Falls

Falls can be significantly debilitating and distressing events for patients. The elderly form an increasing proportion of the general population, meaning falls are a common presentation to the emergency department; they can also prove to be complex and demand that the doctor play detective in uncovering the details before, during and after the fall of a patient who may, or may not, be able to provide a reliable recount of the events.

This Reference will allow for the exploration and revision of the definition, assessment and management of patients after a falls episode.

Falls can be a cause of great distress and debilitation in older adults and occur very often, with around a third of those aged 65 years or over and half of those aged 80 years or over affected (Public Health England, 2020), making it essential that an emergency clinician is able to assess and manage these episodes with confidence.

NICE (2013) defines a fall as ‘an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level’.

The patients most at risk of falls tend to be of advancing age and frailty with debilitating co-morbidities and reduced bone mineral density, meaning that falls with even a modest impact of force can inflict significant trauma upon a patient.

Learning bite

Falls occur when a patient lands below knee level. Advancing age and frailty make it a common and potentially dangerous occurrence.

Relevant patient pathology may be found which can pertain to have been causative, or as a consequence of, the fall. Whilst a large proportion of falls may be deemed to be ‘mechanical’ in nature, in reality it is likely there are detectable disease processes or social factors that might have made the patient susceptible to falling by impairing their consciousness (eg. causes of syncope), ability to balance (eg. causes of vertigo) or safety at home (have they become increasingly frail at home with increased care needs that are unmet?).

Patients who have had a ‘long lie’ on the floor (>1 hour) after having fallen are at high risk of complications such as dehydration, pressure sores, pneumonia, hypothermia and rhabdomyolysis.

These considerations should be taken into account in conjunction with having to assess and manage the harm caused by the fall which can include head injuries, limb injuries and/or fractures (eg. fractured neck of femur).

Learning Bite

Complications of falls are varied and can range from debilitating to potentially life threatening. The consequences of each episode should not blind the clinician to seeking out causative factors for the fall.

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;

1. Alertness
2. Abbreviated Mental Test (AMT-4); Age, date of birth, place (name of building/hospital), current year
3. Attention; instruct patient to list months in reverse order, starting from December
4. 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

A “head-to-toe” examination which incorporates all of the major body systems can ensure a comprehensive approach to examining a patient for pathologies that are causative or a consequence of the fall.

	Examination features
Head	CNS:Level of consciousness – GCS, AVPUPupils equal and reactive? (PEARL)Facial weakness, slurred speech, posterior fossa signs (?CVA), evidence of head injury (eg. scalp laceration, Battles sign)ENT:Haemotympanum?
Neck	Suspicion of c-spine injury? (Kannus et al, 2019)
Chest	Respiratory;Increased breathing effort?Dullness?Crepitations? (pneumonia?)Cardiovascular;Murmur? (eg. Aortic stenosis)Pulse? (arrhythmia?)Blood pressure? (eg. Septic shock, dehydration following fall)Musculoskeletal;Evidence of rib fractures? (eg. Increased mobility of ribs, crepitus)
Abdomen	Gastrointestinal;Abdominal tenderness?Genitourinary;Distended bladder? (eg. urinary retention)
Hips	Musculoskeletal;Fractured neck of femur? (eg. Reduced mobility of hip flexors, shortened and externally rotated leg)
Limbs (arms, legs)	Neurological;Weakness? (eg. CVA)Increased tone? (eg. CVA)Hyper-reflexia? (upper motor neuron pathology)Poor coordination? (eg. Cerebellar pathology)Stable gait?Musculoskeletal;Limb pain or swelling? Reduced mobility? (have them walk for 3 metres if appropriate – assess walking with their usual walking aid)
Back	Musculoskeletal;Spinal tenderness / bruising / swelling; ?vertebral fracture, ?spinal cord injury

Learning Bite

Following a falls episode a comprehensive examination should be performed which looks at the patient from head-to-toe with examination of the many potentially affected body systems.

 

Assessing the frailty of patients following a fall is important in identifying states of vulnerability preceding the episode and circumventing avoidable adverse events in the future, and can be performed as early as from point of triage. Establishing whether or not patients have a baseline state of significant frailty can help determine the beneficence of support services (eg. review by clinical frailty teams) and critical care interventions (establishing an appropriate (ceiling of care).

Below is a depiction of the Clinical Frailty Scale (CFS), known colloquially as the ‘Rockwood score’;

Figure 1: Clinical Frailty Scale (Copyright: Dalhousie University)

Higher CFS scores are associated with longer stays in hospital, greater need for discharge support and in-patient mortality; this relationship is illustrated in the following infographic presented by the NHS Specialised Clinical Frailty Network (2020);

Figure 2: Outcomes in Acute Care (Not Covid Specific) associated with frailty (NHS Specialised Clinical Frailty Network)

The NHS Specialised Clinical Frailty Network has also highlighted the following important aspects of the CFS to be aware of;

• It has only been validated in older patients (65 years and above), and not in younger patients and those with learning disabilities.
• Sometimes it can be difficult to assign a patient to one category as opposed to another in these cases the ability to define the patients level of vulnerability based on their baseline function (not just how theyve presented today), and focussing on the specific changes in their function in recent history, is key.
• Collateral histories from family, friends and carers can be of great value

Further tips to aid the correct assessment of frailty in a patient are included in the infographic below;

Figure 3: Top Tips to help you use the Clinical Frailty Scale (NHS Specialised Clinical Frailty Network)

Learning Bite

Assessing older patients for frailty is essential in establishing safety of discharge and an appropriate ceiling of care, and can be achieved using clinical frailty scores.

Bedside assessment

• Observations – Oxygen saturations, respiratory rate, level of blood pressure, heart rate, temperature, level of consciousness (?hypoxia, ?haemodynamic instability)
• Blood glucose (?hypoglycaemia)
• Cognitive assessment – eg. Abbreviated mental test (AMT) (?confusion)
• ECG(?arrhhythmias, ?brady-/tachy-cardias)
• Urinalysis (?urinary tract infection)

Serum investigations

Full Blood Count (FBC) – eg. Raised WCC (?infection)

Urea and Electrolytes (U+Es) (?acute kidney injury, ?electrolyte abnormalities)

Bone profile – forms part of the confusion screen and abnormalities present in malignancy (eg. hypercalcaemia)

Liver function tests / INR – alcoholic liver disease

Creatine kinase (CK) – rhabdomyolysis

Radiology

Chest x-ray (?pneumonia)

CT head (?cerebrovascular accident, ?subdural/extradural hematoma) – remember that NICE (2014) guidance for CT scan following head injury includes any change in loss of consciousness of amnesia in addition to;

• Age 65 or older
• Any history of bleeding or clotting disorders
• Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
• More than 30 minutes’ retrograde amnesia of events immediately before the head injury.

Consider FAST USS / CT scan in the context of significant trauma to the thorax, abdomen or pelvis

Learning Bite:

It is important to establish the patient’s baseline cognition and mobility. Because elderly patients are more easily prone to delirium a range of bedside and serum screening investigations are very often appropriate to rule out organic pathologies, such as infection.

Any disease process that may have contributed to the patient falling (eg. Infection) or injury resulting from the episode (eg. a fractured neck of femur) will of course need to be addressed in their own way, and may require specialist referral as appropriate.

As we have covered, elderly patients (especially though osteoporosis) are susceptible to fractures from even low-impact injuries which is why analgesia should be a priority early on. RCEM (2018) have published audits stressing the need to provide adequate pain relief for patients with a fractured neck of femur – this may be achieved via a fascia iliac block. When radiological tests are pending, other forms of analgesia can be administered in the interim.

Rhabdomyolysis as a consequence of a long lie might be evident as an acute kidney injury with a marked rise in creatine kinase (CK) (Wongrakpanich et al, 2018), and may be treated with vigorous hydration – however this must be done cautiously in patients who might be prone to fluid overload (eg. those with an impaired ejection fraction).

Additional considerations for patents who have suffered a falling episode would be in addressing the patients social circumstances, ability to carry out activities of daily living safely and measures to prevent further recurrence of falls.

Discharging a patient back to an unsafe environment is unacceptable, and so it might become necessary for the patient to be admitted to hospital so that services can be put in place to support the patient. The prevention of falls is supported by services such as the following:

• Care packages – for patients who require additional help with activities of daily living
• Physiotherapists – can support patients with an unstable gait
• Occupational therapists – strategies to prevent falls at home including modifications to the home environment
• Medication reviews – to address any offending medications which might contribute to falls (eg. antihypertensives) or which otherwise pose a threat to the patients wellbeing if they are deemed to be at increased risk of falls (eg. anticoagulants).

Learning Bite

a multidisciplinary approach to ensuring patients can return home safely is worth remembering, and may require hospital admission to facilitate.

Be wary of dismissing falls as being purely ‘mechanical’ in nature. Even if the patient feels they can clearly recall that they had simply ‘slipped and fell,’ it is very likely that there are confounding factors contributing to this such as impaired vision, unstable gait and/or hazards in their home. The patient may not offer these secondary features by their own initiative, which is why it is important to remember to enquire about them on history taking.

Delirium and frailty should always be considered in the elderly population and can be assessed formally with the use of the 4AT and Clinical Frailty scores respectively.

1. Public Health England. (2020). Falls: applying All Our Health. GOV.UK, [Online]. [Accessed 31 Mar. 2020].
2. National Institute of Health and Care Excellence (NICE). (2013). Falls in older people: assessing risk and prevention. Clinical guideline [CG161]. NICE.
3. Royal College of Emergency Medicine (RCEM). (2019). RCEM National Quality Improvement Project 2019/2020 Assessing for Cognitive Impairment in Older People Information Pack. [Accessed 24 Apr. 2020]
4. OSullivan, D., Brady, N., Manning, E., OShea, E., OGrady, S., O Regan, N., & Timmons, S. (2018). Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees. Age and ageing, 47(1), 61-68.
5. Kannus, P., Niemi, S., Parkkari, J., & Mattila, V. M. (2019). Sharp Rise in Fall-Induced Cervical Spine Injuries Among Older Adults Between 1970 and 2017. The Journals of Gerontology: Series A, glz283.
6. Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D. B., McDowell, I., & Mitnitski, A. (2005). A global clinical measure of fitness and frailty in elderly people. Cmaj, 173(5), 489-495.
7. NHS Specialised Clinical Frailty Network. (2020). Clinical Frailty Scale.[Accessed 25 Apr. 2020]
8. National Institute of Health and Care Excellence (NICE). (2014). Head injury: assessment and early management. Clinical guideline [CG176]. NICE.
9. Royal College of Emergency Medicine (RCEM). (2018). Fractured Neck of Femur Clinical Audit 2017/18 National Report. [Accessed 31 Mar. 2020]
10. Wongrakpanich, S., Kallis, C., Prasad, P., Rangaswami, J., & Rosenzweig, A. (2018). The Study of Rhabdomyolysis in the Elderly: An Epidemiological Study and Single Center Experience. Aging and Disease, 9(1), pp. 17.
11. Forbes, A., Kundishora, T., & Waiting, J. (2019). Fascia Iliaca Block. RCEMLearning. [Accessed 31 Apr. 2020].