Fall Non-Injury
Fall non injuries are often seen as the “bread and butter” of modern ambulance work. Somewhere between 7 and 9% of calls are to “elderly fallers” [1] and this can often be seen as menial or boring work, affectionately termed “nan downs”. It is fair to say attending these type of calls are unlikely to be the reason many ambulance staff joined the job.
There is most certainly the risk that staff become blasé when attending these calls as somewhere between 40 and 59.6%% of these patients are discharged from ambulance care without requiring hospital. [1]
We shouldn’t rest on our laurels however as its estimated 30 – 35% of over 65s who live in their own homes and 50% of over 65s who live in a residential care facility will suffer a fall in a 12 month period [2]. Falls are known to be the leading cause of injury in this age group with 5% of fallers suffering a fracture [2] and 70% of accidental deaths in over 75s being attributed to a fall. [3]
In the modern day NHS the sequela of falls is often increased to include pressure sores, pneumonia, hypothermia, dehydration and in extreme cases, Rhabdomyalosis and AKIs due to prolongued time on the floor.
General Assessment:
Assessment of these patients is broadly separated into:
- Presence and nature of injury,
- Cause of the fall,
- Focused falls assessment
- Further risk stratifying the patient toward further falls.
Presence and nature of inury:
We arent going to focus much on assesment of injury here, As this is something we are typically very good at as ambulance staff. Most crews know what to look for and how to go about this.
Obviously neck of femur fractures are an important injury for us to exclude as 95% of these fractures are caused by falls.
In our experience its really important to assess gait when doing this, as not all NOF's will present with the classic shortening and rotation. Pain on mobilising can be the only symptom in some particularly stoic patients.
Cause of the fall:
What is vitally important for paramedics to exclude, is that fall being a symptom of some other condition, such as a black out, dizziness or vertigo. Its expected that 1/3rd of over 70s will suffer a form of syncope and Up to 30% of these will present with a fall and a poor memory of events. [4] Therefore we must be careful to take a detailed history of events, looking for clues to a potential collapse.
Mechanical Fall:
This is a term that is regularly heard in prehospital and emergency practice, its intention is to suggest that the fall was due to a physical effect such as tripping over the carpet, getting a walker trapped or having lose fitting slippers; as opposed to a collapse, parkinsonism freeze or syncopal prodrome.
This term however, is falling out of preferred use and is being heavily dissuaded by expert groups and the literature. The reason for this is because the term “mechanical fall” is, quite vague and suggestive that the fall is somehow acceptable, trivial or incidental. The result being that patients may rack up a huge number of ambulance attendances, all for mechanical falls and it is only too easy for investigations to stop there.
What is important for clinicians to remember is that falls are not a normal part of aging, there is often an underlying, multifactorial reason behind the fall [6] and by attributing this to “just one of those things” attempts at prevention or mitigation are unlikely to be undertaken. We have already seen how damaging falls can be and so it is important for ambulance clinicians to investigate each fall on its own merit and NOT fall into the trap of assuming it is a normal occurrence.
I have been the worst for continuing to use this phrase in my practice, my thought being “well I know what I mean” and feeling rather vexed at being told what terms I should and shouldn’t use in my paper work. Its not until recently and more so in reading the literature for this article, that I have appreciated the damage and the onward implications a simple diagnosis of “mechanical fall” could instigate for my patient, further down the line.
I now tend to use the terms intrinsic or extrinsic factors, as these are far more clear and attribute an identifiable cause for the fall. So the next time you go to Dorris who has tripped over her poorly fitting slippers, instead of a diagnosis of “Mechanical Fall” consider instead, “Fall due to extrinsic factors (loose slippers)”… And don’t forget to detail what you’re going to do about said slippers in your plan.
Focused falls assessment:
identification of falls history
this is important for helping to risk stratify the patient, people who have fallen more than twice in a 12 month period have a high risk of falling again [8] and so identifying these people is important. It is also important to try and gain information and document the history of previous falls as this may help to identify and construct a pattern of events. This is becoming ever more possible with the advent of EPCR record systems where crews can now see previous ambulance call outs. Beware however of falling into the trap of confirmation bias, as described above, just because there are a number of “mechanical falls” on record previously, does not mean that is both accurate and pertinent to this presentation. A health dose of scepticism is never a bad thing.
assessment of gait, balance and mobility, and muscle weakness
clearly assessment of gait is important when assessing a falls patient. Documenting their use of, dependence on and technique with walking aids is useful information. As well as comments on their gait, where this is normal, shuffling, neurologically ataxic or parkinsonian in nature. What is particularly relevant to document is its bearing to the patient’s norm. If gait is acutely disturbed this could indicate a neurological issue.
Balance is a key component here and this can be assessed by the “tandam walking test” and the “Rhombergs test” of proprioception. Poor performance on these tests increases falls risk.
assessment of osteoporosis risk
generally this is well evaluated by GPs, however it can be useful for paramedics to take a few seconds in their assessment to consider this element.
OP risk increases with advancing age, it favours women by a ratio of 4:1 particularly when post menopausal., steroid use, smoking, cushing syndrome and anorexia also increase OP risk.
Oestrogen plays a large part in regulating bone growth as well as bone turn over, the reduction in oestrogen in post menopausal women causes bone density to reduce due to an increased rate of absorption of bone material
Patients with an OP risk who have an identified falls risk could benefit from OP prophylaxis, patients who aren’t on Vitamin D + calcium supplements should be reffered to their GP as would females of appropriate age for HRT.
assessment of the older person’s perceived functional ability and fear relating to falling
Rather ironically people who perceive themselves to have poor mobility and have a fear of falling tend to be a self fulfilling prophecy. This could be owing to frequent furniture surfing and a poorer perception of their own abilities. Conversly, patients who clearly have a mobility problem and think their mobility is fine are at risk of falls from not using walkers
assessment of visual impairment
clearly if a patient can’t see they are a falls risk. Often in our practice this encompasses temporarty visual impairment from getting up to the bathroom without lights or glasses. We should encourage both and recommend an eye test if patients haven’t had their prescription checked in some time (12 months)
assessment of cognitive impairment and neurological examination
The depth of this assessment is dependant on the condition, neurological deficits in gait could signify a neurological condition and so a deeper neuro exam would be warrented.
assessment of urinary incontinence
As I’m sure we have all encountered elderly fallers in the early hours who have fallen on their way to, or way back from the toilet. Urinary symptoms are a significant contributor to elderly falls, the frequency and urgency with which they demand night time trips to the bathroom and most likely to blame. Studies not a significant increase in falls risk in patients who report 2 or more night time bathroom trips.[7]
When assessing this we should not only assess for signs and symptoms of UTI but also under or over management of conditions which can cause LUTS, such as BPH, Over active bladder syndrome or high doses of diuretics.
assessment of home hazards
More often than not this is loose carpets or crowded/cluttered floor spaces. This is important health promotion advice to dissuade from these trip hazards. What is very useful is including these in falls referrals, specifying that some carpet may need fixing or giving your professional opinion on what aides may be required (seat raisers, chairs etc)
cardiovascular examination and medication review
Much like neurological the extent to which the clinician examines the cardiovascular system will be situationally dependant. However in all fall patients clinicians should examine for the presence of a postural drop.
When we stand up the increased effects of gravity on our body mean that our body needs to work a lot harder to pump blood to our brain (I’m sure we are all familar with the feeling of a head rush). In a healthy person the body compensates for this with a brief increase in heart rate whilst bringing about vasoconstriction to maintain perfusion. This is autonomic and we are often unaware of this fact, however, in older people the vasoconstriction effect is delayed and lessened meaning they are more susceptible to a postural drop so much so that 6% of a healthy elderly population will suffer from this, raising to 76% of patients in a geriatric ward setting [9] . Many clinicians are aware that a significant postural drop is diagnosed by a drop in Systolic BP of more that 20mmhg or 10mmhg diastolic (measured after 3 minutes of standing… this prolongued standing is important to accurately screen for a drop).
What is more significant however is symptoms of PD on standing. Symptoms include dizziness, pallor, diaphoresis , fatigue, lethargy, visual changes, tinnitus, orthostatic tachycardia (>30) and palpitations [10]
It is important to thoroughly screen for these in patients. There is some school of thought immerging that the BP reading is less important and what is relevant is the symptoms demonstrated.
Management:
The managment of these patients is easy right? It is all too simple to bring the Lifting cushion in... or who are we kidding, grab a towl and hoyk them off the floor. However, we should question if this is the best thing for the patient. In some cases is it blatantly obvious that the patient will need to be manually lifted off the floor, but in a significant number of cases ambulance crews attempt, with the right sort of coaching, could be supported to get themselves up.
This is a teachable moment, taking slightly longer with this patient could give them methods to get off the floor themselves, using chairs or nearby aids. This means a shorter time on the floor for them and fewer calls for us.
I have done this with a number of patients who had been convinced they would be unable to get up without my lifting them. Below is a simple demonstration of how we could teach a frail next of kin to support the patieint off the floor with no manual handling required.
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