What is the recommended workup for repeated falls in elderly patients?

Comprehensive Workup for Repeated Falls in Elderly Patients

The recommended workup for repeated falls in elderly patients must include a thorough assessment of fall history, gait and balance evaluation, medication review, and multifactorial risk assessment to identify and address all contributing factors.

Initial Assessment

Fall History Assessment

• Ask about falls in the past 6 months 1
• Document specific details of each fall:
  • Location and circumstances of fall 1
  • Time spent on floor/ground 1
  • Presence of loss of consciousness or altered mental status 1
  • Near-syncope or orthostatic symptoms 1
  • Activity during fall 2
  • Environmental factors present 2

Physical Assessment

• Perform timed Get-Up-and-Go test (normal is <10 seconds) 1
• Evaluate gait and balance 1
• Check for orthostatic hypotension 1
• Perform carotid sinus massage (if not contraindicated) 1
• Visual acuity testing 1
• Neurological examination focusing on peripheral neuropathies 1
• Foot examination for deformities or inappropriate footwear 1, 2

Laboratory and Diagnostic Evaluation

Essential Laboratory Tests

• Complete blood count
• Comprehensive metabolic panel
• Vitamin B12 level 3
• Vitamin D level 1, 3
• Thyroid function tests
• Hemoglobin A1C (if diabetic)

Cardiovascular Assessment

• 12-lead ECG
• Consider 24-hour Holter monitoring or event recorder if syncope is suspected 1
• Consider echocardiogram if cardiac etiology is suspected

Additional Testing Based on Initial Findings

• Head CT/MRI if neurological symptoms are present
• Consider bone density testing for osteoporosis risk assessment 1
• Consider cervical spine imaging if cervical spondylosis is suspected 2

Medication Review

High-Risk Medications

• Review all medications with particular attention to:
  • Psychoactive medications (sedatives, antipsychotics, antidepressants) 1, 4
  • Antihypertensives 1
  • Diuretics
  • Anticonvulsants
  • Anticholinergics (particularly diphenhydramine) 1
  • Polypharmacy (multiple medications) 1, 4

Functional Assessment

Activities of Daily Living

• Assess independence in activities of daily living (ADLs) 1
• Assess instrumental activities of daily living (IADLs) 1
• Evaluate cognitive status using Mini-Cog or similar tool 1
• Screen for depression using Geriatric Depression Scale (GDS) 1
• Assess nutritional status (unintentional weight loss >10% or BMI <21 kg/m²) 1

Environmental Assessment

Home Safety Evaluation

• Consider home safety assessment focusing on:
  • Lighting adequacy 1
  • Floor surfaces (uneven, slippery) 1
  • Presence of handrails in hallways and bathrooms 1
  • Bathroom safety features 1
  • Appropriate footwear 2
  • Trip hazards (rugs, cords, clutter) 5

Special Considerations

Comorbidity Assessment

• Evaluate specific comorbidities that increase fall risk:
  • Dementia, Parkinson's disease, stroke 1
  • Diabetes and peripheral neuropathy 1
  • Previous hip fracture 1
  • Depression 1
  • Alcohol use 1
  • Osteoporosis 1

Common Pitfalls to Avoid

• Failing to distinguish between syncope and falls 1
• Attributing falls solely to age rather than identifying specific causes 5
• Overlooking medication side effects as contributing factors 4
• Neglecting to assess for vitamin deficiencies (B12, D) 3
• Focusing only on injuries rather than prevention of future falls 5
• Failing to follow up on interventions to assess effectiveness

Follow-up Recommendations

• Regular reassessment of fall risk (at least annually) 1
• Expedited outpatient follow-up after ED visits for falls 1
• Physical therapy and occupational therapy evaluations for patients admitted after falls 1
• Consider vitamin D supplementation (800 IU daily) 1
• Exercise program focusing on balance, gait, and strength training 1

Remember that falls in elderly patients are often multifactorial, and a comprehensive assessment addressing all potential contributing factors is essential to reduce morbidity and mortality associated with falls.