Welcome to the Falls module.
This module will provide you with an interactive case study in which you will consider care for a person who has fallen.
Once you have completed the Pre-Module Test below you will be able to commence the Falls Case Study.
If you are returning to the module you can skip the Pre-Test by clicking on the Continue button to go straight to the case.
Mrs Alice Cloverdale is an 86 year old retired school teacher. Her son, Ian, has bought her for an assessment as he is concerned about his mother’s safety and well-being. Her children are not sure if she should continue living on her own.
Review Mrs Cloverdale’s history through the links below before moving on to her assessments.
Mrs Alice Cloverdale is an 86 year old woman. Her children are growing increasingly concerned about their mother’s safety and ability to continue living on her own. They have suggested she sell the house to buy a small villa closer to them, but Mrs Cloverdale is adamant that she wants to remain living where she is. She is independent and her worst fear is ending up in a nursing home.
Mrs Cloverdale’s children have requested an assessment. She has not seen her GP for 2 months because she refuses to go to the clinic. When visiting earlier in the week, Ian established that his mother has fallen twice in the last three weeks and has not left the house in the past month. Mrs Cloverdale’s neighbour, Veronica, also expressed concern when Mrs Cloverdale was reluctant to participate in any of their regular social engagements, except when they were held at her own home. Mrs Cloverdale hasn’t been to bowls for 6 weeks.
Mrs Cloverdale has a history of hypertension, congestive heart failure, type 2 diabetes, osteoarthritis and dizziness.
Mrs Cloverdale is on the following medications:
Mrs Cloverdale is a retired school teacher who is 86 years old. Her husband died two years ago (from prostate cancer) and since then she has been living alone in their family home, a two-storey house in Balcatta. Mrs Cloverdale has two children, Ian and Amy. Amy lives in the country and Ian, on the outskirts of the city.
The community where Mrs Cloverdale resides is very close, with many friends on her street having lived in the neighbourhood for 30 years or more. They regularly call in to each others homes for morning tea during the week and after church on Sundays. Mrs Cloverdale and her friends also get together once a week for quilting and on Saturday afternoons, she enjoys a game of bowls.
Mrs Cloverdale has a family history of osteoporosis, coronary heart disease and diabetes.
Your role is to take a relevant history to enquire about the circumstances surrounding Mrs Cloverdale's recent falls and reasons why she is reluctant to leave her home.
You should then perform a physical assessment and order relevant investigations to help determine the reason for her falls.
Consider how will you ask Mrs Cloverdale about her falls? You need to ascertain all relevant information, but be respectful of her feelings. She may be feeling embarrassed or self-conscious.
Please click on the questions below to obtain Mrs Cloverdale’s answer.
What are the risk factors that make Mrs Cloverdale more susceptible to falls?
Establish Mrs Cloverdale’s goals for the future by clicking on the questions below.
Mrs Cloverdale wants to remain living independently in her own home, so this should be a major goal of her treatment and management plan.
Mrs Cloverdale appears well. Her affect is reactive.
Height: 173cms
Weight: 64kg (has remained constant)
Respiratory Rate: 16/minute
Her glucometer reading is 6.7mmol/L
Please move your mouse cursor over Mrs Cloverdale as if you were examining her. You must complete the examination before you go on.
Request further laboratory tests to help determine cause of fatigue, by clicking on the tabs below. Review results before proceeding.
Hb 145g/L (normal range 115-160 g/L for adult females)
MCV 84 fL (normal range 80-100 fl)
RCC 4.1x1012/L (normal range 3.8-4.8x1012/L for adult females)
Hct 39% (normal range 37%-47% for adult females)
WCC 7.0x109/L (normal range 4.0-11.0x109/L for adult females)
Platelets - 325 x109/L (normal range 150-400x109/L)
Na 143 mmol/L (normal range 134-146 mmol/L)
K+ 4.2 mmol/L (normal range 3.4-5.0 mmol/L)
Urea 9.8 mmol/L (mildly elevated) (normal range 3.0-8.0 mmol/L)
Cr 114 µmol/L (mildly elevated) (normal range 50-95 µmol/L for adult females)
Normal – 2.25 mmol/L (range 2.15-2.60 mmol/L)
Normal – 2.9 mU/L (range 0.40-4.0 mU/L)
Normal – 412pmol/L (range 120-680 pmol/L)
Albumin 41g/L (normal range 35-50 g/L)
Bilirubin 14 µmol/L (normal range <20 µmol/L)
ALP 67g/L (normal range 35-135 g/L)
GGT 34 U/L (normal range <40 U/L for adult females)
ALT 28 U/L (normal range <30 g/L for adult females)
AST 27 U/L (normal range <30 g/L for adult females)
This test measure long term control of diabetes by measuring the average level of glucose over the previous two months. Mrs Cloverdales’s HbA1C is 6.7% (normal range <6%).
This suggests Mrs Cloverdale's diabetes is under good control.
Normal <6.0%
Good control 6.0-7.0%
Acceptable control 7.1-8.0%
Poor control >8.1%
Results at hip (femoral neck): T = 0; Z = -0.5, and spine T=-0.5 Z=-2.5 (normal range T score >= -1; normal range Z score between -2 and +2).
Sinus rhythm with evidence of old Q wave infarction in lateral leads.
You check with Mrs Cloverdale's GP. Her last echo was 8 months ago. She had mild systolic dysfunction, with an ejection fraction of 48%. No diastolic dysfunction was noted.
What do the results of the Bone Mineral Density mean?
What additional tests need to be ordered to rule out reversible causes for increased muscle weakness such as metabolic, endocrine or inflammatory disorders?
Click on those tests you would consider ordering below to find out which are relevant what the results are.
Lack of vitamin D can cause muscle weakness, aches and pains, increasing the risk of falls, fractures and balance problems, especially in older adults.
Mrs Cloverdale’s Vitamin D levels are deficient - 23nmol/L (normal range > 50 nmol/L)
Not relevant
ESR is a measure of the presence and severity of inflammatory and other morbid processes. Mrs Cloverdale’s levels are normal – 6mm/hr (normal range 1-35 mm/hr for adult females)
Not relevant at this point in time
Not relevant
PTH may be requested to help rule out hypercalcaemia as the cause of muscle weakness and fatigue. Mrs Cloverdale’s levels are normal - 4 pmol/L (normal range 0.9-9.0 pmol/L)
Magnesium deficiency can affect the neuromuscular and cardiovascular systems. Mrs Cloverdale’s results are normal - 0.9mmol/L (normal range 0.7 - 1.10 mmol/L)
Creatine kinase (CK) levels can indicate whether muscle or heart cells are injured. Mrs Cloverdale’s levels are normal – 145U/L (normal range <150 U/L for adult females)
What are the MOST likely possible causes of Mrs Cloverdale’s Vitamin D deficiency?
Possible consequences for Mrs Cloverdale
There is some evidence suggesting that vitamin D deficiency is associated with muscle weakness and falls. Chronic deficiency leads to metabolic bone disease (osteomalacia). Development of osteomalacia (a softening of the bones), will increase the risk of fracture if Mrs Cloverdale has any more falls in the future.
There is also some evidence that vitamin D deficiency may impact on mood and cognition.
Vitamin D deficiency could be a contributory reason for Mrs Cloverdale’s increased bone pain (attributed to arthritis) and muscle weakness.
You suspect that there is more to Mrs Cloverdale’s social withdrawal than tiredness and the weather. Now that you have established a rapport with Mrs Cloverdale you decide to speak with her further about this.
Please click on the questions below to obtain Mrs Cloverdale’s answer.
You reassure Mrs Cloverdale that there is no need for her to be embarrassed and explain that while falls are common, with 1 in 3 adults over the age of 65 falling each year, they are preventable. You will work together to find out what is causing her unsteadiness and help her to feel more confident and balanced once again.
To assess Mrs Cloverdale’s level of depression, you ask that she complete the Geriatric Depression Scale. Please click on the link below to review the results.
Geriatric Depression Scale
Based on the physical examination and laboratory test results, what do you feel are the largest contributing factor/s in Mrs Cloverdale’s falls?
Please click on your answer/s to obtain feedback. There are two most likely contributing factors...can you identify them both?
It is possible that this is a contributing factor, but is probably not the primary cause of Mrs Cloverdale’s falls. Please try again.
It is possible that this is a contributing factor, but is probably not the primary cause of Mrs Cloverdale’s falls. Please try again.
It is possible that this is a contributing factor, but is probably not the primary cause of Mrs Cloverdale’s falls. Please try again.
Good job! Mrs Cloverdale has reduced muscle strength due to loss of conditioning and vitamin D deficiency. She also has an altered gait pattern due to her prominent kyphosis and osteoarthritis in her knees.
Note that there is one other answer that is equally important. Can you find it? Close this text box and choose another response.
It is possible that this is a contributing factor, but is probably not the primary cause of Mrs Cloverdale’s falls. Please try again.
Good Job! Mrs Cloverdale has complex health conditions and is on numerous medications. Based on Mrs Cloverdale’s account, physical examination and laboratory test results, polypharmacy is likely to be playing a significant role in contributing to her falls.
In addition, use of benzodiazepines greatly increases falls risk and it is important to note that benzodiazepine withdrawal has been shown to reduce falls as a single intervention.
Note that there is one other answer that is equally important. Can you find it? Close this text box and choose another response.
It is possible that this is a contributing factor, but is probably not the primary cause of Mrs Cloverdale’s falls. Please try again.
You counsel Mrs Cloverdale regarding polypharmacy and explain that adults who take four or more medications are at an increased risk of falls. Even over-the counter drugs can contribute to falls risk. You suggest that the interactions between all of the tablets she is on may be what is making her feel tired, dizzy and prone to falls.
You discuss changing her medication regimen with her and her regular doctor. She agrees to this and you suggest that a blister pack will make it easy for her to know what tablets to take and when.
What medications would you review or change in order to effectively treat the following conditions? Click on each to see the recommended changes to medications
To alleviate dizziness and poor balance, decrease and stop benzodiazeopines, panadeine and betahistine
To reduce polypharmacy, stop NSAID’s and consider increasing ACE inhibitor and swapping to a daily drug
To treat symptoms of osteoarthritis, consider substituting the NSAID’s and panadeine with regular paracetamo
Consider discontinuing HCTZ and or frusemide and decreasing total medications
Consider altering glycaemic medication to either Gliclizide or Metformin *
*Gliclazide has less possibility of inducing hypoglycaemia. Metformin can result in weight loss in overweight patients and is first line agent for type 2 diabetes. Be sure to check for complications of diabetes*
After discussion with Mrs Cloverdale and her regular GP, you recommend that she stop taking the Serc, Naprosyn, glibenclamide, panadeine and after some discussion, she agrees to decrease the temazepam to 10mg daily and then stop. She will start regular paracetamol and change the ACE inhibitor to Ramipril 10mg daily.
Within 4 weeks her heart failure had improved and the frusemide was discontinued. Mrs Cloverdale was commenced on calcium (calcium carbonate 600mg) and Vitamin D (Ostelin 1000 IU), with a loading dose of 3 tablets, 3x daily for 2 weeks, after which she will remain on the maintenance dose.
A follow-up blood pressure is 135/85 with only a 10mmhg postural drop, measured immediately upon standing and then again after two minutes. Her blood sugars are improved with no further hypoglycaemia. Her children comment that she seems clearer in her mind and steadier on her feet. She is no longer experiencing the dizzy spells
What other contributing factors need to be addressed in reducing Mrs Cloverdale’s falls risk?
Click on each of the factors below to see how each is managed and the multi-disciplinary team members involved.
In order to maintain Mrs Cloverdale’s mobility, muscle strength and confidence on her feet, she is referred for a physiotherapist consult.
The physiotherapist finds her Berg balance scale is 33/56. She has difficulty transferring, turning, reaching and balancing on one foot. The physio recommends some lower limb strengthening and gait exercises and some exercises to help rebuild her wasted quadriceps. Bowls is the only regular form of physical activity that Mrs Cloverdale participates in and her health care team would like to enable her to keep playing for as long as possible. The physiotherapist also recommends that Mrs Cloverdale might try a Tai Chi class at the local community centre. The purchase of a walking stick is also recommended, so that Mrs Cloverdale can maintain her neighbourhood social activities.
Mrs Cloverdale attends the optometrist for the first time in 6 years. She currently wears bifocals with only a mild prescriptive lens for distance vision. However, on review, her long distance sight appears fine, while her short distance vision has deteriorated. She is prescribed new reading glasses. The optometrist advises Mrs Cloverdale to remove her reading glasses before getting up to walk around, otherwise her ability to judge distances and see clearly will be affected by her prescription lenses for short-sightedness. This may take a bit of getting used to as she is used to wearing her glasses at all times.
Although in Mrs Cloverdale's case falls risk was increased by wearing bifocal lenses, it is important to remember that other vision related factors can also be contributory, such as visual field loss and poor contrast sensitivity.
During the physical examination you noticed some changes in Mrs Cloverdale’s feet, so you refer her for a Podiatric consult. You are concerned that the diabetes and arthritis may have caused changes in her feet that are further adding to her falls risk. Corns, calluses and age-related gait changes can also add to falls risk, so you feel that a podiatric consult is good option.
The podiatrist confirms bilateral loss of vibration sensation to the metatarsal heads and touch sensation to the ball of the feet and toes as tested with 10g molofilament. Her circulation was found to be reasonable with an absent dorsalis pedis pulse and palpable posterior tibial pulse. Her ankle-brachial index was minimally outside normal range at 0.8. The podiatrist remarked that Mrs Cloverdale had significant structural foot problems, including bilateral hallux valgus and claw toe deformities with associated painful digital corns and plantar calluses. Her footwear was deemed to be inappropriate and more supportive lower-heeled shoes with Velcro straps were recommended. The podiatrist recommended regular podiatry management to help keep Mrs Cloverdale’s feet relatively pain-free and to monitor her lower limb neurovascular status.
A blood glucometer was purchased as recommended and it was established that Mrs Cloverdale experiences occasional hypoglycaemic episodes (BD 2.5, 2.8). This was greatly improved with the changes to medication, but she will monitor her blood sugar levels regularly and visit a diabetes nurse once a month at her local General Practice.
This was found to be due to iatrogenic effects of medications. Symptoms improved once medications were reviewed and changed. Regular monitoring of medications is required to avoid future problems.
While Mrs Cloverdale’s GDS score was 7, her self esteem and self confidence improved once she started to feel steadier on her feet. As a result, she is no longer afraid to leave the house and her mood has improved substantially. She no longer feels hopeless or afraid and is happy to go out to participate in social activities. Mrs Cloverdale spoke to a psychologist but did not require medication for her depression.
All of the personal factors contributing to Mrs Cloverdale’s falls have now been addressed.
An assessment of environmental factors that may contribute to falls risk should now be conducted.
Mrs Cloverdale expressed a wish to continue living in her own home. She is medically well enough for this, but home safety assessment is a priority.
A home assessment is performed and recommendations are made for grab bars in the bathroom and toilet frame. The OT is also concerned about the stairs in Mrs Cloverdale’s home and suggests moving the bedroom to one of the ground floor rooms. However, she will still have to negotiate the steps of her front porch and a small number of stairs that lead in to the lounge room from the family room. Grab rails were therefore put in at the front stairs and those areas inside the house that were considered a falls risk. Non-slip treads were also attached to the end of each step, both indoors and out. The OT was otherwise satisfied with the surface coverings of the stairs.
There were a couple of mats that were considered tripping hazards and it was recommended that these be removed or taped down. Non-slip surfaces were laid in the toilet, bathroom, laundry and kitchen areas.
The lamp shades in Mrs Cloverdale’s living areas make the indoor lighting quite dim. In order to improve the visibility within the house, it was recommended that they be replaced with more open shades with 75 watt globes. They were also advised to install an outdoor light that turns on automatically so that the stairs and paths are well lit when Mrs Cloverdale returns home in the evenings. She already has a bedside lamp that she can easily switch on if she needs to get up during the night.
The family are given information about personal alarms that Mrs Cloverdale can keep on her at all times. This way, she can raise the alert if she ever has a fall and is unable to reach a telephone to call for help. The alarm can also be used for any other medical or personal emergency and helps provide peace of mind. They agree to arrange the personal alarm as soon as possible.
Home help and domestic cleaning will continue to be provided through HACC. Mrs Cloverdale will maintain her fortnightly appointment with her regular GP, who will keep a close eye on her medications and any gait and balance disturbances, as part of an on-going falls risk assessment. She will also assess Mrs Cloverdale’s mood to make sure she does not lapse into depression and withdraw from social activities again. The GP will monitor Mrs Cloverdale’s Vitamin D level. She will likely continue to need some supplementation, especially in the winter months.
Mrs Cloverdale will visit the podiatrist once every 3 months, and have a block of six weeks of physiotherapy for muscle strengthening and balance work. She may require follow-up sessions in the future, and her GP will keep an eye on this. A yearly ophthalmology visit will be arranged to ensure that Mrs Cloverdale does not develop any secondary diabetic eye disease.
Over the next few months, Mrs Cloverdale proceeded well. Her balance and muscle strength improved with the physiotherapy exercises and she is more confident in moving about. She has also commenced Tai Chi and has found that this has improved both her balance and physical and mental health in general. Most importantly, Mrs Cloverdale feels more comfortable in leaving her home to visit neighbours, attend church, play bowls, attend appointments and accompany her children and/or grand-daughter to buy groceries. Her self-esteem has improved greatly and she is no longer feeling depressed. She is very happy that she has been able to remain living in her own home.
Mrs Cloverdale wears a personal alarm just in case she has a fall and can’t get to the phone to call for help. She says this helps her feel more confident that help will always be there if she needs it.
Mrs Cloverdale’s granddaughter has moved to the city to attend university and now lives on the top floor of her grandmother’s home. She keeps an eye on her gran and often helps her with cooking, washing, gardening and grocery shopping. Mrs Cloverdale enjoys the company and feels safer having someone in the house again.
A multi-disciplinary team was crucial to Mrs Cloverdale’s recovery and maintenance of independent living. Together the team established and implemented a falls risk management plan for Mrs Cloverdale.
Before you continue on to complete the feedback form, take a moment to click on each of the specialties below to review the role they played in Mrs Cloverdale’s recovery.
The Psychologist counselled Mrs Cloverdale about her concerns and helped to alleviate her fears about the future.
The Physiotherapist prescribed specific strength and balance exercises, recommended Tai Chi and a walking stick to maintain balance and confidence in moving about.
The Occupational Therapist recommended home modifications to further reduce falls risk. Provided advice regarding a personal alarm.
The Social Worker made sure Mrs Cloverdale had access to care and support services, such as that provided by Silver Chain and HACC, to keep her living in her own home for as long as possible.
The GP oversaw Mrs Cloverdale’s progression, monitored medications, vitamin D levels, gait and balance and mood changes. Continued to manage her diabetes. Provided additional information about health conditions.
The Optometrist reviewed and changed Mrs Cloverdale’s prescription glasses. Arranged for regular review of Mrs Cloverdale’s prescription lenses and potential diabetic eye disease. Recommended avoidance of bifocals due to falls risk. Advised the removal of reading glasses before walking around.
The Podiatrist recommended regular removal of corns and calluses and regular screen for diabetes related foot disease. On-going footwear assessment and possible prescription of foot orthoses to improve gait and stability if required.
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