‘She’s been up at casualty with another fall’
Consultant geriatrician at the Queen Elizabeth Hospital in Birmingham and co-chair of the BGS Falls and Bone Health Section, Dr Jonathan Treml, advises on how to tackle this common tricky presentation in a ten minute consultation. This article first appeared online in Pulse, a website aimed at GPs and other primary care professionals and which tweets @pulsetoday.
Falls are a common and potentially serious problem affecting around a third of older people each year. Often disregarded as an inevitable part of the ageing process by both patients and doctors, falls can be the first sign of frailty, disability and dependence.
Most falls in older people are the result of multiple risk factors, often including impaired gait, balance and mobility. Falls can be the presenting complaint of underlying pathology – including postural hypotension or syncope, vestibular or visual impairment, Parkinson’s or other neurological disease.
A doctor’s main roles in falls prevention are identifying and treating underlying problems, ensuring medication is reviewed for fall risk and bone health, and appropriate referral to falls prevention exercise programmes.
Dementia and postural instability often coexist and cognitive assessment should always be considered in people presenting with falls.
In this example, the patient came to the surgery following a recent fall, but often falls will not be volunteered as a problem without direct questioning. Take a detailed description of the fall and any symptoms prior to the incident from the patient and, if possible, a witness. Ask about previous falls and injuries and assess for common risk factors for falling.
Key components of multifactorial falls risk factor assessment
- Falls history
- Deficits of gait, balance and mobility
- Fear of falling (loss of confidence)
- Visual impairment
- Cognitive impairment
- Urinary incontinence
- Transient loss of consciousness
- Osteoporosis risk
- Medication (more than four prescribed medications or any drug affecting CNS or blood pressure)
- Home hazards
Specifically ask about dizziness before falls and try to establish if the dizziness is best described as:
- ‘spinning’ - suggesting vestibular disease
- ‘light-headedness’ - suggesting syncope or pre-syncope
- ‘unsteadiness’ suggesting impaired balance.
Consider transient loss of consciousness as the cause of a fall if the patient cannot recall the circumstances – e.g. “I suppose I must have fallen”.
Most older people fall due to underlying chronic problems with mobility or balance, but a fall may indicate an acute medical problem, such as an infection, which has lowered the threshold for falling.
In most cases, this acute problem will be clinically apparent at the time, but GPs should always consider the possibility of atypical presentation of acute illness in older people. Bear in mind that a UTI is rarely the cause of an unheralded fall and TIA almost never.
The most important part of physical examination in a faller is to watch them stand, walk and turn. This can be formalised as a timed up and go test, in which a patient is asked to stand from a chair unaided, walk two metres, turn around and return to sit in the chair. A patient is considered as high-risk for further falls if they take longer than 13.5 seconds to complete this task, or look unsafe in doing so.
If a patient reports ‘light-headedness’ before a fall, or has incomplete recall of falling, the resting pulse along with lying and standing blood pressures should be recorded. Ideally, the patient should be lying down for ten minutes before taking the supine and then standing BP readings. For practical purposes, it may be a good idea to use a second consultation room to allow the patient to rest quietly before measuring BP while minimising disruption of a busy clinic schedule.
Other aspects of examination will be tailored to symptoms. A more detailed cardiovascular examination should be performed in cases of suspected syncope, though there will be a low yield of relevant abnormal findings. Falls preceded by vertigo should prompt examination of the vestibular system with Romberg and possibly Hallpike tests.
There should be a low threshold for formal assessment of cognition and vision, but it will usually be appropriate to defer this to a subsequent consultation.
There are no investigations that are mandatory in the assessment of an older person that has fallen. Blood tests may be indicated if the history or examination suggests an underlying physical illness as a cause of contributor to a person’s falls. Similarly, a routine ECG is unlikely to yield abnormalities contributing to falls risk unless there are features suggestive of a cardiovascular cause for falling. Urinalysis may be of value if a patient describes new urinary symptoms in association with a fall. X-rays should be arranged to exclude injury if suspected after clinical assessment, which may not have been immediately apparent at the time of the fall.
DXA bone density assessment should be considered in any older person who has fallen and sustained a fracture, or who is at high risk of fractures (e.g. based on FRAX).
In managing falls, the goals are to reduce the risk of further falls and allow the patient to return to usual activities. Even in the absence of physical injury a fall will often cause an older person to curtail their activities, resulting in a vicious spiral of deconditioning leading to greater dependence and fall risk. Early intervention can help to mitigate this decline. Fall risk can be reduced by a multifactorial approach, addressing modifiable risk factors identified by clinical assessment [Box 2].1,2
Key components of multifactorial risk factor modification
- Strength and balance training
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review with modification/withdrawal
The best evidence for falls reduction comes from trials of strength and balance training. Referral should be to a practitioner trained in either the Otago programme or postural stability instruction. One or both of these exercise programmes are provided in most parts of the UK. Guidelines do not support the use of non-evidenced exercise programmes, particularly brisk walking or chair-based exercises.
The patient should have their medication reviewed. Psychotropic drugs should be identified and a plan agreed to reduce or stop these medications, if appropriate. Anticoagulation should usually be continued but may not be appropriate in patients with a history of frequent or injurious falls.
With the exception of strength and balance training, and cardiac pacing for some types of syncope, all other interventions have only been shown to work as part of a multifactorial approach, most commonly provided by a falls clinic.
Patients reporting more than one fall in a year, a fall with injury, or possible transient loss of consciousness are at greater risk of further falls and injury and should be referred to the local falls service for further assessment.2 This may be to a falls clinic or virtual falls service, depending on local arrangements.
The consultation should conclude with confirming that the patient understands the proposed actions, referrals or follow up, and the offer of an information leaflet such as this one which is available from Age UK.