Falls CDC STEADI algorithm for falls SCREENING Ask all older adults annually: Have you fallen in the past year? If yes: what were the circumstances of the fall? If no: Do you feel unsteady when standing or walking Are you worried about falling? If yes to any of the questions -> at risk of falls -> falls risk assessment If no to all of the questions -> recommend general prevention strategies. FALLS RISK ASSESSMENT Identify risk factors Underlying medical condition: Depression Osteoporosis Cerebral ataxia Hypotension Advanced age Female Arthritis History of stroke Orthostatic hypotension Anaemia Cognitive impairment Lower limb paresis Past history of falls. Visual disturbances. Polypharmacy Chronic conditions Vestibular and cerebellar pathology Medications Benzos Anti-depressants Physical examination Postural vitals -> orthostatic hypotension MSK exams -> evaluate gait, strength and balance. Get up and go -> ask the patient to get up from a straight-backed chair -> walk 3 meters -> turn around -> walk back and sit down again. Neurological examination Visual acuity testing Feet and footwear assessment Other considerations: Cognitive assessment Lab studies: CBC -> rule out anaemia BMP -> rule out electrolyte abnormality Serum vitamin B12 levels Serum vitamin D levels Assessment – History and Examination History HOPC Who -> who witnesses the fall? When -> when they fell? Where -> where they fell? What -> events prior to, during and after the fall. Why -> reasons patient thinks they fell How -> they way they fell and home many times in 12 months. Previous fall information. Full medications history Full social history Underlying chronic diseases Systems review Examinations Full general examination A -> E Full neurological examination PD Vertigo Peripheral neuropathy Visual tests MSK function E.g. up and go test and functional reach tests. Investigations Bedside: Frequent observations BSL U/A ECG Lab FBC, EUC, LFTs Bone profiling Imaging CXR XR of any injured limbs Head CTs -> head trauma Consider transthoracic echo -> cardiac cause for syncope -> fall Management Identify the main contributing cause -> target Falls clinics Supportive measures Physical activity -> aerobics, balance training Medications review Home assessment to modify hazards. Falls prevention in the Elderly ALL PATIENTS Provide general education on: Medications interactions risk Appropriate foot care Home hazards. Recommend regular exercise: Aerobic Balance Strength training Aks about vitamin D intake from: Diet Supplements Sunlight Risk factors for vit D deficiency As indicated by risks assessment Optimise the management of comorbidities, including medications adjustments Minimise the number of medications that contribute to falls. Refer to occupational therapy for home hazard assessment and modification Evidence of poor gait, strength and balance Consult additional specialists as required -> e.g. ophlamologist, podiatrists For hospitalised patients consider additional measures. Neuropsychological Assessment in Older Adults Cognitive Assessment Indications: Suspected mid cognitive impairment (MCI) or dementia. As part of Medicare annual wellness visit. Screening tests Mini-Cog: highly sensitive for early dementia in older adults -> includes clock drawing and three-item recalls. MoCA: assess degree of cognitive impairment includes visuospatial/executive function, naming, memory, attention, language, abstraction and delayed recall. MMSE: screening tool for cognitive impairment in people with suspected dementia -> tests for orientation to time and place, registration (immediate repetition of named prompts), attention, calculation, recall (of previous prompts), language, repetition of a complex phrase or command. Management considerations Consider a diagnosis of delirium instead of or in addition to dementia especially in those with fluctuating symptoms. Early diagnosis of MCI is important as interventions such as aerobic exercise may help prevent dementia progression. For patients with MCI check driving regulations.