Geriatric Quick Consult       Falls in Older Patients      DOs and DON'Ts

Falls are often multifactorial: therefore you should not look for a single cause. When evaluating an older patient that is falling, determine which intrinsic risk factors the patient has and address most or all of those risk factors. One way to remember intrinsic risk factors is to keep in mind that stability requires successful function of three components:
  1. sensory
  2. musculoskeletal
  3. central integrative
Any impairment of these components increases the risk of falling. Systemic factors, such as acute illness or postural hypotension, and extrinsic factors, such as medications, can also affect cerebral (central integrative) function and contribute to increased risk of falling. Multifactorial interventions have been shown to decrease the risk of falling. The American Geriatric Society (AGS) Panel on Falls in Older Persons published guidelines for the prevention of falls in 2001.1 They recommend these multifactorial interventions depending on the setting:
  1. Community-dwelling older persons (i.e. living at home):
    • gait training and advice on appropriate use of assistive devices
    • review and modification of medications
      • especially psychotropic medications
    • exercise programs that include balance training
    • treatment of postural hypotension
    • modification of environmental hazards
    • treatment of cardiovascular disorders including cardiac arrhythmias and carotid sinus hypersensitivity
      • weaker evidence, based on expert opinion or extrapolated from studies
  2. Older persons in nursing homes and assisted living facilities:
    • staff education programs to improve care of at-risk persons
    • gait training and advice for patients on appropriate use of assistive devices
    • review and modification of medications especially psychotropic medications
  3. Older persons in the acute hospital setting:
    • There is insufficient evidence to make recommendations for or against multifactorial interventions. There are no adequate randomized controlled trials.
DO all of these DON'T do any of these
Make sure the patient is not seriously hurt. use physical restraints unless absolutely necessary.
Review risk factors for falls. place/leave bladder catheters in.

Review ALL medications, if possible eliminate those with CNS activity.

keep patients in bed.
Check for postural hypotension: measure blood pressure supine and upright. focus every work-up exclusively on cardiovascular etiologies and seizures.
Do carotid massage, with ECG monitoring, for unexplained falls. forget the psychological impact of falls -- fear.
Check balance and gait.  
Treat osteoporosis.  
Use hip protectors.  
Order a home assessment to check the environmental hazards.  



References:

1. Guideline for the Prevention of Falls in Older Persons. J Am Geriatr Soc.2001.49:664-72.
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