Abstract
Falls are a common problem associated with old age. The UK has an increasingly ageing population, and the care of older people forms a high proportion of a GP’s workload. Early identification of risk factors and prompt intervention are crucial in minimising the long-term morbidity and mortality associated with falls. This article aims to provide a structured approach to the assessment, management and prevention of falls in the community.
The GP curriculum and falls in the elderly
Understand the management of conditions commonly associated with old age such as falls Understand the hazards posed by multiple prescribing Develop policies to effectively manage repeat prescriptions Provide care that promotes the patient’s sense of identity and personal dignity Develop an organisational approach that allows easy access to the primary healthcare team for older people Know how to access support services for older people in the community e.g. home care services, visual and hearing aids
Background
A fall is defined as the movement of a person from a higher to lower level under the force of gravity, typically suddenly, swiftly and without control (World Health Organisation, 2007). Falls and fall-related injury are serious clinical problems faced by older people. Thirty percent of people aged 65 years and over fall at least once a year, increasing to 50% of people aged 80 years and over (The National Institute for Health and Care Excellence (NICE), 2013).
The individual consequences of falls.
Although posing a great challenge to healthcare providers, falls resulting in serious injury or death are potentially preventable. Effective recognition and intervention within a multidisciplinary environment can considerably reduce the frequency of falls. A key government target in the National Service Framework, aims to reduce the number of falls resulting in serious injury and provide effective treatment and rehabilitation for those who have fallen (Department of Health, 2001).
Clinical presentation
Patients often present with acute fall-related injuries. Falls may also be recognised through direct questioning by healthcare professionals. It is important to be aware that elderly patients rarely report falls. Given the multifactorial nature, a detailed history is fundamental to identifying the cause of a fall. Figure 1 demonstrates the common symptoms leading to falls, and Table 1 lists the range of differential diagnoses of these reported symptoms. A collateral history is important if the patient has a poor recollection of the event.
Causes of falls in the elderly. The differential diagnosis of falls.
Ask the patient to describe the circumstances surrounding the fall from the beginning to its end. Enquire about what they were doing at the time, where they were, whether they had any symptoms near the time of falling, and how they were after the fall. Specifically, ask about loss of consciousness, preceding cardiovascular symptoms (chest pain/palpitations/dizziness), and neurological symptoms (e.g. weakness of limbs). If the patient is unable to remember the fall, or if facial injuries are sustained, it is likely that they lost consciousness. A collateral history should be obtained to elicit the length of time the patient was unconscious and whether any seizure activity or confusion on waking was noted. Incontinence is an unreliable sign for seizures in the elderly, as it also often occurs with syncope (Patient UK, 2014).
Fall circumstances indicating a specific aetiology.
The history should also include questions about past medical problems, to identify patients with cardiovascular or neurological disease and multiple co-morbidities. Ask about cardiovascular risk factors (hypertension, high cholesterol and ischaemic heart disease) and chronic conditions such as diabetes and Parkinson’s disease. It is important to enquire about osteoporosis and previous fractures to identify patients at risk of fractures from falls.
A comprehensive drug history is essential, as polypharmacy increases the risk of falls in elderly patients. Enquire about psychotropic and antihypertensive medications, in particular. Identify those patients on anticoagulation or anti-platelet therapy, who are at increased risk of injury from falls.
Ascertaining the baseline functional status of the patient can help identify risk factors for falls. Ask the patient about assistance with activities of daily living, such as feeding, washing and dressing, and whether carers are already in place. Enquire about mobility and the use of walking aids inside and outside the home to identify patients with gait or balance problems. Ask specifically about the home environment, e.g. who they live with, the type of property, whether the patient needs to climb stairs, and about any existing home adaptations. The amount of alcohol consumption and smoking status should be established.
Clinical examination
During the 10-minute GP consultation, the clinical examination should be tailored and focussed towards the suspected causes of the fall and related injuries. However, at the same time, it is pertinent to consider other modifiable risk factors that might have directly contributed to the fall. This assessment may require more than one consultation. Potential areas to include in your examination are outlined below.
Cranial nerve examination
Test the cranial nerves to assess for any gross neurological deficit suggestive of a stroke. Test for nystagmus to identify vestibular dysfunction. Assess the eyes by checking the visual acuity using a Snellen chart and look for cataracts. Consider review by an optician if abnormalities are identified. Fundoscopy can be used to look for papilloedema if there is suspicion of head trauma following a fall.
Neurological examination
Assess the tone, power, reflexes of the limbs and coordination to identify focal neurological signs. Look for muscle-wasting to identify disuse atrophy or a proximal myopathy and check sensation and proprioception to identify a peripheral neuropathy. Assess for gait disturbances and look for features of Parkinson’s disease.
Cardiovascular examination
Assess the heart rate and rhythm to identify atrial fibrillation, bradycardia or a resting tachycardia. Listen for cardiac murmurs or a carotid bruit and look for signs of heart failure. A lying and standing blood pressure, often performed by the practice nurse, can rule out orthostatic hypotension (defined by a postural drop of more than 20 mmHg in systolic blood pressure).
Mental state examination
The AMTS.
Gait and stability assessment
A formal screening gait assessment such as the Tinetti balance test or the ‘timed up and go’ test can identify individuals with gait or balance abnormalities. The Tinetti test is a scoring tool based on the patient’s ability to perform specific tasks related to gait and balance. The ‘timed up and go’ test requests the patient to rise from a chair, walk 3 m, turn around, walk back to the chair and sit down. Observe closely how the patient rises from a chair to identify signs of proximal myopathy. Difficulty initiating movement and turning around may be suggestive of Parkinson’s disease.
Investigations
Laboratory investigations (full blood count and serum electrolytes) and urinalysis are routine first line investigations that may reveal contributing pathology. Second line investigations should be reserved and targeted towards patients with suggestive signs and symptoms (Rubenstein, 2006).
A full blood count may reveal infection or anaemia and the mean corpuscular volume (MCV) may facilitate diagnosis; a low MCV is suggestive of iron deficiency and a raised MCV suggestive of B12 or folate deficiency or even alcohol misuse. Anaemia can cause postural hypotension, whereas alcohol misuse can impair balance and gait, thereby increasing the likelihood of falls. B12 deficiency can cause falls through limb weakness, ataxia or reduced proprioception. Thyroid function tests may be peeformed to investigate a proximal myopathy or increased confusion in the elderly. Diabetes can cause a peripheral neuropathy and autonomic dysfunction and can be diagnosed by elevated HbA1c or fasting serum glucose levels. Hypoglycaemic episodes, secondary to diabetic medications, can also predispose to falls. Serum electrolytes may demonstrate renal impairment or hyponatremia, both of which are significant risk factors for falls. Urinalysis may reveal unsuspected diabetes or infection.
An electrocardiograph (ECG) should be performed in the suspicion of an arrhythmia, such as atrial fibrillation or ischaemia. ECGs may also demonstrate conduction defects. A 24-hour ambulatory electrocardiograph may be required to pick-up paroxysmal arrhythmias. An echocardiogram can be helpful in diagnosing structural heart disease or heart failure. Autonomic dysfunction causing orthostatic hypotension can be confirmed with tilt-table testing.
Further investigations are usually performed in secondary care. A computerized tomography head scan is often organised if there is a suspicion of an acute head injury, a stroke, or as part of routine investigations for dementia. Carotid ultrasounds are performed in the transient ischaemic attack (TIA) clinic, in combination with a neurological consultation, to assess for narrowed carotid arteries that increase the risk of a stroke or TIA. A neurologist may arrange for an electroencephalogram to confirm seizures or electromyography to identify neuromuscular disease.
Risk assessment
Falls are often multifactorial in origin. Identifying modifiable risk factors early can enable preventative measures to be put into place, thus reducing a patient’s susceptibility to falls (Rubenstein, 2006). Elderly patients presenting with falls or considered to be at risk of falling should be offered a multifactorial risk assessment (NICE, 2013), as demonstrated in Fig. 2. This is often done at specialist falls clinics.
Multifactorial approach to risk assessment.
Management
The management of falls requires a holistic and individualised approach, often achieved through intervention by a specialist multidisciplinary falls team. The team usually includes an elderly care physician, physiotherapist, occupational therapist, district nurse and home care teams. In many areas, GPs have access to falls services. NICE recommend that any patient over 65 years in age should be referred to a specialist falls clinic if they seek medical attention due to a fall, report recurrent falls in the last year, or are observed to have gait or balance abnormalities (NICE, 2013). GPs also have access to rapid-response multidisciplinary teams in the community; they can assess and treat patients in their home environment. There is often a great degree of overlap between primary and secondary care management.
An acute change in the patient’s physical condition that is suspected to have contributed to a fall should be initially assessed by the GP to identify any reversible conditions that can be treated immediately e.g. a urinary tract infection.
Prevention
Multifactorial intervention programmes recommended by NICE.
Medication review
Polypharmacy itself is a risk factor for falling; studies have shown a 14% increase in the risk of falls in patients taking more than four medications (Freeland et al., 2012). Polypharmacy also increases the risk of sedation and contributes to impaired coordination. Psychotropic medication (antidepressants, antipsychotics and benzodiazepines) cause confusion in the elderly and increase the risk of falls. Psychotropic medications and sedative medications should be stopped where possible. Antihypertensive medications (diuretics, ACE-inhibitors, alpha-blockers) and tricyclic antidepressants can cause orthostatic hypotension (Patient UK, 2014). These should be reviewed regularly to reduce the risk of falls.
Osteoporosis risk
A patient with untreated osteoporosis is much more likely to sustain a fracture if they fall. Therefore, patients over 50 years in age and at risk of osteoporosis should be investigated and treated promptly. A commonly used tool in general practice is the fracture risk assessment tool (FRAX), which uses independent risk variables to estimate the 10-year probability of an osteoporotic fracture. The FRAX score can determine whether the patient is low, intermediate or high risk. Low-risk patients are often reassured with lifestyle measures and high-risk patients can be considered for bone protection without further investigations. However, patients at intermediate risk should be referred for a DEXA bone scan to measure the bone mineral density (BMD). The BMD can be used as part of the FRAX tool to recalculate the fracture risk and guide management. A BMD less than or equal to 2.5 standard deviations below an equivalent young adult reference population, otherwise known as the T-score, indicates osteoporosis.
Patients over 75 years in age who have fallen and sustained a fracture suggestive of osteoporosis (vertebral or long bone fractures) should be started on bone protection, without the need for further investigation (Longmore, Wilkinson, & Torok, 2010).
Bisphosphonates are usually prescribed first line with alendronic acid or risedronate sodium considered the drugs of choice. Second line drugs include Raloxifene, a selective oestrogen receptor modulator and teriparatide. Osteoporosis can be managed through lifestyle measures such as weight-bearing and balance exercises, stopping smoking and reducing alcohol intake. All elderly patients who are at risk of falls should have their vitamin D levels checked and replaced with cholecalciferol if less than 50 ng/ml.
Education
NICE guidelines recommend that all patients at risk of falling and their carers should be provided with information about their falls prevention programme, in order to improve compliance and maintain independence (NICE, 2013). Doctors are advised to give patients written and verbal information about the following:
Falls prevention measures to prevent further falls as outlined in Box 3 How to maintain motivation and persevere during exercise programmes The benefits, both physical and psychological, of reducing the risk of falls Resources for further information How to cope in the event of a fall
Charities such as AgeUK and the NHS Choices website also provide patients with falls prevention advice and access to further information.
Key points
Falls are important public health problems and have a significant impact on the physical and psychological well-being of older people Falls are often multifactorial in origin; a thorough history and examination can identify multiple modifiable risk factors NICE recommend a multifactorial assessment and intervention within a multidisciplinary team in order to safely manage patients who fall Falls can be managed by optimising medical health problems as well as regular medication reviews, home hazard assessment, correction of visual impairment and muscle-strengthening programmes Consider osteoporosis risk in all elderly patients to reduce the risk of fractures following a fall