Mechanical Fall - Fall in Elderly

Casebank History
1
  • Female with a fall sustain hip fracture.
  • Fell 4 times in the past 6 months.
  • Patient had a stroke and had some weakness.
  • You need to learn how to analyse falls.
  • This fall is a mechanical fall: Happens in old age due to frail body (muscle weakness) or due to unsuitable home conditions.
  • Rule out: postural hypotension, medication side effect
  • Advice to Mobility clinic
  • You might have weakness or neurological cause.
  • BP medication cause this but we checked it was normal
  • Main treatment: offering walking aid
  • Other Rx: physiotherapy to increase muscle strength and occupational therapist to make changes at home

In Recalls

  1. Mechanical falls (BP change lying/standing not significant) 16-01-2024 Both
  2. Mechanical falls- hx of stroke and knee/hip replacement PLAB 2 Recalls: 23-04-2024
  3. Falls (mechanical) Post knee arthroplasty and also had a stroke in the past, polypharmacy but no postural. 08-11-2023 Both
  4. Mechanical fall (has a list of many medications and pervious stroke). 17-11-2023 Both
  5. Recurrent falls- on some hypertensive, 1. Fall due to mechanical. PLAB 2 Recalls: 17-04-2024
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Who the patient is:
Lena Lambert is a 75 year old lady who was admitted due to a fall.

Other info you have about the patient:
The emergency doctor has performed some assessment:

Blood pressure:
Sitting BP: 130/90
Standing BP: 125/85
ECG is normal

Blood tests:
FBC is normal
Urea and electrolytes all normal
LFT normal
Glucose normal
X-RAY of hip and pelvis is normal

What you must do:
Talk to the patient about the fall and address her concern

Patient information:

  • You were admitted yesterday following a fall at home
  • This is the 4th time you have fallen
  • The first time you fell down was 6 months ago while you were gardening. You tripped over one of your gardening tools
  • The second time you had a fall is when you were trying to stand up from a sitting position. This was 3 months ago.
  • The 3rd time you fell down, you cannot remember what you were doing.
  • The 4th time you fell down was yesterday. You were shopping at the time and you bent down to pick up a bag and you suddenly fell down
  • You have a past history of hypertension, stroke and you had a right hip replacement 8 months ago.
  • The stroke left you with mild left sided weakness
  • You are happy that you have not sustained a fracture
  • You have been told by one of the nurses that the physiotherapist will be coming to see you
  • You live with your son and daughter
  • The both of them are not always there, but you feel that you are coping well with your day to day activities.
  • You usually walk independently, but at the moment you cannot walk due to pain.
  • You are on the following medications:
    • Amlodipine
    • Ramipril
    • Simvastatin
    • Aspirin
    • Paracetamol as required

Questions:

  • Why do i keep falling doctor?
  • Do you think I will be able to walk again?
  • Do you think that the fall I had will make the hip replacement I had 8 months ago fail?

Emotions: You are worried you could fall on the bad hip

Approach

  • Number of falls
  • Symptoms before falling
  • PMAFTOSA: Past medical history- Medication-Allergy,Family History-Travel history-Occupation-Social history-Anything else
  • Fear of falling
  • Any use of walking aids

Differentials

  • Dementia
  • Visual impairment
  • Stroke
  • Antihypertensive drugs
  • Postural Hypotension

ICE

Examination

  • Gait
  • Neurological
  • Timed up and go test
  • Turn 180 degree test

Diagnosis

  • Simple Fall

Patient concern

  • Review medications
  • Repeat standing and lying BP

Management

  • Physiotherapist
  • Occupational therapist
  • Strength and balance training
  • Home hazard assessments and interventions
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What does simple fall mean…"?