Falls Risk
Definition:
Falls risk assessment is essential for older individuals, particularly those over 65 years of age, to prevent injury and maintain independence. Falls can lead to fractures, hospitalizations, and even death. Identifying individuals at high risk and implementing preventive measures is crucial for reducing the incidence of falls.
Aetiology/Causes:
Several factors contribute to an increased risk of falls:
Age-related physical decline: Decreased strength, balance, and coordination.
Chronic medical conditions: Conditions such as Parkinson’s disease, stroke, and multiple sclerosis can impair movement and coordination.
Medications: Certain medications, especially psychotropics, sedatives, anticholinergics, and antihypertensives, can cause dizziness or orthostatic hypotension.
Vision and hearing problems: Impaired vision (e.g., cataracts) and hearing loss can increase the risk of falls.
Environmental hazards: Poorly lit areas, slippery floors, or tripping hazards in the home.
Incontinence: Urgency or nocturia can increase the risk of falls due to rushing to the bathroom.
Pathophysiology:
Falls are typically caused by a combination of intrinsic (e.g., muscle weakness, vision impairment) and extrinsic (e.g., home hazards, slippery floors) factors. Decreased strength and balance from aging or neurological conditions, along with medications that cause dizziness or low blood pressure, significantly contribute to falls.
Symptoms:
Recurrent falls: Two or more falls within the past 12 months.
Recent falls: Presenting after a recent fall or fall-related injury.
Balance issues: Difficulty walking, dizziness, or lightheadedness.
Leg weakness: Decreased muscle strength, making it hard to rise from a chair or climb stairs.
Incontinence: Urgent need to urinate, which may lead to rushing and falls.
Visual impairments: Difficulty seeing obstacles or hazards in the environment.
Differential Diagnosis:
Orthostatic hypotension: Dizziness and falls when standing up, commonly due to medications or dehydration.
Vertigo: Dizziness caused by inner ear problems such as benign paroxysmal positional vertigo (BPPV).
Musculoskeletal issues: Joint problems or pain may cause unsteadiness and a risk of falls.
Cardiovascular causes: Arrhythmias or other heart conditions that cause dizziness or fainting.
Neurological conditions: Conditions such as Parkinson’s disease, stroke, or multiple sclerosis that impair motor control.
Investigations:
Postural drop: Check for orthostatic hypotension by measuring blood pressure when the patient stands.
Electrocardiogram (ECG): To identify arrhythmias or heart conditions contributing to falls.
Vision assessment: Evaluate for conditions like cataracts or macular degeneration.
Neurological examination: To assess for cognitive impairments, gait issues, and other neurological conditions.
Urinary assessment: To evaluate for incontinence or urinary urgency, which may increase fall risk.
Bone density tests: To evaluate for osteoporosis if there is a history of falls and fractures.
Screening Guidelines:
If the patient answers "yes" to any of these criteria, they should undergo a thorough history, examination, and risk assessment to determine the underlying causes and appropriate interventions.
History:
Key points to gather during the history include:
Detailed fall history: How many falls, where they occurred (inside/outside), and the perceived cause of the fall (e.g., tripping, dizziness).
Dizziness or lightheadedness: Associated with standing up or during specific activities.
Palpitations: May indicate arrhythmias.
Walking or balance issues: Difficulty with ambulation or fear of falling.
Vision changes: Assess for cataracts or other visual impairments.
Leg weakness: Assess muscle strength and any known history of musculoskeletal problems.
Home hazards: Look for tripping hazards such as rugs or clutter.
Incontinence: Urinary urgency or frequency may contribute to falls.
Examination:
Cognition: Assess alertness and orientation using tools like the GPCOG (cognitive assessment).
Postural hypotension: Check for a drop in blood pressure on standing (orthostatic hypotension).
Heart rate: Irregular heart rhythms can contribute to dizziness or fainting.
Vision and cataracts: Test for visual acuity and screen for cataracts.
Gait and lower limb neurological function: Assess walking ability and any neurological deficits.
Feet and shoes: Check for deformities, poorly fitted shoes, or conditions like bunions or ingrown toenails that may contribute to unsteadiness.
Sit-to-stand and alternate step tests: Evaluate strength, balance, and coordination.
Assessment:
GPCOG: Use this cognitive tool to assess for cognitive impairments.
Falls Risk Assessment Tool: Use a standardized tool (such as a redbook-based tool) to evaluate the patient’s fall risk.
Occupational therapy (OT) assessment: OT assessment in the home to identify hazards and recommend modifications (e.g., grab bars, proper lighting).
Management:
Medication review: Rationalize medications, especially those that may contribute to dizziness or balance problems. This includes reviewing psychotropic drugs, sedatives, anticholinergics, and antihypertensives.
Regular exercise: Encourage home-based or community-based exercise programs, especially those that target balance and strength training (at least 150 minutes per week).
Vitamin D: Ensure adequate levels of Vitamin D (aiming for >60 ng/mL) to support muscle function and bone health.
Home modifications: Recommend home safety modifications, such as removing tripping hazards, improving lighting, and adding support bars in bathrooms.
Referrals:
Optometrist/ophthalmologist: For vision assessment and correction, particularly for cataracts or poor vision.
Occupational therapist (OT): For home safety assessments and modifications.
Physiotherapist: To help with balancing exercises and strengthening, especially if balance issues are present.
Podiatrist: For foot health, including addressing issues with footwear, gait, and any foot deformities.
NOTES:
ATSI individuals should be assessed more frequently due to their higher risk of falls and associated complications.
Medication review is critical in elderly patients, especially with polypharmacy and the use of drugs that may cause sedation, dizziness, or hypotension.
