What lab workup and imaging should be ordered for a 76-year-old male with no prior history of falls who experienced three falls in one day?

Comprehensive Workup for Multiple Falls in a 76-Year-Old Male

A 76-year-old male with no prior fall history who experiences three falls in one day should undergo a complete laboratory workup including CBC, comprehensive metabolic panel, thyroid function tests, vitamin B12 levels, and ECG, along with brain imaging (CT or MRI) to rule out acute neurological causes. 1

Initial Laboratory Evaluation

The sudden onset of multiple falls in an elderly patient with no prior history warrants a thorough diagnostic evaluation to identify potentially reversible causes:

• Complete Blood Count (CBC): To assess for anemia, infection, or other hematologic abnormalities 1
• Comprehensive Metabolic Panel:
  • Electrolytes (sodium, potassium, calcium, magnesium)
  • Renal function (BUN, creatinine)
  • Glucose levels
  • Liver function tests 1
• Thyroid Function Tests: To rule out hyper/hypothyroidism 1
• Vitamin B12 and Folate Levels: To identify deficiencies that could cause peripheral neuropathy 1
• Hemoglobin A1c: If diabetes is suspected
• Medication Levels: For medications with narrow therapeutic indices (if applicable) 1

Cardiovascular Assessment

• ECG: To identify arrhythmias, conduction abnormalities, or ischemic changes 1
• Troponin: To rule out cardiac injury, especially if syncope is suspected 1
• Orthostatic Blood Pressure Measurements: To assess for orthostatic hypotension 2, 1
• Consider Carotid Sinus Massage: Particularly important in elderly patients with unexplained falls, as carotid sinus hypersensitivity is common in this population 2

Neurological Evaluation

• Brain Imaging:
  • CT Head: To rule out acute intracranial pathology, especially with multiple falls in a single day 1
  • Consider MRI: If CT is negative but neurological symptoms persist 2
• Neurological Assessment: With special attention to neuropathies and proximal motor strength 2, 1
• Cognitive Assessment: Using Mini-Mental State Examination or similar tool 2
• Gait and Balance Assessment: "Get Up and Go" test or similar functional assessment 2, 1

Medication Review

A comprehensive medication review is essential, focusing on:

• Psychotropics: Antidepressants, antipsychotics, sedatives/hypnotics
• Cardiovascular Medications: Antihypertensives, diuretics, vasodilators
• Analgesics: Especially opioids
• Polypharmacy: Total number of medications 2, 1

Additional Considerations

• Vitamin D Level: To assess for deficiency associated with fall risk
• Consider Toxicology Screen: If medication misuse is suspected
• Urinalysis: To rule out urinary tract infection as a precipitating factor for altered mental status

Imaging Beyond Brain

• Hip and Pelvis X-rays: To rule out occult fractures, especially if hip/pelvic pain is present 2
• Consider Spine Imaging: If back pain or neurological symptoms suggest vertebral involvement

Special Considerations

1. Multiple Falls in One Day: The sudden onset of three falls in a previously stable patient strongly suggests an acute medical condition rather than typical age-related balance issues 1

2. Diagnostic Pitfalls:

   • Failure to obtain brain imaging in elderly patients with new-onset falls
   • Missing orthostatic hypotension by not checking postural vital signs
   • Overlooking medication side effects as contributors to falls 2, 1

3. Occult Fractures: Consider that negative plain radiographs do not rule out fractures in elderly patients with persistent pain. MRI may be necessary to detect occult fractures, as illustrated in case studies 2

The multiple falls in a single day in a patient with no prior fall history represents a medical emergency that requires prompt and comprehensive evaluation to prevent serious morbidity and mortality. This approach prioritizes identifying acute, reversible causes while also addressing chronic fall risk factors.