Falls & Gait Disorders in Elderly

Essentials of Diagnosis

• Falls in older people are rarely due to a single cause

• Medications are a common and potentially reversible cause of falls in elders

General Considerations

• With age, balance mechanisms can become compromised, reaction time slows, and postural sway increases

• These changes predispose the older person to a fall when challenged by an additional insult to any of these systems

• Effective intervention entails a comprehensive assessment of the patient's intrinsic deficits (usually diseases and medications), the activity engaged in at the time of the fall, and environmental obstacles

• Intrinsic deficits are those that impair

  • Sensory input

  • Judgment

  • Blood pressure regulation

  • Reaction time

  • Balance and gait

• Dizziness may be closely related to the deficits associated with falls and gait abnormalities

• Medications (eg, benzodiazepines, sedative-hypnotics, cardiac medications, antidepressants, neuroleptics) and polypharmacy have been associated with increased risk of falls

• Postural hypotension, including postprandial

• Acute medical illness (pneumonia, myocardial infarction)

• Other contributing factors

  • Urinary urgency

  • Peripheral edema

  • Insomnia

  • Use of multifocal lenses

  • Footwear

• See Table 4–2

Demographics

• Falls are the leading cause of nonfatal injuries in older persons

• Complications from falls (eg, hip fracture, subdural hematoma) are the leading cause of death from injury in persons over age 65, and fall-associated mortality is increasing

• About one-third of people over 65 fall each year, and the frequency increases markedly with advancing age

Symptoms and Signs

• Assessment should include

  • Postural blood pressure and pulse

  • Cardiac examination

  • Evaluations of strength, range of motion, cognition, and proprioception

  • Examination of feet and footwear

• Gait and balance can be assessed using the "Up and Go Test"

  • Patient is asked to stand from a sitting position without using the hands, walk 10 feet, turn around, walk back, and sit down

  • Test performance is qualitative: normal vs abnormal

  • Patient should be timed during the test: < 10 seconds is considered normal

  • Patients who take > 13.5 seconds are considered at increased risk for falling

• Hip fractures are common precursors to functional impairment, nursing home placement, and death

• Fear of falling may lead some elders to restrict their activities

• See Table 4–1 for the evaluation of gait abnormalities

Laboratory Tests

• Laboratory and other diagnostic tests should be directed by the history and physical examination

• Most patients who fall should be assessed for osteoporosis risk

• For a simple geriatric functional screening instrument, see eFigure 4–1

Diagnostic Procedures

• Every older person should be asked about falls; many will not volunteer such information

• Review circumstances of falls, including associated symptoms, location, and exacerbating factors

• Review medications, including over-the-counter sleeping aids

• Review substance use history

• Ask about urinary symptoms

• Examine for postural hypotension

• Examine for peripheral edema

• Ask about vision

Medications

• Eliminate all nonessential medications that can interfere with gait, cause somnolence or urinary urgency

Therapeutic Procedures

• Home safety check: generally reimbursed by third-party payers, including Medicare

• For patients with repeated falls, make available phones at floor level, a portable phone, or a lightweight radio call system

• Physical therapy can instruct in balance, strength, use of assistive devices, and getting up from the floor after a fall

• Evaluate for osteoporosis, and treat when present

• Eyeglasses, particularly bifocal or graduated lenses, may increase the risk of falls

Complications

• Fractures, commonly of the wrist, hip, and vertebrae

• Loss of confidence and independence and self-restricted activity because of fear of repeated falls

• Chronic subdural hematoma

  • Consider in an elderly patient who presents with new neurologic symptoms or signs, particularly obtundation

  • Headache is uncommon

• Dehydration, electrolyte imbalance, pressure sores, hypothermia, and rhabdomyolysis in patients who are unable to get up from a fall

Prognosis

• While it may be impossible to isolate a sole "cause" or a "cure" for falls, gait abnormalities, or dizziness, it is often possible to identify and ameliorate some of the underlying contributory conditions and improve the patient's overall function

• Patients who fall are at high risk for subsequent falls

• Falls are associated with a higher risk of nursing home placement

• There is a high mortality rate (approximately 20% in 1 year) in elderly women with hip fractures

Prevention

• Balance focused exercises (eg, Tai Chi), gait, and strength training appear to be more effective for fall prevention than general exercise programs

• Remedy home hazards

• Evaluate gait and make interventions when abnormal

• Regular vision evaluation

• Evaluate for osteoporosis and treat when present

• Vitamin D supplementation

  • May reduce falls in patients who are vitamin D deficient, but the impact of supplementation on adults who are not vitamin D deficient is not clear

  • High-dose vitamin D (60,000 international units per month) has been shown to increase the incidence of falls

When to Refer

• Patients with a recent history of falls should be referred for physical therapy, eye examination, and home safety evaluation

When to Admit

• Patients with new falls that are unexplained, particularly in combination with a change in the physical examination or an injury requiring surgery