Geriatric Physician Evaluates Fall Risk Prevention Protocol at Assisted Living Facility

This case involves an elderly male patient with dementia who suffered a fatal fall while living in an assisted living facility. The patient had a history of frequent falls and required round-the-clock supervision. The nurse assigned to the patient left him alone for several minutes after feeding him lunch. In the time that the patient was alone, he wandered down the hallway and fell. The patient suffered a subdural hematoma and was taken to the emergency room. The patient died during the hematoma evacuation procedure.

Question(s) For Expert Witness

1. Please describe your background in geriatrics and elder care.

2. How often do you see patients with similar presentations?

3. How can injuries such as a fall affect the overall health of elderly patients?

4. What preventive measures should be taken to mitigate fall risk for patients with a history of falls?

Expert Witness Response E-064387

I have many patients who fall, many of whom suffer head injuries including subdural hematomas. Many have had life-changing injuries from falls, or suffer a cascade of illnesses precipitated by a fall. Only a few of my patients have died as a direct result of head trauma or other injuries. Falls are a leading cause of morbidity and mortality in the older population. Many people who suffer a fracture in a fall, especially a hip fracture, never regain their previous functional level and independence. A fall may result in chronic pain as well as disability. In the presence of a known history of a fall, preventative measures depend on the patient's physical, psychiatric, and cognitive function, medical conditions and medications, and the frequency and circumstances of his/her falls. Standard initial measures would include an assessment of why and how the fall occurred. An assessment and therapeutic plan devised by a multidisciplinary team would be ideal, although this is frequently not available. With or without a coordinated team, a standard evaluation would include a thorough history and medical/neurological/psychological exam, review of the patient's medications and how the patient uses (or does not use) those medications, inquiry into alcohol or recreational drug use, orthostatic blood pressure measurements, vision and hearing exams, cognitive testing. Selective blood tests are often ordered, depending on the circumstances of the fall and the medical history and exam findings of the patient. These might include chemistries to evaluate hydration, nutritional status, and potential electrolyte abnormalities which could lead to weakness/falls, a complete blood count to look for anemia or indications of infection, and possibly urine tests to rule out infection. Other tests that might be indicated would include a test of thyroid function, vitamin B12, vitamin D, folic acid, levels of medications and/or alcohol in the blood. If the patient is at continued risk of falls and does not have the capacity or judgment to exercise the needed caution to prevent future falls, then increased supervision or protective measures will likely be needed.