A Stepwise Approach to a Comprehensive Post-Fall Assessment
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Deanna Gray-Miceli, DNSc, ARPN, FAANP, Jerry Johnson, MD, and Neville Strumpf, PhD, RN-C, FAAN
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.
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.
1. Isaacs B. Falling all over the place. Practitioner 1987;231(8):103-107.
2. Kelly KD, Pickett W, Yiannakoulias N, et al. Medication use and falls in community-dwelling older persons. Age Ageing 2003;32(5):503-509.
3. Smith RG. Fall-contributing adverse effects of the most frequently prescribed drugs. J Am Podiatr Med Assoc 2003;93(1):42-50.
4. Ensrud KE, Blackwell TL, Mangione CM, et al; Study of Osteoporotic Fractures Research Group. Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc 2002;50(10):1629-1637.
5. Neutel CI, Perry S, Maxwell C. Medication use and risk of falls. Pharmaco-epidemiological Drug Saf 2002;11(2):97-104.
6. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47(1):40-50.
7. Stolze H, Klebe S, Zechlin C, et al. Falls in frequent neurological diseases-prevalence, risk factors and aetiology. J Neurol 2004;251(1):79-84.
8. Shaw FE. Falls in cognitive impairment and dementia. Clin Geriatr Med 2002;18(2):159-173.
9. Ooi WL, Hossain M, Lipsitz LA. The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med 2000;108(2): 106-111.
10. Davies AJ, Steen N, Kenny RA. Carotid sinus hypersensitivity is common in older patients presenting to an accident and emergency department with unexplained falls. Age Ageing 2001;30(4):289-293.
11. Heitterachi E, Lord SR, Meyerkort P, et al. Blood pressure changes on upright tilting predict falls in older people. Age Ageing 2002;31(3): 181-186.
12. Kamel HK, Iqbal MA, Malekgoudarzi B. Postprandial hypotension and relation to falls in institutionalized elderly persons. Ann Intern Med 2001;135(4):302.
13. Connell BR. Role of the environment in falls prevention. Clin Geriatr Med 1996; 12(4):859-880.
14. Gill TM, Williams CS, Robinson JT, Tinetti ME. A population-based study of environmental hazards in the homes of older persons. Am J Public Health 1999;89(4):553-556.
15. Rubenstein LZ, Robbins AS, Josephson KR, et al. The value of assessing falls in an elderly population: A randomized clinical trial. Ann Intern Med 1990;113:4,308-316.
16. Gray-Miceli DL, Waxman H, Cavalieri T, Lage S. Prodromal falls among older nursing home residents. Appl Nurs Res 1991;7(1):18-27.
17. Roberts RG, Kenn RA, Brierley EJ. Are elderly haemodialysis patients at risk of falls and postural hypotension? Int Urol Nephrol 2003;35(3):415-421.
18. Guidelines for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664-672.
19. Centers for Disease Control and Prevention. Web-based Injury Statistics Query And Reporting System (WISQARS) [Online] (2003). National Center for Injury Prevention and Control. Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed October 3, 2005.
20. Adekoya N, Thurman DJ, White DD, Webb KW. Surveillance for traumatic brain injury deaths-United States, 1989-1998. MMWR Surveill Summ 2002;51(10):1-14.
21. Leventhal H, Nerenz DR, Steele DJ. Illness representations and coping with health threats. In: Baum A, Taylor SE, Singer JE, eds. Handbook of Psychology and Health, Volume IV: Social Psychological Aspects of Health. Hillsdale, NJ: Erlbaum; 1984:219-252.
22. Moreland J, Richardson J, Chan DH, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology 2003;49: 93-116.
23. American Medical Directors Association (AMDA). Falls and Fall Risk Clinical Practice Guideline. Columbia, MD: AMDA; 2003.
24. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing 2004; 33(3):273-279.
25. Ballinger C, Payne S. The construction of the risks of falling among and by older people. Aging Soc 2002;22(3):305-324.
26. Gray-Miceli DL. Changed life: A phenomenological study of the meaning of serious falls to older adults. [doctoral dissertation]. Wilmington, DE: Widener University; 2001.
27. Braun BL. Knowledge and perception of fall-related risk factors and fall-reduction techniques among community-dwelling elderly individuals. Phys Ther 1998; 78(12):1262-1276.
28. Clemson L, Cusick A, Fozzard C. Managing risk and exerting control: Determining follow through with falls prevention. Disabil Rehabil 1999;21(12):531-541.
29. Sandholzer H, Hellenbrand W, Renteln-Kruse W, et al. STEP-standardized assessment of elderly people in primary care [German]. Dtsch Med Wochenschr 2002;129(Suppl 4):S183-S226.
30. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.”A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
31. Friedman B, Heisel MJ, Delavan R. Psychometric properties of the 15-item Geriatric Depression Scale in functionally impaired, cognitively intact, community-dwelling elderly primary care patients. J Am Geriatr Soc 2005;53(9):1570-1576.
32. Tinetti ME, Fried T. The end of the disease era. Am J Med 2004;116(3):179-185.