The Myth of the Mechanical Fall

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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Similar post:  Falls, Aging and the Bible. 

Comments(9)

  • Kathy, CMT
    August 8, 2016, 3:30 pm  Reply

    Thanks for the clarifying explanation on a “mechanical” fall. I come across this term quite a lot in transcription and have finally found out what it means.

  • Holly PT
    November 7, 2015, 11:42 pm  Reply

    Dr. Levine,
    Thank you for this great info. I have been a PT since 1989 and this “mechanical fall” term seems to have picked up momentum in the past few years. As you mention there can be many reasons that someone falls and as AP alluded to in the above post if we don’t know what contributed to the fall then how can we get to the crux of the problem and prevent falls from happening in the future. Thanks again, I really enjoyed your article.

  • Tess L.
    January 5, 2015, 11:41 pm  Reply

    I am an RN, Case Manager in a large teaching facility. I had never heard this term until I started working at the ‘U’ several years ago…and I have to tell you it is one of the most frequently used admitting diagnoses for the elderly. I have never been able to figure out why ‘we’ just bypass assessing the patient, and settle on this “label”. I have never agreed with it and I think it does a great dis-service to the patient. A way to get them in and out the door… Thanks for validating my thoughts on this subject!

  • January 30, 2014, 5:01 pm  Reply

    Very nice article Dr. Levine. I am a nurse anesthetist, and while working a case with an orthopedic surgeon, he received a call from the ER doctor. “A mechanical fall” had arrived in the ER. The surgeon asked “what the heck is a mechanical fall” after the call ended, and asked someone to google it. This short report in no way aided the surgeon in understanding the situation or background of this patient. A waste of words; even more so when learning the patient was 83 years young.

  • AP
    December 8, 2013, 8:19 pm  Reply

    Josh, I assume you are an ER physician or nurse. Much of your care of patients is diagnosing. Rarely are you required to think about the long-term plan of treatment for patients. That very website you list discusses how a “mechanical fall” can be caused by numerous factors, some of which can be addressed. If someone trips on a rug in their home or over their walker at night, these are often called mechanical falls but can be easily addressed by social work. Your desire to “not make a bigger deal out of things” is because you are not responsible for the long-term care of these patients. You stick to what you do best, triage. Let those of us who manage these patients long-term determine what is and isn’t important. And please explain to me how “mechanical fall” is a better term, or more efficient than saying “this guy slipped on ice” or “this guy tripped on the curb.” By knowing the specific reason for a fall that is how we can prevent future falls. As an ER physician that isn’t part of your care plan but it is important for the long-term care of the patient. But if that information isn’t collected by your team then it prevents primary care doctors, social work, and othropaedics from helping to address these possible preventable falls. Great essay Dr. Levine.

  • Josh
    November 16, 2012, 9:46 pm  Reply

    Sometimes a mechanical fall CAN just be that. Working in an ER we see it all of the time. Perhaps they didn’t see the patch of ice because they weren’t looking down. Perhaps they didn’t see the curb and stepped off of it. I’m 35 and it happens to me. Let’s not consistently make a bigger deal out of everything. At triage we can determine if poor gait or other factors come in to play. Sometimes they simply don’t. http://www.uofmmedicalcenter.org/healthlibrary/Article/116046EN

  • Jennifer Smith
    November 7, 2011, 8:53 pm  Reply

    I saw the word “mechanical fall” in my clients medical records and she was receiving therapy for her “gait.” What was not asked was why she fell. 30 people in line surged backwards and knocked her over… without finding out why someone falls, the wrong treatment can be given and “mechanical fall” seems to indicate that there was something wrong with the patient’s ability to be mobile that caused the fall, when this elderly woman had never had gait or falling problems in her life, she was pushed down in a crowd! Watch out what words are used!

  • Jeff Alfano
    August 22, 2011, 8:55 pm  Reply

    Dr. Levine.

    I heard the term “mechanical fall” this week when a hot shot new EMT was giving advice on how I might improve on my short report to the receiving ER Physician.

    I term I hadn’t heard before, I Googled it, and stumbled onto your blog. Thank you for this wealth of knowledge related to possible causes of falls and exposing this term as lack of critical thinking.

    This is the first time I’ve found a definition on the net for a nonsense assessment. Thank you!

    Jeff Alfano FF EMT

    • August 22, 2011, 9:40 pm

      Thanks for the feedback Jeff, keep up the critical thinking!

      JML

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.