Comprehensive Assessment of Falls Patients
A comprehensive falls assessment must include evaluation of the fall circumstances, medical history, medication review, physical examination with gait/balance testing, and environmental risk factors to identify the underlying cause and prevent future falls. 1
Initial Assessment Framework
History Taking - Critical Components
- Age (particularly those >65 years)
- Location and cause of fall
- Difficulty with gait and/or balance
- Previous falls history
- Time spent on floor/ground
- Loss of consciousness/altered mental status
- Near/syncope/orthostasis
- Specific comorbidities (dementia, Parkinson's, stroke, diabetes, hip fracture, depression)
- Visual or neurological impairments
- Alcohol use
- Medication review
- Activities of daily living
- Appropriate footwear 1
Physical Examination
- Complete head-to-toe examination for ALL patients, even those with seemingly isolated injuries
- Orthostatic blood pressure assessment
- Neurologic assessment focusing on neuropathies and proximal motor strength
- Gait assessment including "get up and go test" 1
Risk Assessment Tools
Several validated tools can be used to assess fall risk:
- Three key questions: 1) Have you fallen in the past year? 2) Do you feel unsteady when standing or walking? 3) Are you worried about falling? A "yes" to any question indicates increased risk 1
- Timed Up and Go (TUG) test: Patient rises from chair, walks 3 meters, turns, returns to chair, and sits down. >12 seconds indicates increased fall risk 1
- 4-Stage Balance Test: Patient stands in 4 increasingly challenging positions for 10 seconds each (feet side by side, semitandem stand, tandem stand, single-foot stand). Inability to hold tandem stand for 10 seconds indicates increased risk 1
- Stay Independent questionnaire: Evaluates multiple domains with a score ≥4 (out of 12) indicating increased fall risk 1
Diagnostic Evaluation
Consider the following diagnostic tests when appropriate:
- EKG (for cardiac conduction abnormalities)
- Complete blood count
- Standard electrolyte panel
- Medication levels when applicable
- Appropriate imaging based on clinical findings 1
Multifactorial Assessment Components
1. Medication Review
- Assess for high-risk medications:
- Evaluate for polypharmacy (≥5 medications)
- Consider medication adjustment in approximately 23% of cases to reduce fall risk 2
2. Physical Function Assessment
- Evaluate balance and mobility impairments (relative risk 1.32)
- Assess sensory and neuromuscular deficits (relative risk 1.51)
- Screen for osteoporosis/osteopenia with DXA scanning 1, 2
3. Environmental Assessment
- Home safety evaluation including:
- Removal of tripping hazards
- Improved lighting
- Installation of grab bars
- Appropriate footwear 2
4. Cognitive and Psychological Evaluation
- Screen for cognitive impairment
- Assess psychological factors (relative risk 1.35) 2
Intervention Planning
Based on assessment findings, implement a multicomponent intervention plan:
1. Exercise Program
- Multicomponent exercise including:
- Balance training
- Strength exercises
- Resistance training
- Gait training 2
- These programs can reduce falls with a relative risk of 0.89 (95% CI: 0.81-0.97) 2
2. Environmental Modifications
- Direct intervention (not just education) to modify home environment
- Consider hospital environment safety features:
- Nonskid floor surfaces
- Even floor surfaces
- Handrails
- Appropriate lighting
- Bedside commodes and grab bars
- Properly positioned bedrails
- Appropriate patient clothing 1
3. Medical Management
- Treat identified medical conditions
- Adjust high-risk medications
- Address vitamin D deficiency if present 2
Discharge Planning and Follow-up
- Consider expedited outpatient follow-up including home safety assessments
- Consider hospital admission if patient safety cannot be ensured
- Refer to physical therapy and occupational therapy for admitted patients
- Consider referral to specialist care for frail elderly patients 1, 2
Common Pitfalls to Avoid
Focusing only on the injury: The fall is often a symptom of underlying issues that must be addressed to prevent recurrence 3
Incomplete assessment: Always perform a complete head-to-toe examination, even with seemingly isolated injuries 1
Failure to assess gait: Patients unable to rise from bed, turn, and steadily ambulate should be reassessed before discharge 1
Overlooking "occult" injuries: Geriatric patients may have traumatic injuries without "classic" signs or symptoms, particularly head trauma, spinal fractures, and hip fractures 1
Not considering multifactorial causes: Falls often result from complex combinations of causes described as "geriatric syndrome" 1
By following this comprehensive assessment approach, clinicians can effectively identify fall risk factors, implement appropriate interventions, and reduce the likelihood of future falls and related injuries in vulnerable patients.