What is the appropriate management for a 78-year-old diabetic (diabetes mellitus) gentleman with hypertension, who has experienced a fall at an aged care facility and presents with normal blood pressure?

From the Guidelines

For a 78-year-old gentleman with diabetes and hypertension who has fallen at an aged care facility but has normal blood pressure, the primary goal should be to prioritize his comfort, prevent distressing symptoms, and preserve his quality of life and dignity, as strict glucose and blood pressure control may not be necessary in this context. The management of this patient should focus on overall comfort and prevention of distressing symptoms, rather than strict control of glucose and blood pressure levels 1. Given his age and the fact that he has experienced a fall, it is crucial to conduct a thorough evaluation for injuries, particularly head trauma or fractures, and to check his vital signs, including blood glucose levels, as hypoglycemia could have contributed to the fall. A medication review should be conducted to identify any drugs that might increase fall risk, such as sedatives or certain antihypertensives, and to consider simplification of his regimens, including the possibility of withdrawing or reducing certain medications, especially those that may cause gastrointestinal symptoms or excess weight loss 1. Implementing fall prevention strategies, including proper footwear, adequate lighting, removing tripping hazards, and considering mobility aids if appropriate, is also essential. A physical therapy assessment would be beneficial to improve his strength and balance. For diabetic management, ensuring regular glucose monitoring and maintaining his usual medication regimen, unless otherwise directed by his physician, is recommended, with a focus on preventing hypoglycemia and hyperglycemia, rather than achieving strict glucose control 1. This comprehensive approach addresses immediate safety concerns while managing his chronic conditions, as falls in elderly diabetic patients can have serious consequences and may indicate underlying issues requiring medical attention. It is also important to involve the patient, his family, and caregivers in the decision-making process to develop a care plan that is convenient and effective for his goals of care 1. In terms of blood pressure management, while the patient's current blood pressure is normal, it is essential to monitor his blood pressure regularly and to be aware of the potential risks of orthostatic hypotension, especially in elderly patients with diabetes and hypertension 1. However, the most recent and highest quality evidence suggests that, in many cases, blood pressure-lowering goals for older adults do not need to differ significantly from those for younger adults, and that careful titration and monitoring of blood pressure-lowering therapy can help minimize risks 1. Ultimately, the patient's care plan should prioritize his quality of life, comfort, and safety, while also addressing his medical needs and managing his chronic conditions effectively.

From the Research

Management of a 78-year-old Diabetic Gentleman with Hypertension after a Fall

• The patient's presentation with normal blood pressure after a fall at an aged care facility requires a comprehensive assessment to identify risk factors for falls and prevent future incidents 2, 3.
• A 10-step protocol including screening for falls, comprehensive fall assessment, gait and balance screening when necessary, and an individualized fall intervention program addressing specific fall risks can be used to manage the patient 2.
• The use of a fall risk assessment tool, such as the one described in the Stopping Elderly Accidents, Death and Injuries toolkit, can help identify patients at risk for falling 4.
• Referral to a physical therapy program, such as the Fall Prevention Initiative Physical Therapy Program (FPIPTP), can help improve gait, balance, and fitness, and reduce the risk of future falls 4.
• Management of hypertension is also crucial, and guidelines suggest that diuretics are the cornerstone of therapy, with a step-care approach using more potent antihypertensives if necessary 5.
• The American Medical Directors Association (AMDA) Clinical Practice Guideline provides guidance for a systematic approach to patient assessment and selection of appropriate interventions for falls and fall risk in long-term care facilities 3.

Considerations for Diabetes and Hypertension

• The patient's diabetes and hypertension should be managed concurrently with the fall prevention strategies, taking into account the potential interactions between these conditions and the risk of falls 6, 5.
• The patient's blood pressure should be monitored regularly, and any changes in blood pressure should be addressed promptly to prevent further complications 5.