RECOGNITION AND ASSESSMENT
- Falls are common in the elderly
- may be the presenting symptom of an acute illness
- Causes are generally multifactorial
Falls and syncope
- Often overlap or difficult to distinguish
- patient may have no memory of the event
- may be no eyewitness accounts
- See blackout/syncope guideline
Risk factors
- Gait and balance impairment
- Reduced muscle strength
- Reduced visual acuity
- Cognitive impairment
- Drugs – polypharmacy
- sedatives/hypnotics, antidepressants, neuroleptics
- diuretics, class 1 anti-arrhythmics, alcohol, anti-cholinergics
- Predisposing conditions
- alzheimer’s disease, stroke, Parkinsonism,
- depression, visual impairment
- peripheral neuropathy, arthropathy, cardiac failure
- Environmental hazards
- poor lighting, loose carpets, lack of safety equipment
- poorly fitting shoes or clothes
History
Circumstances of fall
- Obtain an eye witness account if possible
- Ask for information that may suggest:
- syncope
- vertigo
- dizziness
- unsteadiness
- seizures
Consequences of the fall
- Time spent on floor
- Injuries sustained
Document any risk factors
- Medications that can precipitate postural hypotension
- History of falls, including previous fractures
- Impaired mobility
- Fear of falling
- Poor vision
- Incontinent of urine
- Confirmed dementia
Social history
- Carer support
- Lives alone?
- Environmental hazards
Examination
Cardiovascular
- Check for postural drop (after standing for 3 min)
- 20 mmHg in systolic BP or 10 mmHg in diastolic BP
- if drop confirmed, review diuretic therapy, antihypertensives and major tranquillizers
- Arrhythmias
- Structural heart disease
- Heart failure
Neurological
- Evidence of head injury
- Glasgow Coma Score
- Vision
- Muscle strength
- Tone
- Lower extremity peripheral nerves
- Proprioception
- Extrapyramidal and cerebellar function
Cognitive assessment
Locomotor
- Evidence of hip fracture or other bony injury
- Presence of muscle wasting
- Leg ulcers
- Deformities
INVESTIGATIONS
- FBC, U&E
- ECG
- Urinalysis
- Imaging to identify injuries or acute illness
RISK ASSESSMENT
A&E
- Check the Patient Risk Assessment booklet completed by A&E nursing staff
Falls in hospital
- Complete a post falls proforma
- ensure all interventions required have taken place
IMMEDIATE MANAGEMENT
- Treat injuries
Acute medical problems
- Commence treatment and refer to appropriate medical team
- If patient meets Frailty criteria for frail elderly and requires admission, request elderly care bed
- If syncope suspected, see blackout/syncope guideline
No acute medical problem
- If no acute medical problem and patient not independently ambulant, refer to physiotherapy
- Consider referral to intermediate care team for supervision at home or,
- if necessary, in an intermediate care bed
Patients discharged
- If at high risk of falls (a YES answer to any of the 4 falls risk screening questions) explain in the A&E summary letter
- If medical team feel further outpatient investigation or attendance at a Falls programme required, refer patient to Falls service
- information about recent falls and falls-related injuries
- known contributing factors (medical history etc.)
SUBSEQUENT MANAGEMENT
- Ward nursing staff complete Patient Risk Assessment booklet
- Start falls prevention care plan with a list of interventions
- In plan, doctor/pharmacist complete a medication review
- assess stopping/reducing drugs e.g. antidepressants, night sedation, antipsychotics, and antihypertensives
Full multifactorial assessment
Drugs
- Check medications that may cause falls
- Polypharmacy, especially if:
- cardiovascular drugs
- insulin or oral hypoglycaemic agents
- hypnotics
- psychotropic drugs
- Alcohol
Environment
- Refer to occupational therapy
Neurovascular problems
- Gait and balance, refer to physiotherapy
Living arrangements
- Social work referral
Investigations
Cardiovascular
- If aortic stenosis or hypertrophic obstructive cardiomyopathy (HOCM) suspected, echocardiogram
- 24 hr tape if:
- bradycardia
- first degree atrioventricular block
- right bundle branch block (RBBB) and left axis deviation
- second or third degree atrioventricular block
- recurrent episode of loss of consciousness, with no features of epilepsy
- if abnormalities on 24 hr tape, cardiology referral may be needed
Neurological
- If epilepsy suspected, EEG
- if EEG suggestive of epilepsy, see First seizure guideline
Osteoporosis Assessment
- Check for a history of fragility fracture (wrist, spine, hip, pelvis or neck of humerus)
- Vertebral fractures are common and often missed
- check imaging for any vertebral wedging/height loss/collapse
- if back pain, kyphosis, or height loss > 2inches, consider x-ray thoracic and lumbar spine
Previous fragility fracture
- Refer to Fracture Liaison Service
- For any patient not taking a bisphosphonate, check if it is contraindicated or tried and not tolerated
- If there is no contraindication and no report of intolerance, prescribe an oral bisphosphonate
- alendronate 70 mg or risedronate 35 mg once per week on the same day plus calcium and vitamin D supplementation
- if fracture spontaneous, check bone profile, thyroid function, and consider myeloma screen
No history of fragility fracture
- Check bone profile and consider Calcium and Vitamin D supplementation
- Use FRAX (remember to enter UK and if Bone Mass Density (BMD not available, leave blank) to determine future fracture risk and need for further treatment or DXA scan
- if at intermediate risk (yellow) in FRAX, refer for DXA scan
- if at high risk of fracture in FRAX, consider an oral bisphosphonate, or if intolerant/unsuitable, refer to osteoporosis service
Specialist referral
- Depending on clinical findings, refer to appropriate specialist
Recurrent falls
- Unless patient has moderate–severe dementia, refer to Falls service
DISCHARGE
- If at high risk of falls (a YES answer to any of the 4 falls risk screening questions in Patient Risk Assessment booklet) explain in discharge letter
- If medical team feel further outpatient investigation or attendance at a Falls programme required, refer patient to Falls service
- information about recent falls and falls-related injuries
- known contributing factors (medical history etc.)
- If inpatient echo and 24 hr tape have been requested, doctor who ordered the test to forward the results to the GP
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa