Comprehensive Fall Workup for Older Adults
A multifactorial risk assessment with comprehensive management is essential for older adults who have experienced a fall, focusing on evaluations of balance, mobility, vision, orthostatic hypotension, medication review, and home environment assessment. 1
Initial Risk Assessment
Screening Questions
- History of falls in the past year
- Concerns about falling or balance/gait problems
- Use the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) screening tool 2:
- Have you fallen in the past year?
- Do you feel unsteady when standing or walking?
- Do you worry about falling?
Physical Assessment
- Timed Up and Go test: Patient rises from an armchair, walks 3 meters, turns, walks back, and sits down. Normal time is less than 10 seconds for healthy adults over 60 years 1
- 30-second chair stand test: Assesses lower body strength 2
- Four-stage balance test: Evaluates static balance 2
- Gait speed assessment: Speed less than 0.8-1 m/s indicates high risk 3
Comprehensive Risk Factor Evaluation
Medical Factors
Medication review:
Orthostatic/postural hypotension assessment:
- Measure blood pressure lying and standing 1
- Check for significant drop (≥20 mmHg systolic or ≥10 mmHg diastolic) within 3 minutes of standing
Vision evaluation:
- Visual acuity testing
- Consider early cataract surgery for those with cataracts (reduces falls by 32%) 3
Chronic condition optimization:
- Diabetes management
- Hypertension control
- Pain management
- Urinary urgency/incontinence treatment
- Depression screening and treatment 2
Functional Assessment
- Balance and mobility evaluation
- Muscle strength testing, particularly lower extremities
- Neurological examination focusing on proprioception and coordination
- Podiatry assessment (foot problems can significantly impact balance) 3
Environmental Assessment
- Home safety evaluation
- Identification of environmental hazards:
- Poor lighting
- Loose rugs
- Lack of grab bars in bathrooms
- Obstacles in walkways
- Inappropriate footwear 5
Intervention Plan
Exercise Interventions
- Most effective component for fall prevention with high certainty of moderate benefit 1
- Recommended components:
- Balance training (3+ days per week)
- Gait and functional training
- Strength training (2+ days per week)
- Flexibility exercises
- Consider group classes or home-based programs
- Tai chi has shown effectiveness 4
- Typical effective regimen: 3 sessions per week for 12 months 1
Multifactorial Management
- Particularly beneficial for high-risk individuals (those with 2+ falls in past year or 1 fall with gait/balance problems) 1
- Components based on identified risk factors:
- Medication adjustment or withdrawal
- Treatment of orthostatic hypotension
- Vision correction
- Home hazard modification
- Physical therapy referral
- Appropriate use of assistive devices
- Podiatry referral for foot problems and appropriate footwear 3
Vitamin D Supplementation
- May provide moderate benefit in preventing falls 1
- Consider particularly for those with suspected or confirmed deficiency
Follow-Up and Monitoring
- Regular reassessment of fall risk
- Monitoring of intervention adherence
- Adjustment of interventions based on progress and changing risk factors
Common Pitfalls to Avoid
- Focusing only on acute injuries without addressing underlying fall risk factors
- Failing to perform a comprehensive medication review
- Neglecting to assess home environment
- Implementing single interventions rather than a multifactorial approach
- Inadequate follow-up on intervention implementation
- Overlooking cognitive impairment that may affect fall risk and intervention adherence 2
Falls in older adults are a significant cause of morbidity and mortality, with 30-40% of community-dwelling adults aged 65+ falling at least once per year 1, 3. A thorough workup addressing multiple risk factors with targeted interventions is essential to reduce the risk of future falls and their potentially devastating consequences.