What is the appropriate workup for a 91-year-old female who presents to the Emergency Department (ED) after a fall?

Comprehensive Emergency Department Workup for a 91-Year-Old Female After a Fall

A 91-year-old female who presents to the Emergency Department after a fall requires a structured multifaceted assessment including medical evaluation, injury assessment, fall risk factors identification, and appropriate referrals to reduce morbidity and mortality.

Initial Medical Assessment

History

The attending physician should obtain a detailed history including:

1. Circumstances of the fall:

   • Location and cause of fall
   • Time spent on floor or ground
   • Loss of consciousness/altered mental status
   • Presence of syncope or near-syncope symptoms 1

2. Fall risk factors:

   • Previous falls history
   • Difficulty with gait and/or balance
   • Orthostatic symptoms
   • Visual or neurological impairments
   • Specific comorbidities (dementia, Parkinson's, stroke, diabetes, hip fracture, depression)
   • Alcohol use 1

3. Medication review:

   • Complete medication list with special attention to:
     • Vasodilators
     • Diuretics
     • Antipsychotics
     • Sedative/hypnotics
     • Other high-risk medications 1

4. Functional assessment:

   • Activities of daily living
   • Use of assistive devices
   • Appropriate footwear 1

Physical Examination

1. Complete head-to-toe examination for ALL patients, even those with seemingly isolated injuries 1

2. Vital signs including orthostatic blood pressure measurements 1

3. Neurological assessment with special attention to:

   • Presence/absence of neuropathies
   • Proximal motor strength
   • Mental status 1

4. Gait and balance assessment:

   • "Get up and go test" - patients unable to rise from bed, turn, and steadily ambulate should be reassessed 1

Diagnostic Evaluation

While there is no standardized set of diagnostic tests for falls, consider:

1. Laboratory tests:

   • Complete blood count
   • Standard electrolyte panel
   • Measurable medication levels (if applicable) 1

2. Cardiac evaluation:

   • EKG (especially with syncope or near-syncope) 1

3. Imaging:

   • Head CT for patients with head trauma, altered mental status, or on anticoagulation
   • Targeted imaging based on physical examination findings and mechanism of injury
   • Consider more extensive imaging for non-ground level falls, which carry higher injury burden 2

Disposition Planning

1. For patients being discharged:

   • Ensure patient safety with gait assessment before discharge
   • Arrange expedited outpatient follow-up including home safety assessment 1
   • Consider referral to fall prevention programs that include multiple interventions 1

2. For patients requiring admission:

   • Evaluation by physical therapy and occupational therapy is recommended for all admitted patients 1
   • Consider admission if patient safety cannot be ensured at home 1

Post-ED Care Recommendations

1. Medical and environmental assessment with client education about risks 1

2. Referrals to relevant healthcare professionals (primary care physician, occupational therapist) 1

3. Structured interdisciplinary approach to management, which has been shown to reduce future falls 1

Common Pitfalls to Avoid

1. Focusing only on the obvious injury: Occult injuries are common in geriatric patients after falls and may present without classic signs or symptoms 1

2. Failing to assess fall etiology: Always question "if this patient was a healthy 20-year-old, would they have fallen?" If not, a comprehensive assessment of underlying causes is needed 1

3. Inadequate medication review: Medication assessment should be performed on all patients who have fallen or are at risk 1

4. Discharging without safety assessment: Patients unable to demonstrate safe mobility should be reassessed before discharge 1

5. Missing non-ground level falls: These account for 14% of elderly falls but are associated with significantly higher injury burden and morbidity 2

By following this structured approach to the ED evaluation of an elderly patient after a fall, clinicians can identify and address both acute injuries and underlying risk factors, potentially reducing future fall risk and improving outcomes.