- 1/3 rd. of young old (60-79 yrs.) and ½ of the old old (>80yrs) have at least 1 fall annually
- Women starts falling between 65 - 69 yrs. whereas men after age of 80
- More than half of the fall occur at home in which bedroom and bathroom are the commonest place.
- Acute Illness (UTI, Pnemonia, Skin/Soft tissue, Abdomen, Other Infections)
- Environmental Hazards (Slippery floor, absence of grabbers, low chair, high bed, dim bulbs, poor walking aids)
- Medications (Anticholinergics, Antihistaminics, BZD, TCA, See Beer's Criteria)
- CNS and Neurodegerative (CVA, TIA, Vertigo, Seizures, Dementia, Parkinsons, Myelopathy, Cerebellar causes, Postural Hypotension)
- Miscellaneous (ACS, PE, Syncopy, Vision and hearing issues, Arthritis)
- Triaging errors - the triage nurse will obviously triages fall patients to trauma bay, in addition the registrar or attending who lacks experience in handling Geriatric case will just focus on consequences of fall such fracture NOF, IT, SDH or minor abrasion and lacerations and forgets to work up the patient based on query in the mind – what precipitated the fall?
- Subsequently patient will be seen by Orthopaedics/Neurosurgery fellows with minimal geriatric experience. Patient is managed conservatively or surgically and discharge from the ward without looking at the precipitating event. This might lead to subsequent falls and vicious cycle continues.
- ED is the first point of contact and we need to ensure patients take the appropriate route or see the appropriate specialist on admission.
- Check whether patient is in Delirium using CAM score (Google it)
- GCS is not good tool to assess sensorium in elderly non traumatic patient
- Pulse – any arrhythmia, most common is AF in the OLD
- BP – if patient is ambulant checking postural drop (Peripheral neuropathy with autonomic dysfunction, Neuro - cardiogenic syncope etc)
- Auscultation – check for any AS murmur (most common), carotid brute
- Focussed Abdo and RS examination
- Detailed neuro exam in ED is not possible but a focused Lower limb neurology such motor power, DTR, sensory examination including JPS , gait and cerebellar signs
- A detailed history and examination will dictate what additional investigation to be done to answer the question in mind apart from trauma series of x-ray and CT brain
- Beware most elderly will be on some or other blood thinners
- Most of them need a broad work up to rule out infection.
- Elderly who are not fit to get discharged as a consequence of fall (#, Head injury, ACS etc) should be referred to respective units for further Rx
- All stable elderly with falls before discharge has to be addressed by physiotherapist (PT) or occupational therapist (OT) who may not be there in most Emergency Departments
- The PTs assess neurology of patient and prescribe appropriate exercises and walking aids while OTs check safety of patients house or old age home whether it is elderly friendly environment such non slippery floors, comfortable bed and chair etc.
- Those patients who does not have care taker at home or home safety is an issue should not be discharged rather admitted to Geriatric inpatient ward until social problems are sorted out or else they will definitely bounce to ED with another fall
- A Geriatric clinic appointment should be arranged in the next couple of day for a comprehensive geriatric assessment.
- During all the stages of working up, ask yourself - what could have precipitated this fall? Spend more time on history (next of kin, nursing home, paramedics)
- Have a low threshold for admitting elderly with unexplained events
- Keep the thought process broad with all differentials and causes in mind
- Some times you may not be able to get that answer, that's okay – make sure you are not missing any thing gross.
Rishal Rahman MBBS, FEM (Vellore), MRCEM (UK)
Department of Emergency Medicin
Christian Medical College
Vellore, Tamil Nadu
Rishal is dual certified in Emergency Medicine and Geriatrics. He is currently practicing as a Consultant in Emergency Medicine at Christian Medical College, Vellore. CMC Vellore has been one of the pioneers of Emergency Care in India that caters around 200 critically ill patients/day. In addition to General EM, his interests also include Geriatric EM, Geriatric Neurology, Academics and dealing with complexities of Geriatric Medicine such a poly-pharmacy, poly-morbidities and medication management. Rishal often swifts between the mindsets of an ED Doc and an in-patient Geriatric Consultant based on his work environment to ensure optimal patient care.