Geriatric EM: Falls Can Be Sentinel Events

A 72-year-old woman is brought to your Emergency Department (ED) after falling while rushing to the toilet. She has no visible deformity on examination and is discharged with pain medications. Two weeks later, EMS transports her to the ED after a loss of consciousness. Computed tomography (CT) of the head at that time shows a subdural hematoma.

Unfortunately, this scenario is common. Given time constraints in the ED, management plans often miss opportunities to assess a patient’s risk for falling and may not be compliant with recommendations [1, 2]. However, falling can be a sentinel event for older adult patients [3].

Falls can be sentinel events

While emergency physicians may focus on trauma burden or concern for cardiac arrhythmia acutely, falls have a surprisingly high one-year mortality rate at 21.9% [4]. Falling causes up to 12% of deaths in the geriatric population [5]. They can lead to both serious and non-serious complications, for example, fractures and intracranial injury, a decline in health and function, social isolation, increased risk of nursing home admission, and loss of confidence [6-11]. Providers in the ED can begin the process of detecting who is at high-risk for falling in the future to prevent such high morbidity and mortality.

Quick assessment in the ED

Unfortunately, while there are many tools to screen for fall risk, none have been validated in the ED. Below are some tools that can be used as part of a more complete clinical assessment.

The STEADI Algorithm [12, 13] comprises various components, including:

1. Screening questions
   • Have you fallen in the past year? If so, how many?
   • Do you feel unsteady when standing or walking?
   • Do you worry about falling?
2. Timed Up and Go (TUG) test [12, 14, 15]
   • The patient sits in a standard armchair. When the provider says “Go,” the patient stands up from the chair, walks 3 meters (10 feet), turn, and walk back to sit at the chair. The provider records the time.
3. Observe the patient for gait/balance instability.

If “Yes” to any question, a TUG ≥12 seconds, or gait or balance instability, the patient may be at risk of fall and further assessment should be considered.

Tiedemann’s Brief Performance-Based Fall Risk assessment tool [16]

1. History taking
   • Previous fall? (Y/N)
   • Medication review
     • Four or more (excluding vitamins)? (Y/N)
     • Any psychotropic? (Y/N)

2. Visual acuity test – Unable to see all of line 16 on a low contrast visual acuity test (Y/N)
3. Peripheral sensation test – Unable to feel 2 out of 3 trials (Y/N)
4. Balance/Coordinated Stepping/Strength
   • Near tandem stand test (balance)- Unable to stand for 10 secs (Y/N)
   • Alternate step test (coordinated stepping)- Unable to complete in 10 secs (Y/N)
   • Sit to stand test (strength)- Unable to complete in 12 secs (Y/N)

Each “Yes” gets 1 score. We can compare the score(s) with the probability of falling.

Carpenter’s ED fall risk questions [6]

1. Presence of non-healing foot sore?
2. Any fall in the past 12 months?
3. Inability to cut his/her own toenails?
4. Self-reported depression?

If there is more than 1 factor present, the patient is at increased risk for a fall in 6 months. If you are unable to use one of these screening tools, it may be most useful to review high-risk medications and observe them walk.

High-risk medications [17]

• Sedative-hypnotic and anxiolytic drugs (especially long-acting benzodiazepines)
• Tricyclic antidepressants
• Major tranquilizers (phenothiazines and butyrophenones)
• Antihypertensive drugs
• Cardiac medications
• Corticosteroids
• Nonsteroidal anti-inflammatory drugs
• Anticholinergic drugs
• Hypoglycemic agents
• Any medication that is likely to affect balance

Educate the patient

An important consideration is to educate the patient on fall prevention. The American College of Emergency Physicians sponsored the creation of a video, the 7 Step Challenge to Prevent Falls, that you can include in your patient’s discharge summary or have them watch prior to discharge.

Take Home Points

• Falls can be sentinel events and represent a high risk for morbidity and mortality for older adult patients.
• Emergency physicians can play a crucial role in identifying patients at risk and preventing future injury.

References:

1. Davenport K, Alazemi M, Sri-On J, Liu S. Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall. Ann Emerg Med. 2020;76(6):730-738. doi:10.1016/j.annemergmed.2020.06.020. PMID: 33010956
2. Tirrell G, Sri‐on J, Lipsitz LA, Camargo CA Jr, Kabrhel C, Liu SW. Evaluation of Older Adult Patients With Falls in the Emergency Department: Discordance With National Guidelines. Academic Emergency Medicine. 2015;22(4):461-467. doi: 10.1111/acem.12634. PMCID: PMC6778963
3. Carpenter CR, Cameron A, Ganz DA, Liu S. Older Adult Falls in Emergency Medicine-A Sentinel Event. Clin Geriatr Med. 2018;34(3):355-367. doi:10.1016/j.cger.2018.04.002. PMID: 30031421
4. Tan MP, Kamaruzzaman SB, Zakaria MI, Chin A-V, Poi PJH. Ten-year mortality in older patients attending the emergency department after a fall: Ten-year ED fall mortality. Geriatrics & Gerontology International. 2016;16(1):111-117. doi:10.1111/ggi.12446
5. Greenhouse AH. Falls among the elderly. In: Clinical Neurology of Aging. 2nd ed. Oxford University Press; 1994:611-626.
6. Carpenter CR, Scheatzle MD, D’Antonio JA, Ricci PT, Coben JH. Identification of Fall Risk Factors in Older Adult Emergency Department Patients. Academic Emergency Medicine. 2009;16(3):211-219. doi:10.1111/j.1553-2712.2009.00351.x. PMID: 19281493
7. Tinetti ME, Williams CS. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. N Engl J Med. 1997;337(18):1279-1284. doi:10.1056/NEJM199710303371806. PMID: 9345078
8. Boele van Hensbroek P, van Dijk N, van Breda GF, et al. The CAREFALL Triage instrument identifying risk factors for recurrent falls in elderly patients. The American Journal of Emergency Medicine. 2009;27(1):23-36. doi:10.1016/j.ajem.2008.01.029. PMID: 19041530
9. Tromp AM, Pluijm SMF, Smit JH, Deeg DJH, Bouter LM, Lips P. Fall-risk screening test. Journal of Clinical Epidemiology. 2001;54(8):837-844. doi:10.1016/S0895-4356(01)00349-3. PMID: 11470394
10. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65:993–998. doi:10.15585/mmwr.mm6537a2. PMID: 27656914
11. Gill TM, Murphy TE, Gahbauer EA, Allore HG. The Course of Disability Before and After a Serious Fall Injury. JAMA Intern Med. 2013;173(19):1780. doi:10.1001/jamainternmed.2013.9063. PMCID: PMC3812391
12. Stevens JA, Phelan EA. Development of STEADI: A Fall Prevention Resource for Health Care Providers. Health Promotion Practice. 2013;14(5):706-714. doi:10.1177/1524839912463576. PMCID: PMC4707651
13. Centers for Disease Control and Prevention. STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention among Community-Dwelling Adults 65 years and older. Published online 2019. Accessed November 20, 2020. https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf
14. Podsiadlo D, Richardson S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of the American Geriatrics Society. 1991 Feb;39(2):142–8. doi: 10.1111/j.1532-5415.1991.tb01616.x. PMID: 1991946
15. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of fall in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14. doi:10.1186/1471-2318-14-14. PMCID: PMC3924230
16. Tiedemann A, Lord SR, Sherrington C. The Development and Validation of a Brief Performance-Based Fall Risk Assessment Tool for Use in Primary Care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2010;65A(8):896-903. doi:10.1093/gerona/glq067. PMID: 20522529
17. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-2168, 2173-2174. PMID: 10779256

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