UBC Objectives: Care of the Elderly & Priority Topic: Disability

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Construct a differential diagnosis (including risk factors) and plans for the evaluation, management and prevention of falls
• Identify consequences of immobility in the elderly patient
• Work with interdisciplinary teams to prevent, manage and treat consequences of immobility in the elderly patient
• Develop and implement plans for the assessment and management of patients with functional deficits, including the use of adaptive interventions, in collaboration with interdisciplinary team members
  

Disability

Key Feature 6: In patients at risk for disability (ex: those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (ex: exercises, braces, counselling, work modification).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Recently, I had a really long post on dementia and mentioned that part of the management of these patients is ongoing cognitive and functional assessment, and screening for the many complications that are the sequelae of the decline. Psychiatric conditions such as dementia are indeed one of the reasons to assess fall risk in the elderly, and there are many others. My differential for etiologies underlying a fall (which are conversely risk factors for a patient to sustain a fall) is as follows:

1. Medical conditions (ex: vertigo, gait disturbances, syncope) 
2. Psychiatric conditions (ex: cognitive impairment, substance abuse) 
3. Medications 
4. Environmental or behavioral risk factors (ex: walking surface, choice of footwear) 
5. Other contributors (ex: decreased vision, urinary urgency)

My approach to evaluate and manage patients who have fallen is derived from the LMCC approach to falls, which includes the following steps:

1. Gather a description of the events surrounding any recent and remote falls
   1. Consider the following points:
      1. When and where the fall occurred
      2. What the patient was doing at the time of the incident
      3. Were there any prodromal Sx (such as dizziness, lightheadedness, imbalance)
      4. Did the patient lose consciousness? (associated with orthostatic hypotension, cardiac disease, and neurologic disease)
2. Review the patient's medical history for risk factors (ex: medical conditions, medication history, substance abuse)
   1. Pain and urinary urgency may precipitate falls, and consider the timing of medications and substance use in relation to falls
3. Assess for any environmental hazards that may have contributed 
   1. Consider: Lighting, floor covering, door thresholds, railings, and furniture
4. Perform a complete physical examination and functional evaluation
   1. Things that I always want to check off my list during such an assessment are as follows:
      1. Postural vitals (BP and HR) supine and then at 1 and 3 min after standing
      2. Mental status examination (especially cognitive assessment)
      3. Cardiovascular examination (heart sounds, volume assessment)
      4. Musculoskeletal examination (examination of lower extremities and footwear)
      5. Neurological examination (visual acuity, hearing screen, lower extremity neuro exam)
5. Obtain a CBC to rule out anemia as this may increase the risk of falling; other labs as indicated
6. Optimize the management of any acute and chronic illnesses, and perform a medication review. General dietary recommendations include good nutrition and supplementation with Vitamin D and calcium, as indicated.
7. Suggest specific interventions to prevent future falls (ex: balance/gait training, muscle strengthening exercises). Consider referral to a physiotherapist to assist with this. As the expression goes, if you don't use it, you lose it, and it rings true for physical ability. Patients who are sedentary will lose muscle strength and become physically deconditioned, which increases their risk of falling. Sometimes a previous fall leads to fear of moving as much, which results in a vicious cycle of decompensation and increased risk of falling, not to mention the other sequelae of immobility including increased risk of skin breakdown (aka pressure sores) and of developing a clot (venous thromboembolic disease).

Although a few conditions require absolute bedrest (ex: unstable fractures and certain critical illnesses), most medical conditions do not necessitate immobility. Activity orders for bed rest should be avoided unless absolutely medically required. Staff should attempt to get patients out of bed to a chair with meals, which also decreases risk of aspiration and, when possible, encourage patients to walk several times daily.

Patients who have difficulty ambulating on their own or who pose a significant fall risk may need supervision by trained staff (ex: physical therapy) or referral to a specialized mobility program. Increased activity during hospitalization can mitigate functional decline so that patients can transition optimally outside the hospital setting 

1. Suggest appropriate home safety interventions (ex: removing environmental hazards, grab bars, emergency response systems). Enlisting the help of an Occupational Therapist can be very useful. Patients who are capable may also do their own home assessment (https://www.cdc.gov/steadi/patient.html).
2. Consider if there is a need or potential for benefit if consultation is arranged with other medical specialists or allied health care professionals. For complex geriatric patients, they could likely benefit from a referral to a Geriatrician for a comprehensive assessment. Consider the community resources available locally.