Most likely Underlying Cause of Falls

Cardiovascular causes

• Arrhythmias
• Orthostatic hypotension

Orthostatic hypotension is defined as a systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing.

BP AND ORTHOSTATIC TESTING

Have patient lie supine and rest for 5 minutes.   Then have the patient stand and take BP measurements at 1 minute and 3 minutes after standing up.

• Carotid blockage
• Other cardiovascular diseases causing impaired cerebral perfusion

Psychological status

Delirium – An acute change in cognition

• (See Try This: Confusion Assessment Method)

Dementia - Signs of impaired judgment

• (See Try This: Mini Cog  

This is a simple test that can be used as a part of a neurological test or as a screening tool for Alzheimer's and other types of dementia.

The person undergoing testing is asked to;
Draw a clock
Put in all the numbers
Set the hands at ten past eleven.

Scoring system for Clock Drawing test (CDT)
There are a number of scoring systems for this test. The Alzheimer's disease cooperative scoring system is based on a score of five points.
1 point for the clock circle
1 point for all the numbers being in the correct order
1 point for the numbers being in the proper special order
1 point for the two hands of the clock
1 point for the correct time.

A normal score is four or five points.

Mini-Cog

Fast Diagnostic Test for Alzheimer's Disease and Dementia

The Mini-Cog is a very simple and quick test carried out by a doctor or clinician. It takes about 3 minutes to administer and is often used in emergency departments to identify people who require further investigation into their clinical presentation.

The test consists of a three item recall and a clock drawing test.

  (1)First the 'patient' is asked to repeat three unrelated words. This is the same as in the Mini Mental State Examination (MMSE).

  (2)The 'patient' is then asked to draw a clock. This is the same as the Clock Drawing Test (CDT).

  (3)The 'patient' is then asked to recall the three words.

Results of the Mini-Cog
If the 'patient' is unable to recall any of the three words then they are categorized as 'probably demented. (See Alzheimer’s disease.com)

If they can recall all three words then they are categorized as 'probably not demented'. People who can recall one or two words are categorized based on their clock drawing test.

Results of The Clock Drawing Test
If the 'patient draws a clock that is in any way abnormal they are considered as 'probably demented'. If the clock is normally constructed then they are considered 'probably not demented'.

The mini-Cog test results only contribute to a diagnosis of dementia. The test cannot be used in isolation in diagnostic tests for Alzheimer's disease.

Evidence of Depression (See Try This: Geriatric Depression Scale)

Musculosketal disorders

• Osteoporosis
• Myopathy
• Degenerative joint disease
• Trauma: fracture, sprain, ligament tear
• Gout
• Polymyalgia

Decline or change in function: change in ability to sit, stand, ambulate, toilet, transfer, or eat

Neurological Causes

• Transient ischemic attack
• Stroke
• Parkinson's Disease
• Change in balance (sitting or standing); new onset dizziness or vertigo
• Peripheral neuropathy
• Polio

History of prior fractures

Orthostatic hypotension - determine underlying cause:

• Medications
• Infection
• Dehydration
• Underlying disease: e.g. cardiovascular, diabetes, Parkinson's

New onset bowel or bladder incontinence

New onset sensory impairment: change in vision, hearing, tactile sensation (neuropathy)

Dehydration suspected

• Decline in fluid intake
• Increased demand (e.g. infection, surgery)
• Medications (diuretics)

Acute illness (See:Delirium topic)

• Infection (pneumonia, urinary tract infection, skin)
• Anemia/GI bleeding
• Fluid & electrolyte imbalance
• Congestive heart failure
• Atrial fibrillation
• Myocardial infarction

Use of restraints

Medications (See: Assessment for High Risk Medications in the Elderly)
Consider newly added drugs, polypharmacy, drug interactions:

• Cardiovascular drugs
• Diuretics
• Antianxiety drugs
• Medication that promote sleep
• Antidepressants
• Antihistamines
• Pain medications