Falls in elderly can be common. How do you go about deciding clinically if there is an underlying organic etiology that warrants further work up?
Falls and unsteady gait are common presenting complaints that physicians routinely evaluate. How do you decide if further work up is warranted vs the fall being an etiology of environmental factors? Falls remain a major threat to the elderly. Being unsteady on feet or lack of confidence in their own mobility can hamper a patient’s ability to remain independent. However, care must be taken in allowing vulnerable individuals to try to remain independent without proper support as falls remain a major cause of morbidity and mortality accounting for over 36000 deaths a year. In 2020 there were over 3 million emergency room visits due to a fall in individuals over the age of 65.
Fall Assessment Algorithm
General Evaluation Of A Patient For Assessment Of Fall Risk Etiology Should Include the Following:
- Environmental Conditions
- Improper fit of shoes
- Improper fit of clothes
- Wet or slippery floor
- Irregular walking surfaces (carpeting, uneven surfaces, slopes, steps)
- Weather related (ice, rain, sun, etc.)
- Poor lighting / glare
- Small walkways / doorways
- Gait Conditions
- Orthopedic conditions and diseases
- Rheumatological conditions and diseases
- Foot deformities / impairments (plantar fasciitis, valgus/varus deformities, charcot joints, gout, fractures, etc.)
- Impairment of ADLs (Activities of Daily Living) – transferring, ambulation, continence (bowel and/or bladder), bathing, dressing, eating.
- Infection causing delirium or dehydration
- Inappropriate medication prescribing (Beer’s List, new medications, medications causing sedation, medication interactions, etc.)
- Organic Etiologies
- Cardiac / Pulmonary – orthostatic hypotension, aortic stenosis, anemia, peripheral vascular disease, hypoxia (COPD/asthma), CHF, anything affecting cardiac output.
- Central Nervous System – CVAs, degenerative brain conditions, seizures, movement disorders (Parkinson’s disease, Huntington’s disease, demyelinating conditions, etc.), spine injuries, cranial nerve impairments, CNS tumors, etc.
- Peripheral Nervous System – neuropathy, radiculopathy (pain/imbalance), Gillian Barre, other demyelinating conditions.
- Diet and Nutritional Factors – Low Vitamin D levels, thyroid dysfunction, low B12 levels, low folate levels, improper caloric intake, etc.
- Functional Impairment – lack of endurance due to debility, Ischemic heart disease, CHF, underlying cardiomyopathies, muscular dystrophies, COPD, other lung diseases, impaired balance, etc.
- Vision Impairment – age related macular degeneration, cataracts, glaucoma, retinopathies, visual field impairments, etc.
- Psychiatric Conditions – Depression, substance abuse, intoxication, withdrawal, BPV, middle ear infections, inner ear infections, malingering, etc.
- Orthostatic blood pressure check
- Full neurological exam including checking of proprioception, monofilament, vibratory sense
- Romberg balance test
- Check visual fields, Snellen eye chart
- Get up and Go test
- Labwork: B12, folate, thiamine, Vitamin D levels (25-hydroxy D3), TSH, CMP, CBC, iron studies if needed, imaging if suspicion of possible organic etiology