Falls are a common problem in the elderly and for busy GPs there are multiple challenges: managing the immediate injuries, trying to establish the cause (or causes) of a fall, remedying these causes and limiting the harm patients will come to if they do fall.
Why do elderly people fall?
Diseases of the eyes, ears, brain, heart, peripheral nerves, muscles and joints can all contribute to falls. There are also normal age-related changes, such as increased sway, a slower gait with smaller steps, reduction in muscle strength and slower reactions that increase the falls risk. Trip hazards should also be considered. There will often be multiple contributing factors.
An elderly patient who falls is more likely to sustain more severe injuries, and injuries that take longer to heal. Social isolation can result in a long lie with the attendant risks of hypothermia, dehydration, blood loss, rhabdomyolysis and pressure sores. Loss of confidence after a fall can lead to a premature loss of independence.
The history may reveal whether the faller blacked out (suggesting syncope, a seizure or a transient ischaemic attack [TIA]) or whether they tripped (suggesting a balance or gait problem or possibly just the presence of a trip hazard). A vague or absent history may indicate that dementia or delirium resulted in poor decision-making leading to the fall.
Loss of consciousness
Syncope, where there is loss of consciousness due to reduced cerebral blood flow, can be caused by:
- Vasovagal syncope (a faint)
- Cough or micturition syncope
- Orthostatic hypotension, which can be due to autonomic failure (such as in diabetes) or a medication side-effect. Anaemia, dehydration and infection can contribute to this.
- Carotid sinus hypersensitivity - shaving can be a trigger
- Arrhythmia, which may be heralded by palpitations
- Structural heart disease such as aortic stenosis or hypertrophic obstructive cardiomyopathy
Seizures may have a metabolic cause such as hypoglycaemia, hypocalcaemia, hyponatraemia or alcohol withdrawal. Other causes are epilepsy, structural brain disease, subdural haematoma and CNS infections.
TIAs are a rare cause of loss of consciousness.
Vision, the vestibular system and proprioception all contribute to balance.
- Failing eyesight or unworn, damaged or out of date glasses may contribute to a fall.
- Common causes of vertigo are benign paroxysmal positional vertigo (BPPV), vestibular neuronitis and migraine. The elderly can be more sensitive to the extrapyramidal side-effects of drugs such as prochlorperazine, so alternative treatments such as vestibular rehabilitation exercises or the Epley manoeuvre (for BPPV) may be more appropriate.
- Proprioception will be affected by joint degeneration and also peripheral neuropathy. Proprioceptive fibres run in the dorsal column, which can be damaged by B12 deficiency or alcoholism, leading to a wide-based, high-stepping gait.
Neurological, muscle and joint diseases will affect gait.
- Parkinson’s disease causes postural instability. The classical triad of bradykinesia, rigidity and tremor may be present. Reduced arm swing, shuffling gait and slow turning are also clues to this diagnosis.
- Chronic cerebrovascular disease can cause the high stepping gait seen in `marche a petit pas’. Strokes may leave survivors with a hemiplegic gait.
- There are also more rare CNS diseases to consider such as normal pressure hydrocephalus with a lurching gait. Cerebellar disease will cause marked ataxia and unsteadiness on standing.
- Proximal myopathy due to osteomalacia or steroid use will cause a waddling gait and difficulty standing.
- Arthritis of the lower limb joints can cause an antalgic, unsteady gait.
- Mononeuropathies such as a peroneal nerve palsy causing foot drop, can increase the falls risk.
Dementia or delirium can impair higher cerebral functions, which will affect the ability to compensate for mobility limitations and to make sensible decisions to avoid trip hazards.
Drugs and alcohol
There is an established link between polypharmacy and falls, so any medications should be scrutinized.
- Anticholinergic medication (such as those acting on the bladder), benzodiazepines and opiates can cause confusion in the elderly.
- Parkinson’s disease medication, tricyclic antidepressants, antipsychotics, diuretics, alpha-blockers, beta-blockers (even in eye drops1) and antiangina drugs are some of the medications that cause orthostatic hypotension.
- In old age even BP at the low end of normal may be too low and the target BP should be tailored accordingly.
- Steroids can lead to proximal myopathy as well as increasing the risk of fractures due to osteoporosis.
- Antidysrhythmics, rate-limiting calcium-channel blockers, beta-blockers and the anticholinesterase inhibitors used in dementia can all cause bradycardia leading to syncope.
- Antipsychotics and some vestibular sedative drugs can have extrapyramidal side-effects as well as causing sedation.
- SSRIs increase the risk of falls although the mechanisms are unclear.
Alcohol intoxication may be the cause of a fall. The Royal College of Psychiatrists estimates that 1 in 5 older men and 1 in 10 older women are drinking a harmful amount.2
Assessing a frequent faller
In a short GP consultation the examination has to be guided by the history. Where there has been loss of consciousness without a seizure, more emphasis should be given to cardiovascular examination including sitting and standing BP. In trips, more time should be spent observing the patient rising from sitting, walking and turning. Consider the value of the Romberg's test to assess proprioception. A simple corrected visual acuity test may be illuminating.
Blood tests may reveal acute, reversible causes of falls or delirium. Hypocalcaemia, thyroid dysfunction or B12 deficiency can affect both cognition and mobility.
NICE guidelines on the assessment and prevention of falls in older people stress the importance of a multifactorial falls risk assessment.3 Particular emphasis is placed on screening for dementia, for which the 6-item cognitive impairment test is a quick and validated test.
Preventing falls and safer falls
Multidisciplinary falls clinics can provide physiotherapy for strength and balance training and occupational therapy to reduce the falls risk at home. For those patients who remain at a significant risk of falls, a personal alarm can prevent a long lie.
The HAS-BLED score can help to guide decision-making regarding anticoagulation in atrial fibrillation, although it is important to note that this does not factor if a patient is falling. Similarly the risks and benefits of antiplatelets need to be weighed up.
There may be a need for bone protection to reduce the chance of fractures if there are further falls. The FRAX score helps to estimate the risk of an osteoporotic fracture as well as helping determine whether a bone mineral density scan may be useful. FRAX can underestimate the short-term risk of fractures in those over 80 years of age and also underestimates the risk of future fractures in patients who have already had multiple fractures. Weight bearing exercise maintains bone strength. Smoking cessation will help to slow bone loss.
Multidisciplinary falls clinics are an important resource in managing a patient with falls but there is still a vital role for GPs in identifying and addressing the causes of a fall and making considered judgments on the benefits and risks of multiple medications.
- Dr Jopling is a GP in Sunbury-on-Thames
Thanks to Cecilia Chapman, falls lead nurse, for reviewing this article.
- Müller ME, van der Velde N, Krulder JW, van der Cammen TJ. Syncope and falls due to timolol eye drops. BMJ 2006; 332: 960.
- Royal College of Psychiatrists. Alcohol and older people www.rcpsych.ac.uk/healthadvice/problemsdisorders/alcoholandolderpeople.aspx
- NICE. Falls: assessment and prevention of falls in older people. NICE, London. 2013