Recently on hospital teaching rounds a medical resident presented an elderly man who fell. The patient suffered no fall-related injuries but was diagnosed with pneumonia and congestive heart failure. The resident called the event a “mechanical fall,” and the interns and residents nodded in agreement regarding the assessment and plan. When I questioned the young doctor, he did not ask about gait and balance, did not complete a neurological examination, and did not ask the patient to stand and walk during the physical examination.
I was puzzled. I had been in the geriatric field for over two decades and never heard the expression “mechanical fall.” It struck me that this term is a simple way to bypass critical thinking about the medical aspects of falls in elderly persons. Since this episode I heard the expression “mechanical fall” several more times, and decided to blog about it.
Falls are one of the most common events that result in injuries for men and women over age 65, and are a leading cause of death in this age group. Fall-related injuries include lacerations, head trauma, and fractures, and these injuries can threaten independence or precipitate a down-hill spiral for elders who are frail or suffer from multiple co-morbid conditions.
Falls rarely result from a single cause, and are often due to complex interactions between sensory loss and other physiologic changes with age, environmental factors, medication side effects, and underlying illness. Comorbidities that contribute to fall risk include neurological impairment such as peripheral neuropathy and Parkinson’s disease, musculoskeletal illnesses such as osteoarthritis and osteoporosis, and various cardiopulmonary diseases and arrhythmias. Cognitive deficits associated with dementia, or altered level of consciousness associated with delirium or oversedation, can increase falls by impairing judgment or safety awareness.
From a diagnostic standpoint, falls need to be viewed within the context of these factors and investigated accordingly. This begins with a careful history and medication review followed by physical examination focusing on gait, balance, and sensory impairments. Once the reason for a fall is ascertained, interventions can be instituted to minimize future fall risk. These can include exercise or physical therapy, modification of environmental hazards, medication adjustment, referrals for visual or hearing impairments, and others.
In this context, the term “mechanical fall” is a misleading pseudo-diagnosis. Every fall is “mechanical” to some degree, and this wastebasket term oversimplifies a complex problem and bypasses critical thinking. A fall in a geriatric patient should be perceived as a symptom of disease, to be investigated like any other serious symptom, and not chalked up to gravity.
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Related post: Falls, Aging and the Bible.