Geriatric ED Guidelines
Obtain History and Physical Exam
History
Focus on key historical factors that increase fall risk
- Visual or neurologic impairments
- Alcohol use
- High-risk medication use
- Activities of daily living
- Appropriate footwear
- Orthostatic hypotension
- Melena
- Near syncope
NOTE
Key historic elements include
- Age >65, location, and cause of fall
- Difficulty with gait and/or balance
- Falls in the previous (XX time)
- Time spent on floor or ground
- Loss of consciousness or AMS
- Near/syncope/orthostasis/Melena
- Specific comorbidities (eg, dementia, Parkinson disease, stroke, diabetes, hip fracture, depression)
Physical Assessment
- Orthostatic blood pressure assessment
- Neurologic assessment
- Evaluation of the patient for injury
- Safety assessment before discharge should include an evaluation of gait and a Timed Up and Go test (TUG)
- All patients admitted to the hospital after a fall will be evaluated by PT/OT
NOTE
Depending on circumstances, also consider EKG, complete blood count, standard electrolyte panel, measurable medication levels, and appropriate imaging.
In a paper by Southerland, a 4-stage balance test in addition to the STEADI screening questions significantly increased the detection of older adults at risk for falls.
Key Concept
The Bottom Line:
We need to get our patients UP to assess their functional status and fall risk.
References
Rosenberg MS et al. American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, Society for Academic Emergency Medicine. 2013: https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf.
Southerland LT et al. Am J Emerg Med. 2017;35(2):329–332.
Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-148.
Abbreviations
ACEP, American College of Emergency Physicians; AMS, altered mental status; ED, emergency department; EKG, electrocardiography; STEADI, Stopping Elderly Accidents, Deaths & Injuries.