What is the recommended treatment for a patient after a fall?

Post-Fall Treatment Protocol

A comprehensive multifactorial assessment and intervention approach is essential for all patients who have experienced a fall, including medical evaluation, physical therapy referral, home safety assessment, and medication review to prevent subsequent falls and reduce morbidity and mortality. 1, 2

Initial Assessment

Medical Evaluation

• Complete head-to-toe examination for ALL patients, even those with seemingly isolated injuries 1
• Key historical elements to assess:
  • Age (especially if over 65)
  • Location and cause of fall
  • Difficulty with gait/balance
  • Previous falls history
  • Time spent on floor/ground
  • Loss of consciousness/altered mental status
  • Near/syncope/orthostasis
  • Relevant comorbidities (dementia, Parkinson's, stroke, diabetes, depression)
  • Visual or neurological impairments
  • Alcohol use
  • Medication review
  • Activities of daily living
  • Footwear assessment 1

Physical Assessment

• Orthostatic blood pressure measurement
• Neurological assessment focusing on neuropathies and proximal motor strength
• Gait and balance evaluation using standardized tests:
  • "Get Up and Go Test" - patients unable to rise from bed, turn, and steadily ambulate require reassessment 1
  • Timed Up and Go (TUG) test - time >12 seconds indicates increased fall risk 2
  • 4-Stage Balance Test - inability to maintain tandem stand for 10 seconds indicates risk 2

Diagnostic Testing

• Consider EKG, complete blood count, electrolyte panel, medication levels, and appropriate imaging 1
• For head pain/stiffness: Non-contrast head CT within 6 hours of symptom onset (sensitivity 98.7%, specificity 99.9%) 2

Intervention Plan

Exercise Interventions

• Implement structured exercise program focusing on:
  • Balance and functional training
  • Resistance/strength training
  • Flexibility exercises
  • Gait training 1, 2
• Recommended frequency: 3 sessions per week for 12 months 1
• Duration: 50-60 minutes daily, with aerobic exercise in 10-20 minute sessions, 3-7 days/week 2
• Intensity: 12-14 on Borg scale (55-70% of heart rate reserve) 2

Medication Management

• Review and modify medications, particularly:
  • Vasodilators
  • Diuretics
  • Antipsychotics
  • Sedative/hypnotics 1
• Consider deprescribing high-risk medications as part of multifactorial intervention 3
• Avoid opioids for routine pain management after falls 2

Environmental Modifications

• Home safety assessment and modifications:
  • Remove tripping hazards
  • Install handrails and grab bars
  • Improve lighting
  • Ensure even floor surfaces
  • Consider rubber or nonskid floor surfaces/mats 1, 2

Additional Interventions

• For high-risk patients: Consider external hip protectors to prevent fractures 1
• For those with osteoporosis risk: Consider bone health assessment and appropriate treatment 4
• For stroke patients: Implement specific falls prevention plan and skills training for safe transfers and mobility 1

Follow-up Care

Referrals

• Physical therapy and occupational therapy evaluation for all patients admitted to hospital after a fall 1
• Consider Fracture Liaison Service (FLS) for systematic risk evaluation and treatment initiation for patients with fragility fractures 1
• For frail patients: Refer to specialist care of the elderly team 2

Monitoring

• Reassess fall risk at all transition points and whenever there is a change in health status 1
• For frail/pre-frail patients: Reassess every 1-2 years 2
• Expedite outpatient follow-up including home safety assessments 1

Special Considerations

Post-Fall Syndrome

• Occurs in approximately 20% of fallers 5
• Requires early intervention with specific physical therapy to prevent regressive syndrome with physical, psychological, and social consequences 5

High-Risk Groups

• Women over 65 living alone have significantly higher fall risk 6
• 30-40% of older adults who fall experience moderate to severe physical health impairment 6

Implementation Pitfalls to Avoid

1. Focusing only on visible injuries while missing occult injuries
2. Discharging patients without proper referrals (occurs in up to 1/3 of cases) 6
3. Neglecting medication review, especially high-risk medications
4. Failing to assess home environment safety
5. Implementing non-selective exercise programs in nursing homes (shown to be ineffective) 1
6. Overlooking psychological impact of falls and fear of falling

By implementing this comprehensive approach to post-fall treatment, healthcare providers can significantly reduce the risk of subsequent falls, with multifactorial interventions showing a reduction from 2317 to 1784 falls per 1000 patient-years (rate ratio 0.77) 3.