# 001 Assessment of Fall Risk Etiology

Fast Facts and Concepts #001 PDF

Authors: Suzanne Gehl, MD, Jennifer Scheeler, MD, Bonnie Bobot, MD, Heather Ho MD, Steven Denson, MD, Bambi Wessel

Objectives:

1. List 10 possible underlying etiologies that may contribute to falls in elderly patients.
2. Describe the assessment of falls, as outlined below in Figure 1.
3. List 5 medical assessments/interventions that may be done to further assess potential fall etiologies.

Context: Patient fall (home, institution)

Action: Perform a “falls assessment” to determine possible contributing factors to patient falls.

Incidence/Prevalence:A “fall” is defined as an unexpected change in position from one level to another lower level. According to the CDC, 1/3 of adults aged 65 years and older fall annually. 

Falls are the leading cause of injury in the elderly, with 18,000 older adult deaths due to unintentional fall related injuries yearly.

Possible Underlying Etiologies for Falls:

1. Cardiac/Pulmonary – Orthostatic hypotension, aortic stenosis, anemia, peripheral vascular disease
2. Central neurologic function – Strokes, degenerative brain conditions, seizures, movement disorders (e.g. Parkinson’s disease, Huntington’s disease, demyelinating disorders), spine injuries
3. Cognitive impairment – Dementia and/or delirium that may impair safe transit through a given environment
4. Diet & Nutritional factors – Low vitamin D levels, thyroid dysfunction, low B12 or folate levels.
5. Endurance and functional impairments – Ischemic heart disease and heart failure, COPD and other lung disease, arthritis, muscle weakness and impaired balance
6. Environmental:
   • Improper fit of shoes/clothes
   • Wet, slippery, irregular walking surfaces (e.g., water, ice, high shag carpeting)
   • Poor lighting /glare
   • Obstructions / doorway thresholds
7. Gait disturbances:
   • Orthopedic and rheumatologic diseases that impair gait.
   • Foot and podiatric impairments – Charcot joints, plantar fasciitis, valgus/varus deformities.
8. Impairments in Activities of Daily Living (ADLs, CADET)
9. Incontinence
10. Infection – Causing delirium or dehydration and subsequent falls
11. Medications – Inappropriate medication prescribing (Beers’ List, sedating medications, new medications, medication interactions)
12. Peripheral nervous system – Neuropathies, radiculopathies (causing pain, decreased balance and function)
13. Psychiatric conditions – Depression, substance abuse/intoxication/withdrawal, vestibular system dysfunction – benign positional vertigo, post traumatic vertigo, middle ear/inner ear infections, cholesteatomas and CNS tumors
14. Vision impairments – Age related macular degeneration, diabetic retinopathy, glaucoma, cataracts, visual field impairments

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the Prevention of Falls in Older Persons

Full Size View

Next steps to further define possible fall etiologies, consider the following assessments:

• Orthostatic blood pressure
• ECG
• Confrontational visual fields, Snellen Eye Chart
• Proprioception, monofilament, vibratory sense
• Romberg balance test
• “Get Up and Go”
• Neurologic function
• Labs: B12, folate, thiamine, 25-hydroxy D3, thyroid stimulating hormone, complete metabolic panel, complete blood count

Underlying Science: The underlying science will vary based on the etiology of the fall. There are numerous possibilities that may be contributing. Examples include:

1. Diabetic neuropathy – Increased glycosylation of hemoglobin due to increased plasma glucose levels may lead to neuronal cell damage and loss over time.
2. Anticholinergic medications – Inhibition of the cholinergic neurotransmitters in the brain has been shown to predispose patients to falls.

ACGME Competencies: Patient Care, Medical Knowledge

References:

1. Yvonne ML, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010 Dec 21; 153(12):815-25.
2. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the Prevention of Falls in Older Persons. J Am Geriatr Soc 2001; 49:664–672.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Suzanne Gehl, MD, Jennifer Scheeler, MD, Bonnie Bobot, MD, Heather Ho MD, Steven Denson, MD, Bambi Wessel, Fast Fact #1: Assessment of Fall Risk Etiology. February 2012

Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.