Clinical assessment and risk stratification
History taking
It is important to establish, to the best of the patients recollection, the circumstances (when/what/how happened) pertaining to before, during and after the fall episode. In addition to these details it should be established whether there are any witnesses to the event (who might be able to provide a collateral history) and if the patient has their care needs met and are in a safe domestic environment.
| Before | During | After | |
| WHEN? | Can they recall what time they fell? | What were they doing when they fell? (eg. Getting up from sitting would suggest postural hypotension) | When did get up from the floor? (How long was the lie?) |
| WHAT? | Any warning signs? (eg. dizziness, chest pain) (*)Systems review | What surface did they fall on? (eg. hard floor, carpet). From what distance did they fall? (eg. downstairs?)Any loss of consciousness? (Do they have amnesia?)Any evidence of seizure activity? (eg. incontinence, tongue biting)Any vertigo? (eg. Benign Paroxysmal Positional Vertigo) | What injuries have they sustained? (eg. limb/head injury) |
| HOW? | Any changes in medication?Reducing mobility or recent falls? (increasing falls risk)(**)Any other predisposing risk factors | How do they think this happened? (eg. they might say they tripped) | How they have been affected? (eg. Weakness – TIA, can no longer walk independently – lower limb injury)Are they confused? (In which case be wary of their recollection of events) |
| WHO? | Does anyone else lives with the patient? Any care package in place? | (***)Did anyone witness the fall? (ie. is a collateral history available?) | Did anyone need to assist the patient off the floor? Do they need assistance in resuming activities of daily living? |
(*)As with any history a systems review should be performed to pick up any clues behind a disease process that might have predisposed the patient to falling:
- Cardiovascular – chest pain, syncope, palpitations
- Respiratory – dyspnoea, cough
- Neurology – impaired consciousness, seizures, weakness, slurred speech
- Gastrointestinal – abdominal pain, change in bowel habit
- Genitourinary – dysuria, urinary retention
- General – reduced mobility or exercise tolerance, neglect, (eg. Inadequate feeding, poor hygiene, not able to perform activities of daily living), weight loss
Learning Bite
History taking should be comprehensive with regards to ascertaining the course of events before, during and after each fall episode, and exploring symptoms with a system review
Risk stratification
(**) Predisposing risk factors;
- Age > 65 years
- Increasing frailty – an electronic frailty index (eFi) may be consulted where available
- Cognitive / visual impairment
- Reduced mobility (eg. arthritis, previous cerebrovascular disease, Parkinsons disease, Diabetes mellitus)
- Medication history (particularly polypharmacy) – eg. Psychoactive drugs (such as benzodiazepines), antihypertensives (may contribute to postural hypotension), diabetic medication (risk of hypoglycaemia), antibiotics (suggests a recent infection), anticoagulants (predisposes to haematoma formation)
- Environmental hazards
- Osteoporosis
- Alcohol misuse
- Depression
- Recent falls
(***) Collateral history – to be collected by witnesses to the event or close contacts of the patient where possible;
- What happened? – eg. Did the patient look unwell, unstable on walking/standing or demonstrate symptoms? (eg. Confusion, seizure activity)
- What is the patients baseline function? (ie. Baseline cognition / mobility)
- Any recent concerns about the patient?
Learning Bite
There are a wide range of possible contributing factors to a fall, making it less likely that the patient’s episode is purely due to a ‘mechanical’ cause rather than a predisposition not being explored.
Delirium
Delirium is often missed or misdiagnosed in older patients presenting to the emergency department with the potential to contribute to inaccurate history-taking, morbidity and/or mortality in such cases. The performance of EDs in assessing for delirium has been the subject of a recent national Quality Improvement Project (QIP) ran by RCEM (RCEM, 2019).
The ‘4AT’ is a quick and accurate tool for the exclusion of delirium (OSullivan et al, 2019), comprised of four components;
- Alertness
- Abbreviated Mental Test (AMT-4); Age, date of birth, place (name of building/hospital), current year
- Attention; instruct patient to list months in reverse order, starting from December
- Acute change / fluctuating course; significant variation in mental status over the past 2 weeks and persisting over the past 24hours
The tool can be easily accessed from: www.mdcalc.com
Learning Bite
Assessment for delirium is of great importance in older patients but is underperformed. 4AT is a quick method for reliably ruling out delirium