Falls

I. Background
Falls are most common at age extremes. In children older than 1 year of age, injuries are the number one cause of death. Falls account for 25% of these deaths. Bike injuries account for 68% of falls in children from 5 to 14 years of age (1). In patients older than 65 years of age, the incidence of falls is 30%; in those older than 80 years of age, it is >50%. Accidents are the fifth leading cause of death in patients 65 years of age and older, and falls account for two thirds of these deaths. Of elderly patients hospitalized for falls, only 50% are alive l year later (2).
II. Pathophysiology
Factors that contribute to falls need to be identified and evaluated for preventive measures to be taken. Children fall from heights; elderly fall from level surfaces.
A. Children and adolescents
Falls from heights over 3 feet and falls of infants younger than 1 year of age result in increased risk of skull fracture and intracranial bleeding. Emergent evaluation is needed in cases of loss of consciousness, behavioral changes, seizures, or ongoing vomiting.
B. Falls in the elderly
One half of the falls are secondary to accidents, including factors affecting stability. The other half of the falls are secondary to medical disorders (see Table 2.4.1). If syncope occurred with a fall, it must be determined whether the cause is cardiac or noncardiac (see Table 2.4.2) (Chapter 2.12). Cardiac mortality in falls related to syncope at 1 year is 20% to 30%, whereas noncardiac mortality is <5%(3). There is a strong association between falls and nursing home placement in the elderly; furthermore, specific individualized interventions help prevent falls (4). The risk of hip fracture in the frail elderly can be reduced with the use of an anatomically designed external hip protector (5).
III. Evaluation
A. History
  • History of the fall An interview of a witness to the fall is essential. This may identify any seizure activity, loss of consciousness, and method of fall. Ask what the patient was doing prior to the fall, including occurrence with positional changes or after voiding, eating, or constipation. Are there associated palpitations implying arrhythmia? Did the patient have a fall or syncope during exercise, which may indicate a cardiac cause? Is there any confusion that is new or changed from the past that suggests central nervous system trauma or seizure? Was urine or bowel incontinence present? Questions concerning home and risk factors should be raised (Table 2.4.1).
  • Past history Explore coexisting illness that may have contributed to the fall (Table 2.4.1). A family history of sudden death can imply arrhythmias. Furthermore, inquire about any history of prior falls.
B. Physical examination
This should include:
  • Assessment of vital signs, including heart rate and rhythm, orthostatic blood pressure changes, temperature, and respiratory rate.
  • A general body survey for any evidence of trauma.
  • Examination of the eye (funduscopic, visual acuity, and fields), mouth (tongue lacerations), neck (bruits), lung (congestive heart failure or infection), and cardiovascular (murmurs and rhythm).
  • A neurologic examination that includes mental status, evaluation of balance, gait, mobility, and tests for peripheral neuropathy.
  • The “get up and go test” (rise from a chair, walk 10 feet, return, and sit down), which is a simple rapid way of assessing general condition and musculoskeletal and neurologic status (6).
TABLE 2.4.1 Factors Affecting Falls
Factors affecting stability Medical problems contributing to falls
Decreased muscle tone/strength Arthritis
Changes in gait Previous stroke
Changes in postural control Hip fracture
Decreased depth perception Dementia
Decreased hearing Osteoporosis
Decreased proprioception Parkinsonism
Decreased vision Foot disorders
Slower reflexes Peripheral neuropathies
Hazardous living arrangements (e.g., poor lighting, slick floors, loose rugs, stairways, unstable furniture) Hyperthyroidism
Alcoholism
Medications
Hypertension
-- Hypotension
-- Myocardial infarction
-- Arrhythmias
-- Congestive heart failure
-- Acute stroke
-- Internal bleeding
-- Infections
-- Valvular heart disease
-- Seizures
C. Testing
  • Clinical laboratory tests Most blood tests are of low yield and should be done to confirm clinical suspicion. An electrocardiogram is useful in the elderly to rule out arrhythmia, atrioventricular block, prolonged QT syndrome, or ischemia. A diagnosis of the cause of the fall can be obtained in 50% to 60% of cases based on history, physical, and electrocardiographic study (7).
  • Diagnostic imaging Skull x-ray (fracture) and computed tomography studies to detect intracranial bleeding are recommended in all infants younger than 1 year of age or if the fall was from >3 feet. Also consider imaging with any loss of consciousness, evidence of head trauma, behavioral changes, seizure disorder, ongoing vomiting, or focal neurologic deficits.
  • Other testing to consider includes echocardiogram (valvular heart disease), electroencephalogram (seizure), carotid ultrasound (bruits), carotid sinus massage (if suggested by history), and tilt table testing (if a vasovagal cause of fall is considered). Ambulatory cardiac monitor for sudden infrequent falls.
IV. Diagnosis
A fall by an elderly individual frequently requires a home visit to evaluate factors contributing to falls and to correct unsafe conditions (Table 2.4.1). Symptoms of cardiac disease can occur with exertion or straining. Cardiac arrhythmias tend to be sudden without warning, although once in a while, patients can complain of palpitations. Noncardiac causes include the vasovagal reaction where the patient generally complains of dizziness or lightheadedness prior to a fall, often with changes in position or when upright. These can be associated with sweating and nausea.
P.19

Orthostatic noncardiac causes have gradual onset and resolution. These are most often associated with medications, including antihypertensives, sedatives, anxiolytics, antidepressants, hypoglycemics, psychotropics, histamine2 blockers, alcohol, over-the-counter cold medicines, and medications with extended half-lives. Neurologic noncardiac events can usually be diagnosed by history and physical examination. A psychiatric cause for falls is less likely, but one should be suspicious in cases of frequent symptoms with no injury.
TABLE 2.4.2 Causes of Syncope
Cardiac Noncardiac
Obstructive Vasovagal
Valvular disease Pain
Hypertrophic cardiomyopathy Voiding
Pulmonary hypertension Increased stress
Pulmonary emboli Cough
Myxomas Simple faint
Arrhythmia Carotid sinus disease
Sick sinus syndrome Orthostatic
Atrial fibrillation Medication
Arrhythmias Volume depletion
-- Diabetes
-- Parkinsonism
-- Neurologic
-- Stroke
-- Seizure
-- Migraine
For the differential diagnosis, refer to Tables 2.4.1 and 2.4.2.
References
1. Gruskin KD, Schutzman SA. Head trauma in children younger than 2 years: are there predictors for complications? Arch Pediatr Adolesc Med 1999;153:15 - 20.
2. Steinweg KK. The changing approach to falls in the elderly. Am Fam Physician 1997;56:1815 - 1824.
3. Wiley TM. A diagnostic approach to syncope. Resid Staff Physician 1998;44:2947.
4. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. New Engl J Med 1997;337(18):1279 - 1284.
5. Kannus P, Parkkari J, Niemi S. Prevention of hip fracture is elderly people with use of a hip protector. New Engl J Med 2000:343(21):1506 - 1513.
6. Albert S, David R, Alison M. Comprehensive geriatric assessment. In: William H, Edwin B, John B, et al. eds. Principals of geriatrics, 3rd ed. New York, NY: McGraw-Hill, 1994: Chapter 17:206.
7. Hupert N, Kapoor WN. Syncope: a systemic approach for the cause. Patient Care 1997;31:136 - 147.