Introduction

Falls are common among the older people. It is a major cause of injury and trauma in the elderly. Falls could lead to significant morbidity and mortality in the elderly, as well as affecting the quality of life of the older persons. The risks of falls are related to the complex interaction among intrinsic factors, extrinsic factors and situational factors and the majority are preventable. Therefore, screening for risk of fall is very important in the elderly especially in high-risk groups to prevent future fall and its’ consequences.

Assessment of falling patient

It is recommended that individuals with risk of falls to be referred for multi-factorial falls assessment by a multi-disciplinary team.

The multi-disciplinary team should ideally consist of:

• Doctor

• Occupational therapist

• Physiotherapist

• Medical social worker

• Nurse/ Assistant Medical Officer

• Psychologist

• Prosthetist & Orthotist

• Dietician

• Family member

• Manufacturer for the assistive devices

• Counselor

Primary care interventions by multi-disciplinary team to prevent falls among older persons are effective. These interventions can reduce fall risk and prevent falls. Hence, screening and assessment for risk-factors of falls is recommended for the older persons.

Fall assessment

Screening tools

There are many tools to assess risk of falls. However, there is no single screening tool which is adequate for predicting falls. Most tools  cannot differentiate between potential fallers and non-fallers.

Common tests used such as gait and balance test (eg. the get-up and go test and turn 180 degrees tests) are based on clinical assessment.

It is suggested that screening should start by history-taking by asking if the elderly has fallen in the past year.

History

The elderly often do not report falls, therefore, they should be asked about history of falls in past years as a routine part of screening.

When falls are reported, acute injuries should be evaluated and treated first.

Next, the history should focus on:

• Intrinsic, extrinsic and situational factors

• Questions about present and past medical problems

• Drug use

• Witnesses to the fall should be questioned if available

Physical Examination

The physical examination should be comprehensive enough to diagnose/ exclude obvious intrinsic causes of falls. Evaluation should include:

• Blood pressure- measured with the patient supine and standing to rule out orthostatic hypotension.

• Vision screening.

• Cardiovascular examination – helps to diagnose/exclude underlying arrhythmia, valvular heart disease and heart failure.

• Musculoskeletal:

• • Assess footwear (stability and grip)

  • Remove footwear and examine feet

  • Examine major joints for deformity, instability and stiffness

• Neurological- includes assessment of muscle strength and tone, sensation, coordination and gait. It helps to diagnose/include:

• • Stroke

  • Parkinson’s

  • Myelopathy

  • Cerebellar degeneration

  • Cognitive impairment/ dementia

• Gait and balance test

• • Rhomberg’s test (the patient stands with feet together and eyes closed)

  • One legged stance for 30 secs, eyes open (the patient stands on one leg for 30 seconds with the eyes open)

  • Turn 180 degrees tests

  • Get-up and go test

  • Appropriate foot wear

The get-up and go test

• Record the time it takes for a person to:

• • Rise from a hard-backed chair with arm -rest

  • Walk 10 feet (3 meters)

  • Turn

  • Return to the chair

  • Sit down

• Interpretation:

• • Most adult can complete the test in 10 seconds

  • Most frail elderly adults can complete in 11-20 seconds

  • More than 14secs increased risks of falls

  • More than 20 seconds requires comprehensive evaluations

• Results are strongly related with functional independence in the activity of daily living.

Frequency and schedule for screening

Older persons with risk of falls should be screened every 12 months or more frequent if indicated.

Laboratory screening

• Tests eg. ECGs, cardiac monitoring, measurement of cardiac enzymes and echocardiograms are recommended only when a cardiac cause is suspected.

• A full blood count, blood electrolytes and tests for occult blood in stool are useful only when systemic disease is suspected.

• Spine x-rays, CT or MRI of the head or EEG are only indicated when the history and physical examination detect new neurologic abnormalities.

Please note that the decision on tests to be done and  interpretation   of above tests must be done by trained personnel.

Conclusion

The risks of falls are usually related to the complex interaction among intrinsic factors, extrinsic factors and situational factors and majority are preventable. Therefore, screening should be carried out routinely to identify older persons with risk of falling and prevent future falls and its’ consequences.

References

1. Scott V et al. Multifactorial and mobility assessment tools for falls risk among older adults in community, home support long term patient care setting. Age Ageing 2007;36:130-9

2. Simon G, Lesley A, Joanne AF, Sarah EL. Systematic Review of Accuracy of Screening Instrument for Predicting Falls Among Independent Older Adults. Journal of Rehabilitation Research and Development. 2001;45:1105-116.

3. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA. 2007; 297(1):77-86.