Falls in the Elderly

Initial Evaluation

  • History

    • Fall

      • Description of event

      • Loss of consciousness +/- head injury

    • Functional status

      • History of recent falls

      • Use of cane or walker

    • ROS: Diaphoresis, lightheadedness, dizziness, changes in vision, difficulty speaking, cough, palpitations, disuria, incontinence, weakness, muscle/joint pain, loss of consciousness, convulsions, tremor, difficulty walking, anxiety, confusion

    • Associated conditions: Acute illness (e.g. pneumonia, UTI), heart failure, hypertension, diabetes mellitus, peripheral neuropathy, nocturia

    • Review medications (see Medications/Substances below)

  • Physical

    • Orthostatic vital signs

    • Mental status exam

    • NIH Stroke Scale

    • Dix-Hallpike maneuver

    • Timed “Up and Go” Test

      • Patients stands from chair, walks 3 meters, and returns to chair

      • Duration > 30 seconds indicates impaired mobility

      • Observe gait during test (see below)

  • Labs: CBC, CMP, U/A, TSH, B12/folate, RPR, urine drug screen

  • Imaging: EKG, x-ray, head CT, MRI

  • Considerations

    • Recurrent falls is defined as two or more falls within 6 months

    • Falls account for 70 percent of deaths in patients age > 75 years

Etiology

Mechanical

  • Debility

  • Trips and slips

Syncope

  • Neurally mediated: Vasovagal

  • Cardiac: Arrhythmia

  • Orthostatic hypotension

    • Associated with change in position

    • Positive orthostatic vital signs: Sitting to standing

      • Decrease in systolic ≥ 20 mmHg

      • Decrease in diastolic ≥ 10 mmHg diastolic

Gait disorder

  • Cerebellar ataxia: Wide based gait with reduced step length

  • Upper motor neuron: Hyperreflexia + narrow gait with toe scraping

  • Lower motor neuron: Hypo reflexia + high stepping gait with foot drop

  • Myopathy: Waddling gait with abnormal pelvic tilt

Neurologic

  • Stroke/TIA: Facial droop, arm weakness, aphasia

  • Vertigo

  • Less common

    • Seizures: Stiffening followed by jerking/switching, frothy sputum production, urinary incontinence

    • Parkinson disease: Bradykinesia + resting tremor or rigidity

    • Normal pressure hydrocephalus

      • Mental status change, incontinence, wide-based and magnetic/glue footed gait (see video)

      • Diagnosis: MRI shows ventriculomegaly out of proportion to sulcal enlargement

      • Treatment: Consult neurosurgery for shunt placement

  • Medications/Substances

    • Sedating medications

      • Anticholinergics

      • Tricyclic antidepressants

      • Antipsychotics (typical and atypical)

      • Benzodiazepines

    • Antihypertensives

    • Hypoglycemic agents

    • Alcohol and/or recreational drugs

Common Injuries

  • Head injury: Subdural hematoma

  • Fall on Outstretched Hand (FOOSH)

  • Hip fracture: Evaluate for osteoporosis