Thanks Beth for the awesome case of a 90 yo F with pmhx of HTN, CKD presenting after multiple falls who developed urinary retention and fecal incontinence found to have cervical spine myelopathy from spinal stenosis.
Key Learning Points
- Approach to a patient with falls: Consider a physiologic approach thinking about the systems that need to be functioning properly to walk: cognition, motor strength, sensation, musculoskeletal apparatus, cardiovascular fitness, navigable environment
- Use the CHIP rule for determining which patients presenting to urgent care or the ambulatory setting need a head CT. The Canadian head CT rule is for patients with loss of consciousness
- The Timed Get-Up and Go test is helpful for assessing falls risk
Falls in the elderly
Step 1– Assess if the fall is consistent with syncope or pre-syncope vs. mechanical cause.
Step 2 – Assess the patient for injuries related to the fall.
- When to get a head CT?
- Decision rules to help us decide who needs a head CT after a fall. The Canadian CT Head Rule is often applied in the Emergency setting and only applies to patients with loss of consciousness. The Canadian head CT rules are the most widely validated.
- For the ambulatory and urgent care setting you could consider using the CHIP rule because it applies to patients without loss of consciousness. Note that the CHIP rule recommends head CT in patients over 60 years of age. This is a nice reminder that our older patients are at a much higher risk of subdural hematomas due to cerebral atrophy even with minor head trauma.
Step 3 – Evaluate for the etiology of the fall
Falls in the elderly are multifactorial and each fall could have a different etiology so needs to be evaluated separately.
You can use a physiologic approach to falls. Think about all the systems you need to walk (which is actually a very complex task!):
- Dementia from any cause
- Dementias associated with decreased physical functioning: parkinsons, spinal muscle atrophy
- Normal pressure hydrocephalus
- Drugs and toxins: alcohol, medications (see below)
- Motor strength
- Primary muscle disease
- Neuromuscular junction disorder
- Peripheral neuropathy
- Poor vision
- Vestibular dysfunction
- Musculoskeletal apparatus
- Ligamentous Injury
- Cardiovascular fitness
- Orthostatic hypotension
- Navigable environment
- Lighting, irregular floor surfaces, unsafe stairs, cords and carpets
- Medications (always include as a category of your differential in the elderly!)
- Sedative-hypnotics, TCAs, antihypertensives, cardiac medications, corticosteroids, NSAIDs, anticholinergic meds, hypoglycemic agents
Timed Up and Go Test
- Can be used to help with the global gait assessment
- How to perform: Instruct the patient to get out of the chair (without using armrests), stand up, walk forward 10 feet, turn around and walk back to chair, sit down.
- Normal is < 10 seconds and indicates the patient is mobile. > 20 seconds indicates the patient is variably mobile. > 30 seconds indicates impairments in mobility
- Aside from timing, observing the patient’s ability to perform each maneuver of the test can help you determine what area the patient is deficient .
Interventions for abnormal results of the Timed Up and Go test (Table copied from Preventing Falls in the Geriatric Population reference below)
|Difficulty rising from chair||Proximal muscle weakness||PT referral for lower extremity strengthening|
|Staggering or reported dizziness upon rising||Possible orthostasis||Check orthostatic vital signs; review medications that may contribute to orthostasis|
|Pill-rolling tremor, stooped posture, shuffling/festinating gait||Possible parkinsonism||Consider neurology referral|
|Increased sway, magnetic gait||Possible normal pressure hydrocephalus||Ask about urinary incontinence and memory issues. If these are highly suspected, consider head CT|
|Path deviation||Possible peripheral neuropathy, cerebrovascular disease||Consider neuropathy workup, examination of feet, PT referral for assistive device|
|Slow, antalgic gait||Pain from osteoarthritis, peripheral neuropathy, podiatric disorders||Pain control, examination of feet|
Differential for Urinary Retention in Women
- Detrusor underactivity: aging, DM, neurologic disease (stroke, spinal cord compression),
- Outflow obstruction: pelvic organ prolapse, pelvic masses
- Functional: Dysfunctional voiding, Detrusor sphincter dyssynergia, bladder neck obstruction
- Meds: Most common: anticholinergic and sympathomimetic
- Infection – UTI, genital herpes
Smits M, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med. March 20, 2007;146(6):397–405.
AAFP article on falls in the elderly: http://www.aafp.org/afp/2000/0401/p2159.html