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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 20-23

Fall assessment in older adult


1 College of Medicine, King Faisal University, Al Ahsa, Saudi Arabia
2 Aljaffer Family Medicine Training Center, Al Ahsa, Saudi Arabia

Date of Submission17-Jan-2020
Date of Decision10-Feb-2020
Date of Acceptance12-Feb-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Qasem Mohammed Aljabr
Al-Jafer Family Medicine Training Center, Al Ahsa
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_5_20

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  Abstract 


Falls are caused by many factors. For an individual, the cause may be a complex interaction between these factors. For this case, fall assessment is mandatory because the patient has hypovitaminosis D, stroke, arthritis, urinary incontinence, cognitive impairment, “dementia,” and osteoporosis. This patient in the past 12 months, he experienced tow falls. The fall assessment was done; it showed gait instability. As the patient complained of back pain, lumbar X-ray was positive for L4 compression fracture; however, his DEXA-scan showed osteoporosis. Osteoporosis magnetic resonance imaging was done to the patient: The result showed normal pressure hydrocephalus and vascular component. lumbar puncture (LP) was done, after the LP, his motor function improved, so the final diagnosis of normal-pressure hydrocephalus was reached. As a clinical guideline, when we face a case of fall, we should perform “a multifactorial falls risk assessment by taking the history, doing the physical examination, some test, and review the medications.”

Keywords: Dementia, fall, osteoporosis


How to cite this article:
AlGhadeer SZ, Aljabr QM. Fall assessment in older adult. Saudi Crit Care J 2020;4:20-3

How to cite this URL:
AlGhadeer SZ, Aljabr QM. Fall assessment in older adult. Saudi Crit Care J [serial online] 2020 [cited 2020 Dec 2];4:20-3. Available from: https://www.sccj-sa.org/text.asp?2020/4/1/20/283642




  Introduction Top


Falls are one of the most common serious events that can be experienced by older adults. In the U.S, one in three adults ≥65 years reports falling each year, one-half of those >80 years. Surprisingly, the leading cause of mortality in people aged more than 65 years is the serious complications of falls.

The definition of falls is coming down to rest inadvertently at a lower level. Most falls are not associated with syncope or trauma. Many works of literature exclude falls that associated with a loss of consciousness. Fall has serious consequences to the individual, such as decreasing the functional status, increasing the nursing home placement with increasing the provided medical service, and the fear of recurrence falls.[1] Falls are associated with functional decline, and it has a lot of costs, such as increased emergency department visits, increasing hospitalizations, and managing its consequences such as fractures. The cause of falls is often multifactorial because of the complex interaction between risk factors, rarely due to a single reason.

As a clinical guideline, when we face a case of fall, we have to ask the older adult about the number of falls in the past year. If the patient record one fall, the balance and gait disturbance should be investigated. If falls were recurrent, we should perform “a multifactorial falls risk assessment through taking the history of falls, performing a physical examination, doing some test, and review the medication.”[2]


  Case Report Top


A 78-year-old Saudi male known case of diabetes mellitus 2, HTN, epilepsy presents for initial evaluation of frequent falls. This patient in the past 12 months, he experienced tow falls. The last one was 6 months ago; it was in the afternoon, he had a hypoglycemic attack and dizziness, and he did not remember the specific event because he passed out. He has joint pain and instability, so he uses a cane recently. Fall assessment was done; it showed gait instability. The patient also complained of back pain, an X-ray of the back showed compression fracture at the lumbar spine.

A comprehensive geriatric assessment was done to the patient and showed dementia, urine incontinence.

Regarding the memory: The patient was not able to recall the name of three objects which were given.

Regarding the urinary incontinence screening: The patient has urine incontinence, which gets worse by bending down. It is associated with a slow stream. These voiding problems happened for a few minutes.

Regarding the depression: The PHQ9 quick depression assessment questionnaire was done: The score was 5 which indicate mild depression

The generalized anxiety disorder-7 was also done, the score: 3

Regarding the physical functional capacity: The patient was dependent on most of his daily activities such as doing heavy work around the house, shopping for groceries or clothes, driving, but he was independent in bathing, showering, dressing, and buttoning.

Regarding the fall assessment

This patient in the past 12 months, he experienced tow falls. The last one was 6 months ago; it was in the afternoon, he had a hypoglycemic attack and dizziness, and he did not remember the specific event because he passed out. He has joint pain and instability, so he uses a cane recently. The fall assessment was done; it showed gait instability.

Regarding vision and hearing

The patient has no vision problem, but he had a hearing loss.

Regarding the nutrition

The patient has noticed change of his weight in the past 6 months; his weight increased 10 kg.

The (montreal cognitive assessment) result was: 9/30 this result was unexpected for a previous teacher [Figure 1]
Figure 1: The (montreal cognitive assessment) result was: 9/30

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As the patient complained of back pain, the DEXA-scan was done: It showed osteoporosis [Figure 2] and [Figure 3].
Figure 2: Region area (cm2) BMC (g) BMD (g/cm2) T-score Z-score L1 11.54 9.49 0.822 − 2.3 − 1.3 L2 11.90 7.94 0.668 − 3.9 − 2.8 L3 13.04 9.31 0.714 − 3.5 − 2.4 L4 14.92 9.86 0.661 − 3.9 − 2.8 total 50.40 36.60 0.712 − 3.4 − 2.4

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Figure 3: Region area (cm2) BMC (g) Gmd (g/cm2) T-Score Z-score neck 4.97 2.71 0.546 − 2.8 − 1.4 total 34.24 24.80 0.724 − 2.0 − 1.110 - year fracture risk FRAX not reported because: Some T-score for spine total or hip total or femoral Neck at or below − 2.5

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Magnetic resonance imaging was done to the patient [Figure 4] and [Figure 5]: The result showed normal pressure hydrocephalus and vascular component. LP was done, after the LP, the motor function and the pain improved, so the final diagnosis of normal-pressure hydrocephalus was reached.
Figure 4: Findings: Senile brain involutional changes manifested as prominent extra-axial cerebrospinal fluid spaces and ventricular system. Periventricular and subcortical white matter high T2/fluid-attenuated inversion recovery signal intensities. Vascular impression on the right side of the pons. Impression: Dilation of the supratentorial ventricular system with effacement faux and periventricular high T2/fluid-attenuated inversion recovery signal intensity findings raise the possibility of normal-pressure hydrocephalus for clinical correlation if the patient has a triad of dementia, unsteady gain, and urinary inconsistence

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Figure 5: Findings: Senile brain involutional changes manifested as prominent extra-axial cerebrospinal fluid spaces and ventricular system. Periventricular and subcortical white matter high T2/fluid-attenuated inversion recovery signal intensities. Vascular impression on the right side of the pons. Impression: Dilation of the supratentorial ventricular system with effacement faux and periventricular high T2/fluid-attenuated inversion recovery signal intensity findings raise the possibility of normal-pressure hydrocephalus for clinical correlation if the patient has triad of dementia, unsteady gain, and urinary inconsistence

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  Discussion Top


Falls is a significant issue among older adults; it results in marked mortality and morbidity.[3]

Being old, being female, having cognitive impairment “dementia,” recurrent falls, gait abnormalities, a problem in balance, hypovitaminosis D, pain, arthritis, Parkinson's disease, stroke, and the usage of psychotropic medication are considered important risk factors of falls among older adults.

For this case, the fall assessment is mandatory because this old patient has hypovitaminosis D, stroke [Figure 6] and [Figure 7], arthritis, urinary incontinence, cognitive impairment, “dementia,” and osteoporosis.[4]
Figure 6: Nonenhanced computed tomography scan of the brain Findings: There is no significant interval change with redemonstration of the following: age related brain atrophied changes manifested by prominent cerebrospinal fluid spaces. Periventricular deep white matter hypodensity suggestive of chronic ischemic microangiopathy. Bilateral old lacunae infarcts affecting the external capsules. There is no computed tomography evidence of recent territorial infarction, intracranial hemorrhage. For further clinical correlation and further work up clinically warranted

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Figure 7: None enhanced computed tomography scan of the brain Findings: Age-related brain changes manifested by prominent intra- and extra-axial cerebrospinal fluid space. Periventricular deep white matter hypodensity suggestive of chronic microangipathy. Bilateral old lacunae infarction affecting the external capsule. Otherwise, the normal density of the remaining brain parenchyma with preserved gray-white matter differentiation. No midline shift mass effect. No intra- or extra-axial hemorrhage, collection, or space occupying lesion. No computed tomography evidence of established infarction

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Dementia

Having a cognitive impairment is a significant risk factor because it increases the likelihood of falling in comparison with people who do not have any cognitive problems.

Falls is an essential cause of increase hospitalization in a dementia patient, in comparison with dementia patient with no history of falls. In addition, people who have dementia at high risk of dangerous falls' complications, such as hip fractures, head trauma, and death.[1],[5]

In addition, psychological factors play an essential role in falls risk. “Having verbally disruptive and attention-seeking behavior,” cortical changes on imaging studies, visual perception problems, and caregiver burden' are found to increase the risk of falls.[6]

It is essential to identify the specific risk factor and estimate the risk of falling in dementia patients accurately. This estimation will help in targeting preventive strategies by physiotherapists to initiate changes regarding the specific intrinsic or extrinsic factors through interventions.[1]

Osteoporosis

Another critical risk factor in falls assessment is osteoporosis. Osteoporosis increases the risk of falling by causing many changes in balance and physical performance and psychosocial consequences.

Osteoporosis causes fear of falling, which may cause a decrease in physical and mental performance which result in more falls and more serious complication, according to a study done by Sinaki (2005).[7]

Furthermore, many people with osteoporosis have vertebral fractures, which considered a significant risk factor of falls.[8]

Vertebral fractures cause falls by many mechanisms. The patient will have increased in kyphosis of the thoracic spine, which may affect the body posture and lower the muscle strength in the lower extremities and the back, so there will be an increase in forwarding displacement of the trunk which will affect in the recovery after a fall disturbance.[9]

Furthermore, crossing the obstacle has a significant risk of falling in a patient with osteoporosis. Patients with osteoporosis complain of low dynamic stability while crossing a barrier during walking. Crossing the obstacle is a very challenging gait task and should be managed to reduce the risk of falls.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148-57.  Back to cited text no. 1
    
2.
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.  Back to cited text no. 2
    
3.
Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012;12:CD005465.  Back to cited text no. 3
    
4.
Stinchcombe A, Kuran N, Powell S. Seniors' Falls in Canada: Second Report: Key Highlights. Vol. 34. Ottawa: Public Health Agency of Canada; 2014.  Back to cited text no. 4
    
5.
Shaw FE. Prevention of falls in older people with dementia. J Neural Transm (Vienna). 2007;114:1259-64.  Back to cited text no. 5
    
6.
Asada T, Kariya T, Kinoshita T, Asaka A, Morikawa S, Yoshioka M, et al. Predictors of fall-related injuries among community-dwelling elderly people with dementia. Age Ageing 1996;25:22-8.  Back to cited text no. 6
    
7.
Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 2008;37:19-24.  Back to cited text no. 7
    
8.
Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR. Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int 2005;16:1004-10.  Back to cited text no. 8
    
9.
Sinaki M, Khosla S, Limburg PJ, Rogers JW, Murtaugh PA. Muscle strength in osteoporotic versus normal women. Osteoporos Int 1993;3:8-12.  Back to cited text no. 9
    
10.
Berg WP, Alessio HM, Mills EM, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing 1997;26:261-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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