Elderly Falls (ALS) > History Of Present Illness

Your EMS crew is dispatched to the scene of a woman in her 70’s that is found lying
on the floor after a fall. Her granddaughter witnesses her fall on the floor and
immediately calls 911. The patient apparently fell after standing up. In addition, she
drank a “few” brandies prior to the fall.
Past medical history :  Hypertension, atrial fibrillation

Medications:  Metoprolol, digoxin, and coumadin

Allergies:  None

Social history:  Does not smoke, occasionally drinks alcohol, no drugs

Last meal:  3 hours ago
Vital  signs :

 Temp  98.6

 BP  100/74

 Resp  14

 Pulse:  60 (irregular)

 O 2 sat  97% on room air, 100% on oxygen

Blood sugar:  80 mg/dL (4.4 mmol/L)

Physical Exam

General:  Calm and cooperative, no apparent distress 

HEENT:  Atraumatic, pupils are slightly dilated and reactive, extraocular motions
intact, oropharynx clear without evidence of trauma or obstruction, no JVD. No
evidence of head trauma. No tenderness or deformities noted with palpation of
head or neck
Lungs:  Lungs are clear bilaterally. No respiratory distress
Cardiac:  Heart rate is irregularly irregular 
Abdomen:  Soft, non-tender, no bruising, no pulsatile masses
Back:  Non-tender, no bruising
Extremities:  Non-tender, no pain on palpation, no pedal edema, no deformities noted
Skin:  No evidence of bruising or trauma
Neuro:  Alert and oriented x3, no facial asymmetry, normal strength in all
extremities, normal speech, stroke screen negative, GCS 15
The elderly are the most rapidly growing segment of the population, making up
12% of the population, yet are responsible for 36% of all EMS transports, 25% of
hospitalizations, and 25% of all trauma costs. Treating the elderly patient who has
fallen can be tricky because there can be a multitude or reasons why your elderly
patient has fallen. When injured, the elderly are much more likely to die from
their injuries than the younger trauma patient, making them a much higher-risk
patient population. Being familiar with the many different physiologic and unique
differences in the elderly trauma patient will make you much more adept at treating
the elderly EMS patient.

Elderly Fall Statistics

 Falls occur in >30% of age over 65 years in community 

 Serious injury occurs in >20% of falls in older adults 

 Most falls occur in and around the patient’s home 

 Risk Factors: 

o Environmental hazards (most common) 

o Age over 80 years old 

o Female gender History of prior falls or Fractures 

o Hospital discharge in the last month 

o Altered gait or balance 

o Lower extremity Muscle Weakness 

o History of CVA or TIA 

o Postural Hypotension 

o Decreased visual acuity 

o Arthritis 

o Dementia or Altered Level of Consciousness 

o Major Depression 

o Alcohol Abuse 

o Diabetes Mellitus 

o Vitamin D Deficiency 

o Medication use (especially more than 4 medications) 

 Class IA Antiarrhythmics 

 Digoxin 
  Diuretics 

 Anticonvulsants 

 Psychotropic medications 

 Tricyclic Antidepressants 

 Benzodiazepines 

 Antipsychotics

The Scene

As soon as the crew arrives on the scene the lead medic immediately calls for a
thorough scene survey. A scene survey is important on every call as you never
know what you may find when you carefully survey the scene. When evaluating the
scene of an elderly fall patient, it is always a good idea to try to determine the
reason for the fall. Many elderly will say they tripped, but upon further questioning,
they really don’t remember the reason for their fall, or if they actually tripped in the
first place. As the first medical professional on scene, you should be a detective. Is
there a car running in the garage? Does it seem that the appropriate amount of
medicines had been taken when surveying pill bottles? Is there any evidence that
the patient may have been abused? Is a suicide attempt a possibility? How about
recent alcohol or drug ingestion? Do not assume that because your patient reminds
you of your sweet elderly grandmother that she is not possibly addicted to alcohol
or recreational drugs. Asking the right ques- tions can often provide you with many
valuable clues, and may lead you to the correct diagnosis.

ABC's

Airway:  Airway is clear without signs of obstruction.

Breathing:  Clear bilaterally. No distress. Oxygen is quickly applied.
Circulation:  Pulses are present with a heart rate of 60. 
It is important not to be fooled by the elderly patient with seemingly normal vital
signs. As patients age, they are less capable of mounting a tachycardic response to
stress. Also, as in this case, the patient may be taking beta blockers, like
metoprolol, or have a pacemaker, that prevents a tachycardic response.

 Immediate Treatment

 Scene safety and scene survey

 ABC’s

 Oxygen therapy (as necessary)

 Cervical spine precautions

 History and Physical

  Vitals (including temperature)

 O 2  saturation monitoring

 Cardiac monitoring

 Blood sugar check (as necessary, if paramedic care is available)

 IV line (if paramedic care is available)

 Continuous re-evaluations

What Is This Patient's Preliminary Diagnosis?

From the information we have been given in this scenario, this patient’s diagnosis is
a fall of an unclear etiology, with the possibility of head and neck injuries. The fact
that our patient hit her head and is taking coumadin should increase your suspicion
of a possible head injury. Also, as older patients often suffer from osteoporosis and
degenerative joint disease, seemingly benign falls can result in dangerous high level
cervical spine fractures. I have been fooled several times by the elderly fall patient
that had no complaints of head or neck pain but was later found to have a serious
intracranial bleed or cervical spine fracture.

What Is Your Immediate Treatment?

First, ensure scene safety for you, your crew and your patient. Simultaneously,
assess the patient’s ABC’s and quickly initiate oxygen therapy per protocol, while
maintaining cervical spine precautions. Conduct a thorough history and physical
exam, and remember, your history taking skills can be critical in helping determine
why your patient has fallen. Because, depending on your patient’s mental status,
the elderly patient may not be an accurate historian. Gather information from all
possible sources including family, bystanders or neighbors. Examine the fall site to
see if there are any obstacles that may have caused the patient to fall. Ask about
any symptoms prior to the fall such as weakness, palpitations, headache, shortness
of breath, chest pain, or abdominal pain. Many falls in the elderly are preceded by
syncopal event. It is important to realize the many seemingly innocent falls may
originate from a serious medical cause like stroke, acute coronary syndrome,
dangerous heart rhythms, or other underlying illness. Perhaps your patient has
been recently sick and weak with a fever or has been having chest pain for a few
days. Also, don’t rule out the possibility of physical abuse. Many elderly are living
on the fringe of society and are both socially and physically isolated making them
prime victims for abuse. Physical abuse in the elderly is not uncommon and often
goes unreported. If you have any suspicions about elder mistreatment, be sure to
contact your local authorities as directed by your department’s protocols. Consider
whether your patient has been taking their medications correctly or if they have
been compliant with their medications. Assess the patient’s vital signs, including a
temperature. The presence of a fever is an important clue that an infection may be
present. Perform O2 sat monitoring and if paramedic care is available, initiate
cardiac monitoring, perform a blood sugar check, and start an IV. Finally, transport
your patient to the nearest appropriate receiving emergency department.
Pearls Of Wisdom

The existence of multiple chronic diseases in the elderly often leads to the use of
multiple medications. Remember to ask your patient if they are taking their
prescribed medication as directed. The elderly often suffer from
short- term  memory loss and are notorious for taking the wrong amounts of
medicines, not refilling prescriptions, and taking wrong dosages. Due to financial
constraints and fixed incomes, elderly patients may often try to conserve their
medicine and cut their pills in half, trying to extend the use of their medication
supply and reduce the often very high cost of prescription medications.

It is always a good idea to thoroughly examine the pelvis and hips in the
elderly trauma patient as hip fractures are very common with elderly falls.

Keep in mind that elderly patients may be taking multiple medications. Remember
to ask your patient if they are taking their medications as directed.

Scene Survey

Along with questioning your patient about medication compliance during your scene

survey, be sure to check the dates of medications and count the pills you find to
more accurately determine if your patient has been taking the prescribed dosages.
Elderly patients are often prescribed dozens of medications by many different
specialists that may not be familiar with medicines being prescribed by other
physicians. Some of these medicines may conflict with each other or expose the
patient to an increased risk of side-effects, like bleeding. Commonly prescribed
medications that may increase the risk of bleeding are aspirin, plavix, non-steroidal
anti-inflammatory drugs (NSAIDS), and coumadin. Patients may mix up their
medicines with their spouse who may also be taking dozens of medications. Many
of these medicines may have very undesirable cross-reactions with each other that
can cause a myriad of side-effects, including increasing the risk of syncope and
falls.

What Happened To Our Patient?

Our patient was transported to the local emergency department where she had a
CT scan of the brain, cervical spine x-rays, an EKG, and several blood tests. CT
scan of the brain showed a large subdural hematoma that required emergency
reversal of her coagulopathy (e.g., increased risk of bleeding) from coumadin over
usage, and emergency brain surgery to evacuate the bleeding in her head. Her fall
was most likely secondary to a sudden drop in blood pressure when she stood up
(postural hypotension), compounded by having a few alcoholic beverages prior to
standing, and by being medicated with beta blockers. A sudden drop in blood
pressure is the most likely cause of her syncopal event and the sudden fall. Her
blood was found to be dangerously thin, possibly from taking too much coumadin,
which most likely contributed to the subdural hematoma.
Elderly Falls And Documentation

Your documentation about your elderly fall patient can provide critical information
about why your patient fell. Ask questions. Is this your patient’s first fall, or have
they fallen before? Have they been unsteady recently or experiencing one-sided
weakness? Doc- ument any environmental concerns that you find. Is there a loose
throw rug, a dimly lit room, or a dangerous living condition? Document any concern
about over- or under- medication that you may suspect based on your survey of
the patient’s medications. Count the medications you find on the scene and the
number of pills in each container and document these facts. If your elderly patient
cannot provide an accurate history, document your interview with neighbors or
bystanders. Document the scene. Does it appear to be safe and clean? Is there any
concern that the patient’s living environment may be unsafe? Is there any suspicion
to suggest alcohol or drug abuse? Your accurate documentation of the scene, and
relaying this valuable information to the ED staff, may help provide valuable pieces
of the puzzle as to why your elderly patient has fallen.

Glossary

Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may

be physical, sexual, psychological, or financial/material.
Beta  : Type of energy that is emitted from a strong radiological source; is slightly
more penetrating than alpha, and requires a layer of clothing to stop it.
Blood Pressure  : The pressure exerted by the pulsatile flow of blood against the
arterial walls.
Brain  : Part of the central nervous system located within the cranium; contains
billions of neurons that serve a variety of vital functions.
Distress  : A type of stress that a person finds overwhelming and debilitating.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate
circumstances and in the appropriate dose.
Drugs  : Any chemical compounds that may be used on humans to help in diagnosis,
treatment, cure, mitigation, or prevention of disease or other abnormal conditions.
Dura Mater  : The outermost layer of the three meninges that enclose the brain and
spinal cord; it is the toughest meningeal layer.
Gait  : Walking pattern.
Hematoma  : An accumulation of blood in the tissues beneath the skin; a potential
complication of IV therapy.
Infection  : The abnormal invasion of a host or host tissue by organisms such as
bacteria, viruses, or parasites, with or without signs or symptoms of disease.
Injuries  : Any unintentional or intentional damage to the body resulting from acute
exposure to thermal, mechanical, electrical, or chemical energy or from the absence
of such essentials as heat or oxygen.
Joint  : The point at which two or more bones articulate, or come together.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG
that shows the electrical conduction in the heart.
Medication  : A licensed drug taken to cure or reduce symptoms of an illness or
medical condition or as an aid in the diagnosis, treatment, or prevention of a
disease or other abnormal condition.
Oropharynx  : Forms the posterior portion of the oral cavity, which is bordered
superiorly by the hard and soft palates, laterally by the cheeks, and inferiorly by
the tongue.
Osteoporosis  : A condition characterized by decreased bone density and increased
susceptibility to fractures.
Palpation  : Physical touching for the purpose of obtaining information.
Pill  : A drug shaped into a ball or oval to be swallowed; often coated to disguise an
unpleasant taste.
Professional  : A person who follows expected standards and performance parameters
in a specific profession.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
and so on.
Subdural Hematoma  : An accumulation of blood beneath the dura but outside the
brain.
Suicide  : Any willful act designed to bring an end to one's own life.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Syncope  : Fainting; brief loss of consciousness caused by transiently inadequate
blood flow to the brain.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result
of the rapid dissipation of energy delivered by an external force.

References

1. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-

Hill. 

2. Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th

ed.). Massachusetts: Jones and Bartlett Publishers. 

3. Family Practice Notebook (Update 2013, May 14) www.fpnotebook.com. “Fall

Prevention in the Elderly” as retrieved from
www.fpnotebook.com/Geri/Prevent/ FlPrvntnInThEldrly.htm.