Pearls:

Diagnosing an elderly patient with a mechanical fall is a diagnosis of exclusion.

Assess syncope versus mechanical fall.

Intervening on reversible risk factors can help prevent future falls.

CASE: An 84 year old man presents to the urgent care first thing in the morning after a ground level fall at home. He states he was walking to the bathroom, tripped forward and injured his wrist. He denies loss of consciousness or head injury. The fall was unwitnessed but the patient insists he tripped over some loose throw rugs on the poorly lit pathway leading from his bedroom to the bathroom.

DDx:

Seizure

Syncope

Mechanical fall

The exact history of how geriatric patients fall is often unclear. Ask specific questions to evaluate for features concerning for more serious causes of falls.

"Any seizure or shaking activity, biting of the tongue or blood in the mouth, urinary incontinence?

"When you woke up, did you know who you were and where you were?"

“Did you have any dizziness, chest pain, lightheadedness, shortness of breath?"

Why do falls in our geriatric patients matter?

Every year, about ⅓ of community-dwelling adults over the age of 65 have standing level falls.

In patients over the age of 80, that number becomes a 1/2.

Falls are the most common cause of traumatic mortality in geriatric patients.

Risk Factors Contributing to Falls in Geriatric Patients:

POLYPHARMACY:

Polypharmacy is extremely common in the elderly population and many medications put patients at an increased risk for falls.



The American Geriatric Society has published the Beers Criteria (also known as the Beers List), which identifies and groups medications that should be avoided in patients over the age of 65. There are five medications that providers in the Urgent Care should avoid:



Benzodiazepines - These medications are associated with dizziness and can absolutely contribute to falls and worse health outcomes.





Anticholinergics - Place elderly patients at high risk for imbalance and recurring falls (i.e. oxybutynin for urinary incontinence).





The anticholinergic toxidrome has a mnemonic: “Hot as a hare, dry as a bone, blind as a bat, red as a beet, and mad as a hatter.”







The list of medications that fall into this category are easily remembered as the four “Anti”s:







Antihistamines









Antipsychotics









Antidepressants









Antiparkinsonian





Tricyclic antidepressants (TCAs)- These medications are becoming increasingly used to treat patients with chronic pain. In addition to their anticholinergic properties (see above), independently, they can lead toward unsteadiness, gait instability and falls





Muscle relaxants - Ex. cyclobenzaprine.





Antiepileptics

ENVIRONMENTAL FACTORS:

Determine what physical impediments in this patient's home could lead them to fall.



Suggest simple interventions for fall prevention:



Non-slip mats under rugs





Leave a light on at night





Sit on the edge of the bed for a minute to allow things to equilibrate before standing up





Handrails or non-slip mats in the tub.



Preventing a future fall is just as important as finding out why a patient fell in the first place.

ANTICOAGULANT USE:

Inquire about the use of blood thinners like warfarin or rivaroxaban as well as anti-platelet agents such as plavix or aspirin.



Nishijima DK, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-8.e1-7. [PMID 22626015]



Even without injury or evidence of injury to the scalp itself (i.e. hematomas, scrapes, swelling) the risk of an intracranial bleed is high - a non-contrast head CT scan is indicated in all anticoagulated patients with a fall.

Common Injuries Sustained in a Fall:

Head injuries

Lacerations

Hip fractures, wrist fractures, ankle fractures, and long-bone fractures are very common due to osteopetrosis.

Rib fractures and pulmonary contusions are just as common as they are in younger populations, but certainly carry with them a higher morbidity and mortality in this older population.

Hip injuries can present a diagnostic challenge to providers in the Urgent Care, especially when a hip series appears negative but the patient is still tender or they are not able to bear weight or ambulate.

The gold standard for diagnosing hip fracture is not an X-Ray. A patient with a high pretest probability of having a hip fracture, needs advanced imaging with either an MRI or multislice CT if the plain film is negative.



The threshold for sending a patient for higher level imaging should be inability to bear weight in the urgent care.

Work up in the Urgent Care:

If a mechanical fall is certain, the only work up required is the evaluation and treatment of injuries sustained.

If a mechanical fall is less certain, consider digging a little deeper: