alls in the Elderly

First, ask: IS THIS THE FIRST TIME THIS YEAR? Two-thirds of those who
HISTORY and EXAMINATION experience a fall will fall
- Usually not too difficult to tell what happened again within six months.
Often obvious injuries
-
WHY DO OLD PEOPLE FALL OVER?
- Often helpful family to explain things The risk factors: ASK ABOUT THEM.
Anatomy of- a Fall Bell et al; MJA 2000; 173: 179-182 - There are EXTRINSIC and
- Aged about 75 – 80, maybe even older INTRINSIC factors for falling;
- Living in own home Often missed question: - Increasing age favours INTRINSIC
How long did Granny factors eg. confusion, instability;
- About 35% have fallen before
spend on the floor? - The 65-75s tend to fall over because
THIS TIME FALLING: Longer than 1 hour? Ingrate of extrinsic factors eg. loose carpets
children left her there. That
- 70% will sustain an injury. means she needs to have her and alcoholism
- 16% will be lacerations living situation re-evaluated.
- 17% will be soft tissue injuries
- 37% will be fractures (more frequent in women)
- 17% fracture their NOF
- 8% fracture their wrists
- 7% fracture their humeral neck
- 5% fracture their pelvis
LIST OF MEDICATIONS !! You NEED to know if somebody
has recently doubled their Lasix dose, added another antidepressant,
given them a major CNS tranquilliser; OR TAKEN AWAY the
antidepressant or tranquilliser which was keeping them safely in bed.
NORMAL AGE-RELATED GAIT CHANGES:
On EXAMINATION: Gait velocity declines 15% every decade (shorter steps); .
Assess the obvious injuries; and then More double-foot time (when both feet are in the ground);
ASSESS THE CAUSES OF THEIR FALL Neuro problems and claudication make it assymmetrical.
THE PETS ARE TO
BLAME: a study found
- TEST GAIT: commonest diagnosable cause of falls is gait disturbance.
many instances where pets
were the primary cause of a
- Test lower limb joints - its hard to balance on osteophytes
fall. Dogs, cats, birds, goats - Test proximal muscle weakness and lower limb nerves
and a donkey were
implicated. - Test cerebellar signs and vestibular CN Ifthere’s
they pass the “get up and go”,
probably no intrinsic falls risk
Kurrle et al, MJA 2004; 181
(11/12): 682-683 - “get up and go test”: get them to get out of a chair without
“Pokey Parlour Syncope”: an often using their hands. Not even specialists can easily and
unrecognised syndrome: an elderly person sits down to reliably describe gait, so don’t even try. Just ask
play the pokeys, stays upright for hours, gets dehydrated yourself: Does this method of locomotion look
and falls over; some kind soul tries to keep them upright trustworthy enough to propel 60kg of half-blind Nonna
and this causes them to have a slight convulsive fit.
through a cat-infested maze of old furniture?
- TEST VISION: degenerate maculae will prevent you from seeing the cat you tripped over
- Listen to their CAROTIDS: ? bruitt, stenosis? Syncope…
- Listen to the HEART: AF? Arrhythmia
- Postural drop: and can it be due to dehydration?…
- HYDRATION: did they become dehydrated for any good reason?..
Is there some cause of vomiting, diarrhoea, blood loss or infection?
Did that UTI cause their delirium, and they fell over on their 50th daily trip to the toilet?

HAS THERE BEEN AN UNRECOGNISED CEREBROVASCULAR EVENT?
Could they have haemorrhaged intracranially when straining secondary to constipation?

COULD THEY BE OTHERWISE ENCEPHALOPATHIC? Eg. liver failure, uraemia, myxoedema madness,
steroid psychosis (COPD management gone wrong), hypoglycaemia, drug reaction, B12 depletion, alcoholism?…
 Investigations : dictated largely by what the story is
…and by the potential for orthopaedic surgery to follow if the fracture needs repairing
It came from the SBA…
The 2001 answer paper claims that a subcapital FBC macrocytic anaemia? Huge WBCs suggesting sepsis?
fracture of NOF should be treated by prosthetic
replacement within 24 hours, even in a frail 94 year old.
EUC renal failure, hyponatremia, K+ induced arrhythmia?
LFT hypoalbuminaemic hypovolemia or hepatic encephalopathy?
THESE tests are useful. The imaging is
optional and guided by the clinical picture. TFT hypothyroid
Fancy tests wont teach you anything. B12 peripheral neuropathy
Much more likely to be confronted with an BSL hypo or hyper glycaemia
essentially healthy old person whose only
problem is an accidental dive off their back porch. Urinalysis renal failure, or more likely UTI?
Often there is no background problem to treat.
Often their living circumstances are involved. ECG walking around in SVT all day?
Often their biochemistry will be deranged for a
completely unrelated reason.
Chest Xray Hidden pneumonia?
However now and then it is the herald of some Abdo Xray Bowel obstruction?
new nightmarish complication which you don’t
want to miss; and sometimes there is a chronic Head CT blood? Normal dementing changes? TUMOUR??
cause which you can treat, and thus prevent
further falls. BONE DENSITY by Dual Energy X-Ray Absorptiometry
OSTEOPOROSIS is responsible for much morbidity, but its
unclear if it contributes to risk of falling. It sure makes fracture
more likely though.
And of course YOU WANT TO X-RAY THE FRACTURES
MANAGEMENT The key is to RESTORE FUNCTION TO PREVIOUS LEVELS
1. Fix the broken parts. …
- ADDRESS ALL EASILY REVERSIBLE ISSUES:
- Fix electrolyte abnormalities, give antibiotics, restore normoglycaemia, rehydrate etc.
- Reduce any reducible fractures, apply back slab, page orthopaedics registrar.
- ANALGESIA: mighty opium + paracetamol (consider laxatives in parallel)
2. Prevent short-term complications
- They may be staying in hospital for a while:
- HEPARINISE until INR ~ 2.0-3.0; give TED stockings;
- Manage the post-operative complications by the appropriate means, whatever they are
- MOBILISE EARLY: the longer they stay, the weaker they get, the more they fall
3. Prevent long-term complications
- FEAR of falling again severely restricts activities; this must be addressed with
appropriate supportive measures- preventative devices such as walkers etc;
- PLUS: explain to the patient that inactivity actually causes more falls than activity
4. Reduce the risk of further falls
Overview of their medications: eg. do they really need 3 kinds of beta blocker?…
MULTIFACTORIAL INTERVENTION: just one modality is not enough;
Consisting of: - GAIT and BALANCE TRAINING- Tai Chi, etc
ASK: HOW MUCH MOBILITY CAN YOU - ASSISTIVE DEVICE TRAINING
EXPECT WITH THIS NEW DISABILITY?
i.e, can you expect a complete functional
- MODIFY ENVIRONMENTAL HAZARDS IN THE HOME
recovery in a 99year old with a bilateral - REDUCE FRACTURE RISK WITH BISPHOSPHONATES
fractured NOF? Probably not. The rehab - FIX THEIR VISION AND POSTURAL HYPOTENSION
program must be tailored to realistic
outcomes, not idealised PPD guidelines. - hip protectors may do something, but does anybody actually wear them?