Falls risk assessment

Falls are common in elderly patients and are often multi-factorial. Risk factors should be minimised and all patients who fall frequently need multidisciplinary assessment by doctors/nurses, physiotherapists, occupational therapists and social services (in case more care is required). The differential diagnosis of falls is covered here.

Falls history

• Age
• Frequency of falls (in past 12 months)
• Reason for falls, e.g. mechanical, unsteadiness, syncope
• Injuries sustained
• Fear of falling

Past medical history/review of systems

Drug history

• Polypharmacy (>5 is an independent risk factor for falls)
• Medications with potentially troublesome side effects: antihypertensives (hypotension), antiepileptics (seizure control), benzodiazepines (sedation), psychotropics (extrapyramidal side effects), corticosteroids (osteoporosis, myopathy), beta-blockers (bradycardia), hypoglycaemics (hypoglycaemia), antidepressants (postural hypotension), diuretics (urinary frequency, dehydration), anticoagulants (bleeding risk)
• Bone protection: bisphosphonates, calcium, vitamin D (reduce fracture risk)

Social history and environment

• Living situation 
  • Accommodation type
  • Access/stairs
  • Who they live with
  • Carers
• Who performs their daily tasks (if the patient does them, how well?)
  • Washing
  • Dressing
  • Cooking
  • Cleaning
  • Shopping 
• Mobility: baseline, mobility aids
• Alcohol
• Footwear: appropriately fitting?
• Exercise: increases muscle strength, reduces frailty and sarcopenia, reduces falls risk
• Home hazards: rugs, furniture, hard floors, lighting

Examination – adapt depending on risk factors from history

• General examination: frailty, myopathy, sarcopenia
• Cognitive assessment
• Neurological examination: including gait, balance and signs of parkinsonism
• Visual examination
• Cardiovascular exam, postural BPs and ECG

• Specific falls risk tests
  • Timed ‘up and go’ test: ask the patient to stand up from a chair without the support of their arms, walk 3 metres, then turn round and sit down again. A walking aid can be used if required.
  • ‘Turn 180°’ test: request that the patient stand up and turn around until they are facing the opposite direction. If more than two steps are required to do this, falls risk is likely to be increased.
• Physiotherapy and occupational therapy assessments

Conclusion

• Thank patient
• Summarise your findings and risk factors
• Suggest how risk factors could be mitigated

Test yourself!

How can falls risk be mitigated?

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List some causes of parkinsonism

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