What is the appropriate workup for a patient experiencing recurrent falls?

Comprehensive Workup for Recurrent Falls

A thorough workup for recurrent falls should include a detailed history, physical examination, medication review, orthostatic vital signs, and targeted diagnostic testing to identify underlying causes that contribute to falls risk.

Key Historical Elements

When evaluating a patient with recurrent falls, the following historical elements are essential 1:

1. Age (particularly those over 65)
2. Location and circumstances of falls
3. Gait and balance difficulties
4. Pattern and frequency of previous falls
5. Time spent on floor after falling
6. Presence of loss of consciousness or altered mental status
7. Syncope or near-syncope symptoms
8. Gastrointestinal symptoms (including melena)
9. Relevant comorbidities:
   • Dementia
   • Parkinson's disease
   • Prior stroke
   • Diabetes
   • Previous hip fracture
   • Depression
10. Visual or neurological impairments (especially peripheral neuropathies)
11. Alcohol use
12. Medication review
13. Activities of daily living assessment
14. Footwear evaluation

Physical Examination

The physical examination should focus on:

1. Orthostatic vital signs - Measure blood pressure and heart rate supine and after 1-3 minutes of standing 1
2. Neurological assessment - Evaluate for:
   • Peripheral neuropathy
   • Proximal muscle strength
   • Cognitive function (using standardized tools)
   • Cerebellar function
3. Cardiovascular assessment - Including carotid sinus massage if not contraindicated 1
4. Gait and balance evaluation - Perform:
   • Get Up and Go test
   • Tandem walking
   • Balance assessment

Diagnostic Testing

While there is no standard set of diagnostic tests for falls, consider 1:

1. Laboratory studies:

   • Complete blood count
   • Comprehensive metabolic panel
   • Vitamin D level
   • Medication levels when applicable

2. Cardiac evaluation:

   • ECG
   • Consider Holter monitoring or event recorder if syncope is suspected

3. Imaging:

   • Brain imaging if neurological symptoms or signs are present
   • Consider bone density testing for osteoporosis risk assessment

Specialized Testing

For patients with unclear etiology:

1. Carotid sinus massage - To evaluate for carotid sinus hypersensitivity (found in 11% of patients in specialized falls clinics) 2
2. Tilt table testing - For suspected vasovagal syncope 1
3. Vestibular function testing - For suspected vestibular disorders 3

Interdisciplinary Assessment

An interdisciplinary approach is crucial for comprehensive evaluation 2:

1. Physical therapy - For detailed gait and balance assessment
2. Occupational therapy - For ADL and home safety evaluation
3. Pharmacy - For medication review and deprescribing opportunities
4. Specialty consultation - Neurology, cardiology, or otolaryngology as indicated

Risk Factor Identification

The most significant risk factors for recurrent falls include 4, 5:

1. Balance and mobility impairments (RR: 1.32)
2. Medication-related factors (RR: 1.53)
   • Polypharmacy (>5 medications)
   • High-risk medications:
     • Vasodilators
     • Diuretics
     • Antipsychotics
     • Sedative/hypnotics
     • Antidepressants
3. Psychological factors (RR: 1.35)
   • Depression
   • Fear of falling
4. Sensory and neuromuscular deficits (RR: 1.51)
   • Vision impairment
   • Peripheral neuropathy

Common Pitfalls to Avoid

1. Focusing only on the most recent fall - Recurrent falls often have multiple contributing factors
2. Missing cognitive impairment - Present in 5% of 65-year-olds and 20% of 80-year-olds 1
3. Overlooking medication contributions - Medication review and adjustment is needed in approximately 23% of cases 2
4. Failing to identify rare but serious causes - Such as normal pressure hydrocephalus, subdural hematoma, or malignancy 2
5. Not addressing fear of falling - Can lead to activity restriction and deconditioning, further increasing fall risk 6

Management Recommendations

Based on findings from the workup:

1. Exercise/physical therapy - Recommended for nearly all patients with recurrent falls 2
2. Medication adjustment - Required in approximately 23% of cases 2
3. Pacemaker implantation - Consider for those with carotid sinus hypersensitivity or other bradyarrhythmias (5% of cases) 2
4. Home safety evaluation - To identify and modify environmental hazards
5. Vestibular rehabilitation - For those with vestibular disorders 3

Recurrent falls significantly impact quality of life, with recurrent fallers showing poorer physical performance on standardized tests and lower health-related quality of life scores compared to single fallers 7. Therefore, thorough evaluation and targeted interventions are essential to reduce morbidity, mortality, and improve quality of life.