What is the assessment and plan for a patient with a history of present illness (HPI) of a fall with no apparent injury?

Assessment and Plan for a Fall with No Injury

For patients who have experienced a fall with no apparent injury, a comprehensive assessment should be performed to identify the cause of the fall and prevent future falls, as falls are a leading cause of morbidity and mortality in older adults. 1

Assessment Components

History

• Obtain detailed information about the fall circumstances:

  • Location and cause of fall 1
  • Time spent on floor or ground 1
  • Presence of loss of consciousness or altered mental status 1
  • History of previous falls (particularly within the past year) 1, 2
  • Symptoms of near-syncope or orthostasis 1

• Assess for risk factors:

  • Age (particularly those over 65) 1
  • Difficulty with gait and/or balance 1, 2
  • Comorbidities (dementia, Parkinson's, stroke, diabetes, depression) 1
  • Visual or neurological impairments 1
  • Alcohol use 1
  • Current medications, especially high-risk medications (vasodilators, diuretics, antipsychotics, sedative/hypnotics) 1
  • Activities of daily living capabilities 1
  • Appropriate footwear 1

Physical Examination

• Complete head-to-toe examination to rule out occult injuries 1
• Orthostatic blood pressure assessment 1
• Neurological assessment focusing on neuropathies and proximal muscle strength 1
• Gait and balance evaluation using standardized tests:
  • Timed Up and Go (TUG) test (>12 seconds indicates increased fall risk) 1
  • 4-Stage Balance Test (inability to hold tandem stand for 10 seconds indicates increased fall risk) 1

Diagnostic Testing

• Consider the following tests when appropriate:
  • EKG 1
  • Complete blood count 1
  • Standard electrolyte panel 1
  • Medication levels when applicable 1
  • Appropriate imaging if trauma is suspected 1

Plan

Immediate Management

• Safety assessment prior to discharge using "get up and go test" 1
• Patients unable to rise from bed, turn, and steadily ambulate should be reassessed 1
• Consider admission if patient safety cannot be ensured 1

Risk Stratification

• Stratify fall risk based on:
  • Fall history (previous falls significantly increase risk of future falls) 1, 2
  • Gait and balance abnormalities (strongest predictors of future falls) 2
  • Use standardized risk assessment tools like the Stay Independent questionnaire or Three Key Questions 1

Fall Prevention Interventions

Exercise and Physical Therapy

• Refer to physical therapy for patients with gait or balance problems 1
• Recommend balance training 3 or more days per week for those at risk 1
• Include strength training twice weekly 1

Medication Review

• Perform medication assessment with special attention to high-risk medications 1
• Consider referral to primary physician for medication review if polypharmacy concerns exist 1

Environmental Modifications

• Recommend home safety assessment 1
• Consider expedited outpatient follow-up including home safety evaluation 1

Vitamin D Supplementation

• Consider vitamin D supplementation (800 IU daily) for those at increased risk for falls 1

Education

• Provide patient and caregiver education on fall prevention strategies 1
• Discuss appropriate footwear and environmental hazards 1

Follow-up

• Arrange appropriate follow-up based on risk stratification 1
• Consider multidisciplinary approach for high-risk patients 1
• For admitted patients, ensure evaluation by physical therapy and occupational therapy 1

Common Pitfalls and Caveats

• Falls in older adults are often multifactorial and require comprehensive evaluation 1
• "Occult" injuries may present without classic signs or symptoms in geriatric patients 1
• A single fall without injury still warrants thorough evaluation as it may indicate increased risk for future falls 2
• Focusing only on the absence of injury may lead to missed opportunities for prevention of future falls 1
• The question "if this patient was a healthy 20-year-old, would they have fallen?" helps identify underlying causes requiring assessment 1