II. Epidemiology

IV. History

  1. Acute history is often unreliable (e.g. cognitive deficits, unwitnessed falls)
    1. Gather history from the patient's family, accompanying friends and residential facility staff
  2. Description of fall
    1. Fall onto what surface (e.g. concrete, carpet)?
    2. What body parts struck the ground?
    3. Loss of consciousness or confusion following the fall?
  3. Precipitating events prior to fall
    1. Syncope
    2. Seizure
    3. Acute Vestibular Syndrome
    4. Micturation Syncope
    5. Standing from a seated position shortly before the fall (Orthostasis)
    6. Unlevel ground or curb
    7. Recent illness
  4. Prolonged immobility on the ground is associated with additional complications
    1. Rhabdomyolysis
    2. Pressure Injury
    3. Dehydration
  5. Medications and substances
    1. See Medications to Avoid in Older Adults
    2. Anticoagulation
    3. New medications or dose increase (e.g. Beta Blockers or other Antihypertensives)
    4. Alcohol
      1. Associated with more severe head and neck injuries
  6. Contibuting Factors
    1. Prior falls or fear of falling (most predictive of future fall)
    2. Assistive Devices unused or used incorrectly
    3. Cognitive Impairment
    4. Visual Impairment
    5. Hearing Impairment

V. Exam

  1. See Fall Prevention in the Elderly
  2. Vital Signs
    1. Orthostatic Blood Pressure and pulse (for Postural Hypotension)
  3. Trauma Exam
    1. See Trauma in the Elderly
    2. See Trauma Evaluation
  4. Neurologic Exam
    1. Mental Status Exam
      1. Consider formal testing (e.g. SLUMS Exam via occupational therapy)
    2. Cranial Nerve exam
      1. Including Visual Fields and Extraocular Movement testing
      2. Evaluate for Nystagmus (Acute Vestibular Syndrome)
    3. Motor Exam
      1. Upper extremity (e.g. grip strength, proximal Muscle Strength)
      2. Lower extremity (e.g. stand from chair without pushing off)
    4. Assess coordination and balance
      1. Rhomberg test
      2. Ambulation in the hallway
      3. Get Up and Go Test
      4. Proprioception and vibration sense

VI. Labs

  1. See Trauma in the Elderly
  2. Typical lab evaluation in ground level falls
    1. Complete Blood Count
    2. Basic Metabolic Panel including Renal Function tests
    3. Urinalysis
      1. Caution in treating asymptomatic bacteruria in elderly women
  3. Other testing to consider
    1. Thyroid Function Tests
    2. Serum Vitamin B12
    3. Vitamin D level

VII. Diagnostics

  1. Electrocardiogram and telemetry
    1. Assess for Arrhythmia (Cardiac Syncope)
  2. Other diagnostics to consider
    1. Point Of Care Cardiac Ultrasound
      1. Assess volume status (acute Dehydration, acute Congestive Heart Failure)
    2. Electroencephalogram (EEG)
      1. Consider if history suggests Seizure (more common in Alzheimer Dementia)

VIII. Imaging

  1. See Trauma in the Elderly
  2. Use a low threshold for imaging the head and neck (high Incidence of occult injury)
    1. CT Head
      1. Exam alone has a nearly 40% False Negative Rate
    2. CT Cervical Spine
      1. Exam alone has an 80% False Negative Rate
  3. Other imaging to consider
    1. Chest XRay
      1. Consider CT chest if multiple Rib Fractures are suspected
    2. XRay Pelvis with unilateral hip
      1. Consider CT Pelvis if non-diagnostic

IX. Management

  1. See Trauma in the Elderly
  2. Treat falls as a sentinel event
    1. Falls should not be considered a normal part of aging
    2. Patients should present for acute evaluation after a fall
      1. Even older patients with a normal GCS of 15 and not on Anticoagulants may have Intracranial Bleeding
      2. Even older patients without NEXUS Criteria, may still have Cervical Spine Injury
  3. Consider Syncope evaluation
    1. Evaluate for Carotid Sinus Hypersensitivity (a risk for recurrent unexplained falls)
      1. Management with cardiac Pacemaker placement
    2. Non-syncopal falls ("mechanical falls") require as thorough an approach as for syncopal falls
      1. Identify and treat reversible contributing factors
      2. Evaluate for Dehydration, Electrolyte abnormality, Arrhythmia and infections
      3. Evaluate for Postural Hypotension, Vision Loss, vestibular abnormalities, Muscle tone loss, Polypharmacy
  4. Use this to prompt team evaluation
    1. Fall safety and home safety evaluation
    2. Evaluate for Osteoporosis
    3. Hearing and sight evaluation
    4. Review medications (see Polypharmacy)
    5. Consider Elder Abuse
    6. Discuss Advanced Directives
  5. Assess Safety for returning home (e.g. recurrent Fall Risk)
    1. Walk patient in the emergency department for postural stability
    2. Use the same type of Assistive Devices to which they have access
    3. Assess functional status and ADL participation

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