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Social Determinants of Health

The Case of the Elderly Tripper

Bui, Simonetti, Benson, Malek and Anderson
Published 03/25/2016

A 78-year-old woman is seen by her PCP for follow-up after an ED visit for a right distal radius fracture from tripping and falling on her outside steps.  She denies having experienced palpitations, chest discomfort, light-headedness, vertigo or loss of consciousness at the time of the fall. Prior to her fall, she was active and walked daily.  She lives by herself.

On physical examination, her blood pressure is 144/82 mm Hg and pulse is 96/min. No orthostatic hypotension is observed.  BMI is 26.  Lenses are slightly opacified bilaterally with visual acuity of 20/40 in both eyes.  Pulmonary and cardiac exams are normal.  She has a cast from the right elbow to her hand.  Her fingers are swollen but warm with good capillary refill.  Neurological exam is normal including proprioception, muscle strength and gait testing.  She is able to stand upright with her feet together, both with her eyes open and closed.  

Lab:  B12 – 310 ng/L; electrolyte/creatinine/BUN normal; 25-OH-D – 32 ng/ml; CBC is normal with hemoglobin of 12.6; MCV 89.

Q: You refer patient to physical therapy for group or home-based fall prevention exercise program.  Which additional intervention would reduce injuries from falls for this patient?

  1. Advise her to wear slip-resistant footwear

  2. Refer her to ophthalmology for potential cataract surgery

  3. Refer her to an agency to assist with home safety modifications

  4. Start her on daily dose of 800 IU vitamin D3 and 1200 mg of calcium supplementation

Fast Fact:

Falls and fall-associated injuries are common among community dwelling older adults.  Exercise programs designed to improve balance, gait, strength, and flexibility can prevent serious falls in older adults living at home.  Home modifications such as handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, and slip-resistance surfacing for outside areas such as decks and porches have also been shown to reduce injuries from falls.  There is conflicting data on the benefit of Vitamin D supplementation in the reduction of falls.  In terms of combined Vitamin D and calcium, the USPSTF concludes that the current evidence is also insufficient to assess the balance of the benefits and harms of supplementation with greater than 400 IU of vitamin D and greater than 1,000 mg of calcium for the primary prevention of fractures in non-institutionalized postmenopausal women. The role of cataract surgery in preventing falls remains inconclusive.