M3 Orientation Case - POGOe



Emory Reynolds Program

Nathan Flacker, M.D.

Birju B. Patel, M.D.

M3 Orientation

Falls in the Elderly, an Orientation for the Medical Student

Chief complaint: Fall

You are called by the team intern to help evaluate an 82-year-old man, Mr. John Schneider who is on 5B after being hospitalized for new onset confusion and urinary incontinence. He has fallen 4-5 times at home in the past few weeks.

HISTORY:

Mr. Schneider lives at home with his daughter who is present in the room with him. His daughter is concerned that her father needs further evaluation. Yesterday after dinner, (“all of his falls seem to happen after dinner”) just prior to admission, Mr. Schneider was going to the kitchen and he experienced a fall. The daughter states that she saw her father on the floor when she came to the dining room after she heard a loud noise. Mr. Schneider was not unconscious and states he felt dizzy and lost his balance. He got up with some assistance and was escorted by his daughter to the couch in the living room. He denied any chest pain, palpitations, loss of consciousness, fever, jerky movements, or incontinence. He said that he tripped (“over the damn cat probably”). After about an hour of resting he improved. His daughter, who is a nurse, checked his blood pressure and blood sugar while he was resting on the couch. His blood pressure was 158/74 with a blood sugar of 186. There were no falls prior to last month, and no previous falls or passing out, but now he needs some assistance to get out a chair. He has also had more trouble “controlling his urine”. She brought him to the ER because this was his third fall in a week and “there must be something wrong”.

PMH: Mr. Schneider has a history of type II Diabetes Mellitus, hypertension, mild cognitive impairment, coronary artery disease, cataracts, and chronic stable angina.

Medications: Atenolol, Gabapentin, Simvastatin, Glipizide, Aspirin, Isosorbide Mononitrate, Ambien, vitamin E, and multiple vitamins. Haldol 0.5 mg BID started 1 week prior to admission.

Social History: Mr. Schneider is a WWII veteran and a retired postal worker. He lives at home with his daughter. He is independent in his basic activities of daily living (ADLs). He is able to drive but tries to drive only short distances and during the day due to his vision. He is usually able to function well at home and enjoys doing housework to help his daughter.

Review of Systems: Difficult to obtain. He states no dyspnea, chest pain, or pains in general. Otherwise there are no other problems on review of systems.

LABS: Admission laboratory work shows a normal CBC and SMA-12. The urinalysis has 2-5 WBC per high power field and no bacteria. EKG shows normal sinus rhythm, with PACs. Chest X-ray shows a possible infiltrate in the right lower lobe.

M3 Orientation

Falls

Questions

1. What are the most essential elements of the history to elicit regarding falls in a patient like Mr. Schneider?

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2. What are the essential components of a focused physical examination in this patient with a fall?

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1. What are his significant risk factors for future falls?

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M3 Orientation

Falls

ANSWER KEY

1. What are the most essential elements of the history to elicit regarding falls in a patient like Mr. Schneider?

• Specific details of the events at the time of the fall

• Patient’s current condition

• Previous falls

• Confusion

• Depression

• Altered elimination (incontinence, obstruction, diarrhea, constipation)

• Number of medications

• Type of medications (Sedatives, Cardiac, Diabetic, Seizure)

• Timing of medications

• Timing of meals

• Dizziness/vertigo

• Aura/seizure activity

• Loss of consciousness

• Chest pain

• Substance abuse

2. What are the essential components of a focused physical examination in this patient with a fall?

• Postural vital signs

• Apical heart exam for

1. Arrhythmia

2. Significant murmur

• Basic visual examination

• Get Up and Go test (get up from a chair, walk, and turn around)

• “Talk and Walk” test

• Focused neurological examination for

1. Focal deficits

2. Peripheral neuropathy

3. Orientation and confusion

• Auscultation of the lungs to rule out pulmonary edema

• Check feet and fit of shoes

3. What are his significant risk factors for future falls?

• Gender

• Confusion

• Incontinence

• Medications: Gabapentin

• Medications: Ambien

• Medication: Atenolol

• Medication: Glipizide

• Difficulty with transfers

• Postprandial hypotension

• Orthostatic hypotension

• Visual impairment

• Environment (cat, etc.)

DISCUSSION POINTS

What assessments/intervention(s) may help Mr. Schneider?

• Medications Assessment:

o Special attention to nitrate, and beta-blocker if patient has postural hypotension.

• Correction of postural hypotension if present

o Altering medications

o Support stockings

o Behavioral techniques.

• Further assessment of cataracts and vision

• Home assessment to correct potential environmental contributors to falls, including looser objects, lighting, etc.

• Assessment of diabetes control with attention to hypoglycemia and postprandial hypoglycemia.

• EKG/telemetry to rule out arrhythmia

• Laboratory Assessment to rule out:

o Anemia

o Dehydration

• Physical therapy evaluation for strengthening, balance training and the use of proper assistive device(s).

For more information see:

Krauss MJ, Evanoff B, Hitcho E, et al. A case-control study of patient, medication, and care-related risk factors for inpatient falls JGIM 2005;20:116-122

American Geriatrics Society. Guideline for the Prevention of Falls in Older Adults J Am Geriatr Soc. 2001; 49:664-672.

Hendrich, A., Nyhuuis, A., Kippenbrock, T., Soga, M.E. Hospital falls:

development of a predictive model for clinical practice. Applied Nursing Research

1995;8:129-139.

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