Clinical evaluation

History. The patient history is key to the evaluation of a fall. Ask about the circumstances of the fall (i.e., location, time, related activities) and whether there were any witnesses. Find out about such associated symptoms as dizziness, vertigo, syncope, weakness, palpitations, incontinence, confusion, hypoglycemia, or loss of consciousness. A history of previous falls or near-falls should be followed up, since fallers by definition fall again. Did an injury occur? Was the individual able to arise without help? Was an assistive device involved, and if so, was it being used appropriately? Is there indication of another acute illness? Perhaps most important of all, has there been any recent change in medication, or was alcohol involved? Finally, a thorough review of prescription medications and OTC agents is absolutely essential as this stage.

Physical exam. The most important aspect of the physical examination is often the most overlooked—a careful evaluation of the patient’s pulse and BP in the supine, sitting, and standing positions. Because older adults may not show orthostasis immediately on changing position, repeat measurement of standing BP at one and two to three minutes after arising. Is the individual dizzy during the evaluation? Elevation of temperature is not always seen with infection, but if present, usually indicates bacterial disease. Hypothermia may be a sign of sepsis or prolonged exposure to a cold environment.


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Evaluation of the patient’s mental status is another important component of the physical exam. Demented persons fall more often. Depression is associated with falls, and as stated earlier, delirium may produce a fall. Delirium represents a medical emergency and should always be rapidly assessed because of its high likelihood of excess mortality and morbidity.

After testing vision and hearing, the remainder of the physical exam should focus on the cardiovascular, neurologic, and musculoskeletal systems. The Tinetti get-up-and-go test is a simple means of verifying good balance and gait: Ask the patient to arise from a chair without using his or her arms, walk a few paces, turn, and return to the chair again without using the arms. If the patient is able to perform these maneuvers, balance and proximal muscle strength are adequate. The speed with which the test is completed should also be assessed, as gait speed is highly correlated with mortality. Inspect the feet for bunions, corns, and calluses.

Laboratory evaluation. Recommended blood work for individuals who have fallen includes complete blood count, serum electrolytes, renal function, blood urea nitrogen, glucose, vitamin B12, thyroid-stimulating hormone, and 25-hydroxy vitamin D (25[OH]D). Obtain drug concentrations for such medications as anticonvulsants, tricyclic antidepressants, and antiarrhthymics.

Diagnostic studies. Tailor diagnostic studies to the individual needs of the patient: Use CT or MRI of the brain for those with new head injury or abnormal neurologic findings on exam or if a central nervous problem is suspected; arrhythmia evaluation if there is a history of cardiac disorders or an abnormal electrocardiogram; and densitometry screening for those with risk factors for osteoporosis. Of course, any defined abnormalities require intervention. Referral to other health-care providers including a geriatric specialist, occupational therapist, ophthalmologist, or physical therapist may be very helpful in preventing further falls.

Strategies to reduce falls

Since falls are a geriatric syndrome with complex interaction of medical, aging, and other extrinsic factors, fall prevention requires a comprehensive approach. The combined efforts of multiple heath-care disciplines will usually be required. The goal is to reduce the number of risk factors without compromising patient mobility and function.

The first step is to identify those at risk. Ask frail older adults about falls at every visit; healthy individuals should be asked about them once a year. A nonjudgmental, open-ended question, such as, “Tell me about your last fall,” will elicit the necessary information as well as clues as to the cause or causes. Review each record for potentially hazardous medications. If the risk of trauma outweighs the benefit of the drug, discontinue use.

Recommend osteoporosis prevention, including appropriate intake of calcium and vitamin D and engaging in weight-bearing exercise. Balance training may also be useful, whether through tai chi or with the help of a physical therapist. Advise patients to avoid excess alcohol, and advocate for tobacco cessation. Whenever possible, reduce or eliminate such medications associated with osteoporosis as long-term heparin, anticonvulsants, steroids, and excessive exogenous thyroid hormone.

Inquire about positional dizziness at each visit, and consider orthostatic BP and pulse, especially for those individuals taking antihypertensive medication. For some patients, an ideal BP may not be possible without producing orthostasis and falls. Each individual’s clinical situation must be carefully weighed. Consider the following questions: Is the fall risk greater than the risk of an elevated sitting BP? Which is more likely to result in functional loss for this particular patient? What are the patient’s preferences? Avoid very tight control of blood sugar in older adults, as it is associated with falls, cognitive impairment, and excess mortality. Inquire about visual changes or difficulties, and recommend ophthalmologic evaluation at least yearly. Removal of cataracts in women has been shown to reduce falls, although there are few studies supporting this intervention.

If the individual has balance difficulties or deficits in activities of daily living, consider referral to occupational and physical therapy for education and home safety evaluation. Assistive devices may be helpful if indicated, but they must be appropriately fitted to the individual, and training by a physical or occupational therapist is essential for safe use.

Obtain a 25(OH)D level, and supplement to achieve a level of 50 ng/ml, if possible. This level has been found to result in significant reduction in falls and fractures in older adults. Reduction in fall risk occurs much more rapidly than reduction in fracture risk, so it is not simply a result of improved bone strength. Many older adults suffer from osteomalacia, a condition that presents with muscle and joint aches and, often, depression. These symptoms are easily mistaken for osteoarthritis, but dramatic improvement frequently occurs with resolution of vitamin D deficiency. Oral supplements are adequate for most individuals, but dietary intake alone will not produce the desired amount. Vitamin D toxicity does not occur until a level of 150 ng/ml is reached, which is very difficult to attain without extremely high doses of exogenous origin.4 Most patients need 800 to 2,000 IU/day to achieve adequate serum levels. Because there is great variability in absorption among individuals, reassessment of post-treatment levels after several months is essential.

Interventions with less evidence of efficacy include referral for arrhythmia management, targeted interventions for dementia patients, and vision refraction (new glasses may temporarily increase fall risk). Very frail older adults may be at greater fall risk during rehabilitation, so remain alert for this possibility.

Summary

Falls are a common and devastating event for older adults. PCPs can be the first line of defense against their associated disability and mortality. Be aware of the importance of screening, and act quickly when deficits are found. Vitamin D supplementation is a cost-effective and simple therapy. Avoidance of osteoporosis is also vital for reducing fractures in the event that a fall occurs. Careful review and pruning of prescription medications is essential at every visit. Referral to other providers can be very useful for gait and balance training as well as hazard reduction in the environment.

Ms. Kemle is Assistant Director, Division of Geriatrics, Department of Family Medicine, Mercer University School of Medicine in Macon, Ga.

References

1. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003;348:42-49.

2. Rao SS. Prevention of falls in older patients. Am Fam Physician. 2005;72:81-88.

3. Gill SS, Anderson GM, Fischer HD, et al. Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study. Arch Intern Med. 2009;169:867-873.

4. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.

All electronic documents accessed January 15, 2011.