Don't miss the chance to stop falls in older patients
An elderly woman comes to your ED with the flu, but this patient also has osteoporosis and is at high risk for fracture. Would you assess this patient for fall risk?
When elderly patients present with a complaint that has nothing to do with a fall injury, you may have an opportunity to prevent a future fall and a potentially devastating outcome.
"Certainly, we see many falls with the elderly that result in trips to the ED," says Anne Newcombe, clinical nurse manager for emergency services at Harborview Medical Center in Seattle. "However, we also see patients who on discharge have the potential of falling at home."
In a recent study, researchers found that more than half of 117 elderly patients who came to a large urban ED after a fall and discharged from the ED were scheduled for follow-up of their fall-related injury only, with no follow-up scheduled to address prevention of future falls.1 Miguel A. Paniagua, MD, the study's lead author, says, "ED nurses are in many ways the front line for risk factor screening in susceptible ED elders, particularly those who present after having fallen." Paniagua is the assistant professor of clinical medicine in the division of gerontology and geriatric medicine at Veterans Affairs Medical Center in Miami.
Falls in elder patients are a serious problem and the No. 1 cause of accidental death in those older than age 65, adds Paniagua. "Those who present and are discharged from the ED need more than just suturing or setting of a fracture," he says. "They need proper risk factor evaluation and at minimum, referral to a provider who can do a falls evaluation. It's not just the injury that should be addressed; the fall should be addressed as well."
A patient's fall may be a symptom of an underlining condition that is not yet diagnosed and treated, says Newcombe. For example, patients may have carotid artery disease with transient ischemic attacks, or a patient may have undiagnosed gastrointestinal hemorrhage that led to postural hypotension, says Eric Marsh, RN, MSN, director of the ED at University of Pittsburgh Medical Center.
"When older people do fall, they fall hard, and they often have other comorbidities that lead to bad outcomes," says Marsh. "For example, we often see patients on anticoagulants fall and hit their heads with resultant intracranial hemorrhage such as subdural or epidural bleeds." These often can be life-threatening, he says.
Check for duplicate medications
According to the study's findings, elderly patients had different risk factors for falls than younger patients. Researchers found that polypharmacy was the most common risk factor for elderly patients, followed by cognitive impairment and more than one comorbidity.
"I am still amazed at the number of medications the elderly are on prescribed by multiple providers," says Newcombe. "Often, the common denominator is that they may be refilled at the same pharmacy so interactions can be caught."
Make the effort to be sure older patients aren't taking duplicate medications, advises Marsh. "Medications are one of the largest risks that can lead to falls. You also have to look at nonprescription drugs as well because they can have interactive effects," he says. For example, many patients take a daily aspirin and should not also take warfarin or other anticoagulants, because this combination can increase risk of spontaneous bleeding anywhere in the body, including the brain.
Patients may be taking multiple prescriptions from different doctors, adds Marsh. "A typical scenario is that the patient brings a brown bag in with 20 pills, and we find out that three or four are the same prescriptions," he says. Contact the patient's pharmacy if you can't get an accurate and complete medication history from the patient or family, he recommends. "The pharmacy could confirm what the patient is currently supposed to be taking, and you could avoid prescribing a similar drug for the same problem or duplicate prescriptions."
If a patient reports dizziness or rapid heart rate when they stand up quickly, these symptoms may mean that their medications need to be adjusted, says Marsh. He recommends routinely asking elder patients about these symptoms.
Perform careful screening of the patient's medications, eyesight, living conditions, and nutritional status, since these are all important components of fall prevention, Newcombe suggests. "The ED is the place where fall potential can be identified and referred for in-depth assessment," she says. "I've seen a fall injury case when a patient just needed new glasses. It can be as simple as that."
Reference
- Paniagua MA, Malphurs JE, Phelan EA. Older patients presenting to a county hospital ED after a fall: Missed opportunities for prevention. Am J Emerg Med 2006; 24:413-417.
Sources
For more information on fall prevention, contact:
- Eric Marsh, RN, MSN, Director, Emergency Department, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213. Telephone: (412) 647-9099. E-mail: [email protected].
- Anne Newcombe, RN, Clinical Nurse Manager, Emergency Services, Harborview Medical Center, 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 731-6141. E-mail: [email protected].
- Miguel A. Paniagua, MD, Assistant Professor of Clinical Medicine, Division of Gerontology and Geriatric Medicine, University of Miami Miller School of Medicine, P.O. Box 01690 (D-503), Miami, FL 33101. Telephone: (305) 575-3388. Fax: (305) 575-3365. E-mail: [email protected].
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