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In the clinical evaluation of a geriatric patient, it is important to keep in mind identified independent risk factors for falling (Table 25–1). In addition, more often than not, falls in older adults are not owing to a single cause, but occur when there is an additional stress, such as an acute illness, new medication, or an environmental hazard, that makes an older person unable to compensate as well as a younger person, and thus more likely to fall. The activity profile of the older person also will affect their risk for falling. Sedentary individuals may have multiple risk factors for falling, but not be at danger because they modify their behavior to avoid the opportunity for falls. More active older adults may be less cautious and therefore be at increased risk for falling, because they may not be able to compensate as well as a younger person to threats against postural stability.
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To help prevent falls in older persons, multifactorial risk assessments have been advocated by the AGS/BGS and other organizations. These assessments begin with a basic falls history that inquires whether the patient experienced any fall in the past year. If a fall is reported, important details with regards to the activity that lead to the fall, any prodromal symptoms (eg, lightheadedness, imbalance), and where and when the fall occurred should be obtained. Patients should be asked about the number of falls in the past year, whether any injuries were sustained from any of the falls, and if they suffer from a fear of falling. Finally, patients should be asked if they suffer from any difficulties with walking or balance. All of the above questions are important because a “yes” answer to any would indicate a high likelihood of sustaining a future fall.
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When inquiring about a specific fall, if there was an associated loss of consciousness, then orthostatic hypotension, or underlying cardiac or neurologic causes should be considered as precipitating factors. Other chronic medical conditions associated with an increased fall risk should be considered and include cognitive impairment, dementia, chronic musculoskeletal pain, knee osteoarthritis, urinary incontinence, stroke, Parkinson disease, and diabetes. Another crucial part of the medical history for an older person who might be at increased risk for falling includes a functional assessment of the activity of daily living skills, including use of adaptive equipment and mobility aids. In a patient who reports multiple falls, an inquiry into alcohol use is warranted as most patients would not volunteer this information freely, and frequent alcohol consumption could increase fall risk. Finally, physicians should perform an up-to-date and careful review of the patient’s medication list that should include current prescriptions and over-the-counter medications. One large observational study of 4260 older community-dwelling men demonstrated that 82.3% of participants reported inappropriate medication use (eg, polypharmacy, inappropriate medicine consumption, underutilization). And both polypharmacy (≥5 medications) and taking 1 or more potentially inappropriate medications were associated with having had a fall in the past year, highlighting the importance of addressing inappropriate use of medications as modifiable fall risk factor.
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Once the history is obtained, clinicians should make sure that orthostatic vital signs, visual acuity, cognitive status, and cardiac system be included in a basic physical exam. Of vital importance is the evaluation of gait and balance. There are quite a few balance and mobility assessments that are effective at assessing fall risk, but are not practical in a busy clinical setting. Such tests include the Performance-Oriented Mobility Assessment (POMA; Table 25–2), Short Physical Performance Battery (SPPB), Berg balance test, and Safety Functional Motion test. However, there are 2 other tests, the Get Up and Go and the Functional Reach tests, that are more frequently used because they each take less than a minute to administer. For the Get Up and Go test, the physician should ask the patient to rise from a standard arm chair (without the use of arms if possible), walk a fixed distance across the room (3 meters), turn, walk back to the chair and sit down. Besides observing the patient for unsteadiness, if it takes >13.5 seconds to complete this task, the patient would be considered to be at increased risk for future falls. The functional reach test requires using a yardstick mounted on a wall at shoulder height. The patient is asked to stand close to the wall at comfortable stance with an outstretched arm with the shoulders perpendicular to the yardstick. The patient is then instructed to extend the arm forward as far as possible without taking a step or losing balance; the functional reach is measured along the yardstick in inches, and if <10 inches in men, there has been reported a 2 times greater risk for falling.
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Finally, also important to the physical exam is the examination of the feet and footwear. High-heels, floppy slippers, shoes with slick soles can predispose people to trip and fall. Ill-fitting footwear that is too big, without sufficient grip or too much friction, and/or without proper fixation (untied or loosely tied shoes) will also contribute to increasing someone’s fall risk. When selecting shoes, the upper shoe should be soft and flexible with smooth lining. The toe box should be deep enough to allow for toe wiggle room. The sole should be strong and flexible for good grip. The heel should provide a broad base for stability and be no higher than 4 cm. Finally, the fastening should provide a stable fit with some flexibility to allow for unusually shaped feet or swelling.
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In completing a work up for an older patient with falls or determined to be at increased risk for falling, other than a general medical work up, there is no standard diagnostic evaluation. However, laboratory tests for hemoglobin to rule out clinically significant anemia, a chemistry panel to rule electrolyte disorders, and/or hyper or hypo-osmolar states, thyroid-stimulating hormone (TSH) to rule out hypothyroidism, vitamin B12 level to rule out B12 deficiency (linked to proprioceptive problems), and serum 25-hydroxyvitamin D levels to rule out vitamin D deficiency (linked to falls and fractures) could be considered appropriate. In addition, falling can be a sign of medical illness and it is not uncommon for older patients to present with a fall to the emergency room, and later be diagnosed with an underlying urinary tract infection or pneumonia. A standard urinalysis and chest radiograph might be appropriate depending on the clinical scenario, especially if the patient suffers from significant cognitive impairment or dementia.
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Fewer than 10% of falls are caused by a loss of consciousness, but when there is a history of such, a different approach to evaluation and prevention might be indicated. An electrocardiogram to evaluate for significant cardiac pathology should be included; routine Holter monitoring has not been shown to be effective. However, on cardiac exam if a crescendo–decrescendo systolic murmur is appreciated at the right upper sternal border, then echocardiogram would be indicated to rule out clinically significant aortic stenosis that when critical, can present with syncope. Carotid sinus sensitivity has also been linked to falls, and pacemaker placement might be considered in patients who experience carotid sinus massage-induced heart rate pauses of >3 seconds. Contraindications to carotid sinus massage include presence of carotid bruits, recent myocardial or cerebral ischemia, or previous ventricular tachyarrhythmias.
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In patients who present with falls who have new or unexplained neurologic findings on examination, imaging with head CT or MRI may be indicated to rule out stroke, mass, normal pressure hydrocephalus, or other structural abnormality. If the patient has significant gait abnormalities, then spine radiographs or even MRI imaging may help exclude cervical spondylosis or lumbar stenosis as a cause of falls. Clinical signs consistent with cervical spinal spondylosis include neck stiffness, deep aching neck, arm and shoulder pain, and possibly stiffness or clumsiness while walking. If the condition is chronically progressive, there may be significant associated muscle atrophy. The hallmark symptom of cervical spondylotic myelopathy is weakness or stiffness in the legs and patients may present with gait instability; characteristically, there should be evidence of hyperreflexia, and a stiff or spastic gait would be expected in advanced cases. Lumbar spinal stenosis usually presents with pain, muscle weakness and tingling of the legs in the L4-S1 distribution with classic symptoms of pseudoclaudication, more recently referred to as neurogenic claudication (pain improves with sitting, worsens with standing or walking).