• Older adults (65 years and older) make up 30% of BC Emergency Department visits.
• Falls are very common. 1/3 of older adults have at least one per year.
• They are more likely to present unwell and require admission.
• Challenging to diagnose due to difficulties in history taking, vague/delayed presentations, underlying comorbidities and polypharmacy.
• Physiological changes include impaired immune response, decreased cardiac functional reserve, decreased peripheral sensation and blood supply, impaired renal function, altered medication metabolism.
  • Consider older adult as a “beta blocked immunocompromised 50-year-old”.
• Vitals are unreliable.
  • Heart rate of 100 may represent maximal tachycardia (especially if calcium channel or beta blockers).
  • Systolic blood pressure of 120 may represent hypotension if chronically hypertensive.
• Traditional “mechanical” fall management is focused on traumatic injury, but there is increased recognition that falls represent larger dysfunction and geriatric falls syndrome.
  • Movement away from term ‘mechanical fall’. This inaccurately implies a benign source (i.e. external mechanical force causing fall).
  • Consider term “non-syncopal” fall instead.
• Fall is likely a sign of underlying issue: postural hypotension, polypharmacy, loss of muscle tone or difficulty with gait, balance, vision or proprioception.
• High associated morbidity and mortality:
  • 1/3 ED patients with minor falls will functionally decline within 3 months.
• Most patients can be discharged, but a high suspicion for underlying pathology and recognition of geriatric considerations needed.

Recommended steps in ED management of falls.

Cause of Fall

• Conduct full history to differentiate from syncope (cause/location of fall, time on ground, loss of consciousness or altered mental status, melena, substance use, prior falls or gait/balance difficulties).
• If patient is confused, obtain collateral and determine baseline.
• Consider atypical presentations contributing to fall:
  • Alcohol use common but under recognised.
  • Elder abuse underreported and increasing, consider in head/neck/upper extremity injuries, delay to presentation, signs of neglect.
• Depression associated with falls. More likely to be somatic complaints (sleep, pain, anxiety) versus mood.
• Rule out medical cause: cardiac, infection, GI bleed, metabolic or electrolyte dysfunction, seizure, stroke, etc.
• Conduct full head to toe exam noting neuropathy or strength deficits, +/- orthostatic vitals.
• Obtain CBC, electrolytes, renal function, medications levels (e.g. digoxin), ECG.
  • Troponin, serum toxicology screen (salicylates, acetaminophen, ethanol), extended electrolytes, blood cultures may be indicated.

Injuries

• Commonly lower extremity, trunk/spine and skull/intracranial.
  • More likely to sustain skeletal injury (fragile bones), occult bleeding (fragile vessels, anticoagulation), intracranial injury (fragile brain, atrophy).
• Conduct full exam. Patient may lack awareness of physical issue (impaired sensation).
• Extremity, hip/pelvis, thoracic or lumbar X-rays if clinical concern.
• Lack of clinical decision rules for imaging head/cervical spine in older patients.
  • Low threshold for imaging based on mechanism (exam may be unreliable).
  • Generally, all older patients with head injury require CT head if anticoagulated.
  • X-rays of cervical spine unreliable, CT higher yield.

Safe Discharge Plan

• Ideally multi-disciplinary team (in addition to family), depending on setting may include:

• Estimate future falls risk, considering risk factors:
  • Prior falls (especially if associated injuries)
  • Polypharmacy (especially benzodiazepines, anticholinergics, sedatives)
  • Impaired hearing, eyesight or proprioception
  • Loss of mobility
• If no PT, consider performing timed “up and go” test. The time to rise from chair and take 6 steps (3 metres), predicts increased falls risk if >15 seconds.
• De-prescribe inappropriate medications associated with fall, or at minimum flag for family physician follow-up.
• Minimize delirium development risk in ED by encouraging monitor removal, mobilizing, feeding, ordering home medications and oral analgesics as needed.
• Admission Criteria:
  • Systemic illness
  • Cardiac syncope (e.g. no symptoms prior to syncopal fall or new rhythm abnormality)
  • Pathological (insufficiency) fracture
  • Ongoing medication issue (e.g. supratherapeutic cardiovascular or hypoglycemic medication)
  • Increasing falls without obvious cause

Prevent Future Falls

• Low grade evidence that moderate balance/mobility exercise may help reduce risk (e.g. Tai-chi).
• If you have access to falls or geriatrics clinic, refer high-risk patients.
• For low impact falls causing fracture, emphasize family physician follow-up for osteoporosis management.
• Emphasize to patient that fall is potentially lethal and encourage follow up appointment attendance.

• Serial CT head to rule out delayed intracranial hemorrhage in anticoagulated patients after 24 hours generally not recommended in BC.
  • Overall incidence low, consider associated cost, resource strain and radiation.
  • Counsel about delayed bleed and return to ED.

1. Geri-EM. An open access, Canadian, resource. Provides CME credits for six online modules on managing geriatric patients in the ED.

   
   

2. Geriatric Trauma. EM:RAP podcast episode. Provides excellent 20-minute approach to geriatric trauma.

   
   

3. Geriatric Emergency Department Guidelines. The American College of Emergency Physicians. Cover various topics including urinary catheters, medication management, falls and delirium.