What is the recommended management for a patient who has experienced a fall with no apparent injury?

Management of a Patient Who Has Experienced a Fall with No Apparent Injury

A comprehensive assessment should be performed for all patients who have fallen, even without apparent injury, to identify fall causes and prevent future falls which can lead to significant morbidity and mortality.1

Initial Assessment Components

• Obtain detailed information about fall circumstances including:

  • Location and cause of fall 2
  • Time spent on floor or ground 2
  • Presence of loss of consciousness or altered mental status 2
  • Symptoms of near-syncope or orthostasis 2
  • Difficulty with gait and/or balance 2
  • History of previous falls 2

• Assess for key risk factors:

  • Age greater than 65 2
  • Comorbidities (dementia, Parkinson's, stroke, diabetes, depression) 2
  • Visual or neurological impairments 2
  • Alcohol use 2
  • Current medications, especially high-risk medications (vasodilators, diuretics, antipsychotics, sedative/hypnotics) 2
  • Activities of daily living 2
  • Appropriate footwear 2

• Perform physical examination:

  • Complete head-to-toe examination to rule out occult injuries 1
  • Orthostatic blood pressure assessment 2
  • Gait and balance assessment using validated tools like Timed Up and Go Test 2, 1

Intervention Plan

Immediate Management

• Perform safety assessment prior to discharge using the "get up and go test" 1
• Consider admission if patient safety cannot be ensured 2

Fall Prevention Interventions

Exercise Interventions

• Refer to physical therapy for patients with gait or balance problems 1
• Recommend balance training 3+ days per week and strength training twice weekly 2, 1
• Exercise interventions have been shown to reduce the number of persons experiencing falls (RR, 0.89 [95% CI, 0.81 to 0.97]) and injurious falls (IRR, 0.81 [95% CI, 0.73 to 0.90]) 2
• Group-based exercise with multiple components including strength/resistance exercises may be more effective 2

Medication Review

• Perform medication assessment with special attention to high-risk medications 2, 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 2
• Environmental modifications for high-risk individuals have been shown to reduce falls (RR, 0.74; 95% CI, 0.61-0.91) 3

Vitamin D Supplementation

• Consider vitamin D supplementation (800 IU daily) with adequate calcium intake (1000-1200 mg/day) 2, 1
• Vitamin D supplementation with adequate calcium intake is associated with 15-20% reduction in non-vertebral fractures 2
• Avoid high pulse dosages of vitamin D as they may increase fall risk 2

Multifactorial Interventions

• For high-risk patients, implement multifactorial interventions that systematically assess and address multiple risk factors 2, 3
• Multifactorial interventions have been shown to reduce falls (IRR, 0.79 [95% CI, 0.68 to 0.91]) 2

Follow-up Recommendations

• Arrange appropriate follow-up based on risk stratification 1
• For low-risk individuals (no falls or 1 noninjurious fall with no gait/balance impairment), reassess in 1-2 years 2
• For high-risk individuals, consider multidisciplinary approach 1
• Expedited outpatient follow-up should include home safety assessments 2

Clinical Pitfalls to Avoid

• Don't assume a fall without injury is benign - falls are a strong predictor of future nursing home placement 4
• Don't overlook "occult" injuries that may present without classic signs or symptoms, especially in geriatric patients 2
• Don't focus solely on the physical injury; address the underlying cause of the fall 2
• Don't forget to assess orthostatic blood pressure, as orthostatic hypotension is a common modifiable risk factor 2, 3
• Don't underestimate the importance of medication review, as certain medications significantly increase fall risk 2, 1