Assessment

 

A multifactorial assessment, should include the following elements :

 

1)  Obtain details of falls

 

• How did you fall?  What exactly happened?

• How many falls have you had in the past year?

This helps to differentiate between a one off fall and recurrent falls.

The first ever fall, or an increase in fall frequency, may indicate an acute illness.

 

• Have you ever blacked out or “just gone down” without warning?

Beware the patient who says “I must have tripped.” Do they actually remember tripping? Older people with or without cognitive impairment may try and be helpful by saying this but you should assess their risk factors.

Consider the possibility of syncope or near syncope causing falls that are unexplained.

 

• Do you get dizzy if you stand up quickly?  Do you get light-headed?  Do you ever feel the room spinning round?  Do you feel unsteady or unbalanced?

Consider the possibility of syncope or near syncope causing falls that are unexplained.

Conditions such as orthostatic hypotension or those causing vertigo may contribute to falls.

 

• Do you have to rush to get to the toilet?

Older people with overactive bladder or urinary incontinence will rush to go to the toilet, placing them at increased risk of falls.

 

2) Consider the impact of co-morbidities and review medications

 

Older people may have multiple co-morbidities for which they may be receiving treatment which may increase the risk of falling, e.g. antihypertensives, anticoagulants, psychotropics.

A pragmatic approach should be adopted in these circumstances, taking into account the benefit of current or intended treatment, the potential harm from continuing or discontinuing the medication, and the patient's own preferences and goals.

Medication reduction and withdrawal should be considered for older people with falls, especially if they are frail with multiple morbidities.

The STOPP/START criteria are recommended when dealing with polypharmacy in older people

There is often concern about an increased risk of subdural haemorrhage with the use of anticoagulants in patients who fall, although this may be over-estimated. A mathematical model estimated that, in a patient who takes warfarin because of atrial fibrillation and an annual risk of stroke of 5%, a patient would have to fall nearly 300 times a year for the increased risk of subdural haemorrhage with anticoagulation to outweigh its benefits. (Man-Son-Hing M,1999).

An individualised decision should be made for the patient taking into account patient preferences, and the potential benefits and harms of treatment.

 

3) Perform a physical examination focusing on:

• Vision

• Heart rhythm and rate

• Muscle strength

• Neurological impairment

• Knee exam

• Peripheral sensation

• Feet/footwear

 

A routine ECG should be performed. If falls are unexplained or may be consistent with syncope e.g. "I just go down doctor" then consider the possibility of cardioinhibitory carotid sinus hypersensitivity or  arrhythmia that may require further assessment. Arrhythmia should particularly be suspected if the resting ECG shows the following abnormalities (Brignole M, 2004) :

• Bifascicular block

• Trifascicular block

• Prolonged QRS

• Second degree heart block

• Sinus bradycardia <50pbm or sinus pause >3 seconds

• Long or short QT interval

• Non sustained VT

• Ventricular ectopics

• Q waves suggesting myocardial ischaemia

 

Older people living in the community with a history of recurrent falls and/or a balance and gait deficit are mostly likely to benefit from referral for professional strength and balance training.

 

4) Measure both lying and standing blood pressure

 

Orthostatic hypotension can be tested by asking the patient to lie down for 5 minutes; blood pressure can then be checked supine, immediately on standing, and again at 1 minute and 3 minutes. It is usually defined by a fall in systolic blood pressure of at least 20mm Hg or in diastolic blood pressure of at least 10 mm Hg.

Patients who become bedbound for long periods of time may become deconditioned, and may develop orthostatic intolerance such that they feel tired or dizzy when sitting out.

Postprandial hypotension can occur due to splanchnic vasodilatation after eating.

6) Perform a "Get up and Go Test"

 

5) Assessment of home hazards

 

This may identify common hazards such as loose carpets, seats that are too low or dim lighting, or identify required safety devices such as handrails or grab-rails.