Mrs. G., an 84 y.o. woman, has fallen at home 5 times in the past 4 months. Her medical history is notable for mild Parkinson's disease and mild congestive heart failure. She states that the falls have all occurred when she was walking from one room to another in her house. She denies any syncope or lightheadedness, and states she fell because she lost her balance. Her medications include carbidopa/levodopa and benztropine for the Parkinson's disease, digoxin and furosemide for the congestive heart failure, ibuprofen for joint pain, and diazepam for insomnia.

On examination, she is alert and well-hydrated. Her blood pressure is 140/90 supine and 128/90 after 3 minutes of standing. Her pulse is 80 and regular supine and standing. Musculoskeletal exam is notable for bilateral bunion deformity. Neuro exam is notable for mild resting tremor of the left forearm, and although she appears fully intact during conversation, a Folstein MMSE score is 23/30. She is unable to arise from a chair without pushing off with her hands. She is somewhat unsteady with walking, with decreased step height and length and increased unsteadiness during turns. Lab evaluation is unremarkable.

Q: What potential factors could contribute to falls in this case?

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Risk factors for falls include "intrinsic" patient-related factors and extrinsic factors

I. "Intrinsic" risk factors:

• Older age
• White race
• Cognitive impairment
• Medication use - most modifiable risk factor
• long-acting benzodiazepines, barbiturates, antidepressants, neuroleptics, antihypertensives, diuretics
• Specific chronic diseases
• arthritis, lung disease, stroke
• Foot problems
• muscle strength
• balance
• Gait disorder
• Dizziness
• Acute illnesses
• Recent hospitalization
• number of intrinsic risk factors

II. "Extrinsic" Risk Factors

• Significance depends on vulnerability of patient + frequency of exposure to situation
• Environmental hazards
• slippery floor, poor lighting
• Ordinary activities
• walking, stairs
• Movements potentially leading to loss of balance
• turning, transferring, reaching

Factors associated with major injury

• Characteristics of faller 
  • Older age
  • History of falls resulting in fracture
  • Chronic illnesses like diabetes or strokes
  • Low body mass index (thin)
  • Decreased bone mass (osteoporotic female)
  • Decreased protective reflexes (e.g., parkinsonism)

• Circumstances of the fall
  • Falling from > body height
  • Landing on hard surface
  • Falling sideways or straight down on hip

Pre-hospital evaluation of falls

• Determine extent of trauma, stability for transport, i. e., ABCDE evaluation (Airway, Breathing, Circulation, Disability, Exposure)
• Remember falls may be nonspecific presentation of acute illness
• Obtain diagnostic information as circumstances permit , i.e., history from patient and/or bystanders

• History
  • circumstances, causes of fall
  • previous falls
  • baseline and current functional status
  • recent changes
  • general medical issues
  • premonitory symptoms
  • syncope (loss of consciousness, spontaneous recovery)
  • dizziness, vertigo
  • palpitations
  • chest pain, dyspnea
  • neurologic symptoms (weakness, dysarthria, confusion, ataxia, etc)
  • medication history - any changes
  • alcohol use

• Exam
  • vital signs
  • skin & extremities
  • evidence trauma
  • hip pain is due to a fracture until proven otherwise (foreshortened, externally rotated lower extremity confirms but not always seen)
  • cardiovascular
  • arrhythmias
  • signs of aortic stenosis (systolic murmur, decreased volume and upstroke of carotid pulse, congestive heart failure signs)
  • neuro
  • mental status
  • focal signs
  • other (tremor, spasticity, bradykinesia)

• Rapid environmental assessment (for falls at home)
  • General clutter
  • Poor lighting
  • Specific hazards
  • throw rugs, electrical wires

• Even if patient is unhurt, falls warrant early evaluation by a physician
  • Falls are "markers" for underlying serious conditions

Treatment of falls

• Falls are usually multifactorial: no standard approach
• Correct obvious problems (e.g., discontinue medications associated with postural hypotension)
• Syncope: management depends on cause; cardiac causes more common in elderly
• May require a combination of medical, rehab, environmental, behavioral strategies

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University of Washington, Division of Gerontology and Geriatric Medicine

Copyright 1999, 2000 David A. Gruenewald, M.D. and Kayla I. Brodkin, M.D. All rights reserved.