
  • Already dependent
  • Polypharmacy
  • Confusion
  • Other illness
  • Urinary incontinence
  • Inappropriate footwear
  • Home hazards
  • Depression
  • Alcohol abuse¬†

When someone presents with a fall, you should try and figure out why they fell, as this will affect your management significantly. Furthermore, patients will often hide the fact that they’re falling as they’re aware this increases the chance of admission to a care home. Make it clear that you want to help them maintain as much independence as possible, and by telling you what’s causing it, you might be able to help!

  • I tripped over the rug – Occupational Therapy help make homes safer
  • I stood up and everything went fuzzy – Orthostatic hypotension¬†
  • I leant my head back and fell – balance issues
  • I forgot to take my diabetes medications – hypoglycaemia
  • I got up straight away and felt fine – less worrying than ‘I was on the floor for five days’
  • I found it difficult to talk afterwards – stroke/TIA
  • I can’t find my glasses – eyesight problems

One of the best ways to figure out what happened is a collateral history – ask the patient if anyone else saw what happened.

  • Did they shake/bite their tongue

Bone health is also an important factor to consider, as fractures are more likely to occur in the elderly due to:

  • Osteoporosis
  • Osteomalacia
  • Paget’s disease of bone
  • Metastasis and malignancy

Two simple tests:

  • Timed up and go – ask the patient to stand up without using their hands, walk three metres and turn around and sit down again
    • If they can do this without wobbling then they are low risk
  • Turn 180 – ask the patient to turn so they’re facing the other way
    • If this requires more than four steps then further investigation is warranted

Preventing falls in the future:

  • The house
    • reduce risky obstacles, rugs, exposed wiring, furniture etc
    • wet floors
    • handholds and railings
  • The patient
    • ensure a good diet
    • encourage mobility and exercise
    • pilates and yoga to improve balance are best
    • encourage socialising and group activities to ensure independence and to allow others to check they are alright
  • The treatment
    • always review and query any medications and whether they are indicated
  • The fall
    • ensure that if the patient does fall, they are able to call for help quickly – pendant alarms etc

My general rule – If this person were my grandmother, would I be happy with her living on her own?

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