A Stepwise Approach to a Comprehensive Post-Fall Assessment
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Falling, which was first described in the geriatric literature by Isaacs1 as “inadvertent landing to the lowest level,” was defined as a sudden and involuntary happenstance (hence, inadvertent), as in the case of an accident, and “not the result of loss of consciousness.” Since 1987, knowledge of fall etiology has expanded beyond the assumption that falls are mainly the result of accidents. Falls are a multidimensional phenomenon, attributable to medications,2-6 chronic7,8 and acute disease, age-related reasons,9-12 environmental causes,13,14 prodromal causes,15,16 or other etiology17 or idiopathic phenomena.
Although national guidelines for fall prevention exist,18 they are incomplete with regard to a comprehensive post-fall assessment. These guidelines leave much to the discretion of each clinician. A practical, organizational approach is needed that includes specific fall-related questions concerning symptoms, historical accounts, and situational contexts, and a pertinent physical examination in order to distinguish among various fall etiologies. This approach is especially important given the likelihood of symptom underreporting or dismissal of falls altogether by older adults.
As a widespread public health problem, falling has no geographic boundaries or age criteria, but its greatest impact is among the elderly. In 2001, more than 1.6 million seniors were treated in emergency departments for fall-related injuries, nearly 388,000 were hospitalized, and more than 11,000 elderly individuals died from fall-related injuries.19 Of the 50,000 U.S deaths from traumatic brain injury, falls are the leading cause among those age 75 and older.20 Because falls are such a pervasive, multifactorial, geriatric syndrome, the types of questions posed to older adults must also reflect a multifactorial set of content by care providers serving the elderly.
This article will outline a stepwise, organizational approach to the fall evaluation of an older adult that identifies symptoms and contexts associated with falls so that interventions can be tailored to likely etiologies. This approach takes into account the many interactive contexts that surround the older adult’s experiences, interpretations, and perceptions of a fall. As a vehicle toward greater understanding of the person’s experience and perception of a fall, it fosters opportunities for education, clarification of misconceptions about falling, and assistance in tailoring individualized plans of care.
THEORETICAL FOUNDATION
The stepwise approach for post-fall assessment is derived from two models: the Medical Model and the Illness Representation Model.21 Both models are clinically valuable in the formulation of any comprehensive fall evaluation and plan of care among individuals who are capable of discussing their thoughts. The combination of these models assists in identifying the causes of falls, directing medical plans of care, and identifying the individual’s perspective of the problem, which forms the basis of patient education initiatives, such as teaching the patient about causes of falling or clarifying ageist stereotypes associated with falling.
References
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