Initial Assessment and Management for an Elderly Patient Who Has Fallen
Every elderly patient who has fallen should receive a comprehensive multifactorial assessment including fall circumstances, medication review, orthostatic blood pressure measurement, gait and balance evaluation, and home safety assessment, followed by targeted interventions to address identified risk factors. 1
Initial Assessment Components
History Taking
- Detailed circumstances of the fall (including witness accounts if available) 2
- Pattern of falls: single fall vs. recurrent falls 2, 1
- Symptoms before, during, and after the fall (dizziness, loss of consciousness, etc.) 1
- Medication review (especially psychotropics, vasodilators, diuretics, antipsychotics, sedatives) 1
- Medical conditions (diabetes, stroke, neurological disorders) 2, 1
- Cognitive status and mental health assessment (depression, dementia) 2, 1
Physical Examination
- Vital signs including orthostatic blood pressure measurements 1
- "Get Up and Go Test" - observe patient stand from chair without using arms, walk several paces, and return 2
- Gait and balance assessment 2, 1
- Neurological assessment with focus on neuropathies and proximal motor strength 1
- Visual acuity assessment 2, 1
- Musculoskeletal examination with focus on lower extremity joint function 2
- Assessment for injuries (especially hip, head, and facial injuries) 3
Diagnostic Evaluation
- Laboratory tests: complete blood count, electrolytes, renal function, glucose, thyroid function 1
- Consider vitamin B12 levels and hemoglobin/ferritin to detect deficiencies 1
- Hip/pelvis X-rays if pain present to rule out occult fractures 1
- Brain imaging if head injury, altered mental status, or neurological symptoms 1
Risk Stratification
High-Risk Factors Requiring Urgent Attention
- Broken bones/fractures (especially hip fractures) 3
- Head or facial injuries 3
- Falls due to loss of balance/dizziness 3
- Falls occurring inside the home 3
- Living alone 3
- Cognitive impairment or delirium 2, 1
- Multiple medications (≥4) 1
- History of recurrent falls 2
Management Plan
Immediate Interventions
- Treat acute injuries - prioritize fractures, head injuries, and other trauma 3
- Medication review and modification - reduce or eliminate medications that increase fall risk 1
- Address orthostatic hypotension if present 1
- Refer to specialist care (geriatrician, physical therapy) for high-risk patients 1
Long-Term Interventions
- Structured exercise program - focus on balance, strength, and gait training (3 sessions/week for 12 months) 1
- Home safety assessment and modifications - remove hazards, install handrails/grab bars, improve lighting 2, 1
- Vision correction if needed 2, 1
- Assistive devices - properly fitted walking aids if appropriate 1
- Education on fall prevention strategies for patient and caregivers 1
Follow-Up and Monitoring
- Expedited outpatient follow-up including home safety assessments 1
- Reassess fall risk at all transition points and whenever health status changes 1
- For frail or pre-frail patients, reassess frailty status every 1-2 years 1
- Monitor functional status and quality of life for improvement 1
Common Pitfalls to Avoid
- Relying on advice alone without implementing recommended changes is ineffective 1
- Focusing only on the injury rather than addressing underlying fall risk factors 2, 1
- Neglecting cognitive assessment which is critical for compliance with interventions 2, 1
- Overlooking medication review - psychotropic medications significantly increase fall risk 1
- Failing to assess home environment where many falls occur 2, 1
- Missing orthostatic hypotension as a potentially reversible cause of falls 1
Special Considerations
- For patients with diabetes, assess for peripheral neuropathy and vision problems 2
- For stroke patients, implement specific falls prevention plan and skills training 1
- For patients with osteoporosis risk, consider bone health assessment and treatment 1
- For patients with urinary incontinence, evaluate and treat as it's associated with falls 2