Geriatrics and Falls

Our approach to older patients in Emergency is often an opportunity for a holistic assessment. These patients need special consideration. Falls are an incredibly common presentation, something we see more and more in an aging population. Rather than just looking for the injuries caused by the fall, which is important, we look hard for a reason the fall happened in the first place. A “mechanical” fall is rarely the full picture and something I would caution against writing in your notes.

When we see an older patient who has had a fall we usually screen for infectious causes and ensure they’re managing in their current environment.

History

Many older patients are unable to give a good history themselves, particularly if they have a degree of cognitive impairment or are in a nursing home. Many patients with memory issues will still be able to outline current symptoms like pain or shortness of breath, and I would focus on these. If they are unable to give an accurate history of the presenting complaint there are several places to look for clues.

Nursing home staff often have some extra information that is not obvious at the bedside. The summaries they send with patients don’t often have a history of the exact event that led them to hospital. If you call early enough, you can sometimes get hold of the nurse that was taking care of the patient. They may be able to give you more insight into whether the patient was behaving differently to usual or how they were found, in the case of a fall.

The paramedic notes are also quite helpful as the pithy history can capture detail of the presenting complaint that would otherwise get lost along the way. They are often at the bedside and take just a moment to flip through.

If the patient is from home, then any history from family is crucial, and they can often be the very best source of information. We want to know what happened today, but a partner or child will also be able to outline any decline that has happened over time and how the patient is coping in their home life.

Nursing home patients should come to hospital with a care summary including past medical issues and a current medication list.  

Social History

I cannot overstate the importance of the social history in our older population. This information will often decide the disposition of the patient. In many patients, I often start with the social history. Take your time, be thorough and be curious.

I often ask a few questions that paint a picture of home life.

• Who do you live with?

• Who does the shopping?

• Do you drive a car?

• Do you use a walking stick or four-wheel walker to get about?

• Do you have any services or an aged care package? What are they?

If they live alone, this places the person at higher risk. If they can’t do the shopping because of mobility issues and they don’t drive a car, it’s clear that attending follow-up appointments will be very difficult. Do they have social supports nearby like children? How do they take care of themselves when they’re unwell? A completely independent person who lives with a partner and still drives is a very different patient to a largely home bound and frail person who lives alone.

Many Emergency Departments will have an aged care assessment team (ASET) in the department itself. They are experts in exploring these issues and determining what services and supports a person needs. The ASET team is for patients who still live at home.

If someone is from a nursing home, then that gives you some indication of their baseline function. I want to know the reason that they’re in a nursing home – is it about physical limitations or cognitive impairments? And I want to know what life looks like day to day for them.

• Can they mobilise independently?

• Do they need assistance with toileting, showering and dressing?

• Do they need help feeding themselves?

• Are they bedbound?

If the nursing home is struggling with some aspect of their care, then it’s worthwhile involving Geriatrics. Many hospitals have a community wing of the Geriatric service (like the Geriatric Flying Squad) that can help keep patients in the nursing home and treat them there instead of in hospital.

Physical Exam 

A good physical exam will help guide the investigations you order. Do a full top to toe, ensuring you have fully uncovered any wounds. If their hair is matted with blood, they need a good scrub so you can see what’s underneath. Do they have neck or back pain? Any skin tears? Broken fingers or toes? Have you looked for cellulitis? Did you take off their socks to look at pressure ulcers? Sacral pressure wounds?

It’s easy to miss things because the patient is in their own clothes, their wounds are dressed or they’re tricky to sit up. Get a nurse to help you, expose the patient briefly and with dignity to ensure you have seen anywhere that could have a pressure ulcer, an injury or that may be a site of infection.

Crucially, the patient must walk. If a patient is from home and they cannot walk, they are unable to go back home. Physiotherapy can help if you can’t get the person up out of bed yourself. If the nurses have seen the patient mobilise to the toilet without any help, then this is a good sign.  

From here you’ll have some idea of what imaging to order.

Investigations 

Older patients who have fallen or who are unwell will need blood tests. I find a CRP particularly useful as they can point you towards a bacterial infection, but some bosses will not agree. Any older person with a fall with me will get a chest xray, a urinalysis (dipstick) and bloods. If they are an unclear historian, have evidence of a head wound or are on anticoagulants, then I will also complete a CT brain.

If I’ve found any sites of pain, broken fingers, a sore vertebra then I will also image these. X-rays are usually enough for limb injuries. I order a CT for any back injuries as x-rays are usually unhelpful.

I will also have a relatively low threshold to complete a CT abdomen for any elderly patients with abdominal pain.

Disposition

With the above information you’ll have enough to make a safe disposition decision. There are more options available in this situation than with other patients.

Nursing home patients with an infection may be suitable for return to their nursing home on once daily IV antibiotics with the Geriatric Flying Squad. This can be organised by talking with them directly or with the Geriatric team.

If you discharge an older person to their own home but want to ensure they’re safe, you can make a referral to the community nursing team. They will follow-up with a phone call or in-person to assess their home environment and this is a wonderful safety net when available.

If a person from home is unable to mobilise safely, they may require a short admission for some allied health involvement. One option for privately insured patients is a private hospital admission with their agreement. This can save a public hospital bed and help with patient flow in ED.

Of course, sick patients will need to be admitted to hospital. Older patients who have comorbidities like cognitive impairment will need a discussion around goals of care or advanced care planning. If you’ve never been involved in this before, ask your senior for help. Every situation is different and there is nuance between patients.