In my experience, almost every ER visit will fall under one of two categories.
We’ll discuss both in this post.
While you read, keep in mind, your person will be highly likely to face one, or both, of these overarching issues at some point in their life.
First, let’s discuss falls.
This is one of the top reasons people living with dementia (PLWD) come into the ER.
As we age, we are all at higher risk of falls.
People who have diseases in their brain are even more at risk.
I could write an entire post dedicated to the reasons why people living with dementia fall, but I’ll save that topic for later.
Here’s a glance into an ER physician’s brain…
One of my first objectives when assessing a patient who has fallen is to categorize the underlying reason for the fall.
I aim to tease out if a fall fits more into:
1 – Did something inside the person contribute to, or cause, this fall?
OR
2 – Was the fall a result of more outside factors?
Simply put, I’m thinking, “Is this a medical issue or not.”
You should do this too.
When your person falls I want you to be an investigator.
In the ER there is only so much we can do to figure out the WHY behind the fall.
You are way more likely to figure out the WHY than me, unless it was due to a medical issue you don’t know about.
The caregivers I have met have been some of the most in tune, observant people. They were forced into the role of being an investigator.
I want to help you think a little more like me and the people who will be taking care of your person.
Consider, has your person been ill, drinking less fluids, vomiting, or having diarrhea.
Could they be dehydrated? Could they have an infection causing them to be weak?
Are they taking too many of their pain pills or other medications?
Did they seem in pain prior to the fall?
Did they pass out? If they did, what did they look like before it happened?
Were they complaining of a headache, chest pain, or shortness of breath before passing out?
These are some of the questions I’m asking to try and figure out what happened.
You can consider questions like these too.
It is OK if you did not see your person fall. You still can think back on what has been happening.
Any information you can give about what has been going on could be very helpful.
If your person is in an ER part of the medical team’s job is to try and figure out if there is a medical reason, especially if it is life threatening, for why the fall happened.
On the other hand, many falls are due to external factors and not a medical issue.
Here are some examples of what I mean.
Tripping over a rug, getting a foot caught in a chair leg, turning too quickly and toppling over, visually missing a step, misjudging where their foot was when going down stairs, and slipping on ice.
Over the years I’ve borne witness to some mind boggling causes of falls not due to a medical issue. I wish I had been keeping a log of some of these cases.
Recently I had a patient who tripped and fell inside their home and dislocated their elbow.
They got up, adrenaline surging and headed downstairs to tell their partner.
Nearly down the stairs they looked at their arm, saw the deformity, passed out, fell again, and as a result fracture-dislocated their ankle.
Thank goodness this person did not have dementia, but what if they did?
It would have been much more complicated to care for them in the ER.
My patient did not go home and neither would have someone living with dementia. Everything that comes after would be more complicated.
To recap so far, our first step after someone falls is to try and figure out if it was a medical issue that caused them to fall. Here are some other thoughts going on in my brain when I evaluate a person living with dementia who has fallen.
1 – Did this fall cause an injury?
This may seem obvious, but people living with dementia often struggle to communicate how they feel.
They absolutely feel pain, but may struggle to say where.
The pain may be positional; meaning, they don’t seem to be hurting or might deny pain while sitting there.
It may be only when you move them that you are able to realize they hurt and find an injury.
We sometimes have to image more of their body (take more x-rays or CTs) than we would if the person had a healthy brain and was able to weigh in and tell us how they felt.
When we can not see an obvious injury, the testing we choose to do needs to be based on what likely caused the fall AND what the person’s goals of care are.
If your person is living in a facility you want to know what the policies are if they fall.
Will they automatically send your person to the ER for evaluation?
What if your person seems like they normally do, not in pain, and there is no obvious injury?
Consider the same when your person is living in your home or their own.
Having a plan for how you will handle this situation is wise.
2 – If there is no injury, are we sure it was not due to a medical issue?
If we aren’t sure, how much risk are we willing to tolerate?
Let me explain my thought process to you.
If the fall was not witnessed by anyone, how do we know it was not due to the person passing out and falling?
This is a KEY turning point in the decision making process in the ER.
A person living with dementia is often not able to recall the events of why they fell.
Side note: You may read the term “unreliable historian” in your person’s medical record.
This is not an insult. It simply communicates to other staff members that the person struggled to recall what happened.
When a person can not tell us why they fell, I can not exclude that there was not a brain, heart, or other medical problem which caused them to fall.
We can not diagnose or “rule out” every condition in the ER.
This is why people are often admitted to the hospital under observation status.
The team may recommend observation because there is a higher risk in someone who is aging that their fall was due to a medical issue.
It may be recommended for the person to be monitored overnight considering their age, medical issues, and the events of the day.
I have goals of care discussions with family members of people living with dementia in the ER almost every day I work for this exact situation.
I can not stress enough how important it is to know your person’s goals of care and when they might change. I have written about this in the past and teach it in my course.
Go check out past blog posts. Here is one for you to read.
Your person’s goals of care will help you determine what to do in this situation.
If you do nothing else for your person when it comes to planning for their future medical decisions, please identify and communicate their goals of care.
Keep in mind, a hospital stay is not beneficial for every person living with dementia. You can read my post about this topic here.
One of the final questions I myself is,
3 – Can this person go home?
When someone living with dementia falls, does not have a medical issue as the cause, and is not seriously injured, from a medical standpoint they can return home.
CAN being the key word. We also need to consider if they SHOULD.
In real life this can be very complicated.
I want to paint you a picture.
Say you fall and break your arm.
It is injured. You know this and purposefully try not to use it.
You remember. You know it will hurt.
When it hurts you know it will get better. It’s really inconvenient and annoying to you, but you are aware of the next steps in care. Someone is helping you make sure it heals.
You tell yourself the pain will get better and that you can take something to help it when it is bad. When you need to do something you ask for help.
Some, if not all, of this thinking is likely not going to be available to the person living with dementia.
This understandably can cause outward changes in their mood and behavior.
An injury those with a healthy brain can deal with at home can cause the need for a hospital stay, a rehabilitation stay, sudden need for more care at home, and/or a permanent need for a move for someone living with dementia.
One day you are going along with your life.
You know your Mom/Dad/spouse/sibling has dementia, but everything is OK, right?
Then, seemingly out of the blue there is an accidental fall and everything changes. It is always terrible timing.
If you are not prepared ahead of this need, you could easily be caught in a situation where you are scrambling to find help, a rehab facility you trust, a new living situation, or to hire an employee to come into you or your person’s home.
It can be a life changer for you and for your person.
Please trust me on this. Treating people and considering what happens next after falls is a huge part of what I do every day for a living.
I designed a course for caregivers which has an entire section on falls with injuries, how each injury can impact the person living with dementia’s life differently, the ins and outs of how we diagnose common injuries, and the questions you need to ask based on the type of injury.
For more of what is included and the cost, click here.
One planning tip I share with my clients, and any dementia caregiver, is to know the rehabilitation facilities around them.
Know their reputations. How is their care of dementia patients?
My best advice for you is to ask around.
Ask people you know, ask in a support group, your person’s doctor, a trusted local medical professional you know, or the local Area Agency on Aging.
Figure out what your preference would be ahead of the need.
When the discharge planner in the hospital comes to you saying your person’s plan is to be discharged to “rehab” you can make a more informed decision if you have thought about this choice in the facility.
Doing this homework may also make you want to take your person home and arrange services there. Know where you might hire these services.
After reading all of this I hope I have made you want to avoid falls in your person.
Remember, you know your person best. A fall could change everything for them, and you.
Be an investigator. Be proactive.
Do whatever you can to help prevent a fall.
This may sound silly, but watch them walk. If you are worried about a fall when you look at them, trust your gut.
Talk to their medical care team. Ask for a gait evaluation. Tell the team you want to draw upon any available resources to decrease their risk of falling.
If you want to learn more on your own, there are people out there who can help you.
Look at YouTube. Find an occupational therapist.
I recommend Emilia Bourland with Higher Standards Caregiver Training who has a course for sale right now to help you learn what you do not know about fall prevention.
Here’s the link to check it out.
Falls negatively impact people’s quality of life.
There are a lot of decisions which need to be made after a fall.
It can be incredibly stressful if you are not informed and prepared.
What I find even more stressful for caregivers making medical decisions, is the second overarching category people living with dementia come to the ER for.
A change in the way the person is acting or behaving is the second most common reason.
This often looks like increased confusion, agitation, or the person speaking less and being more withdrawn than usual.
We call this a change in mental status, “altered mental status,” or you may also see the term “acute encephalopathy.”
To be clear, this is not worsening dementia. That typically happens more gradually.
I’m talking about a sudden change in the person. There is a spectrum in how severe this can become.
When a change in mental status or the way someone is acting is severe, is starting to affect the person’s level of consciousness or attention, it is labeled as “delirium.”
I plan to do a post on delirium for you, so I am not going to go into details here.
I do want you to recognize the term “delirium” and know that it means a serious change in someone’s mental abilities and can be life threatening if it goes unchecked.
Some people do not recover their mental abilities after having delirium which can mean permanent worsening of their dementia symptoms.
Be aware that a new medical problem is often the reason for a quick change in mental status.
At the beginning of this post I told you people come in for two main categories.
Falls and changes in their mental status.
You should know it is very common that these two issues happen together.
At some point your person living with dementia will have an episode where they are more confused. It will put them at a greater fall risk.
Let’s put falls aside for a moment to focus on a change in mental status as an issue by itself.
I want you to know there is a huge list of reasons why someone could have a change in mental status.
Too many to teach you about here.
I teach the most common conditions causing mental status changes inside my course which I will tell you more about at the end of this post.
Despite what you might read inside online support groups, this change is not always due to a urinary tract infection (UTI).
People will say check them for UTI. They are not wrong, but it is way more complicated than that.
When your person has a change in the way they are acting, you will need a strategy. Acting quickly to troubleshoot could help you prevent delirium.
Try the following 6 step process.
It’s not all inclusive, but hits some of the most common things to consider.
1 – First consider pain.
Pain anywhere, even pain which would be minor to you could provoke a change in mental status.
Consider joint pain, back pain, and headaches.
Any place you can have pain, so can your person.
History repeats itself. Think about where they have had pain in the past.
Learn to interpret your person’s non verbal cues.
What do they do when they are in pain? What does their face look like?
You and your family know your person better than anyone who will try to diagnose what is going on.
2 – Constipation has its own step in the process. It is that common.
Think back to the last time you did not have a bowel movement for a couple of days. It is uncomfortable and sometimes it really hurts.
In medicine, constipation is well known to be a mimicker of appendicitis.
I’ve seen plenty of people in the ER who thought they had something life threatening happening inside their belly, only to find out they were constipated.
3 – On a somewhat similar note, make sure your person is able to urinate.
Not being able to relieve your bladder becomes extremely uncomfortable.
This issue is more common in men thanks to the prostate gland.
I once had a man grab my arm and tell me to kill him because he hurt so bad.
Instead, a member of our team placed a foley catheter and decompressed his bladder.
He hugged me afterwards. He should have hugged his nurse.
When there is a change in your person, you are first thinking about what could be happening inside their body which could be causing this issue.
Pain, constipation, and difficulty urinating are common triggers for confusion that fit under this category.
Then I want you to consider,
4 – Is there a new medical problem happening? Any new issue, life threatening or not, can cause a change in your person.
The same medical emergencies you have had, or will have, so can your person.
Modules 5, 6, and 7 of my course are all about medical issues common to dementia and aging.
All of them can cause a change in mental status for your person.
The more severe and the longer an issue goes undetected and untreated the more likely the person is to become delirious.
For example, as we age we become more at risk for stroke, “heart attacks”, abnormal heart rhythms, and failure of our organs (lung, heart, liver, kidney). These are a few of the conditions I discuss inside Module 6.
We are all at a certain risk of developing medical conditions simply from aging, but your person’s past medical history can also help you see what new issues might happen to them in the future.
When your person is confused or acting differently, think about the medical issues they have had before and what they are at risk for while considering if there could be something new happening.
Considering if a new infection is happening is a HUGE category to consider underneath step 5. This is where thinking about a UTI (urinary tract infection) falls into this process.
Are they having symptoms of infection you can notice or see?
Could those symptoms point you to the source of infection?
I teach you how to think through this in the course.
What we have been discussing are issues happening due to a past medical issue or something new happening internally.
Next, I want you to think, what could be happening TO them?
What is coming from something outside their body and could be causing this change in the way they are acting?
5 – Consider, what medications are they taking?
Are they taking them correctly? Is the dose too high? Are they causing side effects?
Could there be medication interactions?
If you need a quick question answered about a medication, you can probably reach a pharmacist faster than a physician.
Are they taking pain medications?
What about over the counter medications?
Do not forget about alcohol.
Could they be drinking too much alcohol?
Could alcohol be interacting with one of their medications?
Also, if they drink alcohol regularly and stop for any reason, could they be withdrawing?
6 – Lastly, consider their environment.
This is where your investigative skills are really needed. Medical professionals are not likely to be as helpful with this.
Are they too hot or cold?
Could they be bored, hungry, or thirsty?
Is it too noisy? Overstimulation can cause a change in mental status.
If thought about and addressed quickly you can prevent worsening confusion, anxiety or agitation.
We all need a process to fall back while troubleshooting.
None of us are born knowing the best way to care for and respond to a person living with dementia.
Use a process, like this one I have laid out for you, when you think through things.
If you find a pattern in your person’s behavior you just may have found a cause you can act on.
Determining what has caused or what could be contributing to your person’s change in behavior or overall worsening confusion is not always easy, but
I believe you have an advantage over a medical professional because you know your person better than we do.
You will interpret their feelings and needs better than we will.
We’ve covered a lot in this post.
Let me sum it up for you.
- Your person living with dementia is at risk of falling.
- A fall could change their life and yours. Do what you can to try and prevent a fall. If your person is living in your home, consider self education with a course. Look up occupational therapist Emilia Bourland.
- When there is a fall, try to figure out the reason behind it. Maybe you can prevent an additional fall.
- If your person does fall, I want you to know your person’s goals of care so you can decide what to do next.
- Make sure you know the policy of what comes next after a fall if your person is not living in their or your home.
- Coming to the ER should be a decision not a knee jerk reaction.
- Know the rehabilitation facilities available to your person and which you would prefer if needed. The same can be said for living facilities.
- Your person might fall because of a medical issue.
- A change in mental status is going to happen to your person at some point.
- Follow my 6 step process for thinking through what might be the cause or a contributing factor when your person becomes more confused or has a change in them. We want to prevent it from worsening and do not want them to become delirious.
- Again, know your person’s goals of care. Any medical problem can cause a change in mental status, including a fall with an injury. The medical team needs to know what the overall goals are.
I hope after reading this you realize there is a lot to consider before your person falls or has a change in their mental status.
Do you want to learn the specifics of how we diagnose and treat injuries and the conditions that can cause confusion in your person?
I want to help you learn what your person is at risk for due to having a diagnosis of dementia and because they are a human being who is aging. I do this inside my online course.
Make Your Plan with Dr. Lamb is a self-paced program. You do it on your own time.
After 60 days, if you take it week by week, you will have a written organized plan inside of a document which includes the most common conditions (30+) people living with dementia are at risk for.
This document will be your go to reference point when you have to make a medical decision on behalf of your person.
For each condition I break down the decisions you will have to make, the treatment options from most to least aggressive, things to consider, and give you questions you should ask your person’s care team in real time.
You have access to log into a website so you can see the course materials and videos in each section.
As long as this course exists, you will have lifetime access to it.
The videos for each condition are short with as little medical jargon as we can do without. Almost all of them are less than 10 minutes long.
This means if something happens to your person, you will be able to log back in and re-watch the video on that topic to refresh your mind.
You will learn a process for making any medical decision, how to determine your person’s goals of care, when their goals and decision plan might need to change, and the tools you can use to advocate for them on a practical level.
If you are an adult child of someone living with dementia, take the course to become informed and better able to support your parent(s). It is not too soon and you are not overstepping. This is something you can do right now, ahead of a crisis to help out. Learn on their behalf so you can be prepared to help them make decisions.
If you are the spouse of your person, take the course so you can feel confident and at peace knowing you are making medical decisions which line up with what you know your partner would want.
Are you a part of the team of family decision makers? This is how you can pitch in to help your family.
If it feels like you are just waiting for something to happen, now is the time to jump in and learn.
Doctors in offices, the ER, and the hospital want you to have this information, but do not have the time to teach it to you.
This is a course geared toward decision making in dementia, but the person living with dementia is at risk of all the same medical issues as anyone else who is aging.
Unless you are a physician, PA, or NP practicing in the ER, ICU or hospital, I know I will teach you things you didn’t know about common medical emergencies you or another family member might be at risk for now or in the future.
Click here to read more about the course and what’s inside.
As always, please let me know if you have questions about what I do or what I wrote here today.
Until next time, all my best to you and your family,
Brittany Lamb, MD