CAP 13 Falls

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Disclaimer

The purpose of these notes is to provide a practical minded but detailed background to the vague and wishy washy curriculum.  I am only including information that I think is relevant to either a) treating falls, or b) passing a question on falls in the MRCEM.

This is not an exciting topic for most ED trainees, whenever many of us pick up a ‘fall’ from the box your heart sinks a little bit, and a small part of your soul shrivels up and dies.  Despite this it’s a massive part of our work, and it’s only going to get bigger.  Instead of grumbling about it, we should embrace these patients who are equal parts medical mystery, and ATLS scenario wrapped into one slightly wrinkly package.

Being old

Ageing, as I’m sure your more err ‘spry’  colleagues will attest, is no fun.  As our bodies age things start to fall apart.  Muscle mass decreases, neurones atrophy and die.  Coordination, and eye sight get worse.  Calcium starts to leach from our bones, rendering them brittle and probe to fracture.  The autonomic nervous system starts to malfunction.  Tendons calcify. We get stiffer, more sedentary and less quick witted.  Cumulative damage from atheroma makes our arteries harden and become less compliant.  Our blood pressure goes up, our hearts enlarge to cope.  Our immune system becomes sluggish to activate, and less efficient at doing its thing.  We collect a plethora of minor chronic medical conditions, and the drugs to match them.  All of these changes make us more likely to fall, and more likely to injure ourselves when we do, they also make recovery more challenging.

The elderly fall over a lot.  “Falls” as a medical problem always struck me as too broad, and too vague to be useful in the ED.  As the fall can be from a myriad of reasons; the gin stashed in the sideboard, to a tangle of cats, some of them on the face of it mechanical, others seemingly mechanical but with odd medical antecedents. Falls can also be an entry point for a patient who has syncope, major trauma, mental health problems, hip fracture, sepsis, but the list is effectively endless.

It’s certainly not a surprise to anyone that has ever set foot in a British ED that elderly falls make up a large volume of our most complex patients. what did surprise me was the mortality statistics: 33% of people over 65 you see and admit to hospital will be dead in a year.  If you are having a ‘good’ day in majors that might be 2 people a day1.  This means we can treat it as a warning sign.

What I’m trying to cover with these notes, is an approach to the elderly patient who has fallen so that you can feel more confident (and more excited about) seeing “a fall”.

Being old

Ageing, as I’m sure your more err ‘spry’  colleagues will attest is no fun.  As our bodies age things start to fall apart.  Muscle mass decreases, neurones atrophy and die.  Coordination, and eye sight get worse.  Calcium starts to leach from our bones, rendering them brittle and probe to fracture.  The autonomic nervous system starts to malfunction.  Tendons calcify. We get stiffer, more sedentary and less quick-witted.  Cumulative damage from atheroma makes our arteries harden and become less compliant.  Our blood pressure goes up, our hearts enlarge to cope.  Our immune system becomes sluggish to activate, and less efficient at doing its thing.

Approach

There are two questions I think need answering at the end of each ED clerking in patients who fall.  These should be investigated and treated concurrently.

  1. What injuries have they sustained because of the fall?
  2. Why did they fall?

 

What injuries have they sustained because of the fall?

A fall from standing can cause horrific injuries (in the right/wrong) patient.  From the obvious fractures, to the less obvious and more insidiuous subdurals, to skin tears, cuts, lacerations, and bruises.

People who have had long lies are at risk of rhabdomyolysis (and we screen for this incredibly regularly) but are also at risk of pressure sores, hypothermia and dehydration.

Elderly patients are more likely to be on anti-coagulants, and are therefore at a higher risk of uncontrolled or more impressive bleeding from relatively minor injuries.

I’m going to briefly discuss some of the injuries I feel are important, the list below is not exhaustive.

Specific Fall Related injuries, the ‘long lie’

The long lie is a phenomena that affects elderly patients who cannot get themselves up safely, or call for help from people, either because they live alone, or because of where they fall.  Depending on the patient and environment you can get pressure sores from a lie as short as 1 hour.  Older patients are dehydrated when well (think of all of the diuretics they are on), and become crispy very quickly if the lie lasts longer than 3 or 4 hours.  If the lie is particularly long skeletal muscle breakdown occurs, flooding the circulation with myoglobin, this gums up the nephron in the kidney, and contributes to, or causes acute kidney injury.  Hypothermia is also going to contribute to physiological derangements, depending on the core temperature expect to see hypotension, arrhythmias, and electrolyte disturbances.  Remember these patients will have a degree of renal dysfunction to start with, and the long lie assaults their remaining solitary nephrons from multiple angles (rhabdo, hypoperfusion, dehydration).  Just because someone doesn’t have a CK of 9000 doesn’t mean they aren’t going to get AKI.

Upper limb fractures

If a patient has a distal radius, humeral shaft, or even a clavicle fracture they may lose the ability to walk (if they use a zimmer frame or two sticks).  Immobilising the upper limb might be the best thing for the fracture, but may not be the best thing for the patient.  Large complex splints or slings will need to be got off and on again by untrained carers, or family members.  Be pragmatic.  Even relatively benign fractures carry an increased mortality risk in the elderly (clavicle fractures 10%).

NOF #

Picture4   This is the classic frailty injury.  NOF’s are governed by pathways and targets in the ED.  There will be pressure to just look at an xray and get someone up to a ward.  I challenge you to resist this urge.  See these people properly, and carefully, flag up and start treating any medical problems that they have.  From the ED’s perspective it doesn’t matter what classification the fracture is, whether it is a Garden IV or a Pauwels II.  As long as it isn’t a femoral shaft fracture (get your Thomas’ splint out) you shouldn’t care too much.  If you really want to tell the ortho sho his job, if its an intracapsular NOF# it will need a hemiarthroplasty.  Everything else will require some form of dynamic hip screw.  My orthopaedic friends will tell me there are exceptions (but I’m not sure I care).

You should be considering a Femoral Nerve Block or Fascia Iliaca Block here.  I’ll be doing a post later about how to do them.  Which is best?  There’s an RCT registered out of Poole hospital comparing fascia iliaca and femoral nerve block at the moment, but it hasn’t reported yet.  They both block essentially the same thing.

Some orthopaedic departments don’t like us doing blocks, because of the theoretical risk of long standing neuropraxia.  That is also an argument for another day.

The 1 year mortality of patients treated for a NOF# is approximately 30-40%5,6, usually as a consequence of the decreased mobility and independence that is caused by the injury.  Though that statistic is a bit disheartening, it’s important to remember that prior to DHS’ locking plates and hemi’s the mortality was much higher8.

 

Pubic Rami #

Picture6Fractures of the superior or inferior pubic rami often present with groin pain and limited mobility.  Depending on the patient they may be able to walk, they may not be able to.  Management is nearly always conservative, but that doesn’t mean they carry a morbidity burden.

Picture5People with pubic rami fractures often have a long period of rehabilitation, and up to 40%3,4 may never regain their previous levels of mobility, their 5 year survival is the same as hip fractures (40%)4,   20% will have another fracture somewhere4.

 

C-spine #

Eldely people who fall from standing or have low speed car accidents are at a higher risk of C-spine injury than you or I, and will have almost impossible to interpret C-spine plain films because of degenerative change.

In one case controlled study I found of elderly patients, 40% of the fractures were from a fall from standing height, and involved more than one level.  The patients who fell from standing were more likely to have a higher injury as well9.

Any suspicion of a c-spine injury should probably necessitate a c-spine CT, as a negative C-spine film is not going to be reassuring enough to clear the spine (some prospective studies suggest you may miss up to 45% of high C-spine fractures on the plain film)10.  Elderly people are more likely to have high level eg peg fractures.  C-spine fracture incidence in general is going down, but is going up in the elderly.

Try not to miss these, but be pragmatic about the management of the injury when you find them in a 106 year old with end stage dementia.

 

Mortality Risk of Fractures [Keller, Julie M., et al. “Geriatric trauma: demographics, injuries, and mortality.”Journal of orthopaedic trauma 26.9 (2012): e161-e165.]

Fracture Mortality
Cervical spine with neuro deficit 47%
C2 fracture 44%
Proximal femur 25%
Pelvic Ring 25%
Clavicle 24%
Distal Humerus 24%

 

Fractures statistically significantly associated with mortality: clavicle, foot joints, humerus, sacroiliac joints, distal ulna.

 

Traumatic Brain Injury

Older people’s brains have shrunk, putting their perforating venous supply under greater tension.  This means it is more likely to snap and bleed if a sheering force in applied to it (like a rear-end shunt).  Older people’s brains tend to respond and recover less well than younger cerebrums.  Symptoms can be more severe, and recovery time is normally longer11.  There is some evidence that repeated head trauma can cause or hasten the onset of some types of dementia.

Clopidogrel is AS dangerous as warfarin12, 13.  And there is little evidence about the safety of your apixibans, or dabigatrans.  I would treat them as at least as dangerous as warfarin until we know more.

Elderly patients following a head injury are more likely to develop depression, become more socially withdrawn, and less mobile.

 

Why did they fall?

“There is no such thing as a mechanical fall unnamed geriatrician

This is the hardest question to answer most of the time.  The answers are often in your history, and taking as broad a history from the patient, and those that know him or her is the best starting point.  You want to establish if there was syncope, and if there is you need to consider arrhythmias as a potential cause.  If the patient did not lose consciousness, but there ‘legs went from under them’ then you need to start considering a wider variety of things.

Have they fallen because of a multifactorial soup of polypharmacy, drug interactions, co-morbidities that evening’s crème de menthe and an errant cat?  Have they fallen because they’ve had a stroke?  Have they fallen because someone has broken into their house and beaten them senseless?  Have they fallen because they are delirious from their UTI and are horrifically septic?  Have they had an epileptic fit?  Have they had an MI?

Patients who are alert enough to talk to you will describe their legs ‘just going’ from under them.  Similarly they might describe ‘being dizzy’ try and dissect what they mean by dizzy, were they pre-syncopal, or were they vertiginous?

Sometimes this history is really very challenging to extract because the patient is confused, delirious, or profoundly unconscious.  Collateral history is the key, and sometimes is very hard to get hold of, my advice is to phone people, care homes, relatives.  If you can’t get a history of what happened a baseline functional status is very useful as well.  We are going to order different investigations in someone who is normally fine and is now talking gibberish, than in someone who normally talks gibberish, and is still talking gibberish at your assessment.

Picture7My advice is to be methodical.  The trick to taking a falls history is to try and quickly work out which focused history you need to take.  This means you need a good collateral history.  If the patient had transient loss of consciousness, think about seizures, glucose control, and syncope.

If the patient collapsed and is delirious, consider sepsis, metabolic derangements, or a head injury.  Remember that metabolic derangements could be a result of a long lie, and no the cause of the fall as well.  The diagnosis of a ‘simple fall’ should probably be considered as a diagnosis of exclusion.

People can also fit into more than one category, they can fall because of relative hypovolaemia, caused by the environmental effects of their horrific UTI which has meant they haven’t drunk anything because it hurts to urinate, which has also caused them to have hypoglycaemia, which is why the paramedics called the case in as a ?CVA.

 

Baseline

This is key to working out what you are going to do.  A patient’s pre-morbid state, or baseline level of fitness and comorbidity will affect their recovery from injury and their resilience to it. This is where assessing exercise tolerance, and normal functional state comes in.  This information is often gleaned best from carers or relatives, and is often placed in the social history.  If you know the baseline you can work out the likliehood of patients being able to cope at home, or their need for further in hospital or step down care.

Useful questions to ask, I like to know if elderly people still drive, and how far they can walk on the flat.  Be persistent, patients who are housebound but managing often obfuscate around here because of a fear that you are going to get intern them in a nursing home.

The past medical history also gives you baseline information, benign essential tremor, parkinsons, previous hip fractures, or lower limb surgery will affect mobility, and ability to right themselves if they do lose their balance.  Previous epsiodes of vertigo.

Risk Factors (though for us this is usually a horse/stable door scenario)

There are tonnes of studies into risk factors in falls, they find the things you would expect, best way to think about them is to divide them into intrinsic and extrinsic risk factors.  It may be that more than one has come into play.  The problem I have with these risk factors is that they just describe the gradual creep of extra medications, and increasing frailty that happens with elderly people.  Also when you see a patient they have usually already fallen.  Rendering the risk factors moot.  Here they are for completeness.  NICE suggests that there is a multidisciplinary falls service, you should be able to refer to this if you think someone has had a near miss.

Intrinsic

Age (falls risks climbs with increasing age)

Female Gender

Previous falls – I feel this is a slight cop out ,as it’s a recursive risk factor.

Orthostatic Hypotension

  • Orthostatic hypotension can cause a fall directly by making the patient pass out, it can also contribute to them feeling dizzy and unsteady and make them fall. Risk factors for OH are; HTN, Atherosclerosis, Varicose Veins, CHF, CKD, DM, Parkinsons, alpha blockers, beta blockers, CCBs, diuretics, TCAs, anti-histamines, anti-depressants, nitrates, and acetylcholinesterase inhibitors.

Musculoskeletal Disease

  • Patients with pre-existing osteoarthrtitis, and osteoporosis are both more likely to fall, and more likely to injure themselves when they do.

Visual Impairment

  • The commonest visual impairment in the elderly is presbyopia (long sightedness), this is treated with Bifocals which worsen depth perception and edge contrast, so can often contribute to less than sure footedness.

 

Extrinsic risk factors

Polypharmacy

This is the big one, and I wonder if it is the one we can do the most about.  The presence of Benzodiazepines, Sedative Hypnotics, Antidepressants, Anti-hypertensives, diuretics, insulins and anti-epileptic medications on someone’s regular prescription increases their risk of falls.  I see at least 4 of these on many patient’s drug lists (should someone kind remember to bring it in).

It’s also important to remember that long term chronic condition can impact on acute processes, long term steroids are going to give patients osteopenia, loop diuretics will cause AKI if the patient slips into dehydration, and novel anticoagulants will cause bleeding that you will not be able to stop.

Home situation

Trip hazards can be things like cables, cords, bad carpet, old slippers, rugs, and pets.  Sometimes even the patient’s furniture can be hazardous, with seats that are too low to sit in and get out of.  Often there is a lack of appropriate hand-rails and other helpful things (unless an occupational therapist has snuck in).

 

Falls Assessment

Get up and Go – is a timed test where you ask the patient to get up out of chair walk a couple of metres, turn around and sit back down again.  On the face of it, it is an excellent test of someone’s ability to stand, walk and turn, and has a certain amount of real world validity.  However it doesn’t seem to predict someone’s propensity to fall.  So if someone can “get up and go” it’s possible that they shouldn’t.

The most recent systematic review I could find for falls risk assessment (October 2014) seems to suggest that if the patient can/does cut their own toenails it suggests that they have a lowish risk of falling.

 

In Summary:

Each patient will have multiple factors causing the fall.  It is our job to work out what’s caused the fall, and what injuries the patient has sustained because of the fall.  Elderly falls are a challenge, we should embrace this as it’s going to become an ever expanding part of our work.

Picture8

 

  1. Carpenter, Christopher R., et al. “Predicting geriatric falls following an episode of emergency department care: a systematic review.”Academic emergency medicine 10 (2014): 1069-1082.
  2. Clement, Nicholas D. “Elderly pelvic fractures: the incidence is increasing and patient demographics can be used to predict the outcome.”European Journal of Orthopaedic Surgery & Traumatology 8 (2014): 1431-1437.
  3. Studer, Patrick, et al. “Pubic rami fractures in the elderly–a neglected injury?.”Nursing91 (2013): 69.
  4. Hill, R. M. F., C. M. Robinson, and J. F. Keating. “Fractures of the pubic rami EPIDEMIOLOGY AND FIVE-YEAR SURVIVAL.”Journal of Bone & Joint Surgery, British Volume 8 (2001): 1141-1144.
  5. Kannus, P., et al. “Epidemiology of hip fractures.”Bone 1 (1996): S57-S63.
  6. Thorngren, K-G., et al. “Epidemiology of femoral neck fractures.”Injury 33 (2002): 1-7.
  7. Zuckerman, Joseph D. “Hip fracture.”New England journal of medicine 23 (1996): 1519-1525.
  8. Dahl, H. K. “[Surgical treatment of femoral neck fractures. The 100-year anniversary].”Tidsskrift for den Norske laegeforening: tidsskrift for praktisk medicin, ny raekke 30 (1994): 3600-3603.
  9. Lomoschitz, F. M., et al. “Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries.”American Journal of Roentgenology 3 (2002): 573-577
  10. Schenarts, Paul J., et al. “Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status.”Journal of Trauma and Acute Care Surgery 4 (2001): 663-669.
  11. Ferrell, Richard B., and Kaloyan S. Tanev. “Traumatic brain injury in older adults.”Current psychiatry reports 5 (2002): 354-362.
  12. Ivascu, Felicia A., et al. “Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel.”Journal of Trauma and Acute Care Surgery 4 (2008): 785-788.
  13. Nishijima, Daniel K., et al. “Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.”Annals of emergency medicine 6 (2012): 460-468.
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