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

Comprehensive Workup for Falls

A comprehensive fall evaluation should include assessment of circumstances, medical conditions, cognitive status, orthostatic blood pressure measurements, gait and balance testing, medication review, and environmental risk factors to identify modifiable fall risks and guide targeted interventions. 1

Initial Assessment

History Taking

• Document detailed circumstances of the fall:
  • Location and cause of fall
  • Time spent on floor/ground
  • Loss of consciousness or altered mental status
  • Presence of witnesses (note: unavailable in 40-60% of cases) 2
  • Prior falls in recent months (recurrent falls significantly increase future risk) 1

Key Risk Factors to Assess

1. Medical conditions:

   • Cardiovascular: syncope, orthostatic hypotension, carotid sinus hypersensitivity
   • Neurological: Parkinson's, stroke, peripheral neuropathy
   • Metabolic: diabetes, thyroid dysfunction
   • Visual impairments
   • Urinary incontinence

2. Medication review (high priority):

   • Psychotropic medications
   • Vasodilators and diuretics
   • Antipsychotics
   • Sedatives/hypnotics
   • Diphenhydramine (particularly problematic in geriatric patients) 2
   • Opioids

3. Functional assessment:

   • Activities of daily living
   • Use of assistive devices
   • Appropriate footwear 2

Physical Examination

Vital Signs

• Orthostatic blood pressure measurements (essential component) 2, 1
  • Measure supine and after standing for 1-3 minutes
  • Drop of ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension

Cardiovascular Examination

• Carotid sinus massage (if no contraindications) 2, 1
  • Particularly valuable in elderly patients with unexplained falls

Neurological Assessment

• Evaluate for neuropathies
• Assess proximal motor strength
• Check for focal neurological deficits

Musculoskeletal Examination

• Evaluate for deformities, arthritis, foot problems
• Assess for pain with movement

Functional Testing

• Gait and balance assessment:
  • "Get Up and Go" test
  • Timed Up and Go (TUG) test (normal: <10 seconds) 1

Cognitive Assessment

• Mini-Mental State Examination or similar tool 1
• Evaluate for delirium, dementia, depression

Laboratory and Diagnostic Testing

Basic Laboratory Tests

• Complete blood count
• Electrolytes and renal function
• Blood glucose
• Thyroid function tests
• Vitamin B12, hemoglobin, and ferritin levels 1

Imaging

• Hip and pelvis X-rays if hip/pelvic pain present (to rule out occult fractures)
• Brain imaging (CT or MRI) if:
  • Loss of consciousness
  • Focal neurological findings
  • Head trauma
  • Unexplained altered mental status 1

Specialized Testing (as indicated)

• ECG if cardiac etiology suspected
• Echocardiogram if structural heart disease suspected
• Head-up tilt testing for suspected neurally-mediated syncope (may be deferred until second occurrence) 2

Risk Stratification

The American Geriatrics Society identifies these relative risks for recurrent falls 1:

• Balance and mobility impairments (RR 1.32)
• Medication-related factors (RR 1.53)
• Psychological factors (RR 1.35)
• Sensory and neuromuscular deficits (RR 1.51)
• Cognitive impairment

Intervention Planning

Immediate Interventions

• Treat acute medical conditions
• Modify high-risk medications
• Address environmental hazards
• Consider assistive devices

Long-term Interventions

• Exercise programs focusing on:

  • Balance and functional training
  • Resistance/strength training
  • Flexibility exercises
  • Gait training
  • Consider Tai Chi 1, 3

• Home safety assessment and modifications:

  • Remove tripping hazards
  • Install handrails and grab bars
  • Improve lighting
  • Ensure even floor surfaces 2, 1

• Vitamin D supplementation:

  • 800 IU daily for those at increased fall risk 1

Special Considerations

Frail Elderly

• May require modified assessment approach
• Consider referral to geriatric specialist 1
• Balance risk of falls against quality of life and independence

Cognitive Impairment

• Increased supervision may be necessary
• Environmental modifications become more important
• Caregiver education is essential

Follow-up Plan

• Expedited outpatient follow-up including home safety assessment 2, 1
• Reassessment at all transition points and with changes in health status
• Regular reassessment every 1-2 years for frail/pre-frail patients 1

Common Pitfalls to Avoid

• Focusing only on injury treatment rather than addressing underlying fall risk factors
• Overlooking medication contributions to fall risk
• Failing to distinguish falls from syncope (up to one-third of syncope events present as falls) 2
• Not considering multifactorial interventions, which are more effective than single interventions 1, 3
• Neglecting home safety assessment and modifications
• Missing occult fractures due to "atypical" presentation in older adults 2