Falls in Dementia

Case 1

80 yo CF, NH resident had a fall 2 days ago. Nurses observed the fall - patient rose from a sitting position, tried to walk with legs crossed and toppled over sideways. No injury was noted, VS were recorded: HR 60, BP 155/83.

Patient does not remember falling at all. She also fell 2 months ago and had a laceration of her right eyebrow which is healed by now.

Problem list from chart:
Dementia (MMSE 18/30), Bipolar disorder, HTN, L hip fracture S/P ORIF 4 yrs ago, LBP, Osteoporosis

Medications: Abilify, Actonel, Aricept, Buspirone, Lisinopril, MVT, Neurontin

What would you do in such situation?
First, examine the patient.

You have to check orthostatics (which were normal).

She is a little but vigorously active lady who performs the "get-up-and-go" test with ease.
There are no visible signs of trauma and the physical exam is normal.

The reason for the fall most likely was incoordination due to her dementia. Cardiovascular or neurological causes are less likely. Her fall risk score is 12 (>10 means increased risk)

What happened?
PT evaluation and treatment was ordered. Nursing staff will continue to follow.


Case 2
91 yo AAF, NH resident fell yesterday. Patient is not able to provide the history since she does not recall falling at all.

What is your best bet to gather the requires information?
Nurses - check the notes and ask them. Nurses reported that when patient was transferring from her wheelchair, she just slid down on the floor w/o hitting herself or LOC.

Problem list: Alzheimer's (MMSE 3/30), severe DJD, CAD, Anemia, PACs, CRI

Medications: Actonel, Aricept, FeSO4, MVT, Prilosec, Oyster shell, Tylenol q 6 hr, Tramadol

What to do?
First, examine the patient. She is a happy-looking elderly lady w/o visible injury - you have to document in your progress note that no injury was found.
Cardiovascular exam shows an irregular rhythm and the EKG reveals just what you expected - her well-known PACs.
Musculoskeletal exam shows severe OA with decreased mobility in knee and wrist joints. No signs of acute inflammation.
Neuro exam is normal.

What is the reason for the fall?
Deconditioning and decreased mobility due to OA.

What to do?
PT evaluation and treatment. Try NSAIDs plus PPI for pain management in addition to Tylenol around the clock. Also, you can add Capsacain cream.

Restraint were suggested as a method to prevent falls in this patient but this idea was dismissed. The patient really enjoys the limited mobility she has, and although this is exposing her to risk of falls, the restraints would put her in more danger.

What did we learn from these cases?
Falls are common in the elderly patients, especially in NH residents.
Often the cause is deconditioning or incoordination.
PT can help to prevent future falls.
Very often, there is no need for extensive investigations (Holter, 2D Echo, CT of the head, etc.), if the cause is obvious, like in the patients with OA above.

Thirty percent of community-dwelling elderly people and 60 percent of NH residents fall each year. A fall can be detrimental to a person's health, for example, more than 90 percent of hip fractures occur as a result of falls.

Causes of Falls According to Frequency:
Accident
Gait or balance problems, weakness, pain due to DJD
Vertigo
Medications, especially more than 4, e.g. long-acting BDZ, TCA, BP meds
Acute illness, e.g. UTI
Confusion and cognitive changes, e.g. delirium or dementia
Postural hypotension
Visual problems, CNS or CVS cause, e.g. syncope, epilepsy

Assess the risk of falls by performing "up & go"test or the simpler "get up & go" test. Ask yourself "How safe does this movement appear for the patient?"

How to reduce the fall risk:
Safe environment
Modify medications
PT and balance training


Resources:
Falls in the Elderly - AFP 04/00, including a mnemonic for fall causes - I HATE FALLING.
Falls - Merck Manual of Geriatrics