AND THE ELDERLY
OUTLINE YOUR APPROACH TO THIS PATIENT.
From the patient
The fall itself
What was she doing at the time?
Did the fall occur while she was standing straight or was she bending over?
id she trip over something?
Did she lose consciousness?
Were the lights on?
Did the fall occur during the day or at night?
Had she been to the toilet
see clearly where she was going?
What time did the fall occu
Did she feel unsteady on her feet before the fall?
Could she have been moving her neck at the time of the fall?
When had she last had food?
Did she notice any symptoms before the fall such as a sensation of movement, light
headedness, palpitations, ch
est pain, loss of power, paraesthesia?
Had she been I pain before the fall?
Had she taken her medication that day? If so, at what times?
Could she have taken an
extra tablet especially either Isosorbide mononitrate or bendrofluazide.? Had she
headedness especially on changing position since starting
Had she taken any OTC medicine? Could she have taken a hypnotic which she might
have obtained elsewhere?
Was she wearing footwear at the time of the fall? If so, what typ
Does she remember banging her head? If so, what did she bang it off?
putting out her hands to protect herself/
How was she feeling in the days beforehand? Any symptoms to suggest an evolving
as pneumonia, urinary tract
Immediately after the fall
was stopping her from getting up? Was she trapped
by an environmental hazard? Was pain stopping her from getting up? Was
weakness/loss of power stopping her from getting up? Was
able to see where she
When she was not able to get up, did she try to reach for the phone
Was she frightened?
Was she aware of any pain anywhere especially wrists, hips/
Did she feel cold?
Did she develop any symptoms such as cough?
Did she develop and ne
the carer helped her up?
How was she feeling now?
Does she feel nervous about further falls?
Has she fallen before especially in the last six months? If so, were the previous
fall/falls similar in nature? Has she injured herself before?
has she been feeling in the previous few days?
Had she alcohol taken on the day of the fall? How much? How much does she drink
Has she noticed any
disimprovement in her eyesight recently?
as she had a lot of symptoms fro
m her oste
oarthritis recently? Which joints?
From the carer
What did she notice on arrival? Was patient alert? Was she coherent? Did she notice
any localised weakness? Was there any evidence of damage to the environment?
Was there a lot
evident on the
Had she noticed any
in her gait
or unsteadiness recently? Had she been eating well?
From the family
The question does not specify if there are family supports. However, if there are
would contact them to inform them, to clarify any
recent history and to involve them
in the immediate and long tem
Level of alertness
Glasgow Coma Scale.
Signs of shock
She may have bled significantly.
Assess level of
Is speech slurred?
there a smell of alcohol?
Look at level of spontaneous activity? Is there evidence of loss of function?
Any signs of tremor?
Measure temperature to outrule pyrexia and hypothermia. Important to have a low
Examine musculoskeletal sy
Look for obvious signs of injury and look for muscle wasting.
Especially examine wrists, lower limbs, hips to outrule the possibility of fracture.
Palpate spine to asses the possibility of osteoporotic fracture.
This lady has a past
history of ost
eoporosis and is therefore at risk of fracture.
Examine the feet. Look for signs of osteoarthritis, corns, ulcers, all of which can
Examine the head wound. Look at depth. Any signs clinically of
Any signs of
lacerations/ Bruising/haematoma formation elsewhere?
Examine pulse to assess
rate, rhythm and strength. Look for signs of heart block,
Examine blood pressure supine. If patient can stand measure the blood pressure after
one minute and five
minutes of standing. To look for signs of postural hypotension.
This is especially important in that
has had a fall within two weeks of starting
bendrofluazide which is a recognised potential cause of postural hypotension.
Examine cardiovascular syst
em. Look for new murmurs. Look for carotid bruits.
Examine respiratory system. Looks for signs of pneumonia.
Examine the ears. Look for signs of infection, Bloody
discharge (? fracture
skull). Look for wax which may affect hearing.
significant are the cataracts?
Check visual acuity if possible.
mental test score to look for signs of confusion.
Central Nervous system examination.
Any localizing signs on examination of cranial
Assess power and
reflexes in upper and lower limbs to detect underlying CVA.
ordination,nystagmus thing about underlying vestibular or cerebellar
Assess position and vibration sense.
If possible stand the patient out. Perform Romberg’s test.
balance and gait.
leg balance test.
Do “get up and go” test.
not be possible to do these in the acute phase. However, it would be very
helpful to do them
near stage in the future.
This is especially important if I am h
appy there is no obvious cardiac
/CNS cause for
What is the floor surface
Linoleum? Carpet? Are there any hazards on the floor
Are there any stray cables?
Are there any sharp edges?
Is there any evidence of damage to contents in th
e room such as glasses, furniture?
This may raise suspicions regarding an underlying sinister cause for the fall.
What is the lighting like? Is the room warm?
Is there alcohol in the room?
Is the room cluttered?
What is the bed like? Is it low down? Co
increase the chances of postural
Evaluate social supports.
Does she have friends? Does she go to Day Care? Are there enough supports to keep
this lady at home if it is felt that she can be managed i
n the home setting?
This will depend on the initial assessment.
I would refer to hospital in the following circumstances
to assess head injury. Outrule fracture skull, acute subdural
Also need to outr
ule underlying acute infection/
Signs of pneumonia.
Signs of acute LVF.
History suggestive of myocardial infarction/acute arrhythmia.
Signs of shock. Could this be due to blood loss?
Signs of fracture especially wrist, pelvis, hip.
Signs suggestive of complete heart block.
If there is a history of syncope, loss of consciousness
, Palpitations, and if the patient is
would arrange urgent geriatric assessment.
If the patient is not confused, is haemodynamically st
able and mobile
to have the scalp laceration sutured either in the house if lighting was satisfactory and
I could access suturing equipment or in the surgery if she could be transferred.
If there are signs of hypothermia, I would encourag
e gradual rewarming in the bed
with encouragement of warm fluid intake.
I would encourage gentle mobilisation within 24 hours to try and get confidence back
and to minimise complications
If the history is suggestive of postural hyp
otension, it may be necessary to stop the
. I would encourage the patient to avoid sudden movements, to sit on
the side of the bed and flex her ankles especially in the am and at night before getting
up. I would consider elastic support st
If she is in pain secondary to head injury and any other injuries, I would prescribe
paracetamol to be taken regularly.
I would arrange follow up, involve the gamily, public health nurse.
geriatric assessment and falls ri
Blood testes would be helpful to outrule anaemia, electrolyte disturbances,
hypokalaemia, hyponatraemia secondary to recent diuretic use.
in order of importance) the principle factors, which you consider may have
contributed to the fall.
Living by herself.
She is on five medications. Elderly people on four or more drugs are at a greater risk
She is on cardiac medication which increases her risk of falling. She has
started bendrofluazide which is associated with postural hypotension and risk of
has generalised osteoarthritis. This will reduce mobility, affect balance, and slow
one’s responses to losing balance. It will als
o increase her chances of sustaining
fractures and interfere with her ability to get up after falling.
s bilateral cataracts. These will affect her vision which is important for
proprioception and would therefore increase her risk of falling.
This is very strongly associated with falls. She had a pacemaker inserted 7 years ago.
Is it working correctly?
List 6 measures, which in your view will reduce patients risk of a further fall.
for bendrofluazide. Review blood pressure.
Consider 24 hour blood pressure monitor.
risks of stroke against risks
of harm secondary to medication. Consider referral for tilt testing.
consideration be given to
erral for cataract surgery. Improvement in visual acuity will
significantly reduce the risks of further falls.
Home safety check. Involve community occupational therapy and public health
nurse. Try to eliminate environmental hazards. Consider safer f
hand rails in bathroom and stairs.
Consider referral for community physiotherapy. This will help improve mobility
through muscle strengthening exercises. The physiotherapist will also be able to
assist with the provision of the most
appropriate walking aids. They may also be able
to assist with balance training.
Involve the family. Get their assistance with modification of hazards in the
. Get their assistance with the provision of an alarm system which the
can carry herself. Get the name of a family member with whom the
primary care team can liaise with.
Follow up and education re falls. An information leaflet on prevention of falls
would be helpful.