Physician Role

Rationale

- As part of the initial assessment, help identify individuals with a history of falls and other risk factors for falling
- Identify individuals with medications, or medication combinations, associated with increased falling risk

- Falls often have medical causes; they are not just a "nursing" issue
- A MD should be aware of anyone with a history of falling
- A history of falling is one predictor of subsequent fall risk
- Other risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, balance and gait problems, musculoskeletal abnormalities, medications or illnesses affecting central nervous system and blood pressure, etc.
- Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling

Diagnosis / cause identification

- Help identify causes and contributing factors to falls

- Medical conditions and medications may cause or contribute to falls
- The MD should be able to identify individuals for whom a workup may be helpful
- An extensive work-up may not be appropriate in some individuals or knowing the cause may not change the interventions
- A limited work-up or review for causes may be appropriate even if an extensive one is not
- For various reasons, it is preferable to explain why a potential evaluation is not being done rather than to just not do one

- Document relevant observations and conclusions
- Address issues involving medical judgments (for example, why a higher dose of a medication associated with falls cannot be tapered, even for a trial period)

Treatment / Management

- In new or repeat fallers, discuss proposed interventions with the nursing staff, for relevance to identified causes

- MD is trained specifically in how to make correct diagnoses and select cause-specific interventions

- Help identify, and authorize, appropriate interventions

- Specific causes should be addressed, whenever possible, if doing so might affect risk of falling
- For various reasons, it is preferable to explain why likely causes cannot or should not be managed, rather than to just not do anything

Monitoring

- Follow up on falls with associated injury until stable

- An injured individual needs follow-up attention to ensure that proper measures are taken and to review for complications
- The MD should check on patient status by phone, or evaluate patient directly as needed, depending on severity of situation

- Discuss progress of repeat fallers until falling stops OR help identify or verify likely reasons why falling continues despite interventions

- MD is trained to reconsider differential diagnosis when a problem does not respond to various interventions

- Re-evaluate significant condition changes of individuals who might have delayed complications of a fall

- Delayed complications such as delayed fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall
- The MD should be alert to these possibilities and help staff identify when subsequent signs and symptoms might reflect delayed complications