Falls

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Falls in Elderly Patients

It is known that approximately one in three people over the age of 65 living in the community will fall each year. This figure approaches one in two by the age of 80, and fall rates are even higher for residents of nursing homes and those in institutions. Falls cause injuries such as bruising, lacerations and fractures, for example Colles’s fracture and fractured neck of femur. These injuries are both costly to the individual, in terms of loss of independence and functional ability, and costly to the health and social care services.
It is estimated that the Government in England and Wales spends an average of £15 million annually on fall-related injuries; this excludes hip fracture, which costs the Government in the UK £1.7 billion annually. Further hidden costs for the individual occur in terms of depression, loss of confidence and even mortality. One of the leading cause of accidental death in older people are unfortunately falls. Up to 30% of falls are preventable if a standardised multidisciplinary approach is used.

Guidelines

Guidelines do exist from the National Institute for Health and Clinical Excellence (NICE), the Joint British and American Geriatric Societies and the American Academy of Orthopaedic Surgeons and the Scottish Intercollegiate Guidelines Network (SIGN), and are derived from a robust body of evidence.
There is now a political will within the National Service Framework for Older People in England and Wales and within the Scottish Executive to tackle this problem uniformly throughout the UK.
Australian community is yet to address this issue in more specifics terms with approaches formulated addressing this specific issue by the government.

The high incidence of osteoporosis and risk of fracture in the older population means that it makes sense to combine falls prevention with fracture prevention measures. Falls and fracture assessment depends on accurate history and examination. Risk factors are addressed individually, but also essentially as part of a multidisciplinary team assessment. The risk of future falls increases with the number of risk factors found. It is of note that some risk factors are not modifiable. The essential features of this risk assessment and interventions that are of proven benefit are discussed below.

Risk Assessment

An accurate history is vital in order to dictate how a fall is investigated. Gathering proper information to know whether this is the first fall, or has the patient fallen before? It is important to judge if this fall is in the context of an acute illness.

Risk factors for falls

• Lower limb weakness
• History of falls
• Gait/balance problem
• Visual impairment
• Arthritis of lower limb joints
• Postural hypotension
• Polypharmacy, i.e. four or more drugs
• Cognitive impairment
• Incontinence
• Age over 65


Common causes of postural hypotension

• Drugs
• Dehydration
• Anaemia
• Sepsis
• Alcohol
• Prolonged bed rest following illness
• Carotid sinus disease
• Autonomic failure
• Adrenal insufficiency


Causes of vertigo

• Benign positional vertigo
• Viral labyrinthitis
• Ménière’s disease
• Brainstem stroke
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