📚 Geriatrics — L6: Falls In The Elderly

📚 Lecture Overview

This lecture covers the definition, incidence, risk factors, and comprehensive management of falls in the elderly population. Understanding these concepts is critical because falls are a major cause of morbidity, loss of independence, and mortality in older adults, yet many risk factors are modifiable and preventable.

🎯 Key Concepts & Definitions

• Fall: An event resulting in a person coming to rest inadvertently on the ground, excluding loss of consciousness, sudden onset of paralysis, or epileptic seizure.
• Long Lie: Remaining on the ground for greater than one hour after a fall, which can lead to severe complications like rhabdomyolysis and hypothermia.
• Ptophobia: A phobic reaction or extreme fear of standing or walking resulting from the psychological trauma of a fall.
• Get Up and Go Test: A rapid screening tool where a patient stands from a chair, walks 3 meters, turns 180 degrees, and sits back down; taking $≥$14 seconds indicates increased fall risk.
• Intrinsic Factors: Risk factors inherent to the older adult, such as age-related physiological declines, chronic diseases, and medications.
• Extrinsic Factors: Environmental hazards circumstantial to the older adult, such as loose rugs, poor lighting, and cords.

📖 Main Content

1. Incidence & Impact

• Trauma is the fifth leading cause of death in persons $>65$ years of age.
• Falls are responsible for 70% of accidental deaths in persons $≥ 75$ years.
• Community-dwelling older adults fall at a rate of 30% to 40% annually; nursing home and hospitalized rates are three times higher.
• 20% to 30% of older adults who fall suffer significant injuries leading to immobility and dependence.
• Adults $≥ 85$ years are 10 to 15 times more likely to suffer a fracture compared to those aged 60 to 65.

2. Risk Factors for Falls

Risk factors are divided into intrinsic, extrinsic, nursing home causes, and situational activities:
- Intrinsic Factors:
- Aging: Vestibular and visual decline (glaucoma, cataracts).
- Cardiac: Arrhythmias, carotid sinus hypersensitivity.
- Neurologic: Parkinson disease, normal pressure hydrocephalus, sensory neuropathy, prior stroke.
- Musculoskeletal: Lower extremity weakness, impaired knee/ankle strength, deconditioning, arthritis, foot problems (bunions, calluses).
- Vascular: Postural hypotension, postprandial hypotension, vertebrobasilar insufficiency.
- Medications: Benzodiazepines, sleeping medications, neuroleptics, antidepressants, anticonvulsants, class I antiarrhythmics, and antihypertensives.
- Extrinsic Factors: Environmental hazards cause $>50%$ of falls in the elderly (cords, slippery surfaces, loose rugs, ill-fitting shoes). Majority happen at home during mild-moderate activity.

3. Fall Injuries & Complications of Long Lie

• Hip Fractures: The most dreaded injury; half cannot return home independently, and up to 20% die within a year.
• Complications of Long Lie ($>1$ hour):
• Pneumonia
• Rhabdomyolysis: Leakage of potassium, phosphate, myoglobin, and CK into circulation. Can lead to acute kidney injury (AKI), hyperkalemia, and hypocalcemia. CK peaks in 1-3 days.
• Dehydration
• Hypothermia: Mild ($<35°C$), Moderate ($<32°C$), Severe ($<28°C$).

4. Assessment and Workup

• Focused History: Circumstances of the fall, witnessed status, medication review, and acute/chronic problems.
• Physical Examination: Vital signs (orthostatics), cardiac exam, neurologic exam, and gait/balance assessment.
• Workup: CBC, chemistries, thyroid/liver function, B12, vitamin D, ECG/Holter monitor, and CT/MRI brain if neurologic impairment is suspected.

5. Treatment and Prevention

• Nonpharmacologic Therapy: Physical therapy, home safety assessment, medication minimization, proper footwear (hard sole, low heel), and assistive devices.
• Assistive Devices & Mobility Rules:
• Canes: Handle at greater trochanter level; hold in the hand opposite the diseased leg.
• Stairs: Go up with the good leg first, go down with the diseased leg first (both hands supported).
• Exercise: Minimum 10 weeks, individualized, group exercises like Tai Chi. Avoid brisk walking as it increases fall risk.

📊 Visual Learning

💡 Important Points to Remember

• Falls cause 70% of accidental deaths in persons $≥ 75$ years old.
• Environmental hazards cause over 50% of falls in the elderly.
• A long lie ($>1$ hour) causes rhabdomyolysis, releasing CK, myoglobin, and potassium, leading to acute kidney injury (AKI).
• Get Up and Go Test: Taking $≥ 14$ seconds indicates increased fall risk.
• Cane usage rule: Hold the cane in the hand opposite the diseased leg.
• Stair usage mnemonic: Up with the good, down with the bad (good leg up first, diseased leg down first).
• Fear of falling (FOF) can occur in both fallers and non-fallers and heavily restricts daily activity.
• High-dose Vitamin D ($≥ 1000$ IU) has been shown in clinical trials not to prevent falls, and can increase risk at higher doses.
• Common culprit medications include benzodiazepines, neuroleptics, and antihypertensives.
• Brisk walking is contraindicated as an exercise intervention because it increases fall risk.

⚠️ Common Exam Questions

• MCQ Trap: Examiners often claim that Vitamin D supplementation reliably prevents falls in the elderly. Correction: Recent trials show high-dose Vitamin D does not prevent falls and may increase risk.
• Stair Navigation Trick: Questions will test whether a patient goes up or down stairs with the bad/good leg first. Remember: Up with the good leg, down with the diseased leg.
• Cane Placement Trick: Asking which hand holds the cane. Remember: Opposite to the side of the weak/diseased leg.
• Definition Distractors: Distinguishing a fall from syncope or epileptic seizures—remember a true fall excludes loss of consciousness or sudden paralysis.

📝 Quick Review Checklist

I can define a fall and list its main incidence statistics
I understand intrinsic vs. extrinsic risk factors
I know the complications associated with a long lie (>1 hour)
I can describe the Get Up and Go Test threshold (14 seconds)
I know how to correctly instruct a patient on using a cane and navigating stairs
I can list key high-risk medications that contribute to falls