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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, June 19, 2017

Falls in Elderly

Definition

An event that leads to a conscious subject unintentionally coming to rest on ground or a lower level, not as a result of a overwhelming hazards or a major intrinsic event. e.g. – not due to trauma, seizure or syncope. A recurrent fall is defined as 2 or more falls occurring within 6 months, which need extensive evaluation for etiology.

Epidemiology
  • 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.
    Etiology
  1.      Acute Illness (UTI, Pnemonia, Skin/Soft tissue, Abdomen, Other Infections)
  2.      Environmental Hazards (Slippery floor, absence of grabbers, low chair, high bed, dim bulbs, poor walking aids)
  3.      Medications (Anticholinergics, Antihistaminics, BZD, TCA, See Beer's Criteria)
  4.      CNS and Neurodegerative (CVA, TIA, Vertigo, Seizures, Dementia, Parkinsons, Myelopathy, Cerebellar causes, Postural Hypotension)
  5.      Miscellaneous (ACS, PE, Syncopy, Vision and hearing issues, Arthritis)

Why is it important?
The world is invariably heading towards an era of exponential rise in elderly population than adults and adolescent group of population. Most ED's in US, Australia, UK, European nations and off course developing nations like India as well are already flooded with elderly population. As such GEM trained specialist are very meniscal in numbers around the world, we need very broad minded thought process and knowledge on Geriatrics to prepare ourselves. 
  •      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. 



Focused Clinical Examination in fall

A good history, keeping the various causes of fall in back of mind should be elicited from patient or care taker especially drug, social and financial history which lead to diagnosis in 90 % of cases. So spend more on it rather than on a detailed clinical examination.I agree eliciting history from an old or a care taker is a pain and very tough but believe me it pays off.
  • 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)

Also do general physical examination just like working up any other case
  • 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

Labs
  • 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.



ED Management
A good EP should always focus on the Q in the minds like Sherlock Holmes till you get that answer and of course managing injuries plus other consequences of fall which is obviously known by every one.



Disposition from ED
  • 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.



Take home
  • 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.


Author:

     
        
  Rishal Rahman MBBS, FEM (Vellore), MRCEM (UK)
  MD (Geriatrics)
  Associate Professor
  Department of Emergency Medicin
  Christian Medical College
  Vellore, Tamil Nadu 
  India
     
     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.

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