Falls
Age changes
- Reduced visual acuity, reduced contrast sensitivity and slower dark adaptation.
- Balance impairment secondary to loss of labyrinthine hair cells reducing vestibular input.
- Sarcopenia: loss of muscle mass and strength, and increased fatigability.
- Slower reaction time.
- Increased prevalence of osteoporosis (kyphotic posture).
- Increased body sway.
- Reduced walking speed with shorter broad-based or more irregular gait pattern, less effective heel strike and more time spent in double support (i.e. both feet on the ground at the same time).
- Cerebrovascular changes, contributing to cognitive impairment.
Introduction
- Falls are common: one-third of over 65s and half of over 80s living in the community fall per year; 50% of these are multiple falls.
- Women fall more frequently; they tend to be frailer than age-matched men and have increased body sway.
- Older people in care homes fall most – most frail.
- Falls are multifactorial, due to interplay between internal and external risk factors. An older person slipping on a wet floor cannot compensate quickly enough to save themselves, lands heavily and is likely to sustain a fracture.
- Falls are not an inevitable part of ageing, but the risks increase with age.
- Only 15% of falls are caused by circumstances that would cause anyone to fall, i.e. a true mechanical fall.
- Falls have important sequelae.
- Falls are a symptom, not a diagnosis.
- The NSF for Older People Standard 6 addresses assessment and prevention of falls and osteoporosis.
- There are multiple guidelines, e.g. NICE (2004) and the Royal College of Physicians (2011).
A simple mnemonic for falls
DAME (reminds you that women fall more frequently than men):
- Drugs (polypharmacy, alcohol).
- Age-related changes (as above: gait, balance, sarcopaenia, sensory impairment).
- Medical (stroke disease, heart disease, PD).
- Environmental (obstacles, trailing wires, poor lighting, etc.).
Intrinsic risk factors
History
An accurate history is an essential part of the detective work to determine all the risk factors leading to falls. It is also important to obtain a witness report.
Aid to remembering what to ask: SPLATT!
• Symptoms: dizziness, light-headedness, chest pain, palpitations?
• Previous falls: is this the first fall? (acute event) or one of many? (frailty/dementia)
• Location: falls occurring outdoors have a better prognosis than those in the home.
• Activity: walking, hanging out washing, extending neck, standing on chair?
• Time: getting out of bed, after taking tablets, after a meal, when coughing/straining/passing urine?
• Trauma sustained?
Symptoms
- Do you ever feel dizzy or light headed?
Dizziness is usually multifactorial. See Table 5.1.
- Do you get the sensation of the world spinning around you?
This suggests vertigo. Vertigo lasting only a few minutes after changing position is suggestive of benign positional paroxysmal vertigo (BPPV). This is diagnosed using the Hallpike manoeuvre. See Examination below. A longer history of vertigo suggests vestibular neuronitis.
- Did you get palpitations? Were they regular/irregular, fast or slow?
This would suggest an arrhythmia.
- Did you get any chest pain?
- Do you think you blacked out? How long for? How did you feel afterwards?
Syncope/transient loss of consciousness (TLOC) is transient global hypoperfusion which resolves completely with no neurological deficit. Exposure to an emotional or unpleasant stimulus, e.g. a funeral or phlebotomy, leading to a brief blackout with rapid and complete recovery is very suggestive of vasovagal syncope/simple faint. Recurrent blackouts merit investigations including tilt table, carotid sinus massage and heart rate monitoring. See Chapter 9.
- Did you bite your tongue? Did you lose bladder control?
This suggests seizures, especially if there was a prodrome, e.g. abnormal smell in temporal lobe epilepsy. Longer duration of LOC with tonic-clonic movements and cyanosis and slow recovery with confusion also suggest fits. See Chapter 8.
- Do you have any numbness in your feet or fingers?
This suggests peripheral neuropathy. Common causes are diabetes, B12 deficiency and alcoholism.
- Have you noticed changes in your eyesight?
Visual impairment (cataracts, glaucoma and inappropriate or dirty glasses) makes detection of hazards difficult. Slowed dark adaptation increases risk of falls at night.
- Do you have difficulty getting going, turning over in bed or freezing in doorways?
These are symptoms of Parkinson’s disease. See Chapter 8.
- Ask about all the drugs the patient is taking; remember over-the-counter medications. See Table 5.1.
- Take a full alcohol history.
Table 5.1 Drugs associated with a high risk of falling
Previous falls?
- A history of falls is highly predictive of future falls. Fifty percent of falls are recurrent.
- If this was the first fall, it may have been caused by hypotension secondary to an acute serious event such as an MI, GI bleed, sepsis associated with pneumonia or delirium.
- Recurrent falls are more likely to be caused by frailty, chronic diseases and dementia.
Location
- Patients who fall outside are fitter than their house-bound peers and have a better prognosis.
- Falls in the bathroom may be related to a slippery floor or use of emollients.
Activity
- What were you doing when you fell?
- Postural dizziness getting out of bed or standing up after sitting for some time suggests orthostatic hypotension.
- Situational syncope, e.g. blacking out after eating (post-prandial syncope), when passing urine (micturition syncope). See Chapter 9.
- Falling over is associated with urinary incontinence; both are markers of frailty.
- Falling after turning the head to one side might suggest carotid sinus hypersensitivity.
- Hanging clothes on washing line and going to the hairdresser are risky activities!
Remember:
60% of over 60-year-olds taking four or more medications will fall in a year.
Time
- Falling in the morning when getting up or following getting up after sitting for some time is suggestive of postural hypotension usually related to medications, but also secondary to Lewy body disease, Parkinson’s disease and diabetic autonomic neuropathy. See Chapter 9.
- Falling during the night may be secondary to nocturia due to BPH (see Chapter 13) in combination with postural hypotension, poor lighting in hallways plus drowsiness secondary to hypnotics.
Trauma sustained
- Minor soft tissue injury in 40–60% of falls: haematoma, skin tear, laceration.
- More serious soft tissue injury in 5% of falls: but would include subdural haematoma (see Figure 5.1), large haematoma requiring blood transfusion.
- Humeral fracture in 5% of falls.
- Wrist fracture.
- Vertebral fracture.
- Pelvic fracture.
- Fractured neck of femur in 2% of falls.
Figure 5.1 CT of the head demonstrating subdural haematoma. Note subcutaneous haematoma over right side of forehead, old darker subdural blood and newer brighter blood from new subdural haematoma.
Determining the causes of falls
This requires a corroborative history. It is essential to get a witness report of the events surrounding the fall because:
- The patient may play down the number and severity of the falls because of fear of consequences, for example being persuaded to move to institutional care.
- The patient may not remember blacking out, especially if the event was transitory.
- The witness can give information about the length of unconsciousness, whether there were tonic-clonic movements and post-ictal drowsiness, helping to differentiate syncope from epilepsy.
- The patient may have cognitive impairment. This may both contribute to the falls and prevent the patient from remembering the details.
- Research shows that even cognitively intact older people living in the community do not remember falls after 3 months.
Examination
Examination must be thorough but pay particular attention to the following:
- Does the patient look ill? If so, consider acute problems such as GI bleed, MI or PE.
- Check pulse rate and rhythm.
- Perform carotid sinus massage with pulse, BP and ECG monitoring if history suggests CSH. See Chapter 9 for method and contraindications.
- Check for postural hypotension: measure the BP – lying and after standing for 3 min. The drop is significant if it is > 10 mmHg diastolic or 20 mmHg systolic and accompanied by symptoms. Note whether there is a compensatory tachycardia. See Chapter 9.
- Listen for murmurs, especially aortic stenosis, carotid bruits.
- Assess the CNS and look for lateralizing signs.
- Look for signs of PD: mask facies, tremor, rigidity and bradykinesia. Examine the gait: shuffling, retropulsion and festination.
- Does the patient have myxoedema?
- Check for peripheral neuropathy.
- Check vision with a Snellen chart. Ask the patient whether they have had their eyes checked recently. Cataracts are easily treated.
- Bifocal and varifocal lenses are associated with falls; the view ahead in the lower portion of the lens may be blurred and impair depth perception and contrast sensitivity. This makes it difficult to negotiate steps and uneven pavements safely.
- Is there evidence of hearing impairment? Are the hearing aids correctly positioned? This does not have a direct bearing on falls risk, but it is helpful to hear shouted warnings! See Chapter 15.
- Examine the neck movements. Does this cause dizziness? If the patient describes true vertigo, do the Hallpike manoeuvre. Sit the patient on the bed and turn their head 45° towards the side producing the most symptoms. Then help them to lie down quickly until their neck is extended by 20°. The test is positive if there is rotational nystagmus towards the floor. Treat using the Epley manoeuvre to reposition the otoliths in the utricle. The patient sits on the bed with their head turned to 45° on the positive side. They then lie flat, keeping the head turned for 30 s. Next they turn their head 90° again, holding the position for 30 s. They roll onto the side they are facing for 30 s more and then sit up, still with the head turned for 30 s more. This process should be repeated three times. Warn the patient that it might provoke nausea and vertigo.
- Check for dementia/delirium. See Chapter 4.
Abnormal gait
- Frontal-related gait pattern: common in cerebrovascular disease, vascular dementia and Alzheimer’s disease. The gait is wide-based and apraxic and the patient may freeze; there is increased risk of falling when the patient turns. These patients fall when distracted as they cannot dual-task.
- Normal pressure hydrocephalus: a wide-based ataxic gait, associated with urinary incontinence and cognitive impairment. Head CT head shows dilated ventricles.
- Hemiplegic gait: steps are slower and shorter and the gait is less smooth because the affected leg is circumducted, i.e. the foot scrapes the floor in an arc.
- Spastic paraparesis: e.g. secondary to cervical myelopathy, bilateral scissoring of stiff legs.
- Cerebellar disease: an irregular, wide-based, unsteady gait.
- Sensory ataxia: e.g. peripheral neuropathy secondary to diabetes, the patient watches the ground and their feet rather than looking ahead. Romberg’s test is positive. The patient may stamp their feet.
- Vestibular ataxia: think of this if the patient complains of nausea, vomiting and vertigo.
- Parkinsonian gait: hypokinetic, festinant, shuffling gait with reduced arm-swing.
- Antalgic gait: e.g. secondary to osteoarthritis, asymmetrical because the patient puts their weight on the side with the painful joint as briefly as possible.
- Waddling gait: weakness of the hip girdle muscles and difficulty getting out of a chair caused by proximal myopathy, e.g. secondary to steroids and osteomalacia.
- Trendelenberg gait: weakness of one side of hip girdle due to gluteal medius weakness causes dipping of the affected side which is compensated for by the trunk leaning over the affected side.
- Foot drop: high-stepping, foot-slapping gait, e.g. secondary to common peroneal nerve palsy caused by compression from a tight lower leg plaster.
Baseline tests
- Full blood count.
- Thyroid stimulating hormone.
- B12.
- ECG.
Further investigations
Most falls are caused by problems with gait and balance. Further investigations depend on findings from the history and examination. If falls continue or remain unexplained, investigate more aggressively:
- Holter monitor: may show arrhythmias if the symptoms are frequent. If not, but the history is highly suggestive of an arrhythmia, consider an implantable loop recorder.
- If there are features of structural or valvular heart disease on examination or an abnormal ECG, echocardiography will be useful.
- Tilt table: measuring beat-to-beat variation in pulse and BP with the patient tilted (head up) to 70̊. See Chapter 9.
- CT scan if multi-infarct disease suspected.
- If seizures are suspected, consider EEG and CT.
Extrinsic risk factors
- Older people tend to live in older housing, which may need repairs.
- Poor lighting, especially near stairs.
- A lifetime’s clutter, especially if the patient has Diogenes’ syndrome.
- Inappropriate footwear; slippers are well-named and shoes with high heels impair balance. Shoes should fit correctly, have a small heel and a firm sole not so thick that it reduces proprioception.
- Incorrect use of walking aids.
- Pets underfoot.
- Trailing electrical cables.
- Slippery floor with loose rugs.
- Bathroom with low toilet, lack of grab rails by bath or shower.
- Unfamiliar environment, e.g. hospital or a care home.
- Wet, icy or uneven pavements.
Sequelae of falls
Sequelae occur in about half of reported falls. In addition to the traumatic complications above, falls may cause:
- Friction burns from carpet.
- Burns needing grafting (fall onto a fire or radiator).
- Quadriplegia due to a central cord lesion in a patient with spinal cord compromised by spondylosis (fortunately rare).
- Fear of further falls is common (up to 30% of fallers) and disabling, leading to loss of confidence, immobility (see Table 5.4) and even institutionalization.
- Anxiety/depression about the future.
- Anxiety in carers (formal and informal) may become intolerable, leading to the potential for elder-abuse.
- The need to move to safer surroundings may separate the faller from their support network. Well-meaning families may move their parents away from where they have been based for many years.
- Up to 25% of frequent fallers are dead within 1 year of presentation, not directly due to injuries but because of the underlying cause of falls.
