Joseph E. Ross
Falls are most common at age extremes. In children aged more than 1 year, injuries are the number one cause of death. Falls account for 25% of these deaths. Bike injuries account for 68% of falls for children aged 5 to 14 years (1). The incidence of falls in patients aged more than 65 years is 30%; in those more than age 80 years, it is above 50%. Accidents are the fifth leading cause of death in the age group 65 years and older. Falls account for two-thirds of these deaths. Of elderly patients hospitalized for falls, only half are alive 1 year later (2).
Factors contributing to falls need to be identified and evaluated for preventive measures to be taken. Children fall from heights; elderly fall from level surfaces.
A. Children and adolescents. Falls from heights over 3 feet and falls of infants aged less than 1 year old result in greater risk for skull fracture and intracranial bleeding. Emergent evaluation is needed in cases of loss of consciousness, behavioral changes, seizures, or ongoing vomiting.
B. Falls in the elderly. One-half of falls are secondary to accidents, including factors affecting stability. The other half are secondary to medical disorders (Table 2.2). If syncope occurred with a fall, it must be determined whether the cause is cardiac or noncardiac (Table 2.3) (Chapter 2.12). Cardiac mortality in falls related to syncope at 1 year is 20% to 30%, whereas noncardiac mortality is less than 5% (3).
A. History of the fall. An interview of a witness to the fall is essential. This may identify any seizure activity, loss of consciousness, and method of fall. Ask what the patient was doing prior to the fall, including occurrence with positional changes or after voiding, eating, or constipation. Are there associated palpitations implying arrhythmia? Did the patient have a fall or syncope during exercise, which may indicate a cardiac cause? Is there any confusion that is new or changed from the past that suggests central nervous system trauma or seizure? Was urine or bowel incontinence present? Are any musculoskeletal injuries present? Questions concerning home and risk factors should be raised (Table 2.2).
B. Past history. Explore coexisting illness that may have contributed to the fall (Table 2.2). A family history of sudden death can imply arrhythmias. Also inquire about any history of prior falls.
A. Assessment of vital signs, including heart rate and rhythm, orthostatic blood pressure changes, temperature, and respiratory rate.
B. A general body survey for any evidence of trauma.
C. Examination of the eye (funduscopic, visual acuity and fields), mouth (tongue lacerations), neck (bruits), lung (congestive heart failure or infection), and cardiovascular (murmurs and rhythm).
D. A detailed musculoskeletal examination to evaluate strength, focal weakness, range of motion, foot abnormality, and possible fractures.
E. A neurologic examination that includes mental status, evaluation of balance, gait, mobility, and tests for peripheral neuropathy.
A. Clinical laboratory tests. Most blood tests are of low yield and should be done to confirm clinical suspicion. An electrocardiogram is useful in the elderly to rule out arrhythmia, atrioventricular block, prolonged QT syndrome, or ischemia. Diagnosis of the cause of the fall can be obtained in 50% to 60% of cases based on history, physical, and electrocardiographic study (4).
B. Diagnostic imaging. Skull x-ray (fracture) and computed tomography studies to detect intracranial bleeding are recommended in all infants aged less than 1 year or if the fall was from over 3 feet. Also consider imaging with any loss of consciousness, evidence of head trauma, behavioral changes, seizure disorder, ongoing vomiting, or focal neurologic deficits.
C. Other testing to consider includes echocardiogram (valvular heart disease), electroencephalogram (seizure), carotid ultrasound (bruits), carotid sinus massage (if suggested by history), and tilt table testing (if a vasovagal cause of fall is considered).
. A fall by an elderly person frequently requires a home visit to evaluate factors contributing to falls and correct unsafe conditions (Table 2.2). Symptoms of cardiac disease can occur with exertion or straining. Cardiac arrhythmias tend to be sudden without warning, although at times patients can complain of palpitations. Noncardiac causes include the vasovagal reaction in which the patient generally complains of dizziness or lightheadedness prior to a fall, often with changes in position or when upright. These can be associated with sweating and nausea. Orthostatic noncardiac causes have gradual onset and resolution. These are most often associated with medications, including antihypertensives, sedatives, anxiolytics, antidepressants, hypoglycemics, psychotropics, histamine-2 (H 2) blockers, alcohol, over-the-counter cold medicines, and medications with extended half-lives. Neurologic noncardiac events can usually be diagnosed by history and physical examination. A psychiatric cause for falls is less likely, but one should be suspicious in cases of frequent symptoms with no injury.
References
1. Gruskin KD, Schutzman SA. Head trauma in children younger than 2 years: are there predictors for complications? Arch Pediatr Adolesc Med 1999:153:15–20.
2. Steinweg KK. The changing approach to falls in the elderly. Am Fam Physician 1997:56:1815–1824.
3. Wiley TM. A diagnostic approach to syncope. Resid Staff Physician 1998:44:29–41.
4. Hupert N, Kapoor WN. Syncope: a systemic approach for the cause. Patient Care 1997:31:136–147.
Read excerpts from these other book chapters related to Falling:
Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X 
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