What is the appropriate workup for a patient who has experienced a fall?

Comprehensive Workup for a Fall

A thorough fall evaluation must include a detailed history, physical examination, medication review, orthostatic vital signs, and targeted diagnostic testing to identify underlying causes that contribute to falls risk. 1

Initial Assessment

History

• Ask three key screening questions 2:

  1. Have you fallen in the past year?
  2. Do you feel unsteady when standing or walking?
  3. Are you worried about falling?

• Collect detailed historical elements 2, 1:

  1. Age (especially if over 65)
  2. Location and circumstances of fall
  3. Difficulty with gait and/or balance
  4. Previous falls and their frequency
  5. Time spent on floor or ground
  6. Loss of consciousness/altered mental status
  7. Near-syncope or orthostatic symptoms
  8. Presence of melena (potential GI bleed)
  9. Comorbidities (dementia, Parkinson's, stroke, diabetes, hip fracture, depression)
  10. Visual or neurological impairments
  11. Alcohol use
  12. Activities of daily living
  13. Footwear assessment

Physical Examination

• Complete head-to-toe evaluation for ALL patients, even those with seemingly isolated injuries 2
• Orthostatic vital signs (measure BP and HR supine and after 1-3 minutes of standing) 2, 3, 4
• Neurological assessment with focus on 2, 1:
  • Peripheral neuropathies
  • Proximal motor strength
  • Cognitive assessment (Mini-Cog, Memory Impairment Screen, or AD8) 2
• Cardiovascular assessment 1
• Gait and balance evaluation:
  • Timed Up and Go (TUG) test (>12 seconds indicates increased fall risk) 2
  • 4-Stage Balance Test (tandem stand <10 seconds indicates increased fall risk) 2

Diagnostic Testing

Laboratory Studies

• Complete blood count 2, 1
• Standard electrolyte panel/comprehensive metabolic panel 2, 1
• Vitamin D level 1
• Medication levels when appropriate 2

Cardiac Evaluation

• EKG 2, 1
• Consider Holter monitoring or event recorder if syncope is suspected 1

Imaging Studies

• Brain imaging if neurological symptoms or signs are present 1
• Consider appropriate imaging for suspected injuries 2
• Bone density testing for osteoporosis risk assessment 1

Additional Testing (Based on Clinical Suspicion)

• Tilt table testing for suspected vasovagal syncope 1, 4
• Vestibular function testing for suspected vestibular disorders 1

Medication Review

• Comprehensive review of all medications 2
• Special attention to high-risk medications 2:
  • Vasodilators
  • Diuretics
  • Antipsychotics
  • Sedative/hypnotics

Safety Assessment

• Evaluate gait with "get up and go test" prior to discharge 2
• Patients unable to rise from bed, turn, and steadily ambulate should be reassessed 2
• Consider home safety evaluation 2, 1

Risk Factor Identification and Management

Key Risk Factors

• Balance and mobility impairments 1
• Medication-related factors 1
• Psychological factors 1
• Sensory and neuromuscular deficits 1
• Cognitive impairment 1
• Environmental hazards 2, 1

Management Recommendations

• Exercise/physical therapy for nearly all patients with recurrent falls 1
• Medication adjustment (required in approximately 23% of cases) 1
• Home safety evaluation and modification 2, 1
• Vitamin D supplementation (800 IU daily) for those at increased risk 2

Disposition Considerations

• Expedited outpatient follow-up for discharged patients 2
• Consider admission if patient safety cannot be ensured 2
• Physical therapy and occupational therapy evaluation for admitted patients 2

Common Pitfalls to Avoid

1. Focusing only on the apparent injury without investigating underlying cause
2. Missing orthostatic hypotension by not performing proper orthostatic vital signs
3. Failing to perform cognitive assessment in elderly patients
4. Not reviewing high-risk medications
5. Discharging patients without proper gait assessment
6. Overlooking the multifactorial nature of falls in elderly patients

Remember that falls in elderly patients are often multifactorial and require a comprehensive approach to evaluation and management to reduce morbidity, mortality, and improve quality of life.